Alternative medicine for premature ejaculation? Surprise, surprise! It doesn't work.

I must admit that the last couple of weeks have been rather grim here on the old blog. Betweemn Donald Trump's White House spewing , an unfortunate patient embracing quackery, pseudoscience at the VA, and more. So it is that I feel as though it might not be a bad idea to step back for a day, to look into an acupuncture "study" that's been making the rounds in the media. Oddly enough, I remember it showing up a week ago and meant to discuss it then. So I'm glad that I saw a new news story on it in —where else?—The Daily Mail in the form of an article entitled Forget Viagra - acupuncture could stave off erectile dysfunction, experts claim.

As soon as I read the article, I laughed. It was so sloppily done that the title didn't even match what the study was about, saying "Acupuncture could help men with premature ejaculation, a new report claims.." So what was the paper about, erectile dysfunction or premature ejaculation? It turns out that it's about premature ejaculation. Darn. There go the boner jokes. Oh, well, there is this:

Acupuncture could help men with premature ejaculation, a new report claims.

The improvements were small, and the studies were of varying quality.
However, researchers in the UK concluded various alternative treatments - including acupuncture, Chinese herbal medicine, Ayurvedic herbal medicine and a Korean topical cream - have significant desirable effects.

Experts claim the finding could bring welcome relief for men who have not got Viagra out of embarrassment, or are marred by a months-long wait to see a doctor.

'It's important to evaluate the evidence for other therapies,' said lead author Katy Cooper of the University of Sheffield.

'To our knowledge, this is the first systematic review to assess complementary and alternative medicine for premature ejaculation.

So wait a minute. Is this study about acupuncture and premature ejaculation or is it about more? I was puzzled. So I did what I always do in cases like this. I went to the source, which, I point out, took a bit of effort to find, thanks to the Mail's failure to link to the actual study. Find it I did (eventually), though, in the form of an article by Cooper et al entitled Complementary and Alternative Medicine for Management of Premature Ejaculation: A Systematic Review. So wait. This is about all CAM for management of premature ejaculation. There go the jokes about sticking needles into men's nether regions and/or early liftoff. Or not. Or, I could just go for the joke about my never, ever having a problem or needing treatment for something like this.

In any case, it's important to understand what premature ejaculation is. According to this article, premature ejaculation (PE) is defined as ejaculation within 1 minute (lifelong PE) or 3 minutes (acquired PE), inability to delay ejaculation, and negative personal consequences. I wasn't familiar with the treatment of PE; so it was of interest for me to read the authors' summary in the introduction:

Management of PE can involve a range of interventions. These include systemic drug treatments such as selective serotonin reup- take inhibitors (SSRIs), tricyclic antidepressants, phosphodiesterase type 5 inhibitors, and analgesics and topical anesthetic creams and sprays that are applied directly to the penis shortly before inter- course.9,10 Behavioral therapies also can be useful.6,9,11,12 These can include psychosexual or relationship counseling for men and/or couples to address psychological and interpersonal issues that could be contributing to PE. Behavioral therapies also can include physical techniques to help men develop sexual skills to delay ejaculation and improve sexual self-confidence, such as the “stop- start” technique, “squeeze” technique, and sensate focus.6,9,11,12 There are sparse data on whether and for how long effectiveness is maintained after cessation of treatment (drug or behavioral) and whether repeat treatments are effective.

Well, OK, then. That's a bit more than I wanted to know.

Now, I can understand why men might try quackery if they have problems in the sack. It doesn't take much searching online to find the veritably panoply of remedies, herbal and otherwise, for PE and erectile dysfunction. That doesn't even take into account the various products sold as aphrodisiacs. So it makes sense to see what the authors defined as "CAM":

CAM has been defined by the Cochrane Collaboration as “a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying the- ories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period.”15 In addition, many CAM therapies are based on a traditional model of health and well-being, and many (although not all) are designed to treat the whole patient as opposed to a specific condition, whereas some (although not all) involve the use of traditional or natural therapies. Therefore, CAM is defined in this study as therapies for PE that have typically not been provided within conventional Western health care systems and that appear on the list of CAM therapies collated by the Cochrane Collaboration.

In other words, CAM is anything outside of science-based medicine. Yeah, that will do it. They looked for randomized clinical trials, with a study being eligible for inclusion if they compared CAM therapies for management of PE against placebo, waitlist, no treatment, or another therapy or assessed combination treatment with CAM. They also had to include standard measures of PE outcomes, including:

• Premature Ejaculation Profile (PEP)
• Index of Premature Ejaculation (IPE)
• Premature Ejaculation Diagnostic Tool (PEDT)
• Arabic Index of Premature Ejaculation (AIPE)
• Chinese Index of Premature Ejaculation–5 (CIPE-5)
• International Index of Erectile Function (IIEF)

Live and learn. I had no idea there were so many measurement of PE. For instance, one of them mentioned is intravaginal ejaculation latency time (IELT), which, I learned through Googling, frequently measured by couples using a stopwatch. (It seems to me that that would really ruin the mood.) Again, I learned more reading this paper than I probably actually wanted to.

