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Trazodone for erectile dysfunction

Clinical bottom line

There is no good evidence that trazodone is effective for erectile dysfunction.


Systematic review
Results
Adverse events
Comment

A number of reviews about male sexual dysfunction mention the use of trazodone for maintaining erections. Many Internet sites about male sexual dysfunction also mention trazodone as a specific treatment, and some give it as much weight as treatments like sildenafil and the newer phosphodiesterase inhibitors. It is clearly important to have a variety of possible treatments, especially as erectile dysfunction may have several causes. A systematic review [1] informs us how little we actually know about trazodone for this indication.

Systematic review

Searching included MEDLINE, the Cochrane Library and specialised registries of trials. For inclusion trials had to include men with erectile dysfunction and be randomised trials comparing trazodone with placebo or other control, have outcomes related to erectile dysfunction and last at least one week. The primary outcome was successful sexual intercourse attempts.

Results

Five trials with 240 men reported trazodone therapy compared with placebo. The dose of trazodone was 50 mg daily in one trial, and 150-200 mg daily in the other four. Duration was four weeks in four trials and 13 weeks in one. Two studies were from Turkey, and one each from Holland, Belgium and the USA. Most men in the trial had erectile dysfunction of three to six months' duration.

Four trials had outcomes, but only one of these had the primary outcome the authors sought, of successful sexual intercourse attempts. The other three had less well defined outcomes for improvement.

The results are shown in Figure 1. Overall, with trazodone 38/104 men (37%) improved, compared with 21/106 men (20%) improved with placebo. The results were better for the two trials (dark symbols in Figure 1) in which men had psychogenic erectile dysfunction, than in the two trials (light symbols) in which the erectile dysfunction had a physiological or mixed aetiology.


Figure 1: Positive response to treatment with trazodone and placebo




The authors of the paper decided a priori that the data were clinically heterogeneous, and used a random effects calculation for statistical significance. This concluded that overall there was no statistical improvement with trazodone (relative benefit 1.6; 95%CI 0.8 to 3.3). A less conservative approach using a fixed effects calculation would have shown statistical significance.

For the two studies in men with psychogenic erectile dysfunction, the effect of trazodone again just about touched statistical significance, with 63% of men with benefit with trazodone and 23% with placebo. The numbers were small (89 men in two trials), but the effect was large, with an imputed NNT of about 2.5.

Adverse events

Adverse events were more frequent with trazodone than with placebo, but failed to reach statistical significance for any one adverse event. Sedation and dry mouth were common, and there was one case of priapism with trazodone. Adverse events or all-cause discontinuations were the same for both trazodone and placebo, at about 9%.

Comment

We have here a nicely done review that leaves us without a definite conclusion because the information it found was just not good enough. The trials were small. They recruited men with different aetiology for their erectile dysfunction. The outcomes were poorly defined, especially given what we have come to expect from modern research into erectile dysfunction. Trials were also generally of short duration.

The best we can say is that we don't know enough. The next best is that we have a hint, and no more than a hint, that trazodone may be useful in men with erectile dysfunction of psychogenic aetiology.

What we have is a nice example of what happens in the early stages of a therapy being used for a different indication. Trials are small and the questions posed and answers obtained are diffuse. There is some evidence, and there may even be a biology, as priapism is a known rare adverse effect of trazodone. What we do not have is enough evidence to make unequivocal decisions. How this limited evidence can be used is simple. With much caution and after a great deal of thought, and for specific reasons in specific patients, or perhaps not at all until better evidence is available.

Additional literature searches to September 2005 found no more RCTs.

Reference:

  1. HA Fink et al. Trazodone for erectile dysfunction: a systematic review and meta-analysis. BJU International 2003 92: 441-446.

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