What are the treatment options for premature ejaculation, including dosages, duration, and potential side effects?

Treatment Options for Premature Ejaculation

The most effective treatment approach for premature ejaculation combines behavioral therapy with pharmacological interventions, particularly SSRIs, which provide greater improvement in ejaculation latency time than either modality alone. 1

Pharmacological Options

First-Line Medications

SSRIs (Daily Dosing)

• Paroxetine: 10-40 mg/day 1
• Sertraline: 25-200 mg/day 1
• Fluoxetine: 5-20 mg/day 1
• Citalopram: 20-40 mg/day 1

SSRIs (On-Demand/Situational Dosing)

• Paroxetine: 20 mg 3-4 hours before intercourse 1
• Sertraline: 50 mg 4-8 hours before intercourse 1

Tricyclic Antidepressants

• Clomipramine:
  • Daily: 25-50 mg/day 1
  • On-demand: 25 mg 4-24 hours before intercourse 1

Topical Anesthetics

• Lidocaine/Prilocaine (EMLA): Apply 2.5%/2.5% cream 20-30 minutes before intercourse; wash off before penetration to prevent partner numbness 1

Second-Line Medications

• PDE-5 inhibitors: Particularly beneficial for patients with comorbid erectile dysfunction 1
• α1-adrenoceptor antagonists: Consider for patients who have failed first-line therapy 1, 2

Important Considerations

Duration of Treatment

• Long-term therapy is typically required as premature ejaculation usually returns upon discontinuation of medication 1
• None of these medications are FDA-approved specifically for premature ejaculation in the US 1

Side Effects

SSRIs

• Common: Nausea, dry mouth, drowsiness, reduced libido 1
• Serious: Risk of serotonin syndrome when combined with other serotonergic drugs 1
• Withdrawal syndrome with sudden discontinuation 1
• Avoid in patients with bipolar depression (risk of mania) 1
• Use with caution in adolescents and patients with depressive disorders 1

Topical Anesthetics

• Local numbness 1
• Potential partner numbness if not washed off before intercourse 1
• Erectile issues with overuse 1

Drug Interactions

• SSRIs may interact with medications metabolized by the cytochrome P450 system 1
• Avoid multiple serotonergic drugs due to risk of serotonin syndrome 1

Classification and Assessment

• Premature ejaculation can be classified as primary (lifelong) or secondary (acquired) 3, 1
• Assessment should include:
  • Frequency and duration of PE
  • Relationship to specific partners
  • Impact on sexual activity and relationships 1
• Distinguish PE from erectile dysfunction, as these conditions frequently coexist 1
  • Treat erectile dysfunction first, as PE may improve once ED is effectively managed 1

Treatment Algorithm

1. First step: Rule out and treat any underlying erectile dysfunction 1
2. For mild cases or initial therapy: Begin with behavioral techniques (squeeze technique, stop-start method) 4
3. For moderate to severe cases:
   • Daily SSRI therapy (paroxetine preferred due to efficacy) 1
   • OR on-demand SSRI therapy 3-8 hours before intercourse 1
4. If inadequate response: Add topical anesthetics 1
5. For treatment-resistant cases: Consider α1-adrenoceptor antagonists 1, 2
6. For cases with comorbid ED: Add PDE-5 inhibitors 1

Monitoring and Follow-up

• Assess treatment efficacy using:
  • Patient and partner satisfaction
  • Intravaginal Ejaculation Latency Time (IELT)
  • Premature Ejaculation Diagnostic Tool (PEDT) scores 1
• Regular follow-up to adjust therapy based on response and side effects 1

Clinical Pearls and Pitfalls

• Patient and partner satisfaction should be the primary outcome measure for treatment success 1
• Safety should be a primary consideration as PE is not a life-threatening condition 1
• Combining behavioral and pharmacological approaches yields better results than either alone 1
• Most pharmacotherapeutic options only provide temporary delay in ejaculation latency time; PE typically recurs when treatment is stopped 2
• Surgical intervention and neuromodulation are not recommended by current guidelines due to safety concerns 2