Sexology Case No 1.Premature Ejaculation

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Sexology Case No 1.Premature Ejaculation

Premature ejaculation :

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Penetration to ejaculation পর্যন্ত সময়টা কত হতে হবে তা নিয়ে ভিন্নতা রয়েছে। অনেকে ব্যাপারটাকে ভার্চুয়াল লাইফের মত মনে করে।

রোগীকে বুঝাতে হবে পর্ণে দেখা ভিডিও একসাথে করা নয়। ভিন্ন ভিন্ন সময়ে করা ভিডিওকে এক করে প্রকাশ করা হয়।

পার্টনার সন্তুষ্ট হওয়ার আগেই যদি বীর্যপাত হয় তখন ই তা দ্রুত বীর্যপাত বা premature ejaculation.

সাধারণত সময় গননা করে বললে এক মিনিটের কম সময়ে বীর্যপাত হলে তা দ্রত। সময় গননা করতে হবে penetration to ejaculation.

বিগত ৬ মাসের মধ্যে যদি শতকরা ৭৫ ভাগের চেয়ে বেশি এই রকম দ্রুত বীর্যপাত হয় তখন তার চিকিৎসার প্রয়োজন।

familial dysharmony, social distress, anxiety, stress থাকলে এমনিতেই performance। খারাপ হবে। এটা স্বাভাবিক।

চিকিৎসা :

SSRI নামক মেডিসিন খুব ভাল কাজ করে। এই মেডিসিন প্রতিদিন সকালে একটা করে দেয়া হয়.

Paroxatine ভাল কাজ করে।

একটা study দেখা যায় এটি 30 mg at morning atleast one month দিয়ে পরে on demand তথা mating এর ১ঘন্টা আগে দিলে ১১’৬% duration বাড়ানো যায়।

Treatment management:- Premature Ejaculation usaually ai 3 ti Drug die Treatment kora hoie thake

Peroxetin = Paroxetine
Dapoxetine = Dapoxetine
Sartaline = Sertraline

এগুলো prescription medicine। Paroxetine/Sertraline/Dapoxetine একসাথে বা অন্য SSRI/SNRI/MAOI/tramadol/linezolid-এর সাথে নিজে নিজে দেওয়া যাবে না—serotonin syndrome, bleeding risk, sexual side effect, withdrawal risk হতে পারে।

Drug	Generic name	Class	কেন used হয়	কাজ কীভাবে করে
Paroxetine	Paroxetine hydrochloride	SSRI antidepressant	Depression, OCD, panic disorder, social anxiety, GAD, PTSD; PE-তে off-label ব্যবহার হয়	Brain-এ serotonin reuptake inhibit করে serotonin activity বাড়ায়; mood/anxiety improve করে, ejaculation delay করতে পারে
Dapoxetine	Dapoxetine hydrochloride	Short-acting SSRI	Premature ejaculation—১৮–৬৪ বছর বয়সী পুরুষে, poor ejaculatory control/distress থাকলে	Serotonin reuptake inhibit করে ejaculatory reflex delay করে; সাধারণত on-demand, intercourse-এর 1–3 ঘণ্টা আগে ব্যবহৃত হয়
Sertraline	Sertraline hydrochloride	SSRI antidepressant	Depression, OCD, panic disorder, PTSD, social anxiety, PMDD	CNS-এ serotonin reuptake inhibit করে serotonergic activity বাড়ায়

Bangladesh available brand names

1. Paroxetine hydrochloride

Available brands: Melev 20 mg, Oxat 10/20 mg, Panirid 20 mg, Parotin 10/20 mg, Paroxet 20 mg.

2. Dapoxetine hydrochloride

Available brands: Daporex 30/60 mg, Dapotin 30 mg, Dapoxen 30/60 mg, Daxetin 30/60 mg, Dejac 30 mg, Dulong 30 mg, Dumax 30/60 mg, Ejalong 30/60 mg, Extreme 30 mg, Impreja 30 mg, Maturex 30/60 mg, Plezer 30 mg, Prolong 30/60 mg, Susten 30 mg, X-Ride 30/60 mg.

