What are the treatment options for premature ejaculation?

From the Guidelines

Premature ejaculation can be effectively treated with daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics as first-line agents of choice. The treatment of premature ejaculation (PE) involves a combination of behavioral techniques, topical medications, and oral medications. For oral medications, selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (10-40mg daily), sertraline (50-200mg daily), fluoxetine (20-40mg daily), and citalopram (20-40mg daily) are effective in delaying ejaculation, with paroxetine exerting the strongest ejaculation delay, increasing ejaculatory latency time (ELT) a mean of 8.8-fold over baseline 1. On-demand administration of clomipramine, paroxetine, sertraline, and fluoxetine 3-6 hours before intercourse is also modestly efficacious and well-tolerated, but is associated with substantially less ejaculatory delay than daily treatment in most studies 1.

Some key points to consider when treating PE include:

• The use of off-label SSRIs is favored over the tricyclic antidepressant (TCA) clomipramine due to a better side effect profile 1.
• Treatment with SSRIs should be avoided in men with a history of bipolar depression due to the risk of mania 1.
• Caution is suggested in prescribing SSRIs to adolescents with PE and to men with PE and a co-morbid depressive disorder, particularly when associated with suicidal ideation 1.
• Patients should be advised to avoid sudden cessation or rapid dose reduction of daily dosed SSRIs as this may precipitate SSRI withdrawal syndrome 1.
• Combining behavioral and pharmacological approaches may be more effective than either modality alone, with behavioral strategies leading to a significantly greater increase in ELT compared to pharmacological therapy alone 1.

Topical options, such as lidocaine or benzocaine sprays, can also be effective in decreasing penile sensitivity and delaying ejaculation. Psychological counseling can address underlying anxiety or relationship issues contributing to the condition. These treatments work by either decreasing penile sensitivity, modulating the neurological pathways involved in ejaculation, or addressing psychological factors. Most men respond well to treatment, though finding the right approach may require trying different options under medical supervision.

From the FDA Drug Label

Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling, are likely to underestimate their actual incidence Table 5 below displays the incidence of sexual side effects reported by at least 2% of patients taking sertraline in placebo-controlled trials Table 5 Adverse Event Sertraline Hydrochloride Tablets Placebo Ejaculation Failure 1 (Primarily Delayed Ejaculation) 14% 1% Decreased Libido 26% 1%

Sertraline can be used to treat premature ejaculation due to its side effect of delayed ejaculation.

• Ejaculation failure (primarily delayed ejaculation) was reported in 14% of patients taking sertraline compared to 1% of patients taking placebo.
• Decreased libido was reported in 26% of patients taking sertraline compared to 1% of patients taking placebo. This information is based on data from placebo-controlled trials 2.

From the Research

Treatment Options for Premature Ejaculation

• Behavioral modifications, such as the squeeze method and stop-and-start technique, have been shown to be effective in treating premature ejaculation 3
• Pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), phosphodiesterase type 5 inhibitors, and topical anesthetics, can also be used to treat premature ejaculation 4, 5, 6
• New pharmacologic drugs, such as dapoxetine, are being developed and have shown significant improvements in ejaculatory latency, control over ejaculation, and satisfaction with sexual intercourse 4
• Integration of pharmacologic drugs with psychologic and/or behavioral therapy techniques may be the optimal approach to the management of premature ejaculation 4

Emerging Therapies

• On-demand rapid-acting SSRIs, oxytocin receptor antagonists, or single agents that target multiple receptors may form the foundation of more effective future on-demand medication 6
• Lidocaine/prilocaine spray is a new formulation that has been launched for the treatment of primary premature ejaculation 7
• Functional-sexological treatment, which aims to improve control over the moment of ejaculation without interrupting sexual activity, has shown significant improvements in duration of intercourse, sexual satisfaction, and sexual functioning 3

Current Therapies

• Daily dosing of SSRIs is likely to be associated with superior fold increases in intravaginal ejaculation latency time compared with on-demand SSRIs 6
• Off-label use of antidepressants and/or phosphodiesterase type 5 inhibitors or alpha-blockers can be effective in treating premature ejaculation 4
• Topical anesthetics, such as lidocaine/prilocaine cream, can also be used to treat premature ejaculation 7