Treatment of Premature Ejaculation
Start with daily paroxetine 10-40 mg as first-line pharmacologic therapy, as it provides the greatest ejaculatory delay (8.8-fold increase over baseline) among all available treatments. 1, 2
Initial Clinical Assessment
Before initiating treatment, obtain a detailed sexual history focusing on:
- Time to ejaculation and frequency/duration of premature ejaculation 1
- Whether the problem occurs with specific partners or all partners 1
- Impact on sexual activity and 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 Treatment Options
Daily SSRIs (Preferred Pharmacologic Approach)
Paroxetine is the most effective SSRI for premature ejaculation, increasing ejaculatory latency time by 8.8-fold over baseline 1, 2. Recommended daily dosing regimens include:
- Paroxetine: 10-40 mg/day (strongest evidence) 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 compatible with reasonable success 1. SSRIs work by targeting serotonergic pathways that centrally mediate ejaculation 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. Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness 1.
Critical Safety Warnings
SSRIs are not FDA-approved for premature ejaculation and are used off-label 1. Common adverse effects include:
- Ejaculation failure/delayed ejaculation: 14% with sertraline, 13-28% with paroxetine 4, 5
- Decreased libido: 6% with sertraline, 3% with paroxetine 4, 5
- Nausea, insomnia, dry mouth 1
Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation, though elevated risk has not been found in non-depressed men with premature ejaculation 1.
Combination Therapy for Enhanced Efficacy
Combining behavioral and pharmacological approaches is more effective than either modality alone 1, 2. Behavioral therapies include:
- Psychotherapy integrating psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model 2
- Functional-sexological treatment teaching arousal control without interrupting sexual activity 6
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 1, 2.
Treatment Goals and Monitoring
Patient and partner satisfaction is the primary target outcome for premature ejaculation treatment, 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.
Common Pitfalls to Avoid
- Do not use behavioral therapies alone as first-line treatment—while the squeeze and stop-start techniques have been traditional approaches, evidence for their long-term benefit is lacking 7
- Do not apply topical anesthetics for longer than 30 minutes to avoid erectile dysfunction 1
- Do not ignore coexisting erectile dysfunction—always address this first 1, 2
- Adherence to SSRI treatments is often low due to limited patient satisfaction, so set realistic expectations 8