3. Sertraline hydrochloride

Available brands: Andep, Chear, Mudiral, Repose, Sartra, SB-Serta, Selotin, Sera, Serofit, Serolux, Seronex, Sertal, Sertlin, Setra, Stalin, Tralin, Zosert—commonly 25/50/100 mg strengths পাওয়া যায়।

Common side effects — shortcut

Paroxetine: nausea, sweating, sleepiness/insomnia, tremor, decreased libido, erectile/ejaculatory dysfunction, discontinuation symptoms.
Dapoxetine: nausea, dizziness, dry mouth, headache, diarrhea, insomnia; alcohol নিলে dizziness/syncope risk বাড়ে।
Sertraline: GI upset/diarrhoea, dry mouth, appetite/weight change, drowsiness/dizziness, headache, tingling, sexual dysfunction possible.

Overview / Summary

Paroxetine ও Sertraline মূলত depression/anxiety spectrum disorder-এর daily SSRI। Dapoxetine মূলত premature ejaculation-এর on-demand short-acting SSRI। PE-তে Paroxetine/Sertraline off-labelভাবে ব্যবহৃত হতে পারে, কিন্তু Dapoxetine specifically PE indication-এর জন্য বেশি targeted option।

Actionable Plan / Steps

১. রোগীর primary problem আগে define করুন: depression/anxiety/OCD/PTSD নাকি premature ejaculation।
২. PE হলে IELT, distress, erectile dysfunction, prostatitis/thyroid/drug cause exclude করুন।
৩. Depression/anxiety হলে PHQ-9/GAD-7, suicidality, bipolar history screen করুন।
৪. SSRI শুরু করলে MAOI/linezolid/tramadol/other serotonergic drugs, anticoagulant/NSAID use, hepatic disease, seizure history check করুন।
৫. Brand availability pharmacy/DGDA/updated local formulary দিয়ে verify করুন, কারণ market availability পরিবর্তন হতে পারে।

Reference List

Textbook

Harrison’s Principles of Internal Medicine, 21st ed. Chapters on depressive disorders/anxiety disorders and psychopharmacology.
Davidson’s Principles and Practice of Medicine, 24th ed. Psychiatry and therapeutics sections.
Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Antidepressants/SSRIs chapter.

Guideline / Drug label

NICE NG222, Depression in adults: treatment and management, 2022.
NICE Evidence Summary ESNM40, Premature ejaculation: dapoxetine, 2014.
DailyMed/NIH labels: Paroxetine and Sertraline indications, contraindications, serotonin syndrome warnings.

Peer-reviewed journals with DOI

Cipriani A, et al. The Lancet. 2018;391:1357–1366. DOI: 10.1016/S0140-6736(17)32802-7.
Pryor JL, et al. The Lancet. 2006. DOI: 10.1016/S0140-6736(06)69373-2.
Zhang D, et al. BMC Urology. 2019;19:2. DOI: 10.1186/s12894-018-0431-7.

Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

1+0+0 Every morning BFM

1 month.

Indications of Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

Paroxet is indicated in:

Major Depressive Disorder
Obsessive Compulsive Disorder
Panic Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
Posttraumatic Stress Disorder.

Pharmacology Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

The efficacy of Paroxetine is presumed to be linked to potentiation of serotonergic activity in the central nervous system resulting from inhibition of neuronal reuptake of serotonin (5-hydroxy-tryptamine, 5 HT). Studies at clinically relevant doses in humans have demonstrated that paroxetine blocks the uptake of serotonin into human platelets. In vitro studies in animals also suggest that paroxetine is a potent and highly selective inhibitor of neuronal serotonin reuptake and has only very weak effects on norepinephrine and dopamine neuronal reuptake. In vitro radioligand binding studies indicate that paroxetine has little affinity for muscarinic, alpha1, alpha2, beta adrenergic, dopamine (D2), 5-HT1, 5 HT2 and histamine (H1)-receptors; antagonism of muscarinic, histaminergic and alpha1-adrenergic receptors has been associated with various anticholinergic, sedative and cardiovascular effects for other psychotropic drugs. Because the relative potencies of paroxetine’s major metabolites are at most 1/50 of the parent compound, they are essentially inactive.

