From the Guidelines
Treatment for premature ejaculation should begin with a combination of behavioral techniques and pharmacological approaches, as this may be more effective than either modality alone, according to the most recent guideline from 2022 1.
Behavioral Techniques
Behavioral strategies, such as the "stop-start" and "squeeze" techniques, can be effective in delaying ejaculation. Practice delaying ejaculation during masturbation or with a partner, and pelvic floor exercises (Kegels) can also help improve control.
Pharmacological Approaches
For more persistent cases, daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics are recommended as first-line agents of choice 1. Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (20-40 mg daily) or dapoxetine (30-60 mg, taken 1-3 hours before sexual activity) may be prescribed. These medications can significantly delay ejaculation but may cause side effects like nausea or decreased libido. Alternatively, low-dose clomipramine (10-50 mg daily) can be effective.
Combination Therapy
Combining medication with behavioral techniques often yields the best results, as supported by a systematic review that found combination therapy to be associated with greater improvement in scores on validated instruments for assessment of PE 1.
Important Considerations
It's crucial to consult a healthcare provider for proper diagnosis and treatment, as premature ejaculation can sometimes be a symptom of underlying health issues or psychological factors that may require additional attention. 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%
Treatment options for premature ejaculation (PE) are not explicitly stated in the provided drug labels. However, it can be noted that:
- SSRIs, such as sertraline and paroxetine, are sometimes used off-label to treat premature ejaculation due to their side effect of delayed ejaculation.
- The provided drug labels list ejaculation failure and abnormal ejaculation as potential side effects of these medications, but do not provide information on their use as a treatment for premature ejaculation.
- No direct evidence is provided in the drug labels to support the use of these medications as a treatment for premature ejaculation. 2 2 3
From the Research
Treatment Options for Premature Ejaculation (PE)
The treatment options for premature ejaculation (PE) are multifaceted and can be categorized into several approaches, including:
- Behavioral modifications: Techniques such as the squeeze and stop-start methods, sensate focus, and pelvic floor rehabilitation have been shown to be effective in extending the time between penetration and ejaculation 4.
- Medications: Various drugs, including selective serotonin reuptake inhibitors (SSRIs), phosphodiesterase type 5 inhibitors, and topical anesthetics, have been used to treat PE 5, 6, 7.
- Pharmacotherapy: Drug treatment is mainly required for lifelong and acquired premature ejaculation, and can be taken on-demand or on a daily basis 5.
- Cognitive behavioral therapy (CBT): Integrated pharmacotherapy and CBT may achieve superior treatment outcomes in some patients 6.
- Diet alterations: Although not extensively studied, diet alterations may also play a role in the treatment of PE 8.
- Surgery: In some cases, major surgery may be considered as a treatment option for PE 8.
Emerging Therapies
New and emerging therapies for PE include:
- On-demand rapid-acting SSRIs: These medications have shown promise in delaying ejaculation and improving sexual satisfaction 6, 7.
- Oxytocin receptor antagonists: These drugs are being studied as potential treatments for PE, although more research is needed to confirm their efficacy 6.
- Single agents that target multiple receptors: These medications may form the foundation of more effective future on-demand treatments for PE 6.
Comparison of Treatment Options
Studies have compared the efficacy of different treatment options for PE, including:
- Behavioral therapy vs. waitlist control: Behavioral therapy has been shown to improve intravaginal ejaculatory latency time (IELT) and other outcomes in some studies 4.
- Combined behavioral and drug treatment vs. drug treatment alone: Combined therapy has been shown to give better outcomes than drug treatment alone in some studies 4, 6.
- Drug treatment vs. behavioral therapy: The results of these comparisons have been mixed, with some studies favoring drug treatment and others showing no significant difference 4, 6.