What is the best treatment for premature ejaculation?

Best Treatment for Premature Ejaculation

The best treatment for premature ejaculation is a combination of behavioral therapy and pharmacological approaches, as this combination is more effective than either modality alone. 1

First-Line Treatments

Pharmacological Options

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

   • Most effective pharmacological option for PE
   • Options include:
     • Paroxetine (10-40 mg daily or 20 mg 3-4 hours pre-intercourse) 1, 2
     • Sertraline (25-200 mg daily or 50 mg 4-8 hours pre-intercourse) 1, 3
     • Fluoxetine (5-20 mg daily) 1
   • Common side effects include:
     • Ejaculatory delay (intended effect) 3, 2
     • Decreased libido (6% vs 1% placebo) 3
     • Dry mouth (14% vs 8% placebo) 3
     • Nausea (25% vs 11% placebo) 3
   • Caution: Patients should be advised to avoid sudden cessation or rapid dose reduction of daily dosed SSRIs as this may precipitate SSRI withdrawal syndrome 1

2. Topical Anesthetics

   • Lidocaine/prilocaine cream (2.5% each) applied 20-30 minutes before intercourse 1
   • Moderately effective in delaying ejaculation 1
   • Potential side effects:
     • Penile hypoesthesia 1
     • Possible transfer to partner causing numbness 1
   • Use a condom or wash penis thoroughly before penetration to prevent partner numbness 1

Behavioral Therapies

1. Physical Techniques
   • Squeeze technique and stop-start method 4
   • Sensate focus exercises 4
   • Pelvic floor rehabilitation 4
   • These techniques can increase ejaculatory latency time by 7-9 minutes in some studies 4

Combination Therapy Approach

1. Combined behavioral and pharmacological treatment
   • Leads to significantly greater increase in ejaculatory latency time compared to pharmacological therapy alone 1
   • Improves scores on validated instruments for assessment of PE 1
   • Provides better long-term outcomes 5
   • Medications can help men better recognize premonitory sensations, facilitating behavioral change 5

Second-Line Treatments

1. α1-Adrenoreceptor Antagonists

   • Consider for men who have failed first-line therapy 1
   • Limited efficacy data available 1
   • Additional controlled studies needed to determine true role in PE management 1

2. PDE-5 Inhibitors

   • Consider for men with comorbid erectile dysfunction and PE 6
   • Treat erectile dysfunction first, then address PE 6
   • May be used in combination with SSRIs in difficult cases 6

Treatment Algorithm

1. For uncomplicated PE with stable partnerships:

   • Start with SSRIs (daily or on-demand dosing) or topical anesthetics 6
   • Add behavioral techniques for enhanced effectiveness 1, 4

2. For severe PE (IELT <30-60 seconds):

   • Consider combination of topical and oral medications 6

3. For PE with comorbid erectile dysfunction:

   • Treat erectile dysfunction first according to AUA Guidelines 1
   • Then address PE with appropriate therapy 1

4. For treatment-resistant cases:

   • Combine multiple therapeutic approaches 6, 5
   • Consider α1-adrenoreceptor antagonists as add-on therapy 1

Important Caveats

1. Surgical interventions should be avoided

   • Surgical management (including injection of bulking agents) should be considered experimental 1
   • Only use in context of ethical board-approved clinical trials 1
   • Risk of permanent loss of penile sensation 1

2. Treatment discontinuation issues

   • Up to 40% of patients refuse to begin or discontinue SSRI treatment within 12 months due to:
     • Concerns about taking antidepressants
     • Treatment effects below expectations
     • Cost 1

3. Tramadol caution

   • While sometimes used off-label, caution is advised due to opioid-like properties 1
   • Risk of dependency should be considered in the context of the opioid crisis 1

Remember that PE can significantly impact quality of life and sexual satisfaction for both the patient and partner, making effective treatment important for overall well-being 7, 5.