What are the treatment options for premature ejaculation?

Treatment Options for Premature Ejaculation

The most effective treatment for premature ejaculation is a combination of selective serotonin reuptake inhibitors (SSRIs), particularly paroxetine (10-40 mg/day), with behavioral therapy. 1

Pharmacological Treatment Options

First-Line Medications: SSRIs

SSRIs are the cornerstone of PE treatment, with several options available:

Daily SSRI Therapy

• Paroxetine: 10-40 mg/day (considered most effective) 1
• Sertraline: 25-200 mg/day 1
• Fluoxetine: 5-20 mg/day 1
• Clomipramine: 12.5-50 mg/day (a tricyclic antidepressant with SSRI properties) 1

On-Demand (Situational) SSRI Dosing

Many clinicians prefer this approach for patients who have intermittent sexual activity:

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

Important note: While on-demand dosing is convenient, daily dosing typically produces superior increases in ejaculation latency time 2

Topical Anesthetics

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

Additional Options for Specific Situations

• PDE-5 inhibitors: Beneficial primarily for patients with comorbid erectile dysfunction 1
• α1-adrenoceptor antagonists: Consider for patients who have failed first-line therapy 1

Important Considerations

Side Effects of SSRIs

• Common: Nausea, dry mouth, drowsiness, decreased libido 1
• Male-specific: Ejaculatory delay (14% with sertraline vs 1% with placebo) 3
• Other sexual side effects: Decreased libido (6% with sertraline vs 1% with placebo) 3
• Paroxetine side effects include abnormal ejaculation (21-28%), decreased libido (3-5%), and impotence (5-8%) 4

Treatment Duration and Expectations

• PE typically returns upon discontinuation of medication 1
• Long-term therapy is usually required for sustained benefit 1

Regulatory Status

• None of these medications are FDA-approved specifically for PE treatment in the US 1

Contraindications and Cautions

• Avoid SSRIs in patients with bipolar depression (risk of mania) 1
• Use with caution in adolescents and patients with depressive disorders 1
• Monitor for drug interactions, especially with medications metabolized by cytochrome P450 system 1

Treatment Algorithm

1. Initial Assessment:

   • Determine if PE is primary (lifelong) or secondary (acquired)
   • Rule out erectile dysfunction, which often leads to secondary PE 1
   • If erectile dysfunction is present, treat it first as PE may improve 1

2. First-Line Treatment:

   • Start with an SSRI (paroxetine preferred due to higher efficacy)
   • Choose between daily dosing or on-demand based on frequency of sexual activity
   • Consider adding behavioral therapy for enhanced results 1

3. If Inadequate Response:

   • Adjust dosage or switch to another SSRI
   • Consider adding topical anesthetics
   • For patients with comorbid ED, add PDE-5 inhibitors 1

4. For Treatment-Resistant Cases:

   • Consider α1-adrenoceptor antagonists 1
   • Evaluate for other underlying conditions

Measuring Treatment Success

• Primary outcome: Patient and partner satisfaction 1
• Objective measures: Intravaginal Ejaculation Latency Time (IELT) and Premature Ejaculation Diagnostic Tool (PEDT) scores 1
• Regular follow-up to assess efficacy and adjust therapy as needed 1

Remember that PE is not life-threatening, so safety should be a primary consideration when selecting treatment options 1.