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.
Overview of Treatment Options
Treatment options for premature ejaculation include:
- Behavioral techniques: stop-start technique, squeeze technique, sensate focus method, and pelvic floor exercises
- Medications:
- Topical options: lidocaine sprays applied 10-15 minutes before intercourse to reduce sensitivity
- Oral medications: SSRIs like dapoxetine, paroxetine, or sertraline, which delay ejaculation by increasing serotonin levels
Medication Details
- Daily SSRIs: paroxetine (10-40mg daily), sertraline (50-200mg daily), or fluoxetine (5-20mg daily) can be effective in delaying ejaculation
- On-demand clomipramine or dapoxetine: can be used 3-6 hours before intercourse, but may have less ejaculatory delay compared to daily treatment
- Topical penile anesthetics: lidocaine/prilocaine cream can be applied 20-30 minutes before intercourse to delay ejaculation
Important Considerations
- Patients should be advised to avoid sudden cessation or rapid dose reduction of daily dosed SSRIs to prevent SSRI withdrawal syndrome
- The use of off-label SSRIs is favored over the TCA clomipramine due to a better side effect profile
- Caution is suggested in prescribing SSRIs to adolescents with PE and to men with PE and a co-morbid depressive disorder, particularly when associated with suicidal ideation
Recommended Approach
A combination approach, including behavioral techniques and medications, typically works best for treating premature ejaculation, as it addresses both psychological and biological factors 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 prescribed to treat 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 the condition.
From the Research
Treatment Options for Premature Ejaculation
- Behavioral therapy: Techniques such as the squeeze method and the "stop-and-start" technique can be effective in treating premature ejaculation, as shown in a study published in 2006 4.
- Pharmacological treatments:
- Desensitizing drugs
- Off-label use of antidepressants and/or phosphodiesterase type 5 inhibitors or alpha-blockers
- New pharmacologic drugs, such as dapoxetine, which has been shown to significantly improve ejaculatory latency, control over ejaculation, and satisfaction with sexual intercourse 5
- Cognitive behavioral therapy (CBT): Integrated pharmacotherapy and CBT may achieve superior treatment outcomes in some patients 6
- Topical anesthetics: Lidocaine/prilocaine spray has been launched for the treatment of primary premature ejaculation, and has been shown to be effective in extending the time between penetration and ejaculation 7
- Selective serotonin reuptake inhibitors (SSRIs): Daily dosing of SSRIs is likely to be associated with superior fold increases in intravaginal ejaculation latency time compared with on-demand SSRIs, and are considered first-line agents for the medical treatment of lifelong and acquired PE 6
- Psychosexual counseling: Although it has a limited role in the contemporary management of PE, it can still be beneficial for some patients 6
- Emerging treatments: New on-demand rapid-acting SSRIs, oxytocin receptor antagonists, or single agents that target multiple receptors may form the foundation of more effective future on-demand medication 6