What are the treatment options for premature ejaculation?

Treatment of Premature Ejaculation

Combine daily SSRIs (paroxetine 10-40 mg preferred) with behavioral therapy as first-line treatment, as this combination is more effective than either approach alone. 1, 2

Initial Assessment

Before initiating treatment, obtain a detailed sexual history focusing on: 2

• Time to ejaculation (median normal is 5-6 minutes) 3
• Frequency and duration of premature ejaculation 2
• Impact on sexual activity and quality of life 2
• Presence of erectile dysfunction 2

If erectile dysfunction coexists, treat the erectile dysfunction first—premature ejaculation often improves when erectile dysfunction is effectively managed. 1, 2

First-Line Pharmacologic Treatment

Daily SSRIs (Preferred)

Paroxetine provides the greatest ejaculatory delay, increasing ejaculatory latency time by 8.8-fold over baseline. 2, 3

Recommended daily dosing regimens: 2

• Paroxetine: 10-40 mg/day (strongest evidence)
• Sertraline: 25-200 mg/day
• Fluoxetine: 5-20 mg/day
• Citalopram: 20-40 mg/day
• Clomipramine: 12.5-50 mg/day

Start at the lowest effective dose compatible with reasonable success. 2

Critical Safety Warnings for SSRIs

SSRIs are not FDA-approved for premature ejaculation. 2 Common adverse effects include: 1, 4, 5, 4

• Ejaculatory delay/failure (11-23% with sertraline, 13-28% with paroxetine)
• Decreased libido (6-12%)
• Nausea (25-26%)
• Dry mouth (14-16%)
• Insomnia (13-25%)

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. 2

Up to 40% of patients may discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, treatment effects below expectations, or cost. 1

Topical Anesthetics (Alternative First-Line)

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

Critical timing: 2

• Apply 20-30 minutes prior to intercourse
• Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness

Use with a condom or thorough penis washing to prevent partner numbness from transfer. 1

Behavioral Therapy Integration

Combining behavioral and pharmacological treatment leads to significantly greater increase in ejaculatory latency time compared to pharmacological therapy alone. 1, 3

Consider referring to a mental health professional with expertise in sexual health, particularly when psychological factors are prominent. 3

Second-Line Treatment Options

Alpha-1 Adrenoreceptor Antagonists

For men who have failed first-line therapy, consider α1-adrenoreceptor antagonists (alfuzosin, terazosin), though efficacy data remains limited and requires additional controlled studies. 1, 2

Combination Strategies for Treatment-Resistant Cases

Sildenafil citrate combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though increases headache and flushing. 2

For treatment-resistant cases, combining multiple therapeutic approaches, including α1-adrenoreceptor antagonists as add-on therapy, may be considered. 1, 3

Treatment Algorithm

1. Assess for erectile dysfunction first—if present, treat before addressing premature ejaculation 1, 2
2. Start daily paroxetine 10-40 mg (or alternative SSRI) plus behavioral therapy 1, 2, 3
3. Alternative: Topical lidocaine/prilocaine cream 20-30 minutes before intercourse 1, 2
4. If inadequate response: Add α1-adrenoreceptor antagonist or combine SSRI with PDE-5 inhibitor 1, 2
5. Consider mental health referral when psychological factors are prominent 3

Critical Pitfalls to Avoid

Never perform surgical interventions—they are considered experimental and may result in permanent loss of penile sensation, and should only be used in the context of ethical board-approved clinical trials. 1

Use tramadol with extreme caution due to its opioid-like properties and risk of dependency, particularly in the context of the opioid crisis. 1

Patient and partner satisfaction is the primary target outcome, not just ejaculatory latency time—treatment choices should be based on patient and partner reports of efficacy, side effects, and acceptance. 2, 3

Discuss the off-label nature of pharmacologic therapies and all risks and benefits before initiating treatment. 2