What are the treatment options for delayed ejaculation?

Treatment Options for Delayed Ejaculation

The most effective treatment approach for delayed ejaculation (DE) combines psychological/behavioral interventions with pharmacological treatments tailored to the underlying cause, as none of these treatments alone have FDA approval or strong evidence of consistent efficacy. 1, 2

Understanding Delayed Ejaculation

Delayed ejaculation is characterized by persistent delay or absence of orgasm following normal sexual excitement, causing personal distress. It affects approximately 1-5% of men but is likely underreported due to embarrassment and reluctance to discuss sexual problems.

Evaluation Considerations

• Determine if DE began after starting specific medications
• Assess if it occurs with all sexual activities or only certain ones
• Rule out underlying causes:
  • Hormonal factors (low testosterone)
  • Neurological conditions
  • Medication side effects
  • Psychological factors

Treatment Algorithm

First-Line: Non-Pharmacological Approaches

1. Psychological and Behavioral Interventions

   • Modify sexual positions to increase stimulation
   • Incorporate sexual enhancement devices
   • Improve communication about sexual needs between partners
   • Vibratory therapy (particularly effective for neurological causes)
   • Pelvic floor physical therapy to improve pelvic floor function 2

2. Address Medication-Related Causes

   • If taking PDE5 inhibitors like tadalafil:
     • Consider dose reduction
     • Switch to on-demand dosing instead of daily dosing
     • Trial off medication to confirm causality 2
   • If taking SSRIs (like sertraline):
     • Consider dose adjustment or medication substitution
     • SSRIs are known to cause delayed ejaculation as a side effect 3

Second-Line: Pharmacological Options

None of these medications have FDA approval for DE, and their use is considered off-label 1, 4.

Most Commonly Used Medications:

1. Cabergoline (dopamine agonist)

   • Dosage: 0.25-2 mg twice weekly 2
   • Most commonly selected medication by specialists 5

2. Bupropion (antidepressant)

   • Mechanism: Dopaminergic and noradrenergic effects
   • One of the most commonly used medications 4, 6

3. Sympathomimetics:

   • Pseudoephedrine: 60-120 mg, 120-150 minutes before sex 2
   • Ephedrine: 15-60 mg, 1 hour before sex 2
   • Midodrine: 5-40 mg, 30-120 minutes before sex 2, 6
   • Caution: Monitor for hypertension, anxiety, and insomnia

4. Other Options:

   • Oxytocin: 24 IU intranasal/sublingual during sexual activity 2, 6
   • Bethanechol: 20 mg daily 2, 6
   • Yohimbine: 5.4 mg three times daily 2, 6
   • Imipramine: 25-75 mg daily 2, 6
   • Testosterone replacement: If biochemically low testosterone levels 2

Important Considerations and Caveats

• Treatment success is limited: Nearly 50% of practitioners report "seldom" success with treatments, and 11% report "never" achieving success 5

• Partner involvement: The American Urological Association recommends shared decision-making with involvement of sexual partner(s) when possible to optimize outcomes 1

• Medication risks: Use sympathomimetics with caution due to potential side effects including hypertension, anxiety, and insomnia 2

• Set realistic expectations: Treatment success varies significantly between individuals, and improvement rather than complete resolution may be the goal 2

• Multimodal approach: Combining psychological therapy with medications and/or penile vibratory stimulation likely provides the best outcomes 4

• Evaluate after 4-12 weeks: Assess response to any intervention within this timeframe 2

• Consider referral: If no improvement after initial management, refer to a sexual health specialist or mental health professional with expertise in sexual health 2

DE remains challenging to treat effectively, with inconsistent practice patterns even among sexual medicine specialists. The condition can significantly impact quality of life and relationships, making appropriate treatment essential despite limited evidence for any single approach.