What are the treatment options for premature ejaculation?

Treatment of Premature Ejaculation

First-Line Treatment: Daily SSRIs

Daily paroxetine 10-40 mg is the most effective first-line pharmacologic treatment for premature ejaculation, providing an 8.8-fold increase in ejaculatory latency time over baseline. 1, 2

SSRI Dosing Regimens

• Paroxetine 10-40 mg/day (strongest evidence, maximal ejaculatory 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

Critical Safety Warnings

• All SSRIs are off-label for premature ejaculation and not FDA-approved for this indication 1
• Common adverse effects include ejaculation failure (14% with sertraline, 13-28% with paroxetine), decreased libido (3-6%), nausea, insomnia, and dry mouth 1, 3, 4
• Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation 1
• Patients must be counseled about the off-label nature and potential side effects before starting treatment 1

Alternative First-Line: Topical Anesthetics

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

Application Guidelines

• Apply to the penis exactly 20-30 minutes prior to intercourse 1
• Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness 1
• This option provides drug-free spontaneity without systemic adverse effects 5

Essential Pre-Treatment Assessment

Before initiating any treatment, obtain a detailed sexual history focusing on: 1

• Time to ejaculation and frequency/duration of premature ejaculation
• Relationship to specific partners
• Impact on sexual activity and quality of life
• Presence of concomitant erectile dysfunction

Critical Management Algorithm for Comorbid ED

If erectile dysfunction coexists with premature ejaculation, treat the erectile dysfunction first—premature ejaculation may improve when erectile dysfunction is effectively managed. 1, 2

Combination Therapy for Enhanced Outcomes

Combining behavioral and pharmacological approaches is more effective than either modality alone. 1, 2

Specific Combination Options

• Sildenafil citrate combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though it increases headache and flushing 1
• Physical behavioral techniques (squeeze, stop-start, sensate focus) combined with SSRIs provide better outcomes than SSRIs alone, with improvements in IELT of 0.5-1 minute and significantly better sexual satisfaction and ejaculatory control 6

Behavioral Therapy Approaches

Behavioral therapies are legitimate treatment options that can improve IELT by 7-9 minutes over waitlist controls. 7, 6

Effective Techniques

• Functional-sexological treatment teaching arousal control without interrupting sexual activity 7
• Traditional squeeze and stop-start techniques 7, 6
• Sensate focus exercises 6
• Pelvic floor rehabilitation 6

Integration with Pharmacotherapy

• Most psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model 2
• Combination therapy addresses both physiological and psychological factors including depression, anxiety, decreased self-esteem, and relationship conflict 2

Second-Line Options for Treatment Failures

For men who have failed first-line therapy, consider alpha-1 adrenoceptor antagonists (alfuzosin, terazosin), though efficacy data remains limited. 1, 8

Treatment Goals and Monitoring

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

Decision-Making Framework

• Treatment choices should be based on patient and partner reports of efficacy, side effects, and acceptance 1
• Start treatment at the lowest effective dose compatible with reasonable success 1
• Discuss risks and benefits of all treatment options before intervention 1

Common Pitfalls to Avoid

• Do not use SSRIs without counseling about off-label use and potential sexual side effects (ejaculation failure, decreased libido) 1, 3, 4
• Do not leave topical anesthetics on for more than 30 minutes to avoid erectile dysfunction from excessive numbness 1
• Do not treat premature ejaculation before addressing coexisting erectile dysfunction 1, 2
• Do not rely solely on pharmacotherapy—combination with behavioral approaches yields superior outcomes 1, 2, 6