Causes and Treatment of Premature Ejaculation
Definition and Diagnosis
Premature ejaculation is defined as ejaculation occurring sooner than desired (within approximately 2 minutes of penetration for lifelong PE, or 2-3 minutes for acquired PE), with poor ejaculatory control and associated distress to the patient or partner. 1
- Lifelong PE begins at sexual debut and persists throughout life, with ejaculation consistently occurring within about 2 minutes of penetration 1
- Acquired PE develops after a period of normal ejaculatory control, with either ELT under 2-3 minutes or a 50% reduction from baseline 1
- Diagnosis requires assessment of medical history, relationship factors, sexual history (including time to ejaculation, frequency, partner-specificity, and impact on quality of life), and focused physical examination 1
Critical Diagnostic Pitfall
If both PE and erectile dysfunction coexist, treat the erectile dysfunction first, as many men with ED develop secondary PE due to anxiety or need for intense stimulation to maintain erection 2. Additional laboratory testing is not routinely necessary for lifelong PE 1, though it may be indicated for acquired PE to identify underlying causes 1.
Etiology
The exact cause of PE remains unknown, but involves both biological and psychological factors 1:
Biological Factors
- Disturbances in serotonergic neurotransmission and specific serotonin receptors in the CNS 3
- Possible neurologic constitution or physical injury 4
- Oxytocinergic neurotransmission abnormalities 3
Psychological and Interpersonal Factors
- Depression, anxiety, and history of sexual abuse 1
- Decreased emotional intimacy and relationship conflict 1
- Lower self-esteem, self-confidence, and increased interpersonal conflict compared to men without PE 1
- Important caveat: These are associations, not proven causal relationships 1
First-Line Pharmacologic Treatment
Clinicians should recommend daily SSRIs, on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics as first-line treatment options. 1
Daily SSRI Therapy (Strongest Evidence)
Daily paroxetine 10-40 mg exerts the strongest ejaculation delay, increasing ejaculatory latency time 8.8-fold over baseline, followed by sertraline 50-200 mg, fluoxetine 20-40 mg, and citalopram 20-40 mg 1. For diabetic patients specifically, start sertraline at 50 mg daily and titrate to 200 mg based on clinical response 2.
- Daily SSRI treatment produces substantially greater ejaculatory delay than on-demand dosing 1, 2
- Off-label use of SSRIs is favored over clomipramine due to better side effect profile 1
- Treatment efficacy in diabetic patients is independent of diabetes duration, glycemic control, or microvascular complications 2
On-Demand SSRI Therapy
On-demand administration of clomipramine, paroxetine, sertraline, or fluoxetine 3-6 hours before intercourse is modestly efficacious but provides substantially less ejaculatory delay than daily treatment 1. Sertraline 50 mg taken 4-8 hours before intercourse produces modest efficacy but less delay than daily dosing 2. On-demand treatment may be combined with initial daily treatment or concomitant low-dose daily therapy 1.
Topical Anesthetics
Topical lidocaine/prilocaine spray applied 20-30 minutes before intercourse increases ejaculatory latency up to 6.3-fold with minimal systemic effects 2. This represents an effective drug-free option during coitus without severe adverse effects 5.
Combination Therapy
For partial responders to SSRIs, consider combining daily low-dose SSRI with on-demand dosing 1, 2.
Critical Safety Considerations
SSRI-Specific Warnings
- Never abruptly discontinue daily SSRIs—always taper to prevent SSRI withdrawal syndrome 2
- Screen for concurrent serotonergic medications before prescribing to avoid serotonin syndrome (symptoms include clonus, tremor, hyperreflexia, agitation, mental status changes, diaphoresis, fever; severe cases may involve seizures and rhabdomyolysis) 1, 2
- Avoid SSRIs in men with bipolar depression due to risk of triggering mania 1, 2
- Caution is suggested when prescribing SSRIs to adolescents with PE, though elevated risk of suicidal ideation has not been found in trials with non-depressed men with PE 1
Common Side Effects
Sexual side effects are common with SSRIs 6:
- Ejaculation failure (primarily delayed ejaculation): 14% vs 1% placebo 6
- Decreased libido: 6% vs 1% placebo 6
- Other common effects include dry mouth (14%), sweating (7%), somnolence (13%), dizziness (12%), nausea (25%), insomnia (21%), and diarrhea (20%) 6
Psychotherapy and Behavioral Interventions
Psychotherapy for men and couples may be useful even when no clear psychological or physiological etiology is apparent 1. Most psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model, delivered in individual, couples, group, or online formats 1.
Effective psychosexual treatment combines multiple strategies including physiological relaxation, pubococcygeal muscle training, cognitive and behavioral pacing strategies, and partner involvement 4. However, behavioral treatments benefit only a minority of men three years after treatment ends, suggesting PE is difficult to treat effectively with behavioral therapy alone 7.
Treatment Outcomes and Patient Counseling
Patient and partner satisfaction is the primary target outcome for PE treatment, not just ejaculatory latency improvement 2. Discuss risks and benefits of all treatment options before initiating therapy, emphasizing that PE is not life-threatening and safety should be a primary consideration 2.
Partner Involvement
Shared decision-making is fundamental in managing PE; involvement of sexual partners in decision-making, when possible, may optimize outcomes 1. PE may be a barrier to seeking new relationships and poses particular challenges to men without partners 1.
Treatment Limitations
Current pharmacotherapeutic options only provide temporary delay in ejaculation latency time, and PE recurs when treatment is stopped 8. Most PE patients are dissatisfied with SSRIs, resulting in low adherence to on-demand or daily SSRI treatments 5. Patient reluctance to begin off-label SSRI treatment is common, with 40% of patients either refusing to begin or discontinuing paroxetine within 12 months due to concerns about medication 1.