What is the current pharmacological treatment for premature ejaculation?

Pharmacological Treatment of Premature Ejaculation

Serotonin reuptake inhibitors (SRIs) and topical anesthetics are the first-line pharmacological treatments for premature ejaculation, with dapoxetine being the most effective on-demand option when available. 1

First-Line Treatment Options

Oral Medications

SSRIs and Other Antidepressants

• Daily SSRI therapy:
  • Paroxetine: 10-40 mg/day (most effective at 20 mg daily) 1
  • Sertraline: 25-200 mg/day 2
  • Fluoxetine: 5-20 mg/day 2
  • Clomipramine (tricyclic): 25-50 mg/day 2

On-Demand Treatment

• Situational dosing (preferred by many clinicians): 2
  • Paroxetine: 20 mg 3-4 hours before intercourse
  • Sertraline: 50 mg 4-8 hours before intercourse
  • Clomipramine: 25 mg 4-24 hours before intercourse

Dapoxetine (Short-Acting SSRI)

• Specifically designed for on-demand treatment of PE 3, 4
• Dosage: 30 mg or 60 mg taken 1-3 hours before sexual activity 4
• Significantly improves intravaginal ejaculatory latency time (IELT) and patient satisfaction 5
• Rapidly absorbed and eliminated with minimal accumulation 4
• Common side effects: nausea (11-22%), dizziness (6-11%), headache (6-9%) 4

Topical Treatments

• Lidocaine/prilocaine cream (EMLA): Apply 2.5%/2.5% cream 20-30 minutes before intercourse 2
• Must be wiped off before intercourse to prevent:
  • Numbness in female partner
  • Loss of erection due to excessive penile numbness 2

Treatment Algorithm

1. Initial Assessment:

   • Determine if PE is primary (lifelong) or secondary (acquired)
   • Rule out erectile dysfunction (ED), which often coexists and should be treated first 1

2. First-Line Treatment Selection:

   • For frequent sexual activity: Daily SSRI therapy (paroxetine preferred)
   • For infrequent sexual activity: On-demand treatment (dapoxetine where available, or situational SSRI dosing)
   • For patients concerned about systemic effects: Topical anesthetics

3. Dosing Strategy:

   • Start with lowest effective dose
   • Some clinicians initiate with daily dosing as a "loading period" before transitioning to on-demand dosing 2
   • Titrate based on response and side effects

4. Treatment Duration:

   • Long-term therapy is typically required
   • PE usually returns upon discontinuation of medication 2, 1

Important Considerations and Precautions

Safety Considerations

• None of these medications are FDA-approved specifically for PE treatment in the US 2
• SSRIs should be avoided in patients with bipolar disorder (risk of mania) 1
• Use SSRIs cautiously in adolescents and patients with depressive disorders 1
• Avoid sudden discontinuation of daily SSRIs to prevent withdrawal syndrome 1

Side Effects

• SSRIs: Nausea, dry mouth, drowsiness, reduced libido, ejaculatory delay 6
• Dapoxetine: Generally better tolerated than daily SSRIs due to short half-life 4
• Topical anesthetics: Local numbness, potential partner numbness, erectile issues with overuse 2

Drug Interactions

• SSRIs can cause serotonin syndrome when combined with other serotonergic medications 1
• SSRIs may interact with medications metabolized by cytochrome P450 system 2

Treatment Efficacy Evaluation

• Monitor improvements in:
  • Intravaginal ejaculatory latency time (IELT)
  • Patient and partner satisfaction
  • Control over ejaculation
  • Sexual-related distress 1

Alternative Options for Treatment Failures

• α1-adrenoceptor antagonists for patients who fail first-line therapy 1
• Consider combination therapy with behavioral techniques for enhanced efficacy 1
• PDE-5 inhibitors may be beneficial, especially in patients with comorbid ED 2

The evidence strongly supports SRIs and topical anesthetics as effective treatments for PE, with dapoxetine offering the advantage of on-demand dosing with fewer side effects than traditional SSRIs when used chronically.