Risk Factors and Treatment for Premature Ejaculation
Combining behavioral therapy with pharmacological approaches (particularly SSRIs) is the most effective treatment for premature ejaculation, providing greater improvement in ejaculation latency time than either modality alone. 1
Risk Factors for Premature Ejaculation
Premature ejaculation can be classified as either primary (lifelong) or secondary (acquired). Understanding risk factors helps guide treatment:
- Erectile dysfunction: Often leads to secondary PE due to anxiety or need for intense stimulation 1, 2
- Performance anxiety: Creates a cycle of anxiety and premature ejaculation
- Psychological factors: Depression, stress, and relationship issues
- Neurobiological factors: Altered serotonin receptor sensitivity or serotonin neurotransmission
- Thyroid disorders: Particularly hyperthyroidism
- Prostatitis/urethritis: Inflammation can trigger PE
- Genetic predisposition: Family history may play a role
Diagnostic Approach
PE is primarily a self-reported diagnosis based on sexual history 2. Key elements to assess:
- Frequency and duration of PE
- Relationship to specific partners
- Occurrence with all or some sexual attempts
- Degree of stimulus causing ejaculation
- Impact on sexual activity and relationships
- Aggravating or alleviating factors
- Relationship to drug use
Treatment Algorithm
Step 1: Address Underlying Conditions
- If erectile dysfunction is present, treat it first 2
- Manage any prostatitis, thyroid disorders, or psychological conditions
Step 2: First-Line Treatment
- Behavioral techniques combined with pharmacological therapy 1, 3
- Behavioral: Stop-start technique, squeeze technique, sensate focus
- Pharmacological: SSRIs (paroxetine, sertraline, fluoxetine)
Step 3: Medication Selection Based on Sexual Frequency
For frequent sexual activity: Daily SSRI treatment
For infrequent sexual activity: On-demand medication
For patients concerned about systemic side effects: Topical anesthetics
Step 4: For Treatment-Resistant Cases
- Consider α1-adrenoceptor antagonists for patients who have failed first-line therapy 1
- Combination therapy with PDE5 inhibitors may be beneficial in selected cases 4
Treatment Efficacy and Considerations
- Behavioral therapy alone: Limited long-term efficacy, with 25% cure rate at 3 months 3, 5
- Pharmacological therapy alone: 75% cure rate at 3 months, dropping to 25% at 6 months post-treatment 3
- Combined approach: 75% cure rate at 3 months, with 50% maintaining benefits 3 months after discontinuation 3
Important Caveats
- None of the medications discussed are FDA-approved specifically for PE treatment 1, 2
- SSRIs may cause side effects including nausea, headache, and decreased libido
- Patients should be advised to avoid sudden cessation of daily SSRIs to prevent withdrawal syndrome 1
- Topical anesthetics may cause numbness that transfers to partners; use a condom or wash thoroughly before intercourse 1
- Surgical interventions should be considered experimental and only used in ethical board-approved clinical trials 1
Monitoring and Follow-up
- Assess treatment efficacy using:
- Adjust treatment based on response and side effects
- Consider maintenance therapy for sustained benefits
The evidence strongly supports that a combination of behavioral and pharmacological approaches provides the most effective and durable treatment for premature ejaculation, with SSRIs being the most effective pharmacological option currently available.