What are the treatment options for premature ejaculation (PE) with a submissive aspect?

Treatment Options for Premature Ejaculation with a Submissive Aspect

The most effective treatment for premature ejaculation with a submissive aspect is a combination of behavioral therapy and pharmacological approaches, which provides greater improvement in ejaculation latency time than either modality alone. 1

First-Line Pharmacological Options

SSRIs (Daily Use)

• Paroxetine (10-40 mg/day)
• Citalopram (20-40 mg/day)
• Sertraline (50-200 mg/day)
• Clomipramine (12.5-50 mg/day)

On-Demand Options

• Paroxetine (20 mg 3-4 hours before intercourse)
• Sertraline (50 mg 4-8 hours before intercourse)
• Clomipramine (25 mg 4-24 hours before intercourse)

Topical Anesthetics

• Lidocaine/prilocaine cream (EMLA) applied 20-30 minutes before intercourse
  • Should be washed off before intercourse to prevent numbness in partner 2, 1

Behavioral Approaches for Submissive PE

For PE with a submissive aspect, consider these specialized behavioral approaches:

1. Partner-Controlled Techniques:

   • Allow the dominant partner to control the pace and stimulation
   • The dominant partner can implement stop-start or squeeze techniques 2, 3
   • This approach aligns with the submissive dynamic while addressing PE

2. Sensate Focus with Power Exchange:

   • Incorporate power exchange elements into sensate focus exercises
   • The dominant partner directs the submissive when to start/stop stimulation
   • Gradually build tolerance to stimulation while maintaining the power dynamic

3. Orgasm Control Training:

   • The dominant partner provides verbal commands about when ejaculation is permitted
   • This reinforces the submissive dynamic while improving ejaculatory control 4

Combination Therapy Approach

The American Urological Association strongly recommends combining behavioral and pharmacological approaches as this provides better outcomes than either approach alone 2, 1:

1. Start with an SSRI (paroxetine preferred due to efficacy) 1, 5

   • Be aware of side effects: ejaculation failure (14%), decreased libido (6%), dry mouth (14%) 6, 5
   • These side effects may actually complement the submissive dynamic for some patients

2. Add behavioral techniques that incorporate the submissive aspect:

   • Partner-controlled stop-start technique
   • Partner-controlled squeeze technique
   • Sensate focus exercises with power exchange elements

3. Consider topical anesthetics for situational use:

   • Can be applied by the dominant partner as part of foreplay
   • Must be washed off before intercourse to prevent partner numbness 2

Important Considerations

• Safety first: None of these medications are FDA-approved specifically for PE treatment 1
• Avoid sudden cessation of daily SSRIs to prevent withdrawal syndrome 1
• Monitor for side effects: SSRIs can cause nausea, dry mouth, drowsiness, and reduced libido 5
• Treat comorbid erectile dysfunction first if present, as PE may improve once ED is effectively managed 2, 1
• Avoid surgical interventions as they should only be considered experimental and used in the context of an ethical board-approved clinical trial 2

Treatment Assessment

• Measure improvement using:
  • Intravaginal Ejaculation Latency Time (IELT)
  • Patient and partner satisfaction
  • Control over ejaculation
  • Quality of sexual experience within the submissive dynamic

By integrating pharmacological treatments with behavioral techniques that respect and incorporate the submissive aspect, patients can experience significant improvement in ejaculatory control while maintaining their preferred sexual dynamic.