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They concluded that the combination of phosphodiesterase-5 inhibitors and SSRIs were more effective than monotherapy [Citation19]. Elbakary and colleagues evaluated the effectiveness of sildenafil combined with dapoxetine for treating PE.

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Eighty patients with PE without erectile dysfunction were allocated into 2 groups.

Final Thoughts on Combination Therapy

When comparing group C with either group A and group B, no significant variation was found (P = 0.821) in the mean pretreatment satisfaction scores (group A: 1 ± 0.6; group B: 1 ± 0.7; and group C: 1.1 ± 0.8; ). When comparing group C with either group A and group B, highly statistically substantial variations were found in the mean satisfaction scores at 4, 8, and 12 months posttreatment in favor of group C (P = < 0.001), also a highly statistically substantial variations were found in the mean Δ satisfaction scores in favor of group C (P < 0.001; ). Post hoc tests at 4, 8, and 12 weeks post-treatment revealed no statistically substantial variations in the mean satisfaction scores (P = 0.71, P = 1, P = 0.353 respectively) or Δ satisfaction scores (P = 0.011) among group A and group B. Highly statistically substantial variations were found among group A and group C and among group B and group C regarding satisfaction scores and Δ satisfaction in favor of group C (P < 0.001; ). No statistically substantial variations were found among groups regarding the side effects except for headache and flushing which were more prominent in group C (P = 0.036 and P < 0.001, respectively; ).

Dosing According to Clinical Indications

Premature ejaculation leads to negative consequences on the partner’s life. Although the importance of this area of male sexual health, it is usually neglected [Citation16]. Our results showed that on-demand administration of tadalafil 5 mg or dapoxetine 30 mg was beneficial for treating PE, but improvement was better with a combination of both drugs. Patients were randomly assigned into 4 groups: dapoxetine was given to the first group, paroxetine to the second, and tadalafil with dapoxetine to the third, and the buy cialis powder fourth received paroxetine combined with tadalafil for one month. The mean pretreatment and posttreatment IELT among groups were 57.8 ± 34.2 vs 204.4 ± 82 in group 1, 59.4 ± 32 vs 208.8 ± 65.1 in group 2, 56.1 ± 31 vs 269.9 ± 100.4 in group 3, and 54.6 ± 30.9 vs 259.3 ± 83.4 in group 4.

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They concluded that combination therapy (tadalafil with dapoxetine or paroxetine) was associated with better improvement in the IELT than mono-therapy. No significant differences were detected between the groups regarding the side effects except for headache and flushing which were significantly higher in the groups who received a combination therapy [Citation17]. In the management of PE, Moudi et al. 100 patients with PE were randomly allocated into two groups. In group 1, patients were given paroxetine 10 mg daily and in group 2, patients received paroxetine 10 mg plus tadalafil 10 mg daily. The 1st group (40 patients) were given on- demand dapoxetine 30 mg for three months, the 2nd group (40 patients) received an on-demand combination of dapoxetine 30 mg and sildenafil 50 mg for three months. The means of pretreatment and posttreatment IELT among groups were 51.72 ± 12.53 vs 322 ± 24.62 in group 1 and 56.6 ± 10.93 vs 352.5 ± 29.33 in group 2 (P < 0.001).

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They concluded that combination therapy was associated with better improvement than mono-therapy [Citation20].

Participants in group 1 were given tadalafil 5 mg and participants in group 2 were given a combination therapy of dapoxetine 30 mg with tadalafil 5 mg.

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• Medication is one tool among many: devices, implants, and surgery also exist.
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The means of pretreatment IELT were 1.49 ± 0.51 and 1.47 ± 0.57 minutes in group 1 and 2 respectively.

The means of post-treatment IELT were 7.35 ± 4.31 and 9.07 ± 4.2 minutes in groups 1 and 2, respectively, with statistically significant improvements in group 2 (P = 0.045) [Citation21].

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A standard deviation of 150 seconds (2.5 minutes) was used for the sample size calculation. The Cohen’s d effect size was approximately estimated to be 0.4. Therefore, with an alpha of 0.05 using the ANOVA test, the enrollment of a total of 84 patients in each group will provide 90% power. The sample size was increased to compensate for any attrition bias. We evaluated the eligibility of 385 patients for this research.

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After exclusions, 92 patients were included in group A and received tadalafil (5 mg) for 12-weeks period, 91 patients were included in Group B and received dapoxetine (30 mg) for 12-weeks period, and 89 patients were included in Group C and received tadalafil (5 mg) and dapoxetine (30 mg) together for 12-weeks period (). All patients reported the medication intake in their files with no dropouts but the needed time for drug intake (two hours before sexual intercourse) was not regularly respected by the patients. No statistically substantial variations were found before treatment among the three groups as regard age, BMI, smoking, fasting blood sugar, FSH, LH, testosterone, E2, and prolactin levels (). The mean of IELT in all the studied patients was 39.3 ± 10.5 seconds, median was 37 (31.25–46) seconds with minimum IELT of 25 seconds and maximum IELT of 65 seconds. When comparing IELT before treatment and at the end of treatment (12 weeks posttreatment), there were highly statistically substantial variations in group A (39.4 ± 10 sec.