Dosage & Administration Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

Major Depressive Disorder:

Usual Initial Dosage: Paroxetine (Paroxetine hydrochloride) should be administered as a single daily dose with or without food, usually in the morning. The recommended initial dose is 20 mg/day. Some patients not responding to a 20 mg dose may benefit from dose increases, in 10 mg/day increments, up to a maximum of 50 mg/day. Dose changes should occur at intervals of at least 1 week.
Maintenance Therapy: Systematic evaluation of the efficacy of Paroxetine hydrochloride has shown that efficacy is maintained for periods of up to 1 year with doses that averaged about 30 mg.

Obsessive Compulsive Disorder (OCD):

Usual Initial Dosage: Paroxetine (Paroxetine hydrochloride) should be administered as a single daily dose with or without food, usually in the morning. The recommended dose of Paroxetine in the treatment of OCD is 40 mg daily. Patients should be started on 20 mg/day and the dose can be increased in 10 mg/day increments. Dose changes should occur at intervals of at least 1 week.
Maintenance Therapy: Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.

Panic Disorder:

Usual Initial Dosage: Paroxetine should be administered as a single daily dose with or without food, usually in the morning. The target dose of Paroxetine in the treatment of panic disorder is 40 mg/day. Patients should be started on 10 mg/day. Dose changes should occur in 10 mg/day increments and at intervals of at least 1 week. The maximum dosage should not exceed 60 mg/day.
Maintenance Therapy: Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.

Social Anxiety Disorder (SAD):

Usual Initial Dosage: Paroxetine should be administered as a single daily dose with or without food, usually in the morning. The recommended initial dosage is 20 mg/day.
Maintenance Therapy: Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.

Generalized Anxiety Disorder (GAD):

Usual Initial Dosage: Paroxetine should be administered as a single daily dose with or without food, usually in the morning. The recommended starting dosage and the established effective dosage is 20 mg/day.
Maintenance Therapy: Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.

Posttraumatic Stress Disorder (PTSD):

Usual Initial Dosage: Paroxetine should be administered as a single daily dose with or without food, usually in the morning. The recommended starting dosage and the established effective dosage is 20 mg/day. Dose changes, if indicated, should occur in 10 mg/day increments and at intervals of at least 1 week.
Maintenance Therapy: Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.

Interaction Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

Food/antacids: The absorption and pharmacokinetics of Paroxet are not affected by food or antacids.

Tryptophan: As with other 5-HT re uptake inhibitors, animal studies indicate that an interaction between Paroxet and Tryptophan may occur, resulting in a ‘serotonin syndrome’ suggested by a combination of agitation, restlessness and gastrointestinal symptoms including diarrhoea.

Drug metabolizing enzyme inducers /inhibitors: The metabolism and pharmacokinetics of Paroxet may be affected by drugs, which induce or inhibit hepatic drug metabolizing enzymes. When Paroxet is to be coadministered with a known drug metabolizing inhibitor, consideration should be given to using doses at the lower end of the range. No initial dosage adjustment of Paroxet is considered necessary when it is to be co-administered with known drug metabolizing enzyme inducers. Any subsequent dosage adjustment should be guided by clinical effect (tolerabilityand efficacy).

Alcohol: Although Paroxet does not increase the impairment of mental and motor skill caused by alcohol, the concomitant use of Paroxet and alcohol in depressed patients is not advised.

Haloperidol/amylobarbitone/oxazepam: Experience in a limited number of healthy subjects has shown that Paroxet did not increase the sedation and drowsiness associated with haloperidol, amylobarbitone or oxazepam when given in combination.

MAOls: As with other 5-HT re uptake inhibitors, animal studies indicate that an interaction between Paroxet and monoamine oxidase (MAO) inhibitors may occur.

Lithium: Since there is little clinical experience, and there have been reports of interaction of lithium with other 5-HT re-uptake inhibitors, the concurrent administration of Paroxet and lithium should be undertaken with caution.

Lithium levels should be monitored. Phenytoin / anticonvulsants: Co-administration of Paroxet and phenytoin is associated with decreased plasma concentrations of Paroxet and increased adverse experiences. Co-administration of Paroxet with other anticonvulsants may also be associated with an increased incidence of adverse experiences.

