From the Guidelines
Treatment for premature ejaculation should prioritize a combination of behavioral techniques and medications, 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
- Behavioral approaches: stop-start technique, squeeze technique
- Topical anesthetics: lidocaine sprays or creams applied 10-15 minutes before intercourse
- Selective serotonin reuptake inhibitors (SSRIs): dapoxetine (30-60mg taken 1-3 hours before sex), paroxetine (10-40mg daily), or sertraline (50-200mg daily)
- Phosphodiesterase-5 inhibitors: sildenafil (50-100mg) taken 1 hour before intercourse
- Psychological counseling: addressing underlying anxiety or relationship issues
- Pelvic floor exercises (Kegels): strengthening muscles involved in ejaculatory control
Medication Considerations
- Daily SSRIs are effective in delaying ejaculation, with paroxetine exerting the strongest ejaculation delay, increasing ELT a mean of 8.8-fold over baseline 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 in most studies 1
- Serotonin Syndrome is a potentially serious complication associated with simultaneous use of multiple serotonergic drugs, and treatment includes cessation of serotonergic agents and short-term use of benzodiazepines to manage symptoms 1
Combination Therapy
- Combining behavioral and pharmacological approaches may be more effective than either modality alone, as recommended by the AUA/SMSNA guideline 1
- Behavioral therapy for PE leads to a significantly greater increase in ELT compared to pharmacological therapy alone, and combination therapy is associated with greater improvement in scores on validated instruments for assessment of PE 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 Table 5 Adverse EventSertraline Hydrochloride TabletsPlacebo Ejaculation Failure1(Primarily Delayed Ejaculation) 14% 1% The most commonly observed adverse events associated with the use of paroxetine (incidence of 5% or greater and incidence for PAXIL at least twice that for placebo, derived from Table 3) were: ... abnormal ejaculation
Treatment options for premature ejaculation include:
- Selective serotonin reuptake inhibitors (SSRIs): Such as sertraline and paroxetine, which can cause delayed ejaculation as a side effect.
- Off-label use of SSRIs: May be considered for the treatment of premature ejaculation, as they can help delay ejaculation.
2 and 3 provide evidence of the use of SSRIs in treating premature ejaculation, although they do not directly address the treatment of this condition.
From the Research
Treatment Options for Premature Ejaculation
The treatment options for premature ejaculation (PE) include:
- Behavioral therapies
- Topical anaesthetics
- Dapoxetine and other selective serotonin reuptake inhibitors (SSRIs) 4, 5, 6
- Phosphodiesterase type 5 inhibitors (PDE5Is) 6
- Off-label use of antidepressants and/or alpha-blockers 4
- Combination therapy of pharmacological treatment, psychosexual behavioural therapy, and psychological therapy 7
Pharmacologic Treatments
Pharmacologic treatments are considered the mainstay of therapy for PE, with dapoxetine being the first medication to be approved for this purpose 6. Other medications, such as anesthetic sprays containing lidocaine and prilocaine (Fortacin™), have also shown considerable efficacy 6.
Emerging Therapies
New pharmacologic drugs, specifically for the treatment of PE, are undergoing evaluation in clinical trials 4, 8, 5. These emerging therapies include on-demand administration of drugs, such as dapoxetine, which have achieved significant improvements in ejaculatory latency, control over ejaculation, and satisfaction with sexual intercourse 4.
Multimodal Therapeutic Regimens
The pathophysiology of PE appears to be multifactorial, implicating the need for multimodal therapeutic regimens to successfully treat PE 8. Future studies may reveal that integration of pharmacologic drugs with psychologic and/or behavioral therapy techniques may be the optimal approach to the management of PE 4.