What medications are used to treat premature ejaculation?

Medications for Premature Ejaculation Treatment

Daily selective serotonin reuptake inhibitors (SSRIs), on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics are the first-line medications for treating premature ejaculation. 1

First-Line Pharmacological Options

SSRIs (Daily Administration)

• Paroxetine: 10-40 mg daily (most effective, increasing ejaculation latency 8.8-fold) 1
• Sertraline: 50-200 mg daily
• Fluoxetine: 20-40 mg daily
• Citalopram: 20-40 mg daily
• Clomipramine (TCA): 12.5-50 mg daily

On-Demand Options

• Clomipramine: 25 mg taken 4-24 hours before intercourse
• Paroxetine: 20 mg taken 3-4 hours before intercourse
• Sertraline: 50 mg taken 4-8 hours before intercourse 2
• Dapoxetine (where available): taken 1-3 hours before intercourse

Topical Anesthetics

• Lidocaine/prilocaine cream (2.5 gm): Apply 20-30 minutes before intercourse 1
• Must be washed off before intercourse to prevent partner numbness

Second-Line Options

α1-Adrenoceptor Antagonists

• Consider for patients who have failed first-line therapy 1
• Examples include alfuzosin and terazosin
• Limited efficacy data available

Treatment Algorithm

1. Initial Assessment: Determine if PE is lifelong or acquired

   • If acquired, check for concurrent erectile dysfunction (ED)
   • Treat ED first if present, as PE may improve once ED is effectively managed 3

2. First-Line Treatment:

   • Start with daily SSRI (preferably paroxetine) OR
   • Topical anesthetic if patient prefers non-systemic approach OR
   • On-demand medication if patient prefers occasional treatment

3. Dosing Strategy:

   • For SSRIs: Start at lowest effective dose and titrate as needed
   • For topical anesthetics: Apply 20-30 minutes before intercourse, wash off before penetration

4. Combination Approach:

   • Consider combining behavioral techniques with medication for better outcomes 1
   • On-demand treatment may be combined with initial trial of daily treatment 1

Important Considerations and Precautions

SSRI Side Effects and Precautions

• Common side effects: Nausea, dry mouth, drowsiness, reduced libido 1
• Avoid in patients with bipolar depression (risk of mania) 1
• Use with caution in adolescents and patients with depressive disorders 1
• Risk of serotonin syndrome when combined with other serotonergic drugs 1
• Avoid sudden discontinuation (risk of withdrawal syndrome) 1
• Ejaculation failure (14% with sertraline vs 1% with placebo) 4

Topical Anesthetic Considerations

• Prolonged application (>30 minutes) may cause erectile dysfunction due to penile numbness 1
• Use condom or wash thoroughly before intercourse to prevent partner numbness 1
• Contraindicated in patients or partners with allergies to components 1

Treatment Efficacy and Follow-up

• SSRIs typically increase ejaculation latency time from seconds to several minutes 2, 5
• Patient satisfaction scores typically improve from <1 to >3 on a 5-point scale 2
• Regular follow-up is essential as symptoms usually return upon discontinuing therapy
• Treatment efficacy should be assessed using patient and partner satisfaction

Special Situations

• For patients with concurrent ED and PE: Treat ED first according to AUA Guidelines 1
• For patients concerned about taking antidepressants: Consider topical anesthetics or emphasize the lower doses used for PE compared to depression treatment 1
• For patients with partial response: Consider combination therapy (behavioral + pharmacological) 1

Remember that none of these medications are FDA-approved specifically for PE treatment (except dapoxetine in some countries), and patients should be informed about the off-label use of these medications.