What are the treatment options for a male patient with low testosterone and premature ejaculation?

Treatment of Low Testosterone and Premature Ejaculation

Treat these as two separate conditions: first address the low testosterone with testosterone replacement therapy if confirmed biochemically, then manage the premature ejaculation with SSRIs or topical anesthetics, as testosterone therapy does not improve PE. 1

Critical First Step: Distinguish the Conditions

The most important clinical distinction is that low testosterone does not cause premature ejaculation 2. These conditions frequently coexist but require independent treatment strategies 1.

Rule Out Secondary PE from Erectile Dysfunction

• Before diagnosing true PE, confirm the patient does not have erectile dysfunction causing secondary premature ejaculation 3
• Many men develop PE as a consequence of ED from anxiety about maintaining erections or requiring intense stimulation to achieve rigidity 3
• If ED is present, treat it first with PDE5 inhibitors (sildenafil, tadalafil, or vardenafil), as PE often resolves once erectile function improves 3, 4

Management Algorithm for Low Testosterone

Confirm the Diagnosis

• Obtain morning total testosterone levels on two separate occasions to confirm biochemical hypogonadism 1
• Document specific hypogonadal symptoms: reduced sexual desire, erectile dysfunction, decreased physical strength, or depressive symptoms 1
• Evaluate for medications interfering with testosterone production (opioids, glucocorticoids, anticonvulsants) 1
• Assess for obesity, metabolic syndrome, or diabetes, which commonly cause functional hypogonadism 1

Initiate Lifestyle Modifications First

• Recommend weight loss through low-calorie diets if obese, as this can reverse obesity-associated hypogonadism 1
• Prescribe regular physical activity, with benefits correlating to exercise duration and weight loss 1
• These lifestyle changes produce modest testosterone increases (1-2 nmol/L) but are essential foundation 1

Start Testosterone Replacement Therapy

• Use testosterone therapy as first-line treatment in confirmed hypogonadal patients 1
• Multiple formulations available: intramuscular, transdermal, or oral preparations based on patient preference 1
• Combining lifestyle modifications with testosterone therapy yields better outcomes than either alone 1
• Absolute contraindication: Do not use testosterone therapy in men actively seeking fertility 1

Monitor for Contraindications

• Screen for active or treated male breast cancer (absolute contraindication) 1
• Assess for severe lower urinary tract symptoms, though testosterone is generally safe in mild-moderate cases 1
• Monitor PSA levels, though recent TRAVERSE trial confirmed no increased prostate cancer risk 1

Management Algorithm for Premature Ejaculation

Confirm PE Diagnosis

• Obtain detailed sexual history assessing intravaginal ejaculatory latency time (self-estimated), perceived control, distress, and interpersonal difficulty 1
• Classify as lifelong versus acquired PE 1, 5
• Perform physical examination to identify anatomical abnormalities or other sexual dysfunctions 1
• Do not perform routine laboratory testing unless specific findings from history suggest endocrine or urological causes 1

First-Line Pharmacotherapy Options

Daily SSRIs provide the most robust evidence for PE treatment 3, 4:

• Paroxetine, sertraline, fluoxetine, or clomipramine as daily dosing 3
• All SSRI use for PE is off-label in the United States 3
• Counsel patients about off-label nature, potential side effects (nausea, sexual dysfunction, mood changes) 3

On-demand dapoxetine (approved in Europe, not FDA-approved in US) 1, 4:

• Available in 30 mg and 60 mg doses 1
• Shows 2.5- to 3.0-fold IELT increases, rising to 3.4- to 4.3-fold in patients with baseline IELT <30 seconds 1
• Taken 1-3 hours before sexual activity 3
• Side effects include nausea, diarrhea, dizziness (dose-dependent) 1
• High discontinuation rates (90% at 2 years) due to cost and disappointment with on-demand nature 1

Topical anesthetics as alternative 1:

• Lidocaine/prilocaine formulations available as creams or sprays 1
• EMA-approved spray formulations available 1

Behavioral Interventions

• Advise modifying sexual positions or practices to increase arousal 1, 6
• Incorporate alternative sexual practices, scripts, or sexual enhancement devices 1, 6
• Consider referral to mental health professional with sexual health expertise, particularly for lifelong PE 1, 3
• Include partner in treatment decisions when possible to optimize outcomes 7, 3

Critical Clinical Pitfalls

Do Not Expect Testosterone to Treat PE

• Research demonstrates that aromatase inhibition normalizes testosterone levels in hypogonadotropic hypogonadism but has no effect on premature ejaculation 2
• Testosterone therapy addresses hypogonadal symptoms (libido, erectile function) but does not improve ejaculatory control 2

Address Comorbid ED Appropriately

• If mild ED coexists with hypogonadism, use testosterone therapy as first-line treatment 1
• For more severe ED, combine PDE5 inhibitors with testosterone therapy 1
• Ensure cardiovascular risk assessment before prescribing PDE5 inhibitors 3
• PDE5 inhibitors are absolutely contraindicated with concurrent nitrate or riociguat use 3

Set Realistic Treatment Expectations

• The primary treatment outcome is patient and partner satisfaction, not arbitrary physiological measures 7, 3
• PE treatment often requires ongoing therapy, with recurrence likely after withdrawal 4
• Testosterone effects on sexual function may take weeks to months 1

Medication Review is Essential

• Review and modify medications contributing to sexual dysfunction: antidepressants, antipsychotics, antihypertensives 1, 6, 7
• Consider dose adjustment or staged cessation when medically appropriate 1, 7