What are the guidelines for managing premature ejaculation?

Management of Premature Ejaculation: Guidelines and Treatment Approaches

Combining behavioral and pharmacological approaches is the most effective strategy for managing premature ejaculation, providing significantly greater improvement in ejaculatory latency time compared to either treatment alone. 1

Definition and Diagnosis

Premature ejaculation (PE) is characterized by:

• Lifelong PE: Poor ejaculatory control, associated distress, and ejaculation within approximately 2 minutes of penetration that has been present since sexual debut 1
• Acquired PE: Consistently poor ejaculatory control, associated distress, and ejaculatory latency that is markedly reduced from prior sexual experience 1

The median ejaculatory latency time in Western countries is between 5-6 minutes following intromission 1.

First-Line Treatment Options

1. Combination Therapy (Preferred Approach)

• Behavioral + Pharmacological therapy: This combination provides significantly greater improvement in ejaculatory latency time and sexual satisfaction compared to either modality alone 1
• Behavioral techniques include:
  • Squeeze technique
  • Stop-start technique
  • Sensate focus exercises
  • Pelvic floor rehabilitation

2. Pharmacological Options (Off-Label)

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Paroxetine: Most commonly used off-label SSRI for PE
  • Important safety considerations:
    • Risk of serotonin syndrome
    • Discontinuation syndrome if stopped abruptly
    • Sexual side effects (which may actually help with PE)
    • Potential for suicidal ideation 1, 2
  • Caution: Patients should be advised to avoid sudden cessation or rapid dose reduction to prevent withdrawal syndrome 1

Topical Anesthetics

• Lidocaine and prilocaine preparations
• Limitations: May cause significant penile hypoesthesia and potential absorption by the partner
• Recommendation: Use a condom or thoroughly wash the penis prior to penetration 1

3. Second-Line Options

α1-Adrenoreceptor Antagonists

• Consider for patients who have failed first-line therapy
• Limitation: Efficacy data remains very limited 1

Tramadol

• Has shown efficacy in delaying ejaculation
• Caution: Risk of dependency; should be used with caution given the opioid crisis 1

Special Considerations

Comorbid Erectile Dysfunction

• Treat according to AUA Guidelines on Erectile Dysfunction
• Evaluate temporal relationships between PE and ED to determine whether to manage concomitantly or sequentially 1

Surgical Interventions

• Not recommended as standard treatment
• Surgical management (including injection of bulking agents) should be considered experimental
• Should only be used in the context of an ethical board-approved clinical trial
• Risk of permanent loss of penile sensation 1

Treatment Algorithm

1. Initial Assessment:

   • Determine if PE is lifelong or acquired
   • Assess for comorbid conditions (especially ED)
   • Evaluate distress level and impact on quality of life

2. First-Line Treatment:

   • Start with combination of behavioral techniques and pharmacotherapy
   • Behavioral: Squeeze technique, stop-start method
   • Pharmacological: Off-label SSRI (e.g., paroxetine) or topical anesthetics

3. If Inadequate Response:

   • Consider alternative pharmacological options (α1-adrenoreceptor antagonists)
   • Re-evaluate technique and adherence to behavioral methods
   • Consider referral to sexual health specialist

4. For Refractory Cases:

   • Consider tramadol (with caution regarding dependency)
   • Do NOT pursue surgical interventions outside of clinical trials

Common Pitfalls to Avoid

1. Inadequate patient education: Ensure patients understand that pharmacological treatments are temporary and PE may recur when treatment is stopped 3

2. Ignoring psychological factors: Address anxiety, relationship issues, and other psychological components of PE

3. Abrupt discontinuation of SSRIs: Can lead to withdrawal symptoms including nausea, dizziness, electric shock sensations, and mood changes 2

4. Pursuing surgical interventions: These remain experimental and carry significant risks of permanent sensory loss 1

5. Treating PE in isolation when ED is present: The conditions may be interrelated and require coordinated management 1