What prevents premature ejaculation in a 45-year-old male?

Treatment Options for Premature Ejaculation in a 45-Year-Old Male

Daily SSRIs, on-demand clomipramine, and topical penile anesthetics are the first-line treatments for preventing premature ejaculation. 1

First-Line Pharmacological Options

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Daily SSRI treatment options with proven efficacy:
  • Paroxetine: 10-40 mg/day (strongest ejaculation delay, increasing ejaculation latency time 8.8-fold over baseline) 2, 1
  • Sertraline: 50-200 mg/day 2, 1
  • Fluoxetine: 20-40 mg/day 2
  • Citalopram: 20-40 mg/day 2, 1
  • Clomipramine: 12.5-50 mg/day 2, 1

On-Demand Options

• Clomipramine: 25 mg taken 4-24 hours before intercourse 1
• SSRIs taken 3-6 hours before intercourse (less effective than daily treatment):
  • Paroxetine: 20 mg 1
  • Sertraline: 50 mg 1

Topical Treatments

• Lidocaine/prilocaine cream (EMLA): Apply 20-30 minutes before intercourse and wash off before penetration to prevent partner numbness 1

Important Considerations with SSRIs

Side Effects

• Common side effects of sertraline include:
  • Ejaculation failure (14% vs 1% with placebo) 3
  • Decreased libido (6% vs 1% with placebo) 3
  • Dry mouth (14% vs 8% with placebo) 3
  • Nausea (25% vs 11% with placebo) 3
  • Somnolence (13% vs 7% with placebo) 3

Precautions

• Avoid SSRIs in patients with bipolar depression due to risk of mania 2, 1
• Be cautious about serotonin syndrome when combining with other serotonergic drugs 2, 1
• Avoid sudden discontinuation to prevent withdrawal syndrome 1
• None of these medications are FDA-approved specifically for premature ejaculation treatment 1, 4

Behavioral Techniques

• Combining behavioral therapy with pharmacological approaches is most effective 1
• Effective behavioral techniques include:
  • "Stop-start" technique: Stimulation is stopped before reaching the point of ejaculatory inevitability 5
  • "Squeeze" technique: Partner squeezes the glans penis when approaching ejaculation 5
  • Modifying sexual positions to reduce arousal 2
  • Increasing the variety of sexual practices to manage arousal levels 2

Second-Line Options

• α1-adrenoceptor antagonists for patients who have failed first-line therapy 1, 6
• For delayed ejaculation, consider:
  • Oxytocin: 24 IU intranasal/sublingual during sex 2
  • Pseudoephedrine: 60-120 mg (120-150 minutes prior to sex) 2
  • Ephedrine: 15-60 mg (1 hour prior to sex) 2

Treatment Algorithm

1. Start with first-line therapy: Daily SSRI (preferably paroxetine) or topical anesthetics
2. Combine with behavioral techniques for enhanced efficacy
3. If inadequate response after 4 weeks:
   • Increase SSRI dose
   • Switch to another SSRI
   • Try on-demand medication
4. If still inadequate: Consider α1-adrenoceptor antagonists

Monitoring and Follow-up

• Assess treatment efficacy using:
  • Patient and partner satisfaction
  • Intravaginal Ejaculation Latency Time (IELT)
  • Side effect profile
• Regular follow-up is essential as symptoms typically return upon discontinuing therapy 1

Important Caveats

• Treatment should focus on both partners' satisfaction, not just ejaculation time
• Be aware that premature ejaculation may coexist with erectile dysfunction; treat ED first as PE may improve 1
• Most treatments provide temporary relief, and PE often recurs when treatment is stopped 6
• The normal median ejaculation latency time in Western countries is 5-6 minutes; men with latencies beyond 25-30 minutes who report distress qualify for delayed ejaculation diagnosis 2