Duloxetine-Induced Retrograde Ejaculation: A Case Report

Retrograde ejaculation refers to the propulsion of semen back in to the urinary bladder rather than the usual anterograde flow. Antidepressant drugs are frequently associated with sexual dysfunct ion (SD). Duloxet ine, a newer antidepressant agent, has sexual dysfunction as a side effect confirmed by placebo studies. In some cases, other rare sexual side effects such as hypersexuality have been reported during duloxetine treatment. Here, we report an unusual case of retrograde ejaculation after duloxetine treatment for major depressive disorder (MDD) with co-morbid generalized anxiety disorder (GAD). Written informed consent was obtained from the patient before writing this report. AN, a 43-year-old married man who met the DSM-IV criteria for MDD with co-morbid GAD. He had been prescribed several medications for MD GAD for 11 years (paroxetine, mirtazapine, venlafaxine, citalopram, escitalopram, tianeptine, milnacipran, sertraline, trazodone, imipramine, and clomipramine). The medications were discontinued because of the adverse effects of these drugs. He had been taking fluoxetine 20 mg/ day PO for the last 6 months. MDD and GAD symptoms were resolved but he was suffering from erectile dysfunction and diminished libido with fluoxetine treatment. The fluoxetine treatment was ended and a duloxetine 60 mg/day PO regimen started. On the second day of duloxetine treatment, difficulties with ejaculation started and continued after the wash-out period for fluoxetine (4 week). In the 4 week of the duloxetine treatment, sexual side effects of fluoxetine (erectile dysfunction, diminished libido) completely resolved and remission of MDD and GAD continued, although he had diff icult ies ejaculating. Due to his complaints, a urine specimen was collected following masturbation. Using a microscope with 10x magnification, the centrifuged urine sediment was examined for the presence spermatozoa. As spermatozoa were seen in the sediment, the patient was diagnosed with retrograde ejaculation according to the European Association of Urology guidelines on ejaculatory dysfunction. The duloxetine dose was decreased to 30 mg/day for two months, but retrograde ejaculation continued. In the 3 month, duloxetine treatment was stopped and bupropion 150 mg/day PO was started. Further confirming his report of retrograde ejaculation related to the duloxetine medication, the patient reported that he was able to ejaculate normally 2 days after cessation of duloxetine, and a urine specimen collected following masturbation contained no spermatozoa. According to the Naranjo probability scale, the adverse drug reaction was considered definite (Naranjo probability scale score: 10). Our patient reported no sexual side effects with bupropion treatment. If sexual function and fertility have priority for the patient, it may be better to choose antidepressants other than duloxetine. Duloxetine was shown to be safe and effective in the treatment of MDD, and no significant differences with placebo were found for duloxetine-induced SD. We replaced fluoxetine with duloxetine DOI: 10.5455/bcp.20130925022238