What are the management options for a patient with early ejaculation?

Management of Early Ejaculation

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

Initial Assessment

Before initiating 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—if present, treat the erectile dysfunction first, as premature ejaculation often improves when erectile dysfunction is managed 1, 3, 2

First-Line Treatment Options

Daily SSRIs (Preferred Pharmacologic Approach)

Start with daily paroxetine as it demonstrates the strongest ejaculation-delaying effect: 1, 2

• Paroxetine 10-40 mg/day (most effective—8.8-fold increase in ejaculatory latency time) 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 for SSRIs: 1

• Not FDA-approved for premature ejaculation (off-label use)
• Common adverse effects: ejaculation failure (14% with sertraline, 23% with paroxetine), decreased libido (6% with sertraline), nausea, insomnia, dry mouth 4, 5
• Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation 1
• Up to 40% of patients may discontinue SSRI treatment within 12 months due to side effects or unmet expectations 3

Topical Anesthetics (Alternative First-Line)

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

• Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness 1
• Use with a condom or wash penis thoroughly before intercourse to prevent partner numbness 3
• May cause penile hypoesthesia and transfer to partners 3

Combination Therapy (Most Effective Approach)

Combining behavioral and pharmacological approaches is more effective than either modality alone and should be the preferred treatment strategy: 1, 3, 2

• Combination therapy leads to significantly greater increases in ejaculatory latency time compared to pharmacotherapy alone 3
• Improves scores on validated instruments for assessment of premature ejaculation 3
• Behavioral techniques include squeeze technique, stop-start method, and sensate focus 6

Second-Line Options

For patients who fail first-line therapy: 1, 3

• Alpha-1 adrenoceptor antagonists (alfuzosin, terazosin) may be considered, though efficacy data remains limited 1, 3
• Sildenafil combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though increases headache and flushing 1

Treatment Considerations and Pitfalls

Patient and partner satisfaction is the primary target outcome, not just ejaculatory latency time: 1, 2

• 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, including off-label nature of pharmacologic therapies 1

Important caveats to avoid: 3

• Never recommend surgical interventions—they are experimental and may result in permanent loss of penile sensation 3
• Use tramadol with extreme caution due to opioid-like properties and risk of dependency 3
• Phosphodiesterase-5 inhibitors should not be prescribed to men with premature ejaculation and normal erectile function 7

Psychotherapy Integration

Psychotherapy represents a legitimate treatment approach and should be considered, particularly when psychological factors are prominent: 2

• Most psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model 2
• Psychological factors including depression, anxiety, decreased self-esteem, and relationship conflict are associated with premature ejaculation 2
• Refer to mental health professional with sexual health expertise when psychological factors are prominent 2