What are the treatment options for premature ejaculation?

Treatment Options for Premature Ejaculation

Premature ejaculation can be effectively treated with serotonin reuptake inhibitors (SRIs) or topical anesthetics, with combination therapy including behavioral techniques providing the best outcomes for improving ejaculatory control and sexual satisfaction. 1, 2

Initial Assessment and Approach

• Diagnosis of PE is based on sexual history alone, focusing on time to ejaculation as the most important feature 2
• In patients with concomitant PE and erectile dysfunction (ED), the ED should be treated first, as PE may improve once ED is effectively managed 2
• Patient and partner satisfaction should be the primary target outcome for treatment 2

First-Line Pharmacological Treatments

Serotonin Reuptake Inhibitors (SRIs)

• SSRIs such as paroxetine, sertraline, and fluoxetine are effective first-line pharmacological treatments 1, 2
• Common side effects include:
  • Ejaculatory delay (14% vs 1% with placebo) 3
  • Decreased libido (6% vs 1% with placebo) 3
  • Dry mouth (14% vs 8% with placebo) 3
  • Nausea (25% vs 11% with placebo) 3
• Up to 40% of patients may discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, suboptimal effects, or cost 1

Topical Anesthetics

• Lidocaine/prilocaine creams can effectively delay ejaculation 1, 2
• Should be used with a condom or thoroughly washed off before intercourse to prevent partner numbness 1
• May cause penile hypoesthesia but generally well-tolerated 1

Combination Therapy Approach

• Combined behavioral and pharmacological treatment leads to significantly greater increases in ejaculatory latency time compared to pharmacological therapy alone 1, 4
• Behavioral techniques include:
  • Squeeze technique and stop-start methods 5, 6
  • Sensate focus exercises 6
  • Pelvic floor rehabilitation 6
• Studies show combination therapy can improve IELT by additional 0.5-1 minute over drug treatment alone, with better outcomes for sexual satisfaction and ejaculatory control 6

Second-Line Treatment Options

• α1-Adrenoreceptor antagonists may be considered for men who have failed first-line therapy 1, 4
• For treatment-resistant cases, combining multiple therapeutic approaches may be beneficial 1

Treatment Algorithm

1. Rule out and treat any concurrent erectile dysfunction first 2
2. Begin with either:
   • Daily SSRI treatment (paroxetine, sertraline, fluoxetine) 2, 1
   • On-demand topical anesthetics 2, 1
3. Add behavioral therapy techniques to pharmacological treatment for enhanced outcomes 1, 6
4. For inadequate response, consider α1-adrenoreceptor antagonists as add-on therapy 1, 4

Important Caveats

• None of the medical therapies currently employed in PE management has been FDA-approved specifically for this indication 2
• Surgical interventions should be avoided due to risk of permanent loss of penile sensation 1
• Behavioral therapies alone show mixed results - some studies report IELT improvements of 7-9 minutes while others show no significant difference 6
• Tramadol should be used with caution due to its opioid-like properties and risk of dependency 1
• Most pharmacological treatments provide only temporary delay in ejaculation latency time, with PE recurring when treatment is stopped 4