Treatment of Premature Ejaculation
The most effective approach combines daily SSRIs (paroxetine 10-40 mg preferred as first-line) with behavioral therapy, as this combination produces significantly greater improvements in ejaculatory latency time than either treatment alone. 1, 2
First-Line Pharmacotherapy
Daily SSRIs (Preferred)
- Paroxetine is the most effective SSRI, increasing ejaculatory latency time by 8.8-fold over baseline 2
- Recommended daily dosing regimens: 2
- Paroxetine: 10-40 mg daily
- Sertraline: 50-200 mg daily
- Fluoxetine: 20-40 mg daily
- Citalopram: 20-40 mg daily
- Clomipramine: 12.5-50 mg daily
Important caveat: These are off-label uses, and 40% of patients discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, effects below expectations, or cost 1. Common side effects include ejaculatory delay (14% with sertraline), decreased libido (6%), dry mouth, nausea, and insomnia 3.
Topical Anesthetics (Alternative First-Line)
- Lidocaine/prilocaine cream applied 20-30 minutes before intercourse is an effective first-line option with minimal side effects 2
- Critical precaution: Use with a condom or wash penis thoroughly before intercourse to prevent partner numbness from anesthetic transfer 1
- May cause penile hypoesthesia 1
Behavioral Therapy Integration
Always combine pharmacotherapy with behavioral approaches for optimal outcomes 1, 2:
- Behavioral interventions enhance psychosexual arousal and remove barriers interfering with sexual excitement 4
- Modifying sexual positions or practices to increase arousal provides additional benefit 4
- Psychotherapy integrating psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model is useful 2, 5
Treatment Algorithm for Comorbid Conditions
If erectile dysfunction coexists with premature ejaculation, treat the erectile dysfunction first, as PE may improve when ED is managed 1, 2
Second-Line Options
For patients who fail first-line therapy:
- α1-Adrenoreceptor antagonists may be considered, though efficacy data are limited and additional controlled studies are needed 1
- Combining multiple therapeutic approaches as add-on therapy for treatment-resistant cases 1
Critical Contraindications
Avoid surgical interventions entirely—they are experimental and may result in permanent loss of penile sensation, and should only be used in ethical board-approved clinical trials 1
Use tramadol with extreme caution due to opioid-like properties and dependency risk, particularly concerning in the context of the opioid crisis 1
Psychological Considerations
- Refer men with lifelong or acquired delayed ejaculation (not premature ejaculation) to a mental health professional with sexual health expertise 4
- Depression, anxiety, decreased self-esteem, and relationship conflict are associated with PE, though causality remains unclear 2
- Opening communication between partners about sexual needs and desires facilitates treatment 4