From the Guidelines
Healthcare providers should first determine the specific type of ejaculatory difficulty (premature ejaculation, delayed ejaculation, retrograde ejaculation, or anejaculation) through careful history-taking and physical examination, and then consider evidence-based treatments such as daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics for premature ejaculation, and psychological counseling and behavioral techniques for delayed ejaculation. When addressing patients with ejaculatory difficulties, it is essential to consider the underlying causes and potential impact on quality of life 1. For premature ejaculation, daily SSRIs, such as paroxetine 10-40 mg, sertraline 50-200 mg, fluoxetine 20-40 mg, and citalopram 20-40 mg, are effective in delaying ejaculation, with paroxetine exerting the strongest ejaculation delay 1. On-demand administration of clomipramine, paroxetine, sertraline, and fluoxetine 3-6 hours before intercourse is also modestly efficacious and well-tolerated 1. Topical anesthetics, such as lidocaine and prilocaine, may be associated with significant penile hypoesthesia and possible absorption by the receptive partner, resulting in discomfort and/or numbness, but can be moderately effective in delaying ejaculation 1.
Some key points to consider when treating ejaculatory difficulties include:
- Careful history-taking and physical examination to determine the specific type of problem
- Evidence-based treatments, such as daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics for premature ejaculation
- Psychological counseling and behavioral techniques for delayed ejaculation
- Potential side effects and interactions of medications, such as serotonin syndrome and suicidal ideation
- Importance of a multidisciplinary approach involving urologists, sexual health specialists, and mental health professionals
- Optimal management of underlying conditions, such as diabetes, neurological disorders, or hormonal imbalances
- Thorough documentation of ejaculatory issues, including onset, circumstances, and impact on quality of life 1.
In terms of specific treatments, daily SSRIs are recommended as first-line agents of choice in the treatment of premature ejaculation, with on-demand clomipramine or dapoxetine and topical penile anesthetics also being effective options 1. For delayed ejaculation, psychological counseling and behavioral techniques are recommended as first-line approaches, with pharmacological options, such as bupropion, cyproheptadine, or cabergoline, also being considered. Retrograde ejaculation may be treated with alpha-adrenergic agonists, such as pseudoephedrine or ephedrine, to increase bladder neck tone, while anejaculation may require specialized treatments, such as penile vibratory stimulation or electroejaculation, in fertility clinic settings 1.
From the Research
Trouble Ejaculating: A Guide for Healthcare Providers
Causes and Prevalence
- Ejaculatory delay is a common problem associated with selective serotonin reuptake inhibitor (SSRI) treatment, as reported in a study published in The Journal of Clinical Psychiatry 2.
- Disorders of ejaculation, including premature or delayed ejaculation, are complex phenomena within the male sexual response cycle, with various pathophysiologies and treatment options available 3.
- Erectile dysfunction (ED) and premature ejaculation (PE) are the two most prevalent male sexual dysfunctions, with ED affecting 5-20% of men and PE affecting 20-30% of men 4.
Treatment Options
- High-dose sildenafil citrate has been shown to be effective in reducing ejaculatory latency in men with SSRI-induced ejaculatory delay, with 9 out of 10 patients reporting significant clinical improvement 2.
- Phosphodiesterase type 5 inhibitors (PDE5-Is), such as sildenafil, tadalafil, and vardenafil, are effective and safe treatments for ED, with high efficacy and safety rates even in difficult-to-treat populations 4, 5.
- Daily dosing of selective serotonin reuptake inhibitors and topical anaesthetics are commonly used to treat lifelong PE, while dapoxetine is the only drug approved for the on-demand treatment of PE in Europe 4.
Associated Factors
- Factors associated with increased risk of ejaculatory dysfunction (EjD) and orgasmic dysfunction (OD) include cardiomyopathy, cardiac failure, and baseline use of antipsychotics, selective serotonin reuptake inhibitors, and tricyclic antidepressants 6.
- Men with EjD or OD tend to be younger, with a mean age of 53.7 years for those with poor ejaculatory function and 54.2 years for those with poor sensation of orgasm 6.