What is the best on-demand medication for premature ejaculation?

Best On-Demand Medication for Premature Ejaculation

Lidocaine/prilocaine topical spray is the best on-demand medication for premature ejaculation, increasing intravaginal ejaculatory latency time (IELT) up to 6.3-fold with minimal systemic side effects. 1

Primary Recommendation: Topical Anesthetics

Lidocaine/prilocaine spray (EMA-approved formulation: lidocaine 150 mg/ml + prilocaine 50 mg/ml) should be your first-line on-demand treatment choice. 1, 2 This recommendation prioritizes both efficacy and quality of life:

• Provides superior IELT improvement (up to 6.3-fold increase over 3 months) compared to oral on-demand options 1, 2
• Minimal systemic effects with only minor local side effects (genital hypoesthesia) 1, 2
• No risk of systemic adverse events like nausea, dizziness, or serotonin syndrome that occur with oral medications 1
• Applied directly before intercourse without the timing constraints of oral medications 1

Alternative On-Demand Option: Dapoxetine

If topical therapy is unacceptable to the patient, dapoxetine 60 mg taken 1-3 hours before intercourse is the second-line on-demand choice: 1

• Specifically approved for on-demand PE treatment in many countries (not USA) 1
• Produces 3.0-fold IELT increase at 60 mg dose in general population 1, 2
• More effective in severe cases: In men with baseline IELT <30 seconds, dapoxetine 60 mg produces 4.3-fold IELT increase 1
• Start with 30 mg if tolerability is a concern, which produces 2.5-fold IELT increase 1

Critical Dapoxetine Limitations

Be aware that dapoxetine has significant real-world adherence problems: 1

• 90% discontinuation rate at 2 years, primarily due to cost (29.9%) and disappointment with on-demand nature (25%) 1
• Dose-dependent side effects: nausea (8.7% at 30 mg, 20.1% at 60 mg), diarrhea, dizziness, and headache 1, 3
• Less effective than daily SSRI therapy for consistent ejaculatory delay 2, 4

Off-Label On-Demand Option: Tramadol

Tramadol on-demand may be considered as a third-line option when approved treatments fail or are unavailable, but use with extreme caution: 1

• Produces up to 2.5-fold IELT increase 1, 2
• Significant safety concerns: addiction potential and limited long-term safety data 1, 2
• Should only be used after careful risk-benefit discussion with patients who understand addiction risks 1

Treatment Algorithm for On-Demand Therapy

Follow this decision pathway: 1, 2

1. First choice: Lidocaine/prilocaine spray for all patients seeking on-demand treatment 1, 2
2. If topical therapy refused or ineffective: Dapoxetine 30-60 mg 1, 2
3. If erectile dysfunction coexists: Treat ED first or concomitantly, as acquired PE may be secondary to ED 1, 2
4. If partial response to monotherapy: Consider combination of dapoxetine with PDE5 inhibitor, which shows superior results and enhances confidence and sexual satisfaction 1, 2

Critical Clinical Pitfalls to Avoid

Do not prescribe PDE5 inhibitors alone for PE in men with normal erectile function—they do not significantly improve IELT 1, 2

Counsel patients that daily SSRI therapy (paroxetine, sertraline, fluoxetine) is more effective than any on-demand option if they have frequent sexual activity, with paroxetine producing 8.8-fold IELT increase compared to 2.5-3.0-fold with on-demand dapoxetine 2, 4

On-demand SSRIs like paroxetine 20 mg taken 3-4 hours before intercourse are less effective than daily dosing and should not be first-line when daily therapy is feasible 2, 4

Screen for concurrent serotonergic medications before prescribing dapoxetine to avoid serotonin syndrome 4, 5