Treatment of Delayed Ejaculation
Begin by identifying and eliminating causative medications—particularly SSRIs, antipsychotics, and antihypertensives—through dose adjustment, replacement, or staged cessation, as this addresses the most common reversible cause of delayed ejaculation. 1
Initial Assessment and Reversible Causes
The first priority is identifying and correcting reversible factors:
- Check morning testosterone levels in all men with delayed ejaculation, as progressively lower serum testosterone correlates with increased symptoms of delayed ejaculation. 1, 2
- Offer testosterone replacement therapy per AUA guidelines for men with biochemically confirmed low testosterone and symptoms. 1, 2
- Treat comorbid erectile dysfunction first according to AUA guidelines, as ED and delayed ejaculation share common risk factors (medications, endocrine conditions, penile sensation loss, psychological factors) and the chronology matters for treatment sequencing. 1, 2
- Obtain basic serum studies including electrolytes, lipids, and glycosylated hemoglobin to identify medical conditions predisposing to neuropathy or vascular disease. 1
First-Line Behavioral and Psychological Interventions
Behavioral modifications represent the lowest-risk first-line approach and should be initiated before or alongside any pharmacotherapy:
- Advise modifying sexual positions or practices to increase arousal, as adequate arousal is essential for optimal ejaculatory function through psychosexual mechanisms. 1, 2
- Incorporate alternative sexual practices, scripts, and sexual enhancement devices to increase both physical and psychological arousal. 1, 2
- Include sexual partners in decision-making when possible, as this is fundamental to optimizing outcomes. 2
- Address age-related increases in ejaculatory latency with psychological and behavioral approaches aimed at increasing the repertoire of behaviors, as age combines psychological and physiological processes that contribute to delayed ejaculation. 1
These approaches avoid the risks of pharmacotherapies that have a very limited evidence basis and carry risk of treatment-related adverse events. 1
Pharmacological Options (All Off-Label)
No FDA-approved treatments exist for delayed ejaculation, and all pharmacotherapy is off-label with weak evidence. 2 Patients require counseling about the limited evidence base and potential for known and unknown side effects. 2
Sympathomimetic Agents
Consider on an individualized basis with appropriate counseling:
- Pseudoephedrine 60-120 mg taken 120-150 minutes prior to sex 1, 2
- Ephedrine 15-60 mg taken 1 hour prior to sex 1, 2
- Midodrine 5-40 mg taken 30-120 minutes prior to sex 1, 2
Other Pharmacological Options
Additional agents with potential benefit include:
- Oxytocin 24 IU intranasal/sublingual during sex 1, 2
- Bethanecol 20 mg daily 1, 2
- Yohimbine 5.4 mg three times daily 1, 2
- Cabergoline 0.25-2 mg twice weekly 1, 2
- Imipramine 25-75 mg daily 1, 2
- Bupropion and amantadine have been reported in case series but lack robust evidence 3, 4
Important Clinical Caveats
- Patient and partner satisfaction is the primary target outcome, not arbitrary physiological measures. 2
- Orgasm and ejaculation are distinct from erection and can be impaired independently; 20% of diabetic men with erectile dysfunction experience orgasmic dysfunction separately. 2
- A multimodal approach combining psychosexual therapy with medications will likely provide the best outcomes, particularly in complicated cases. 3
- Penile vibratory stimulation has been described as an adjunct treatment option but with limited evidence. 3
- Avoid sudden cessation of any initiated medications, particularly if SSRIs are used off-label, as withdrawal syndromes can occur. 1