Treatment Options for Premature Ejaculation
Premature ejaculation can be effectively treated with several serotonin reuptake inhibitors (SRIs) or with topical anesthetics, with the optimal treatment choice based on physician judgment and patient preference. 1
Diagnosis and Assessment
- Premature ejaculation (PE) is diagnosed based on sexual history alone, with time to ejaculation being the most important feature 1
- PE is defined as ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to one or both partners 1
- Lifelong PE is characterized by poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of penetration that has been present since sexual debut 1
- Acquired PE involves consistently poor ejaculatory control with ejaculation latency markedly reduced from prior sexual experience 1
- In patients with concomitant PE and erectile dysfunction (ED), the ED should be treated first 1
First-Line Pharmacological Treatments
Serotonin Reuptake Inhibitors (SRIs)
- Several antidepressants that cause delayed ejaculation have been successfully used in PE management 1:
- Selective SRIs (SSRIs): fluoxetine, paroxetine, sertraline
- Tricyclic antidepressant: clomipramine
- Recommended dosing regimens 1:
- Paroxetine: 10-40 mg/day or 20 mg 3-4 hours pre-intercourse
- Sertraline: 25-200 mg/day or 50 mg 4-8 hours pre-intercourse
- Fluoxetine: 5-20 mg/day
- Clomipramine: 25-50 mg/day or 25 mg 4-24 hours pre-intercourse
Topical Anesthetics
- Lidocaine/prilocaine cream (EMLA) applied 20-30 minutes before intercourse 1
- Should be used with a condom or thoroughly washed off before intercourse to prevent partner numbness 2
Treatment Approaches
Continuous vs. Situational Dosing
- Both continuous daily dosing and situational (on-demand) dosing regimens have been evaluated 1
- Continuous administration may be more effective but could have compliance issues 1
- Situational dosing may be preferable for some men as it uses less medication 1
Combination Therapy
- Combined behavioral and pharmacological treatment leads to significantly greater increases in ejaculatory latency time compared to pharmacological therapy alone 2
- This combination approach improves scores on validated instruments for assessment of PE 2
Behavioral Therapies
- Physical techniques including squeeze technique, stop-start method, and sensate focus can be effective 3
- Some studies report IELT differences of 7-9 minutes with behavioral techniques compared to waitlist controls 3
- Behavioral therapies combined with drug treatments show better outcomes than drug treatments alone, with small but significant differences in IELT (0.5-1 minute) 3
Second-Line Treatments
- α1-Adrenoreceptor antagonists may be considered for men who have failed first-line therapy 2
- For treatment-resistant cases, combining multiple therapeutic approaches may be considered 2
Important Considerations and Cautions
- None of the medical therapies for PE has been approved by the FDA specifically for this indication, and their use is considered off-label 1
- Up to 40% of patients may refuse to begin or discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, treatment effects below expectations, or cost 2
- Common side effects of SSRIs include ejaculatory delay, decreased libido, dry mouth, and nausea 2, 4, 5
- Surgical interventions should be avoided as they may result in permanent loss of penile sensation 2
- Tramadol should be used with caution due to its opioid-like properties and risk of dependency 2