Tobias S. Köhler, MD, MPH, FACSSouthern Illinois University – Springfield, IL

May 16, 2015

AMS, Coloplast, Abbvie – Consulting / Research

I will mention on-label and off-label use of medications by both generic and brand name during this talk

The use of off-labeled medications is not approved by the FDA and use of these medications will be up to the discretion of the treating practitioner based on clinical presentation and experience

What is a normal hormonal profile for ejaculation

Evaluation & Treatment Protocol

Practice Patterns and Outcomes of SMSNA

Medication Review

Testosterone o Androgen Receptors ubiquitous including in pelvic floor muscleso High T = premature & Low T = delayed in someo However T levels very widely in men with DE (one cohort of 2400 men

had a DE prevalence of 26%) Thyroid Hormone

o Similar to testosterone, high Thyroid levels = PE, low Thyroid levels = DE Prolactin

o May be a surrogate marker of serotonergic activityo High levels suppress testosterone and ejaculatory functiono Suppressed during climax, spikes after orgasm (likely at least in part

responsible for refractory period) Oxytocin

o Oxytocin surges during male ejaculation, orgasm and detumescencereturning to baseline by 10 minutes after surge

o Increases ejaculation, paternal nurturing, sexual desire, and long-term romantic bonds and attachments

Sex therapists report better success rates overall addressing underlying causal factors.

DE with concurrent ED should be treated with PDE5Is Vibratory Stimulation shown to be helpful (72% success with

three 1 minute rest/application cycles) Most helpful “drug effect” is switching away from SSRIs to

Bupropion (66%) All published studies use small samples, have no controls, are

nonrandomized and lack validated outcome measures. Disparities in outcomes likely reflect clinically different

treatment populations There is no FDA approved drug for treatment

Normalization ofhypogonadism PDE5i for ED Sexual counseling PVS Medication adjustments

Always 4 5 4 1 8Mostly 24 35 30 16 58Seldom 58 45 50 46 26Never 7 9 9 26 2

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How Successful Are These Treatments in the SMSNA?

30% 43% 37% 19% 70%

Alcohol Clomipramine Lorazepam PhentolamineAlprazolam Desmethylimipramine Mebanizine Phenylzine sulphate

Aminocaproic acid

Fluoxetine* Mesoridazine Prazosin

Amitriptyline Fluvoxamine Methadone Protriptyline

Amoxapine Guanadrel Methyldopa Reserpine

Baclofen Guanethidine Naproxen Sertraline*

Bethanidine Haloperidol Nortriptyline Thiazide diuretics

Butaperazine Hexamthonium Pargyline Thioridazine

Chlordiazepoxide Imiprimine Paroxetine* Trazadone

Chlorimipramine Iproniazid Perphenazine Trifluoperazine

Chlorpromazine Isocarboxazid Phenothiazine * All selective serotonin reuptake Inhibitors (SSRI’s = 7x risk of DE!)Chlorprothixine Labethanol Phenoxybenzamine

DrugGeneric / (Trade)

Delayed Ejaculation Dosage(Not FDA Approved) Indication

(FDA Approved)Side Effects

(At Therapeutic FDA Indication Dose)As needed Daily

Cyproheptadine^(Periactin)

4-12 mg (3-4 hours prior to sex)

--- • Allergic rhinitis• Urticarial• Anorexia nervosa

Nausea, dizziness, urinary retention, photosensitivity, rash, abdominal pain, fatigue, agranulocytosis, thrombocytopenia, heat stroke

Bethanechol^(Urecholine)

20mg po (1-2 hours prior to sex)

--- • Urinary Retention• Neurogenic bladder• GERD• TCA adjunct treatment• Phenothiazine adjunct Tx

Abdominal pain, nausea, diarrhea, headache, urinary urgency, malaise, flushing, miosis, broncospasm, hypotention, tachycardia, seizures

Amantadine^(Symmetrel)

100-400 mg (for 2 days prior to sex)

75-100 mg BID or TID

• Influenza A Tx and Prophylaxis

• Extrapyramidal sx• Parkinsonism

Nausea, dizziness, depression, anorexia, halluncinations, compulsivity, hypotension, abnormal dreams, headache, constipation/diarrhea, arrhythmias, psychosis, coma, impaired vision, pulmonary edema, neutropenia, seizure, heat stroke

Bupropion^(Wellbutrin, Zyban, Budeprion, Forfivo)

--- 75 mg BID or TID • Major Depressive disorder• Seasonal affective

disorder• Smoking cessation• Attention Deficit-

Hyperactivity Disorder (ADHD)

Palpitations, urinary frequency, blurred vision, chest pain, agitation, psychosis, hallucinations, seizures, hepatotoxicity, HTN, arrhythmias**Suicidality, Neuropsychiatric symptoms

Buspirone^(BuSpar)

--- 5-15 mg BID • Anxiety Dizziness, nausea, headache, fatigue, blurred vision, numbness, weakness, abdominal pain, insomnia, serotonin syndrome, tardive dyskinesia, dsytonia, hositity, depression

Loratadine^(Claritin, Alavert)

