What are the treatment options for premature ejaculation?

Treatment for Premature Ejaculation

Daily selective serotonin reuptake inhibitors (SSRIs), particularly paroxetine 10-40 mg/day, should be your first-line pharmacologic treatment for premature ejaculation, as it provides the greatest ejaculatory delay with an 8.8-fold increase in ejaculatory latency time over baseline. 1

Initial Assessment and Comorbidity Screening

Before initiating treatment, obtain a detailed sexual history focusing on:

• Time to ejaculation and frequency/duration of premature ejaculation 1
• Relationship to specific partners and impact on quality of life 1
• Presence of concomitant erectile dysfunction—if present, treat the erectile dysfunction first, as premature ejaculation often improves when erectile dysfunction is effectively managed 1, 2

First-Line Pharmacologic Treatment: Daily SSRIs

Start with daily SSRI therapy using the following evidence-based regimens 1:

• Paroxetine 10-40 mg/day (strongest evidence, greatest ejaculatory delay) 1
• Sertraline 25-200 mg/day 1
• Fluoxetine 5-20 mg/day 1
• Citalopram 20-40 mg/day 1
• Clomipramine 12.5-50 mg/day 1

Critical Safety Warnings for SSRIs

SSRIs are not FDA-approved for premature ejaculation and carry significant side effects 1:

• Ejaculation failure occurs in 14% of sertraline patients vs. 1% placebo 3
• Decreased libido affects 6% of sertraline patients vs. 1% placebo 3
• Paroxetine causes abnormal ejaculation in 13-28% of patients vs. 0-1% placebo 4
• Other common effects include nausea, insomnia, dry mouth, and sweating 1, 3, 4
• Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation 1
• Up to 40% of patients discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, effects below expectations, or cost 2

Begin treatment at the lowest effective dose compatible with reasonable success 5

First-Line Non-Pharmacologic Treatment: Topical Anesthetics

Lidocaine/prilocaine cream (2.5 gm) applied 20-30 minutes prior to intercourse increases ejaculatory latency time with minimal side effects 5:

Application Protocol

• Apply topical anesthetic to penis 20-30 minutes before intercourse 5
• Use with condom or wash penis thoroughly before intercourse to prevent partner numbness 5, 2
• Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness 5

Contraindications

• Patient or partner allergy to any component of the product 5
• Penile hypoesthesia may limit acceptability 5

Combination Therapy: The Most Effective Approach

Combining behavioral and pharmacological approaches is more effective than either modality alone, producing significantly greater increases in ejaculatory latency time and improved scores on validated assessment instruments 1, 2:

• Combined therapy leads to better sexual satisfaction, ejaculatory control, and reduced anxiety compared to drug treatment alone 2, 6
• Physical behavioral techniques include squeeze method, stop-start technique, sensate focus, and pelvic floor rehabilitation 7, 6
• Behavioral therapy alone shows IELT improvements of 7-9 minutes over waitlist control in some studies 6

Second-Line Treatment: Alpha-1 Adrenoceptor Antagonists

For men who have failed first-line therapy, consider alpha-1 adrenoceptor antagonists (alfuzosin, terazosin), though efficacy data remains limited and additional controlled studies are needed 5, 2:

• One clinical trial showed modest efficacy with alfuzosin and terazosin 5
• May be used as add-on therapy in treatment-resistant cases 2

Adjunctive Options for Specific Scenarios

For Patients with Comorbid Erectile Dysfunction

• Sildenafil citrate combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though increases headache and flushing 5
• The hypothesis is that maintaining a rigid erection reduces the patient's need to rush to orgasm 5

Treatments to Avoid

Surgical interventions should be avoided as they are considered experimental, may result in permanent loss of penile sensation, and should only be used in ethical board-approved clinical trials 2:

• Phenoxybenzamine and propranolol lack sufficient evidence for recommendation 5
• Tramadol should be used with extreme caution due to opioid-like properties and risk of dependency, particularly concerning in the context of the opioid crisis 2

Treatment Goals and Ongoing Management

Patient and partner satisfaction is the primary target outcome for premature ejaculation treatment, not just ejaculatory latency time 1:

• Discuss risks and benefits of all treatment options before intervention, including the off-label nature of pharmacologic therapies 1
• Base choice of therapy on patient and partner reports of efficacy, side effects, and acceptance 5
• Provide regular review of alternative approaches 5
• Support and education of the patient and partner are integral parts of therapy 5