What are the interventions for premature ejaculation?

Interventions for Premature Ejaculation

Premature ejaculation can be effectively treated with several serotonin reuptake inhibitors (SRIs) or with topical anesthetics, with treatment selection based on physician judgment and patient preference. 1

Diagnosis and Assessment

Premature ejaculation (PE) is a self-reported diagnosis based solely on sexual history. When evaluating a patient with PE, the following key elements should be assessed:

• Frequency and duration of PE
• Relationship to specific partners
• Occurrence with all or some attempts
• Degree of stimulus resulting in PE
• Impact on sexual activity and relationships
• Aggravating or alleviating factors
• Relationship to drug use or abuse

It's crucial to distinguish PE from erectile dysfunction (ED), as these conditions frequently coexist. Many patients with ED develop secondary PE due to anxiety or the need for intense stimulation to maintain an erection. When both conditions are present, ED should be treated first. 1

Treatment Algorithm

First-Line Pharmacologic Options:

1. Serotonin Reuptake Inhibitors (SRIs)

   • Selective SRIs (SSRIs):

     • Paroxetine: 10-40 mg/day or 20 mg 3-4 hours pre-intercourse 1, 2
     • Sertraline: 25-200 mg/day or 50 mg 4-8 hours pre-intercourse 1, 3
     • Fluoxetine: 5-20 mg/day 1

   • Non-selective SRI:

     • Clomipramine: 25-50 mg/day or 25 mg 4-24 hours pre-intercourse 1

2. Topical Anesthetics:

   • Lidocaine/prilocaine cream (EMLA): Apply 2.5%/2.5% cream 20-30 minutes before intercourse 1

Dosing Considerations:

Both continuous daily dosing and situational (on-demand) dosing regimens can be effective. The choice depends on:

• Frequency of sexual activity
• Patient preference
• Tolerance of side effects

Side Effects to Monitor:

• SSRIs: Ejaculatory delay (14% with sertraline vs. 1% with placebo), decreased libido (6% vs. 1%), dry mouth, nausea, somnolence, dizziness 3, 2
• Topical anesthetics: Local numbness, potential transfer to partner

Behavioral Therapies

While pharmacologic therapies are often the focus of treatment, behavioral approaches can be beneficial:

• Squeeze technique
• Stop-start technique
• Sensate focus exercises
• Pelvic floor rehabilitation

Evidence suggests that combining behavioral therapies with pharmacologic treatment provides better outcomes than drug treatment alone, with improvements in ejaculatory control, sexual satisfaction, and reduced anxiety. 4

Treatment Selection Considerations

1. For patients with frequent sexual activity: Daily SSRI treatment may be preferred
2. For patients with infrequent sexual activity: On-demand medication taken several hours before anticipated intercourse
3. For patients concerned about systemic side effects: Topical anesthetics provide a localized option
4. For patients with both PE and ED: Treat ED first, as PE may improve once ED is effectively managed 1

Important Caveats

• None of the medications discussed are FDA-approved specifically for PE treatment
• Patient and partner satisfaction should be the primary outcome measure for treatment success
• Safety should be a primary consideration as PE is not a life-threatening condition
• Some treatments with high risks (neurectomy, penile prosthesis) have risks that far outweigh benefits and should be avoided 1
• Behavioral therapies may be less effective than pharmacologic options but have minimal side effects 4

The goal of treatment should be to improve the patient's control over ejaculation, enhance sexual satisfaction, and reduce distress associated with PE, ultimately improving quality of life for both the patient and their partner.