What are the treatment options for premature ejaculation?

Treatment Options for Premature Ejaculation

The most effective treatment for premature ejaculation combines behavioral therapy with pharmacological approaches, particularly selective serotonin reuptake inhibitors (SSRIs), which provide greater improvement in ejaculation latency time than either modality alone. 1

Diagnosis and Classification

Premature ejaculation (PE) can be classified as:

• Lifelong (primary) PE: Poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of penetration that has been present since sexual debut 2
• Acquired (secondary) PE: Consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience 2

It's crucial to distinguish PE from erectile dysfunction (ED), as these conditions frequently coexist. When both are present, ED should be treated first, as PE may improve once ED is effectively managed 1.

Treatment Algorithm

First-Line Treatments:

1. Behavioral Techniques:

   • Stop-start technique
   • Squeeze technique
   • Modifying sexual positions to reduce arousal
   • These approaches help enhance arousal control but have limited long-term efficacy when used alone 3, 4

2. Pharmacological Options:

   • SSRIs (off-label use):

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

   • Non-selective SRI:

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

   • Topical Anesthetics:

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

Treatment Selection Guidelines:

• For frequent sexual activity: Daily SSRI treatment preferred
• For infrequent sexual activity: On-demand medication taken several hours before anticipated intercourse 1
• For patients concerned about systemic side effects: Consider topical anesthetics 1

Second-Line Options:

• α1-adrenoceptor antagonists for patients who have failed first-line therapy 1
• Combined approach: Integrating pharmacological treatment with dynamic behavioral rehabilitation shows better sustained results (50% cure rate at 6 months) compared to medication alone (25% cure rate at 6 months) 5

Important Considerations

• Safety warning: None of the medications discussed are FDA-approved specifically for PE treatment 1
• Side effects: Patients should be informed about potential SSRI side effects including nausea, dry mouth, drowsiness, and reduced libido 1
• Treatment duration: PE treatment will likely be needed on a continuing basis, as symptoms usually return upon discontinuing therapy 1
• Monitoring: Treatment efficacy should be assessed using Intravaginal Ejaculation Latency Time (IELT), Premature Ejaculation Diagnostic Tool (PEDT) scores, and patient/partner satisfaction 1
• Withdrawal precaution: Advise patients to avoid sudden cessation of daily SSRIs to prevent withdrawal syndrome 1

Common Pitfalls to Avoid

• Treating PE without assessing for concurrent ED: These conditions frequently coexist and share common risk factors 1
• Relying solely on medication: Combined approaches show better long-term outcomes 5
• Ignoring partner involvement: Partner participation significantly improves treatment outcomes 4, 5
• Expecting permanent cure: Most treatments provide temporary relief, with symptoms returning after discontinuation 3, 6
• Overlooking psychological factors: Anxiety and relationship issues often contribute to PE and should be addressed 1

By following this structured approach to PE management, clinicians can help patients achieve significant improvements in ejaculation control, sexual satisfaction, and overall quality of life.