What are the treatment options for an adult male with premature ejaculation?

Treatment of Premature Ejaculation

Daily SSRIs (paroxetine, sertraline, fluoxetine, or clomipramine) or on-demand dapoxetine (where available) combined with topical penile anesthetics represent first-line pharmacologic treatment for premature ejaculation, with daily paroxetine providing the strongest ejaculatory delay (8.8-fold increase in ejaculatory latency time). 1

Diagnostic Clarification Before Treatment

• Rule out erectile dysfunction first, as many men develop secondary premature ejaculation from anxiety about maintaining erections or requiring intense stimulation to achieve rigidity 2
• Assess intravaginal ejaculatory latency time (IELT), with <2 minutes indicating PE and normal median being 5-6 minutes 2, 3
• Distinguish lifelong PE (present since sexual debut) from acquired PE, as acquired forms warrant additional testing for underlying causes 1
• Screen for psychological factors including depression, anxiety, decreased emotional intimacy, and relationship conflict, though causality remains unclear 1

First-Line Pharmacologic Treatment Algorithm

Daily SSRI Therapy (Most Effective)

• Paroxetine 10-40 mg daily provides the strongest ejaculatory delay (8.8-fold increase in IELT), making it the preferred first-line agent 1
• Alternative daily SSRIs include sertraline 50-200 mg, fluoxetine 20-40 mg, or citalopram 20-40 mg 1
• Clomipramine 12.5-50 mg daily is effective but has inferior side effect profile compared to SSRIs 1
• All SSRI use for PE is off-label in the United States, requiring patient counseling about this status 1, 2, 3
• Daily dosing provides superior fold increases in IELT compared to on-demand dosing 4

On-Demand SSRI Therapy

• Dapoxetine is the only agent approved for PE in Europe (not FDA-approved in US), taken 1-3 hours before sexual activity, increasing IELT by 2.5-3 fold 2, 5
• On-demand clomipramine, paroxetine, sertraline, or fluoxetine taken 3-6 hours before intercourse is modestly efficacious but substantially less effective than daily treatment 1
• On-demand treatment may be combined with initial daily treatment or concomitant low-dose daily maintenance 1

Topical Penile Anesthetics

• Topical anesthetics are recommended as first-line agents alongside SSRIs 1
• Minimal systemic side effects with primarily local effects 5

Critical Safety Considerations

• Avoid SSRIs in men with bipolar depression due to risk of mania 1
• Monitor for serotonin syndrome when using SSRIs, especially with concomitant serotonergic drugs (symptoms: clonus, tremor, hyperreflexia, agitation, diaphoresis, fever) 1
• Caution in adolescents with PE due to elevated risk of suicidal ideation in patients under 18, though not demonstrated in non-depressed adult men with PE 1
• Common SSRI side effects include ejaculatory delay (14-28%), decreased libido (2-6%), somnolence, dizziness, nausea, and diarrhea 6, 7

Adjunctive and Alternative Treatments

When Erectile Dysfunction Coexists

• Treat erectile dysfunction first with PDE5 inhibitors (sildenafil, tadalafil, vardenafil), as many patients experience resolution of PE once erectile function improves 2
• PDE5 inhibitors alone or combined with SSRIs should be limited to men with acquired PE secondary to comorbid ED 4
• Assess cardiovascular risk before prescribing PDE5 inhibitors; absolute contraindication with concurrent nitrate or riociguat use 2

Behavioral and Psychological Interventions

• Behavioral therapy combined with pharmacotherapy provides superior outcomes compared to either modality alone 4
• Psychotherapy integrating psychodynamic, systematic, behavioral, and cognitive approaches within short-term model may be useful even without clear psychological etiology 1
• Referral to mental health professional with sexual health expertise should be considered, particularly for lifelong PE 2, 3
• Modifying sexual positions or practices to increase arousal and control can benefit treatment outcomes 2, 3

Treatment Targets and Expectations

• Primary outcome is patient and partner satisfaction, not arbitrary physiological measures 2, 3
• Treatment goals include regaining control over ejaculation timing, achieving satisfaction for both partners, and reducing distress 2
• Shared decision-making with involvement of sexual partners optimizes outcomes 2, 3
• 40% of patients either refuse to begin or discontinue paroxetine within 12 months due to concerns about medication 1

Treatments to Avoid

• Surgical management (dorsal nerve neurotomy, radiofrequency ablation, hyaluronic acid augmentation) should be considered experimental only, performed only in ethical board-approved clinical trials due to risk of permanent penile sensation loss 3
• Current PE guidelines do not recommend surgical intervention or neuromodulation owing to safety concerns 8