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When comparing group C with either group A and group B, no significant variation was found (P = 0.580) for the mean pretreatment IELT measurements (group A: 39.4 ± 10 sec; group B: 40.8 ± 11.2 sec; and group C: 37.9 ± 10.9 sec; ). When comparing group C with either group A and group B, highly statistically substantial variations were found in the mean IELT at 4, 8, and 12 months posttreatment in favor of group C (P = < 0.001), also highly statistically substantial variations were found in the mean Δ IELT in favor of group C (P < 0.001; ). Post hoc tests at 4, 8, and 12 weeks posttreatment revealed no statistically substantial variations in the mean IELT (P = 0.346, P = 0.508, P = 0.442 respectively) or Δ IELT (P = 0.340) among group A and group B. Highly statistically substantial variations were found among group A and group C and among group B and group C regarding IELT and Δ IELT in favor of group C (P < 0.001; ). When comparing satisfaction scores before treatment and at the end of treatment (12 weeks posttreatment), there were highly statistically substantial variations in group A (1 ± 0.6 vs 3 ± 0.6; p < 0.001), group B (1 ± 0.7 vs 3.2 ± 0.6; p < 0.001), and group C (1.1 ± 0.8 vs 4.1 ± 0.8; p < 0.001) (). Abu El-Hamd M and Abdelhamed A evaluated 150 patients with PE without erectile dysfunction.

Five groups of participants, each with 30 patients, were randomly allocated. For a six-week period, participants in each group received an on-demand placebo, paroxetine (30 mg), dapoxetine (30 mg), sildenafil (50 mg), and a combination of dapoxetine (30 mg) with sildenafil citrate (50 mg).

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A full explanation about the measurement of the ILET (beginning with intromission and ending with ejaculation) was done. The Kim and Paick scale, which ranges from 0 to 5, while 0 denoting severe dissatisfaction and 5 denoting extreme pleasure, was used to evaluate sexual satisfaction in all participants prior to and following therapy [Citation15]. Patients were also advised to note any side effects following medication delivery in their follow-up sheets both during medication intake and at the end of treatment. Patients were followed up every month for three months. The local Ethics Committee approved the study.

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The ethical approval code is: SVU-MED-URO 016-1-21-4-183. The study was performed according to the ethical declaration of Helsinki. Every participant signed a written statement of permission. The Statistical Program for Social Science (SPSS) Version 24.0 was used for the statistical analysis. The mean and standard deviation (M ± SD) were used to represent quantitative data.

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The frequencies and percentages [n(%)] were used to convey qualitative data. Nonparametric data were compared using a Chi-squared (x2) test. When contrasting more than two means, a one-way analysis of variance (ANOVA) was utilized if the data was normally distributed and Kruskal Wallis (KW) test was utilized if the data was not normally distributed. P values were considered statistically significant at P < 0.05. To determine the sample size using the G*Power Version 3.1.9.4, we used the IELT to detect a 60-second (1-minute) variation among groups A, B, and C (based on the previous studies). Each participant was told to record his IELT results.

The means of pretreatment IELT were 40.33 ± 8.6, 38.66 ± 9.9, 38.86 ± 10.35, 38.66 ± 9.9, and 38.33 ± 10.02 and the means of posttreatment IELT were 41.33 ± 8.3, 173.86 ± 19.8, 171.83 ± 20.7, 175.5 ± 22.4, 266 ± 36.6 in groups 1, 2, 3, 4, 5, respectively.

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The combination of dapoxetine and sildenafil had the greatest outcomes (p value < 0.001). Headache, nausea and flushing had been the most prevalent side impacts linked with the combination therapy [Citation22]. In this study, the mean IELT was lower than in other studies as most of our patients did not seek medical advice except if PE is severe and responsible for major negative personal and partnership consequences.

Clinical Reference Topics

At the 3rd month follow-up, the mean IELT in groups 1 and 2 were 4.5 ± 1.5 and 5 ± 2.4 minutes, respectively (P = 0.285) and at the 6th month follow-up, the mean IELT were 4.8 ± 1 and 5.3 ± 2 minutes, respectively (P = 0.278). The authors concluded that tadalafil can increase the mean IELT and can be used for treatment of PE in combination with paroxetine. Flushing episodes, as a side effect, were more obvious in group 2 (P = 0.000) [Citation18]. performed a meta-analysis involving 17 trials with 5,739 participants. Seven single medications (paroxetine, fluoxetine, dapoxetine, sertraline, sildenafil, tadalafil and placebo) and five combination therapies were included (tadalafil with sildenafil, tadalafil with fluoxetine, paroxetine with sildenafil, dapoxetine with mirodenafil, and sildenafil with fluoxetine).