From the Guidelines
Premature ejaculation should be treated with 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.
Treatment Options
The treatment of premature ejaculation involves a combination of behavioral techniques, topical medications, and oral medications.
- Behavioral approaches like the stop-start technique and the squeeze technique can help develop better control.
- Topical options include lidocaine or benzocaine sprays and creams applied 10-15 minutes before sex to reduce sensitivity.
- Oral medications that may help include SSRIs like dapoxetine, paroxetine, or sertraline, which delay ejaculation by increasing serotonin levels.
Combination Therapy
Combining behavioral and pharmacological approaches may be more effective than either modality alone, as suggested by the AUA/SMSNA guideline 1.
- Behavioral strategies have been studied in combination with pharmacological approaches to increase ejaculatory latency time (ELT) and sexual satisfaction beyond that resulting from pharmacological treatment alone.
- Inclusion of behavioral therapy for premature ejaculation leads to a significantly greater increase in ELT compared to pharmacological therapy alone.
Medication
Daily treatment with off-label paroxetine, sertraline, fluoxetine, citalopram, and clomipramine is 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 modestly efficacious and well tolerated but is associated with substantially less ejaculatory delay than daily treatment.
Safety Considerations
Treatment with SSRIs should be avoided in men with a history of bipolar depression due to the risk of mania 1.
- The use of off-label SSRIs is favored over the TCA clomipramine because of a better side effect profile.
- Patients should be advised to avoid sudden cessation or rapid dose reduction of daily dosed SSRIs as this may precipitate SSRI withdrawal syndrome 1.
From the FDA Drug Label
Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling, are likely to underestimate their actual incidence Table 5 below displays the incidence of sexual side effects reported by at least 2% of patients taking sertraline in placebo-controlled trials Table 5 Adverse Event | Sertraline Hydrochloride Tablets | Placebo Ejaculation Failure | 14% | 1% Decreased Libido | 26% | 1% Denominator used was for male patients only (N=1118 sertraline: N=926 placebo)
Sertraline and Premature Ejaculation: The FDA drug label for sertraline reports that Ejaculation Failure, which is primarily delayed ejaculation, occurs in 14% of male patients taking sertraline, compared to 1% of those taking placebo 2. This suggests that sertraline may be associated with delayed ejaculation rather than premature ejaculation. Therefore, sertraline may actually be used to treat premature ejaculation, but the label does not directly support this use.
- Key points:
- Sertraline is associated with delayed ejaculation
- The label does not directly address premature ejaculation
- Sertraline may be used off-label to treat premature ejaculation, but this is not directly supported by the label.
From the Research
Definition and Prevalence of Premature Ejaculation
- Premature ejaculation (PE) is defined by short ejaculatory latency and inability to delay ejaculation causing distress 3
- PE is one of the most common male sexual dysfunctions 4
Treatment Approaches
- Management of PE may involve behavioral and/or pharmacological approaches 3
- Behavioral therapies, including physical techniques such as squeeze and stop-start, sensate focus, stimulation device, and pelvic floor rehabilitation, have been shown to improve intravaginal ejaculatory latency time (IELT) and other outcomes 3
- Cognitive behavioral therapy (CBT) combined with selective serotonin reuptake inhibitors (SSRIs) has been shown to significantly prolong IELT and improve perceived control over ejaculation, sexual life satisfaction, and spouses' sexual life satisfaction 5
- SSRIs have been shown to improve self-perceived PE symptoms, satisfaction with intercourse, and self-perceived control over ejaculation, but may increase treatment cessations due to adverse events and adverse event rates 6
Psychotherapy Techniques
- Psychosexual treatments that integrate behavioral, psychological, and relationship functioning can be effective in managing PE 7
- General strategies underpinning integrative, "process-oriented" elements of psychotherapy most relevant to PE include developing the therapist-patient relationship, expressing empathy, genuineness, and positive regard, and identifying PE-related affect, cognitions, and behaviors 7
- The four main domains that encompass psychotherapy techniques specific to the treatment of PE are: behavioral, cognitive, affective, and relational 7
Combination Therapy
- Combining a specific pharmacologic treatment for premature ejaculation with appropriate cognitive, behavioral, and sex therapy techniques can improve the overall understanding and management of sexual dysfunction, resulting in a sustainable increase in sexual satisfaction and decrease in distress for men 4
- Combination treatment strategy that addresses all elements of PE, including psychological and biological factors, may be more effective than single-therapy approaches 7