What are the management options for premature ejaculation?

Management of Premature Ejaculation

Daily SSRIs, particularly paroxetine 10-40 mg/day, are the first-line pharmacologic treatment for premature ejaculation, providing the greatest ejaculatory delay with an 8.8-fold increase in ejaculatory latency time over baseline. 1, 2

Initial Assessment and Comorbidity Screening

Before initiating treatment, obtain a detailed sexual history focusing on: 1

• Time to ejaculation and frequency/duration of premature ejaculation
• Relationship to specific partners
• Impact on sexual activity and quality of life
• Presence of concomitant erectile dysfunction—if present, treat the erectile dysfunction first, as premature ejaculation often improves when erectile dysfunction is effectively managed 1, 3, 2

First-Line Treatment Options

Daily SSRIs (Preferred Pharmacologic Approach)

Paroxetine provides the strongest effect among SSRIs and should be the first choice for pharmacologic therapy. 1, 2 Recommended daily dosing regimens include: 1, 2

• Paroxetine 10-40 mg/day (most effective, 8.8-fold increase in ejaculatory latency time)
• Sertraline 25-200 mg/day
• Fluoxetine 5-20 mg/day
• Citalopram 20-40 mg/day
• Clomipramine 12.5-50 mg/day

Critical safety warnings: 1, 3

• SSRIs are not FDA-approved for premature ejaculation (off-label use)
• Common adverse effects include ejaculation failure (14% with sertraline), decreased libido (6%), nausea, insomnia, and dry mouth 4
• Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation 1
• Up to 40% of patients may discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, effects below expectations, or cost 3

Topical Anesthetics (Alternative First-Line)

Lidocaine/prilocaine cream applied 20-30 minutes prior to intercourse increases ejaculatory latency time with minimal side effects. 1, 2

Important caveats: 1, 3

• Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness
• May cause penile hypoesthesia and transfer to partners
• Use with a condom or thorough penis washing to prevent partner numbness

Combination Therapy (Most Effective Approach)

Combining behavioral and pharmacological approaches is more effective than either modality alone and should be recommended when feasible. 1, 3, 2 This combination leads to significantly greater increases in ejaculatory latency time and improves scores on validated assessment instruments. 3

Behavioral techniques include: 5, 6

• Squeeze and stop-start techniques
• Sensate focus exercises
• Pelvic floor rehabilitation

Sildenafil citrate combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though it increases headache and flushing. 1

Second-Line Options

For men who have failed first-line therapy, consider alpha-1 adrenoceptor antagonists (such as alfuzosin and terazosin), though efficacy data remains limited and additional controlled studies are needed. 1, 3

Treatment Initiation and Monitoring

Start treatment at the lowest effective dose compatible with reasonable success. 1 Patient and partner satisfaction is the primary target outcome, not just ejaculatory latency time. 1 Treatment choices should be based on patient and partner reports of efficacy, side effects, and acceptance. 1

Discuss risks and benefits of all treatment options before intervention, including the off-label nature of pharmacologic therapies. 1

Critical Pitfalls to Avoid

• Never perform surgical interventions—they are considered experimental and may result in permanent loss of penile sensation. They should only be used in the context of ethical board-approved clinical trials. 3
• Use tramadol with extreme caution due to its opioid-like properties and risk of dependency, particularly in the context of the opioid crisis. 3
• Do not overlook psychological factors including depression, anxiety, decreased self-esteem, and relationship conflict, which are associated with premature ejaculation (though causality is unclear). 2
• Refer to a mental health professional with sexual health expertise when psychological factors are prominent. 2

Treatment Algorithm Summary

1. Screen for and treat erectile dysfunction first if present 1, 3, 2
2. Initiate daily paroxetine 10-40 mg/day OR topical lidocaine/prilocaine cream 1, 2
3. Add behavioral therapy to pharmacotherapy for enhanced outcomes 1, 3, 2
4. Consider alpha-1 adrenoceptor antagonists for treatment-resistant cases 1, 3
5. Monitor for adverse effects and adjust based on patient/partner satisfaction 1