Warfarin: Preliminary data suggest that there may be a pharmacodynamic interaction between Paroxet and warfarin, which may result in increased bleeding in the presence of unaltered prothrombin times. Paroxet should therefore be administered with great caution to patients receiving oral anticoagulants.

Contraindications Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

Concomitant use in patients taking either monoamine oxidase inhibitors (MAOIs) or thioridazine is contraindicated. This is contraindicated in patients with a hypersensitivity to Paroxetine.

Side Effects Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

Major depressive disorder: Asthenia, sweating, nausea, decreased appetite, somnolence, dizziness, insomnia, tremor, nervousness, ejaculatory disturbance and other male genital disorders.

Obsessive compulsive disorder: Nausea, dry mouth, decreased appetite, constipation, dizziness, somnolence, tremor, sweating, impotence and abnormal ejaculation.

Panic disorder: Asthenia, sweating, decreased appetite, decreased libido , tremor, abnormal ejaculation, female genital disorders and impotence.

Social anxiety disorder: Sweating, nausea, dry mouth, constipation, decreased appetite, somnolence, tremor, decreased libido, yawn, abnormal ejaculation, female genital disorders and impotence.

Generalised anxiety disorder: Asthenia, infection, constipation, decreased appetite, dry mouth, nausea, decreased libido, somnolence, tremor, sweating and abnormal
ejaculation.

Post-traumatic stress disorder: Asthenia, sweating nausea, dry mouth, diarrhoea, decreased appetite, somnolence, decreased libido, abnormal ejaculation, female genital disorders and impotence.

Pregnancy & Lactation

This drug should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Labor and Delivery: The effect of Paroxetine on labor and delivery in humans is unknown.

Nursing Mothers: Like many other drugs, Paroxetine is secreted in human milk, and caution should be exercised when Paroxetine hydrochloride is administered to a nursing woman.

Precautions & Warnings Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

Cardiac conditions: Paroxet does not produce clinically significant changes in blood pressure, heart rate and ECG. Nevertheless, as with all psychoactive drugs, caution is advised when treating patients with cardiac conditions.

Epilepsy: As with other antidepressants, Paroxet should be used with caution in-patients with epilepsy.

Seizures: Overall, the incidence of seizures is < 0.1% in patients treated with Paroxet. Paroxet should be discontinued in any patient who develops seizures.

ECT: There is little clinical experience of concurrent administration of Paroxet with ECT.

Ability to drive/use machines: Clinical experience has shown that therapy with Paroxet is not associated with impairment of cognitive or psychomotor function. However, as with all psychoactive drugs, patients should be cautioned about their ability to drive a car and operate machinery.

Discontinuation of Treatment with Paroxet: Recent clinical trials supporting the various approved indications of Paroxet employed a taper phase regimen, rather than an abrupt discontinuation of treatment. The taper phase regimen used in GAD and PTSD clinical trials involved an incremental decrease in the daily dose by 10 mg/day at weekly intervals. When a daily dose of 20 mg/day was reached, patients were continued on this dose for 1 week before treatment was stopped.

Use in Special Populations

Dosage for Elderly or Debilitated, and Patients with Severe Renal or Hepatic Impairment: The recommended initial dose is 10 mg/day for elderly patients, debilitated patients, and/or patients with severe renal or hepatic impairment. Increases may be made if indicated. Dosage should not exceed 40 mg/day.

Therapeutic Class Tablet:Paroxet 20 mg (AS A Paroxetine Hydrochloride AS A SSRIs & related anti-depressant drugs).

SSRIs & related anti-depressant drugs

পার্টনারের সাপোর্ট বেশি প্রয়োজন। পার্টনারের নেগেটিভ মন্তব্য খুবই খারাপ। এতে performance আরো খারাপ হতে থাকবে। self confidence খুব জরুরী।

Pelvic floor exercise

Squeeze technique. Counselling অনেক সুফলতা দেয়।

Raiyyan Tahsan Date:-03-02-2025 Monday Time:-10-52-45 Pm

Raiyyan Tahsan

Raiyyan Tahsan