What are the treatment options for premature ejaculation?

Treatment of Premature Ejaculation

First-Line Pharmacologic Treatment

Daily SSRIs are the recommended first-line pharmacologic therapy for premature ejaculation, with paroxetine 10-40 mg/day providing the greatest ejaculatory delay—increasing ejaculatory latency time by 8.8-fold over baseline. 1, 2

SSRI Dosing Regimens

• Paroxetine 10-40 mg/day (strongest evidence, maximal delay) 1, 2
• 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

Start at the lowest effective dose and titrate based on response. 1

Critical Safety Warnings for SSRIs

• SSRIs are NOT FDA-approved for premature ejaculation—this is off-label use. 1, 3
• Common adverse effects include ejaculation failure (14% with sertraline, 23% with paroxetine), decreased libido (3-6%), nausea, insomnia, and dry mouth. 4, 5
• Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation, though elevated risk has not been found in non-depressed men with PE. 1
• Up to 40% of patients discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, effects below expectations, or cost. 3

First-Line Topical Treatment

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

Application Guidelines

• Apply to the penis 20-30 minutes before intercourse 1, 2
• Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness 1
• Use with a condom or thoroughly wash the penis before intercourse to prevent partner numbness and hypoesthesia 3

Behavioral Therapy Integration

Combining behavioral and pharmacological approaches is more effective than either modality alone (Moderate Recommendation, Evidence Level Grade B). 1, 2, 3

• Behavioral therapy alone shows limited long-term efficacy 6
• Combined treatment leads to significantly greater increases in ejaculatory latency time and improves validated PE assessment scores 3
• Most psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model 2
• Partner involvement is extremely useful for optimizing and stabilizing results 7

Managing Comorbid Erectile Dysfunction

If erectile dysfunction coexists with premature ejaculation, treat the erectile dysfunction FIRST, as PE may improve when ED is effectively managed. 1, 2, 3

Second-Line Options

Alpha-1 Adrenoceptor Antagonists

• Consider alfuzosin or terazosin for men who have failed first-line therapy 1, 3
• Efficacy data remains limited and requires additional controlled studies 1, 3, 8

Combination Therapy

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

Treatment Algorithm

1. Obtain detailed sexual history: time to ejaculation, frequency/duration of PE, relationship to specific partners, impact on quality of life, presence of concomitant ED 1

2. If ED present: Treat erectile dysfunction first 1, 2, 3

3. Initiate first-line therapy:

   • Daily paroxetine 10-40 mg (preferred) OR other SSRI 1, 2
   • OR topical lidocaine/prilocaine cream 20-30 minutes before intercourse 1, 2

4. Add behavioral therapy: Combination is more effective than pharmacotherapy alone 1, 2, 3

5. If first-line fails: Consider alpha-1 adrenoceptor antagonists 1, 3

6. For treatment-resistant cases: Combine multiple therapeutic approaches 3

Treatment Goals

Patient and partner satisfaction is the primary target outcome for PE treatment, not just ejaculatory latency time. 1, 2

Treatment choices should be based on patient and partner reports of efficacy, side effects, and acceptance. 1

Critical Pitfalls to Avoid

• Never perform surgical interventions—they are considered experimental, may result in permanent loss of penile sensation, and should only be used in ethical board-approved clinical trials 3
• Use tramadol with extreme caution due to opioid-like properties and risk of dependency, particularly in the context of the opioid crisis 3
• Always discuss the off-label nature of pharmacologic therapies and their risks/benefits before initiating treatment 1
• Recognize that behavioral therapies alone have limited evidence for short-term efficacy and lack support for long-term benefit 6