What treatment options are available for a male with premature ejaculation and erectile dysfunction?

Treatment of Premature Ejaculation and Erectile Dysfunction

When both premature ejaculation and erectile dysfunction coexist, treat the erectile dysfunction first, as ED treatment often resolves secondary premature ejaculation. 1

Initial Diagnostic Priorities

Distinguish between primary erectile dysfunction versus secondary premature ejaculation. Many men develop PE as a consequence of ED—either from anxiety about maintaining erections or from requiring intense stimulation to achieve adequate rigidity. 1 The sexual history must clarify:

• Whether ejaculation occurs before desired due to lack of control (PE) versus loss of erection after normal ejaculation being misinterpreted as ED 1
• Timing: Does premature ejaculation predate erectile problems, or did it develop after ED onset? 1
• Intravaginal ejaculatory latency time (IELT): Self-estimated timing of ejaculation after penetration, with <2 minutes indicating PE 1

Treatment Algorithm

Step 1: Address Erectile Dysfunction First

Initiate phosphodiesterase-5 inhibitors (PDE5-Is) as first-line therapy for erectile dysfunction. 1, 2 Options include sildenafil, tadalafil, or vardenafil, which have high efficacy and safety even in difficult-to-treat populations like diabetic patients. 2

• Assess cardiovascular risk before prescribing PDE5-Is, as high-risk profiles (unstable angina, uncontrolled hypertension, recent MI <2 weeks, NYHA class IV heart failure) contraindicate sexual activity and PDE5-I use 1
• PDE5-Is are absolutely contraindicated with concurrent nitrate or riociguat use 1
• Many patients experience resolution of premature ejaculation once erectile function improves 1

Step 2: Treat Persistent Premature Ejaculation

If premature ejaculation persists after ED treatment, add selective serotonin reuptake inhibitors (SSRIs) as the primary pharmacologic intervention. 1, 3, 2 All SSRI use for PE is off-label in the United States. 1, 3

SSRI Options:

• Daily dosing SSRIs: Paroxetine, sertraline, fluoxetine, or clomipramine provide the most robust evidence 1, 2
• On-demand dapoxetine: The only agent approved for PE in Europe (though not FDA-approved in the US), taken 1-3 hours before sexual activity 2, 4
• Combination therapy yields superior outcomes: Behavioral therapy combined with pharmacotherapy outperforms either modality alone 3

Alternative Pharmacologic Options:

• Topical anesthetics: Lidocaine-prilocaine creams or sprays applied 20-30 minutes before intercourse effectively delay ejaculation 1, 2, 4
• Combination of PDE5-Is and SSRIs: For men with comorbid PE and ED, this combination can be offered after addressing ED first 5

Step 3: Behavioral and Psychological Interventions

Incorporate behavioral modifications and consider involving the sexual partner in treatment decisions. 1, 3 Shared decision-making with partner involvement optimizes outcomes. 1, 3

• Modify sexual positions or practices to increase arousal and control 6, 3
• Alternative sexual scripts and enhancement devices may benefit both conditions 6, 3
• Referral to mental health professionals with sexual health expertise should be considered, particularly for lifelong PE 3

Critical Safety Considerations

No FDA-approved medications exist specifically for premature ejaculation—all pharmacotherapy is off-label use. 1, 3 Patients require counseling about:

• The off-label nature of treatment and weak evidence base for some interventions 6, 3
• Potential for known and unknown side effects 6
• SSRI adverse effects including decreased libido, delayed orgasm, and discontinuation symptoms 4

Avoid surgical interventions for PE. Procedures like dorsal nerve neurotomy, radiofrequency ablation, or hyaluronic acid augmentation should only be performed in ethical board-approved clinical trials due to risk of permanent penile sensation loss. 3

Treatment Targets

Patient and partner satisfaction—not arbitrary physiological measures—represents the primary treatment outcome. 1, 6 The goals are:

• Regaining sense of control over ejaculation timing 7
• Achieving satisfaction with sexual intercourse for both partners 7
• Reducing distress and interpersonal difficulties 1

Common Pitfalls

Do not treat premature ejaculation before addressing erectile dysfunction when both conditions coexist. 1 This sequencing error leads to treatment failure, as the PE may be secondary to ED-related anxiety.

Do not assume loss of erection after ejaculation represents erectile dysfunction. Some men misinterpret normal post-ejaculatory detumescence as ED when the actual problem is premature ejaculation. 1