Causes and Treatment of Erectile Dysfunction and Premature Ejaculation
When Both Conditions Coexist: Critical First Step
If you have both erectile dysfunction (ED) and premature ejaculation (PE), treat the erectile dysfunction first—the premature ejaculation often improves once erections are restored. 1, 2 Many men develop secondary PE due to anxiety about maintaining erections or requiring intense stimulation to achieve adequate rigidity. 2
Causes of Erectile Dysfunction
Vascular and Metabolic Factors
- Diabetes mellitus, hypertension, hyperlipidemia, obesity, and atherosclerosis are the primary pathophysiological mechanisms causing ED through vascular damage. 3, 4
- ED shares common risk factors with cardiovascular disease and should prompt evaluation for systemic vascular pathologies to prevent cardiac events. 5, 4
Neurologic and Hormonal Factors
- Neurologic disorders and testosterone deficiency contribute to ED. 3
- Prostate cancer treatment is a common iatrogenic cause. 3
Psychological Factors
- Performance anxiety and relationship issues are common psychological causes. 3
Medications and Substance Use
- Antidepressants and tobacco use are the most common medication-related and substance-related causes. 3
Causes of Premature Ejaculation
Classification
- Primary (lifelong) PE begins when a man first becomes sexually active. 1
- Secondary (acquired) PE develops later, often associated with ED, psychological factors (depression, anxiety, decreased self-esteem, relationship conflict), though causality remains unclear. 1, 6
Relationship to Erectile Dysfunction
- Approximately one-third of patients with ED also suffer from PE, and over 30% of patients with PE report concurrent ED. 7
- A vicious cycle may exist: men attempting to control ejaculation reduce arousal (leading to ED), while men trying to achieve erections increase arousal (leading to PE). 7
Treatment Algorithm for Erectile Dysfunction
First-Line: Phosphodiesterase-5 Inhibitors (PDE5-Is)
Start with oral PDE5-Is (sildenafil, tadalafil, or vardenafil)—these have high efficacy and safety even in difficult-to-treat populations like diabetic patients. 2, 5
Critical Safety Considerations
- Assess cardiovascular risk before prescribing: high-risk patients for whom sexual activity is inadvisable should not receive PDE5-Is. 8
- Absolute contraindication: concurrent nitrate or riociguat use (at least 48 hours must elapse after tadalafil before nitrate administration). 8
- Caution with alpha-blockers: start PDE5-Is at the lowest dose in patients taking alpha-blockers due to risk of symptomatic hypotension. 9
- Avoid in patients with: myocardial infarction within 90 days, unstable angina, uncontrolled arrhythmias, stroke within 6 months, or severe heart failure. 8
Lifestyle Modifications (Concurrent with Pharmacotherapy)
- Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia. 3
Second-Line Treatments
- Intracavernous injections of vasodilators, intraurethral alprostadil, or vacuum constriction devices. 5
Third-Line Treatment
Psychological Treatment
- Counseling is recommended for men with psychogenic ED. 3
Treatment Algorithm for Premature Ejaculation
First-Line: Daily SSRIs
Start with daily paroxetine 10-40 mg—this provides the greatest ejaculatory delay, increasing ejaculatory latency time by 8.8-fold over baseline. 10, 6
Alternative Daily SSRI Dosing
- Sertraline 25-200 mg/day 10
- Fluoxetine 5-20 mg/day 10
- Citalopram 20-40 mg/day 10
- Clomipramine 12.5-50 mg/day 10
Critical Safety Warnings
- All SSRIs are off-label for PE (not FDA-approved for this indication). 10, 2
- Adverse effects include: ejaculation failure, decreased libido, nausea, insomnia, and dry mouth. 10, 6
- Caution in adolescents and men with comorbid depression regarding suicidal ideation. 10
First-Line Alternative: Topical Anesthetics
- Lidocaine/prilocaine cream applied 20-30 minutes before intercourse increases ejaculatory latency with minimal side effects. 10, 6
- Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness. 10
On-Demand Option (Europe Only)
- Dapoxetine taken 1-3 hours before sexual activity is the only agent approved for PE in Europe, but not FDA-approved in the United States. 2
Combination Therapy
- Combining behavioral and pharmacological approaches is more effective than either alone. 10, 6
- Sildenafil combined with paroxetine on a situational basis enhances efficacy, though it increases headache and flushing. 10
Second-Line Treatment
- Alpha-1 adrenoceptor antagonists (alfuzosin, terazosin) may be considered for men who have failed first-line therapy, though efficacy data remains limited. 10
Behavioral and Psychological Interventions
- Psychotherapy integrating psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model may be useful. 6
- Modifying sexual positions or practices to increase arousal and control can benefit both conditions. 2
- Referral to mental health professionals with sexual health expertise should be considered, particularly for lifelong PE. 2
Diagnostic Approach
For Premature Ejaculation
- Diagnosis is based on sexual history alone—obtain detailed information on time to ejaculation (intravaginal ejaculatory latency time <2 minutes indicates PE), frequency and duration, relationship to specific partners, impact on sexual activity and quality of life, and presence of concomitant ED. 1, 2
- Laboratory or physiological testing is not required unless history and physical examination reveal indications beyond uncomplicated PE. 1
For Erectile Dysfunction
- Medical and sexual history, including validated questionnaires. 5
- Physical examination and laboratory testing (including morning testosterone) tailored to the patient's complaints and risk factors. 5, 6
Treatment Goals
Patient and partner satisfaction is the primary target outcome—not just ejaculatory latency time or erectile rigidity. 1, 10, 2 Treatment choices should be based on patient and partner reports of efficacy, side effects, and acceptance, with the goals of regaining control over ejaculation timing, achieving satisfaction with sexual intercourse for both partners, and reducing distress and interpersonal difficulties. 2