What are the treatment options for premature ejaculation, including medications and their dosages?

Treatment Options for Premature Ejaculation

Selective serotonin reuptake inhibitors (SSRIs) and topical anesthetics are the first-line treatments for premature ejaculation, with daily SSRIs providing the strongest ejaculation delay. 1

First-Line Pharmacological Options

Oral Medications (SSRIs and Clomipramine)

• Daily SSRI therapy is the most effective pharmacological approach for premature ejaculation 1:

  • Paroxetine: 10-40 mg daily (most effective, increases ejaculatory latency 8.8-fold over baseline) 1
  • Sertraline: 25-200 mg daily 1
  • Fluoxetine: 5-20 mg daily 1
  • Citalopram: 20-40 mg daily 1
  • Clomipramine (tricyclic antidepressant): 25-50 mg daily 1

• On-demand (situational) dosing is also effective but provides less ejaculatory delay than daily treatment 1:

  • 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

Topical Anesthetics

• Lidocaine/prilocaine cream (EMLA): Apply 2.5%/2.5% cream 20-30 minutes before intercourse 1
• Provides moderate effectiveness in delaying ejaculation 1

Dosing Considerations

Continuous vs. Situational Dosing

• Continuous (daily) dosing provides more consistent and stronger ejaculatory delay 1

• Situational dosing may be preferred when:

  • Sexual activity is infrequent 1
  • Patient concerns exist about daily medication use 1
  • Less medication exposure is desired 1

• Some clinicians initiate with a daily "loading period" before transitioning to situational dosing 1

Duration of Therapy

• Treatment is typically needed on a continuing basis 1
• Premature ejaculation usually returns upon discontinuing therapy 1
• No clear evidence that SSRIs will effect an eventual cure of PE 1

Safety Considerations and Side Effects

• Common side effects of SSRIs 2:

  • Ejaculation failure (delayed ejaculation): 11-14%
  • Decreased libido: 6-7%
  • Nausea: 25%
  • Dry mouth: 14%
  • Insomnia: 21%
  • Dizziness: 12%
  • Fatigue: 12%

• Important safety warnings 1:

  • Avoid sudden cessation of daily SSRIs (risk of withdrawal syndrome)
  • Avoid SSRIs in patients with bipolar disorder (risk of mania)
  • Use caution in adolescents and depressed patients (small risk of suicidal ideation)
  • Monitor for serotonin syndrome, especially with multiple serotonergic medications

• SSRIs are preferred over clomipramine due to better side effect profile 1

Treatment Selection Algorithm

1. First choice: Daily SSRI therapy (paroxetine 10-20 mg daily) for most consistent results 1
2. Alternative for infrequent sexual activity: On-demand SSRI or clomipramine 1
3. For patients concerned about systemic effects: Topical anesthetics 1
4. For patients with partial response: Consider combination of daily low-dose SSRI with on-demand dosing 1

Important Clinical Considerations

• None of these medications are FDA-approved specifically for premature ejaculation in the US 1
• Treatment should prioritize safety since PE is not life-threatening 1
• Patient preference and frequency of sexual activity should guide treatment choice 1
• Psychological factors (anxiety, depression, relationship issues) may contribute to PE and should be addressed 1
• Psychological/behavioral therapy may be useful even when no clear psychological etiology is apparent 1

Treatment Efficacy

• Meta-analyses show paroxetine has the strongest ejaculation-delaying effect among SSRIs 1, 3
• Daily SSRI treatment is significantly more effective than on-demand treatment 3, 4
• Topical anesthetics provide moderate efficacy with minimal systemic effects 1

Remember that patient satisfaction and quality of life should be the primary outcome measures when evaluating treatment success 1.