What are the treatment options for premature ejaculation?

Treatment Options for Premature Ejaculation

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for premature ejaculation, with paroxetine (10-40 mg/day) considered the most effective option according to current guidelines. 1

Pharmacological Treatment Options

First-Line Medications: SSRIs

• Daily SSRI therapy options:

  • Paroxetine: 10-40 mg/day (most effective)
  • Sertraline: 25-200 mg/day
  • Fluoxetine: 5-20 mg/day
  • Clomipramine (TCA): 12.5-50 mg/day 1

• Situational (on-demand) dosing options:

  • Paroxetine: 20 mg taken 3-4 hours before intercourse
  • Sertraline: 50 mg taken 4-8 hours before intercourse
  • Clomipramine: 25 mg taken 4-24 hours before intercourse 1

Important note: None of these medications are FDA-approved specifically for premature ejaculation treatment in the US 1

Second-Line Options

1. Topical anesthetics:

   • Lidocaine/prilocaine cream (EMLA) 2.5%/2.5% applied 20-30 minutes before intercourse
   • Must be washed off before intercourse to prevent partner numbness 1

2. PDE-5 inhibitors:

   • Particularly beneficial for patients with comorbid erectile dysfunction 1

3. α1-adrenoceptor antagonists:

   • Consider for patients who have failed first-line therapy 1

Side Effects and Precautions

SSRI Side Effects

• Common side effects include:
  • Nausea
  • Dry mouth
  • Drowsiness
  • Decreased libido
  • Ejaculatory delay (14% with sertraline vs. 1% with placebo) 1, 2

Contraindications and Precautions

• SSRIs should be avoided in:
  • Patients with bipolar disorder (risk of mania)
  • Used with caution in adolescents and patients with depressive disorders 1
• Drug interactions: Use caution with medications metabolized by cytochrome P450 system 1

Treatment Approach

Step 1: Distinguish PE from Erectile Dysfunction

• Treat erectile dysfunction first if both conditions coexist, as PE may improve once ED is effectively managed 1

Step 2: Select Treatment Based on PE Type

• For primary (lifelong) PE:

  • Start with daily SSRI therapy
  • Consider combination with behavioral techniques

• For secondary (acquired) PE:

  • Identify and address underlying causes (anxiety, ED)
  • Consider situational dosing for occasional issues 1

Step 3: Combination Therapy

• Combining behavioral therapy with pharmacological approaches (particularly SSRIs) provides greater improvement in ejaculation latency time than either modality alone 1

Monitoring and Follow-up

• Assess treatment efficacy using:

  • Patient and partner satisfaction (primary outcome)
  • Intravaginal Ejaculation Latency Time (IELT)
  • Premature Ejaculation Diagnostic Tool (PEDT) scores 1

• Regular follow-up is essential to:

  • Adjust therapy based on response and side effects
  • Monitor for adverse events
  • Note that symptoms usually return upon discontinuing therapy 1

Important Clinical Considerations

• Long-term therapy is typically required as PE usually returns upon medication discontinuation 1
• Safety should be a primary consideration since PE is not a life-threatening condition 1
• Patient and partner satisfaction should be the primary measure of treatment success 1

Remember that premature ejaculation can significantly impact quality of life and relationships, so effective treatment can substantially improve overall well-being despite the need for ongoing therapy in most cases.