Full Text:

Dear Editor,

Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) used for treating major depressive disorder, generalized anxiety disorder, and chronic musculoskeletal pain. Dizziness, nausea, vomiting, diarrhea, and insomnia are some side effects associated with the use of duloxetine. Apart from these, sexual side effects such as erectile dysfunction, anorgasmia, or delayed ejaculation have been reported (1). A single case has been found in the literature reporting duloxetine-related retrograde ejaculation (2). Here, we are reporting a case of retrograde ejaculation during treatment with duloxetine in a depressive elderly patient.

Mr. A. was 61 years old. He had been being monitored at a psychiatry outpatient clinic for 10 years with diagnoses of major depressive disorder and somatoform disorder. He had been using 100mg/day sertraline for approximately 6 months. Previously used drugs were venlafaxine, sulpiride, and sertraline. No side effects with these medications were reported. Duloxetine 30mg/day was added to the treatment of the patient, who reported widespread body pain, fatigue, and distress while using sertraline 100mg/day. At the end of 6 weeks, his psychiatric complaints continued. Since no significant side effect was noted, sertraline was discontinued and the duloxetine dose was increased to 60mg/day. A follow-up appointment was made after a month. However, the patient presented to the psychiatric outpatient clinic after 15 days. Despite his pleasure after sexual intercourse, he could not discharge the semen from the reproductive tract. He had wet dreams, had sexual intercourse once per week, and was masturbating without a discharge of semen. No anatomical or psychiatric problems related to his partner (wife) were reported. He reported no discharge of semen during coitus, despite normal erections, libido, and orgasm. There was no history of use of alcohol, cigarettes, or any other substances before presentation. Family history did not indicate any findings of ejaculatory dysfunction. Physical examination revealed no pathology that might be related to organic ejaculation dysfunction. Neurological examination findings were normal. He was referred to the urology department. His total testosterone, free testosterone, luteinizing hormone, prolactin, and estradiol levels were normal. Genital and rectal examination and transrectal ultrasound showed normal testicles, prostate, penis, and seminal vesicles. However, sperm was detected in the urine, and the patient was diagnosed with retrograde ejaculation. Naranjo adverse drug reactions probability scale score was 7 (3). This situation was attributed to duloxetine. Duloxetine was reduced to 30mg/day. After 15 days, there was no retrograde ejaculation after sexual intercourse. It was learned that the patient discharged his semen out of the penis. As the patient’s psychiatric symptoms continued with this drug dose (duloxetine 30mg/day), escitalopram was added at 5mg/day and gradually increased to 15mg/day. Duloxetine was stopped. The patient did not report any side effects at the end of 6 weeks. Partial remission in depressive symptoms was also sustained during follow-up. Written informed consent was taken from the patient to publish his data.

Retrograde ejaculation is rarely seen, although sexual side effects of SNRI use are frequently reported (1).
In the literature, a single retrograde ejaculatory case has emerged secondary to the use of duloxetine (2). That case is of a 43-year-old patient. The same side effect with 60mg duloxetine was also seen with 30mg in that patient. Our case has some characteristics that differ from the patient in the literature: Patient A. is older and no side effects were observed when the dose of duloxetine was reduced to 30mg/day. Alpha-1 adrenergic receptor antagonism can cause retrograde ejaculation (4). Duloxetine has an inhibitory effect on alpha-1 adrenergic receptors and this effect may cause retrograde ejaculation (5). According to our best knowledge, this is the second case related to duloxetine-induced retrograde ejaculation in the literature. However, our study is the first to demonstrate the benefits of dose reduction in this condition. Reducing the duloxetine dose might be beneficial when this side effect occurs, as long as the duloxetine dose is sufficient to treat the psychiatric symptoms. It is important for clinicians to investigate retrograde ejaculation as well as other sexual side effects during the use of duloxetine.

REFERENCES

1. Bitter I, Filipovits D, Czobor P. Adverse reactions to duloxetine in depression. Expert Opin Drug Saf 2011; 10:839-850. [CrossRef]

2. Bulut M, Gozukara K, Kaya MC. Duloxetine-induced retrograde ejaculation: A case report. Bulletin of Clinical Psychopharmacology 2015; 25:429-430. [CrossRef]

3. Kose S, Akin E, Cetin M. Adverse drug reactions and causality: the Turkish version of Naranjo Adverse Drug Reactions Probability Scale. Psychiatry and Clinical Psychopharmacology 2017; 27:205-206. [CrossRef]

4. Kaplan SA. Side effects of α-blocker use: retrograde ejaculation. Rev Urol 2009; 11(Suppl.1):14-18.

5. Dmochowski RR. Duloxetine: a summary of published clinical experience. Rev Urol 2004; 6(Suppl.3):56-63.