From the Guidelines
The workup for premature ejaculation (PE) following paroxetine discontinuation should begin with a thorough medical and sexual history to determine if this is new-onset PE or a return of pre-existing PE that was being treated with paroxetine, and treatment options should include daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics as first-line agents of choice, as recommended by the AUA/SMSNA guideline 1. The diagnosis of PE is determined by application of specified time-based criteria to when/if ejaculation occurs, and disorders of the timing of ejaculation can pose a major impediment to sexual satisfaction for both men and their partners 1. Physical examination and basic laboratory tests (including testosterone, prolactin, and thyroid function) may be considered to rule out underlying medical conditions. Treatment options include:
- Restarting an SSRI like paroxetine (20-40mg daily)
- Using alternative SSRIs such as sertraline (50-200mg daily), fluoxetine (20-40mg daily), or dapoxetine (30-60mg on-demand)
- Non-SSRI options include clomipramine (10-50mg daily or on-demand) or topical anesthetics like lidocaine-prilocaine cream applied 20-30 minutes before intercourse Behavioral techniques are also important and include:
- The stop-start technique
- The squeeze technique
- Pelvic floor exercises Psychological counseling may be beneficial, especially if anxiety about sexual performance is contributing to symptoms, and a combination approach using medication and behavioral techniques typically yields the best results 1. It is essential to note that patients should be advised to avoid sudden cessation or rapid dose reduction of daily dosed SSRIs, as this may precipitate SSRI withdrawal syndrome 1, and that SSRIs should be used with caution in men with a history of bipolar depression due to the risk of mania 1.
From the Research
Workup for Premature Ejaculation Post Paroxetine Discontinuation
- The discontinuation of paroxetine, a selective serotonin reuptake inhibitor (SSRI), may lead to a recurrence of premature ejaculation symptoms 2, 3.
- Studies have shown that SSRIs, including paroxetine, can be effective in treating premature ejaculation, but the efficacy may decrease after treatment discontinuation 4, 5.
- A study on fluoxetine, another SSRI, found that compliance with treatment decreased over time, with dropout rates of 56% and 72% at 6 and 12 months, respectively 6.
- Predictors of continued use of SSRIs, such as fluoxetine, included high partner distress, being unpartnered, and having a post-treatment intravaginal ejaculatory latency time (IELT) ≥5 minutes 6.
Treatment Options
- Behavioral therapies, topical anesthetics, and other SSRIs, such as dapoxetine, may be considered as alternative treatment options for premature ejaculation 3.
- The efficacy and safety of these treatments have been confirmed in many well-designed controlled trials, but more research is needed to find the ideal treatment for premature ejaculation 3, 4.
- Combination therapy, including pharmaco- and behavior therapy, may be a useful approach in treating premature ejaculation, but further studies are warranted 5.
Considerations
- Adverse effects, such as anejaculation, inhibited orgasm, and reduced libido, have been reported with the use of SSRIs, including paroxetine 2, 4.
- The use of SSRIs, including paroxetine, may increase the risk of treatment cessations due to adverse events, and patients should be closely monitored for these effects 4.
- The treatment of premature ejaculation should be individualized, taking into account the patient's medical history, preferences, and partner's concerns 3, 5.