Not surprisingly, the quality of the studies was pretty crappy, too:

The risk of bias within included studies is presented in Table 2. Five studies reported the method of randomization,26, 28, 29, 32, 35 whereas the other five did not report the method but did state that the study was randomized. Allocation concealment was unclear in all studies. Blinding of participants and personnel was reported as being undertaken in five studies.26, 29, 33, 34, 35 Blinding of outcome assessment was unclear in all studies except one,35 which reported that this was blinded. All studies except one35 were considered at low risk of bias for completeness of outcome data, with eight studies including at least 90% of randomized patients in the primary analysis and the two studies of SS cream including 85%34 and 68%,35 respectively. All studies scored a low risk for selective reporting except for one that did not report on IELT.27 Of the nine studies reporting on IELT, this was measured by stopwatch in five studies,26, 28, 29, 34, 35 by questionnaire in one study,32 and the method of IELT assessment was not reported in three studies.30, 31, 33 In summary, all 10 studies were classed as having an overall unclear risk of bias because of unclear reporting of allocation concealment (all 10 studies) and unclear blinding of participants and personnel (five studies).

On to the results. Overall, 2,455 citations were identified through the search strategy chosen, which lead to 14 of them meeting all their criteria. Two of these were studies of Chinese medicine that were excluded because they did not report on IELT or any validated or widely used PE outcome measurement. Two more studies assessing a combination of yoga and pelvic floor exercises were excluded because one was not randomized and the other did not report on IELT or any validated or widely used PE outcome measurement. That left only ten RCTs. Two studies examined acupuncture, five looked at Chinese herbal medicine, one studied Ayurvedic herbal medicine and two of Korean topical 'severance secret' cream.

Despite all the news stories I saw about this systematic review emphasizing acupuncture, of the two acupuncture studies examined, one was from Turkey and one from China, each comparing acupuncture with either sham or various drugs used to treat PE. The results were, at best, quite equivocal. Indeed, the best the authors could say was this:

One study compared acupuncture against sham acupuncture (N analyzed = 60) and In summary, the available data indicate that acupuncture might be slightly more effective than placebo (sham) in treating PE, although this is based on only one study of unclear quality.

Yes, the "positive" result found is based on one crappy study. In other words, there's no good evidence that acupuncture helps PE. This is not surprising, given that there is no physiological reason to think that there would be Basically, what was presented was a grab bag of studies:

The included studies evaluated the effectiveness of acupuncture, Chinese herbal medicine, Ayurvedic herbal medicine, and topical SS cream in improving IELT and other outcomes. Overall risk of bias was unclear in all studies because of unclear allocation concealment and/or blinding. Studies were clinically heterogeneous and stopwatch-measured IELT was reported in only 5 of 10 studies. Acupuncture increased IELT over placebo (one study; MD = 0.55 minute, P = .001). Ayurvedic herbal medicine increased IELT over placebo (one study; MD = 0.80 minute, P = .001). Topical SS cream improved IELT over placebo in two crossover studies (MD = 8.60 minutes, P < .001), although inclusion criteria were broad (IELT < 3 minutes), and there were mild irritant effects in some patients. SSRIs were more effective on IELT than Chinese herbal medicine (three studies; MD = 1.01 minutes, P = .02). However, combination treatment with Chinese medicine plus SSRIs improved IELT over SSRIs alone (two studies; MD = 1.92 minutes, P < .00001) or Chinese medicine alone (two studies; MD = 2.52 minutes, P < .00001). Adverse effects were not consistently assessed but where reported were generally mild. There were sparse data on the potential for drug interactions.

In other words, the results were mixed and pretty unconvincing. Even the Daily Mail article concedes it, stating quite plainly that "The main limitation of the study is the underlying weakness of the studies evaluated" and that "the studies are so different, it's tough to draw conclusions about the different options." In the article, the authors dance around this issue quite impressively:

Pragmatically, because there are so many CAM therapies available, it seems unlikely that they will all undergo further evaluation in large-scale studies. Therefore, it might be reasonable to summarize that the CAM therapies reviewed here have some (although limited) evidence for effectiveness in treating PE, and that they might provide another option for patients who favor a mind-body approach or who wish to avoid long-term pharmacologic treatment. It would need to be borne in mind that the effectiveness evidence is not conclusive, and care would need to be taken to monitor for adverse effects and to consider the potential for herb-drug interactions.

No it isn't reasonable to say that the CAM therapies reviewed "might provide another option for patients," and the evidence for effectiveness is far less than "not conclusive." In fact there's nothing much in this review article to suggest that alternative medicine helps PE.