What are the treatment options for premature ejaculation?

Treatment Options for Premature Ejaculation

The most effective approach for treating premature ejaculation is a combination of behavioral techniques and pharmacological interventions, as this strategy provides superior outcomes compared to either modality alone. 1

First-Line Treatment Options

Pharmacological Approaches

• Selective Serotonin Reuptake Inhibitors (SSRIs) - Daily treatment with off-label SSRIs is highly effective in delaying ejaculation:

  • Paroxetine 10-40 mg (most effective, increasing ejaculatory latency time 8.8-fold over baseline)
  • Sertraline 50-200 mg
  • Fluoxetine 20-40 mg
  • Citalopram 20-40 mg 2

• On-demand SSRIs - Less effective than daily dosing but still beneficial when taken 3-6 hours before intercourse:

  • Dapoxetine (where available)
  • Clomipramine 12.5-50 mg 2, 3

• Topical Anesthetics - Well-established and moderately effective:

  • Lidocaine and prilocaine creams/sprays applied 20-30 minutes before intercourse
  • Use of condom or washing penis before penetration recommended to prevent partner numbness 2

Behavioral Techniques

• Stop-start technique - Stimulation is stopped when ejaculation feels imminent, then resumed after the sensation passes 4
• Squeeze technique - Applying pressure to the glans penis when ejaculation is imminent 4
• Sensate focus - Gradual progression from non-genital to genital touching 4
• Pelvic floor rehabilitation - Exercises to strengthen pelvic floor muscles 4

Treatment Algorithm

1. Assess for comorbid erectile dysfunction (ED)

   • If ED is present, treat this condition first according to ED guidelines 2
   • Acquired PE may be secondary to ED, while some men with lifelong PE may develop ED related to performance anxiety 2

2. First-line therapy:

   • Combined approach: Behavioral techniques plus pharmacotherapy 1
   • Daily SSRIs (paroxetine, sertraline, fluoxetine, citalopram) or topical anesthetics 2

3. If first-line therapy fails:

   • Consider α1-adrenoreceptor antagonists, though efficacy data remains limited 2
   • Try combination therapy with PDE5 inhibitors if there are signs of erectile dysfunction 3

Important Considerations and Precautions

• SSRI side effects: Patients should be informed about potential side effects including:

  • Ejaculatory delay (14% with sertraline vs 1% with placebo)
  • Decreased libido (6% with sertraline vs 1% with placebo)
  • Dry mouth, somnolence, dizziness, and nausea 5

• SSRI discontinuation: Advise patients to avoid sudden cessation or rapid dose reduction of daily SSRIs as this may precipitate withdrawal syndrome 2

• Topical anesthetic cautions:

  • May cause significant penile hypoesthesia
  • Possible absorption by partner causing numbness
  • Use condom or thoroughly wash penis before penetration 2

• Tramadol considerations: While sometimes used for PE, caution is advised due to its opioid-like properties and potential for dependence 2

• Surgical interventions: Should be considered experimental and only used in the context of an ethical board-approved clinical trial 2, 3

  • Procedures like dorsal nerve neurotomy or hyaluronic acid gel glans augmentation may cause permanent loss of penile sensation 2

Emerging Treatments

• New on-demand rapid-acting SSRIs
• Oxytocin receptor antagonists
• Agents targeting multiple receptors 3, 6

Treatment Efficacy

• Combined behavioral and pharmacological approaches show significantly greater increases in ejaculatory latency time compared to pharmacological therapy alone 1
• Daily dosing of SSRIs is associated with superior increases in intravaginal ejaculation latency time compared with on-demand SSRIs 3
• Behavioral therapies combined with drug treatments give better outcomes than drug treatments alone 4