--- 10 mg daily • Allergic rhinitis• Chronic idiopathic urticaria

Drowsiness, fatigue, headache, dry mucous membranes, pharyngitis, bronchospasm, hepatotoxicity, syncope, seizures, thrombocytopenia

Bold terms represent more common reactions Un-bolded terms represent serious reactions** Black Box Warning# None of these drugs are FDA approved for Delayed Ejaculation

DE TREATMENT MEDS WITH SSRI USE

Cabergoline Buproprion Oxytocin Cyproheptadine Buspirone Yohimbine Methylphenid

ate Amantadine Midodrine

First Line 14 11 6 5 1 1 1 0 0Frequently 10 6 5 0 2 1 1 2 1Occassionally 15 13 6 4 11 2 4 2 1Rarely 5 15 12 13 10 6 6 10 10Never 41 39 52 57 58 69 67 65 65

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What Medications Do Members of the SMSNA Use?

First Line Meds used by SMSNA

DrugGeneric / (Trade)

Delayed Ejaculation Dosage(Not FDA Approved)

Indication(FDA Approved)

Side Effects(At Therapeutic FDA Indication Dose)

As needed DailyOxytocin†

(Pitocin)24 IU intranasal during sex or SL prior to sex

--- • Labor induction• Abortion adjunct• Postpartum hemorrhage

Nausea, vomiting, hypertension, afibrinogenemia, SAIDH**Not for elective labor induction

Pseudoephedrine*(Sudafed)

60-120 mg (120-150 min prior to sex)

--- • Nasal congestion Insomnia, anxiety, nausea, insomnia, tremor, urinary retention, headache, palpitations, arrhythmias, hypertension

Ephedrine* 15-60 mg (1 hour prior to sex)

--- • Acute bronchospasm• Hypotension

Nausea, headache, dizziness, insomnia, hypertension, tremor, urinary retention, anxiety, palpitations, arrhythmias, stroke, seizures, MI, nephrotoxicity, hepatotoxicity

Midodrine*(Orvaten, ProAmatine)

5-40mg daily (30-120 min. prior to sex)

--- • Orthostatic Hypotension Dysuria, paresthesia, rigors, pruittus, piloerection, rash,bradycardia, erythema multiforme, visual field defect** Supine Elevated Blood Pressure

Apomorphine(Apokyn)

0.5-1.5mg Intranasal (20min before sex)

--- • Parkinson Ds Yawning, dyskinesia, rhinorrhea, hallucinations, anxiety, UTI, chest pain, diaphoresis, hypotension, syncope, MI, Priapism, abuse potential, hallucinations

Yohimbine(Yocon)

--- 5.4 mg TID • Impotence Urinary retention, hyperglycemia, tachycardia, irritability, tremor, nausea, dizziness, headache, flushing, diaphoresis, hypertension, respiratory depression

Cabergoline†

(Dostinex)--- 0.25-2 mg twice a

week• Hyperprolactinemia Nausea, dizziness, fatigue, abdominal pain, somnolence,

anxiety, vertigo hot flashes, flatulence, breast pain, compulsivity, orthostatic hypotension, pleural effusion, retroperitoneal fibrosis, depression, psychosis, pulmonary and pericardial fibrosis

Roboxetine(not available in USA)

--- 4-8 mg • Major depressive disorder• Panic Disorder• Attention deficit-

hyperactivity disorder (ADHD)

Insomnia, nausea, excessive sweating, constipation, urinary tract infection, dysuria, urinary retention, ejaculatory pain,tachycardia, blood pressure changes

Imipramine*(Tofranil)

--- 25-75mg daily • Depression• Chronic pain

Drowsiness, dizziness, blurred vision, palpitations, increase appetite, weakness, confusion, anxiety, impotence, galactorrhea, gynecomastia, photosensitivity, change in libido, hypotension, syncope, QT Prolongation, AV block, MI, stroke, seizures, ataxia, leukopenia, hallucinations, depression, hepatitis, angioedema, heat stroke, psychosis, withdrawal symptoms**Suicidality

Bold terms represent more common reactions and un-bolded terms represent serious reactions† May help when abnormalities of Prolactin or other hormonal issues considered* Known to help with retrograde ejaculation** Black Box Warning

DE TREATMENT MEDS (NO SSRI USE)

If patient is on SSRIo If possible switch to Bupropion 75 mg PO BID or TID

• Watch for palpitations, chest pain, blurred vision, SUICIDALITY**o If switching not possible, try cyproheptadine 4-12 mg 3-4 hrs before sex

• Watch for nausea, dizziness, urinary retention, photosensitivity, rash, abdominal pain, fatigue

o Next line try loratidine 10 mg po qday, watch for drowsiness, fatigue, headache, dry mucous membranes, pharyngitis

If patient is not on SSRI measure prolactino If prolactin high/high normal try cabergoline 0.25-2 mg po 2/week

• Watch for nausea, dizziness, fatigue, abdominal pain, somnolence, anxietyo If prolactin low/low normal try oxytocin 24 IU/SL intranasal prior to sex

Back up agents (can be used in combination)o Yohimbine 5.4 mg po TID (cheap and easy)

• Watch for urinary retention, hyperglycemia, tachycardia, irritability, tremor, nausea, dizziness, headache, flushing, diaphoresis, hypertension

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