What are the treatment options for delayed ejaculation?

Treatment Options for Delayed Ejaculation

The most effective treatment approach for delayed ejaculation 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

Diagnosis and Assessment

Before initiating treatment, a thorough evaluation is essential:

• Determine if delayed ejaculation began after starting specific medications
• Assess if it occurs with all sexual activities or only certain ones
• Rule out underlying causes such as hormonal factors, neurological conditions, and medication side effects 1
• Conduct a focused neurological examination, genital and prostate examination
• Check testosterone levels, as low testosterone can contribute to ejaculatory dysfunction 1
• Consider post-ejaculation urinalysis to check for retrograde ejaculation 1

First-Line Treatment Approaches

Behavioral and Psychological Interventions

• Modify sexual positions or practices to increase stimulation
• Incorporate alternative sexual practices or enhancement devices
• Improve communication about sexual needs between partners
• Consider vibratory therapy to enhance arousal (particularly effective for neurological causes) 1
• Pelvic physical therapy to improve pelvic floor function and sensation 1

Medication Adjustments

If medication-induced:

• Consider dose reduction of contributing medications (e.g., SSRIs, antipsychotics, antihypertensives)
• Try switching to on-demand dosing instead of daily dosing for medications like tadalafil
• Consider a trial off medication to confirm causality 1

Pharmacological Treatments

All medications for delayed ejaculation are used off-label as none have FDA approval for this condition 1. Options include:

First-line medications:

• Pseudoephedrine: 60-120 mg, 120-150 minutes before sex 1
• Ephedrine: 15-60 mg, 1 hour before sex 1
• Cabergoline: 0.25-2 mg twice weekly 1, 2
• Bupropion: Has shown efficacy in clinical studies 3, 2

Second-line medications:

• Midodrine: 5-40 mg, 30-120 minutes before sex 1, 2
• Oxytocin: 24 IU intranasal/sublingual during sexual activity 1, 2
• Bethanecol: 20 mg daily 1, 2
• Yohimbine: 5.4 mg three times daily 1, 2
• Imipramine: 25-75 mg daily 1, 2

Caution: Use sympathomimetic drugs carefully due to potential side effects including hypertension, anxiety, and insomnia 1

Treatment Algorithm

1. Address underlying causes:

   • Adjust or discontinue medications that may cause delayed ejaculation
   • Treat hormonal imbalances (consider testosterone replacement if levels are low)
   • Manage any comorbid erectile dysfunction according to guidelines 1

2. Initial approach:

   • Begin with behavioral/psychological interventions
   • If medication-related, adjust dosing or consider alternatives

3. If initial approach fails:

   • Add pharmacological treatment based on patient characteristics
   • Consider combination therapy with behavioral techniques and medication

4. Evaluate response after 4-12 weeks:

   • If inadequate response, try alternative medication or combination therapy
   • Consider referral to sexual health specialist if no improvement 1

Special Considerations

• Partner involvement is crucial for optimal outcomes 1
• Age considerations: Ejaculatory dysfunction becomes more common with age and may require more comprehensive management 1
• Comorbid erectile dysfunction: Treat ED first, then address delayed ejaculation; PDE5 inhibitors may help with orgasmic problems when mild ED coexists 1
• Avoid surgical interventions as they should be considered experimental 1

Treatment Pitfalls and Caveats

• Set realistic expectations about improvement rather than complete resolution 1
• Evidence supporting pharmacological treatments is limited to small trials, case series, or case reports 2
• Multimodal approaches combining psychosexual therapy with medications and/or penile vibratory stimulation likely provide the best outcomes 3
• Patients should be counseled on the weak evidence base for medications and potential side effects 1
• Treatment success varies significantly between individuals 1