What treatment options are available for a male patient of reproductive age with decreased libido, premature ejaculation, and erectile dysfunction, possibly related to underlying conditions such as diabetes, hypertension, or depression?

Treatment for Decreased Sexual Desire, Premature Ejaculation, and Erectile Dysfunction

Start by treating erectile dysfunction first with PDE5 inhibitors (sildenafil, tadalafil, or vardenafil), as many men develop premature ejaculation secondary to ED from anxiety about maintaining erections or requiring intense stimulation to achieve adequate rigidity—resolving the ED often eliminates the PE. 1

Initial Diagnostic Priorities

Distinguish whether premature ejaculation is primary or secondary to erectile dysfunction, as this fundamentally changes your treatment approach 1. The sexual history must clarify:

• Timing relationship: Does ejaculation occur before desired due to lack of control, or does the man lose his erection after normal ejaculation? 1
• Intravaginal ejaculatory latency time (IELT): Self-estimated timing after penetration, with <2 minutes indicating PE 1
• Morning testosterone levels on two separate occasions to confirm biochemical hypogonadism if decreased libido is prominent 2
• Cardiovascular risk assessment before prescribing PDE5 inhibitors, as high-risk profiles contraindicate sexual activity and PDE5-I use 1

Treatment Algorithm

Step 1: Address Erectile Dysfunction First

Initiate phosphodiesterase-5 inhibitors as first-line therapy, with options including sildenafil, tadalafil, or vardenafil, which have high efficacy and safety even in difficult-to-treat populations like diabetic patients 1.

Critical contraindications 3:

• Concurrent nitrate use (including recreational "poppers" containing amyl nitrite or butyl nitrite)
• Guanylate cyclase stimulators such as riociguat
• Active ingredient remains in body >2 days after single dose, longer with kidney/liver problems

Many patients experience complete resolution of premature ejaculation once erectile function improves, so reassess PE symptoms after 4-8 weeks of successful ED treatment 1.

Step 2: Treat Persistent Premature Ejaculation

If PE persists after ED resolution, add selective serotonin reuptake inhibitors (SSRIs) as the primary pharmacologic intervention, with all SSRI use for PE being off-label in the United States 1, 2.

Daily dosing SSRIs provide the most robust evidence 4, 1:

• Paroxetine 10-40 mg daily: Strongest ejaculation delay (8.8-fold increase in IELT) 4
• Sertraline 50-200 mg daily 4
• Fluoxetine 20-40 mg daily 4
• Clomipramine 12.5-50 mg daily (tricyclic antidepressant, more side effects than SSRIs) 4

On-demand options 4, 2:

• Dapoxetine 30-60 mg taken 1-3 hours before sexual activity (only agent approved for PE in Europe, not FDA-approved in US; shows 2.5- to 3.0-fold IELT increases, rising to 3.4- to 4.3-fold in patients with baseline IELT <30 seconds) 2
• Clomipramine, paroxetine, sertraline, or fluoxetine 3-6 hours before intercourse (modestly efficacious but substantially less effective than daily treatment) 4

Topical penile anesthetics as alternative first-line agents 4, 2:

• Lidocaine/prilocaine formulations available as creams or sprays
• May cause significant penile hypoesthesia and possible absorption by receptive partner
• Use condom or thoroughly wash penis prior to penetration to prevent partner numbness 4

Critical SSRI safety considerations 4:

• Avoid in men with history of bipolar depression due to mania risk
• Serotonin syndrome risk with multiple serotonergic drugs (symptoms: clonus, tremor, hyperreflexia, agitation, diaphoresis, fever; severe cases: seizure, rhabdomyolysis)
• No significant increase in suicidal ideation in adult men, but caution suggested

Step 3: Address Decreased Libido/Hypogonadism

If morning testosterone levels confirm biochemical hypogonadism on two separate occasions with documented specific hypogonadal symptoms (reduced libido, decreased spontaneous/morning erections, low mood, decreased energy, decreased physical strength) 4, 2:

Lifestyle modifications first 2:

• Weight loss through low-calorie diets if obese, as this can reverse obesity-associated hypogonadism
• Combining lifestyle modifications with testosterone therapy yields better outcomes than either alone

Testosterone replacement therapy 2:

• First-line treatment in confirmed hypogonadal patients
• Absolute contraindications: Men actively seeking fertility, active or treated male breast cancer
• Critical caveat: Testosterone therapy addresses hypogonadal symptoms but does not improve ejaculatory control 2
• For comorbid ED with hypogonadism: Use testosterone as first-line for mild ED; combine PDE5 inhibitors with testosterone for more severe ED 2

Important distinction: Low testosterone does not cause premature ejaculation—these conditions require independent treatment strategies 2.

Behavioral and Psychological Interventions

Combining behavioral and pharmacological approaches is more effective than either modality alone, with significantly greater increase in IELT and improvement in validated PE assessment scores 4.

Specific behavioral modifications 1, 2:

• Modify sexual positions or practices to increase arousal and control
• Incorporate alternative sexual practices, scripts, or sexual enhancement devices
• Include sexual partner in treatment decisions when possible—shared decision-making optimizes outcomes

Referral to mental health professional with sexual health expertise is particularly important for lifelong PE, as psychological factors (depression, anxiety, history of sexual abuse, decreased emotional intimacy, relationship conflict) may precipitate and exacerbate PE 4, 1.

Common Pitfalls and Caveats

The FDA has not approved any medications specifically for premature ejaculation—all pharmacotherapy is off-label use 1, 5. Patients require counseling about:

• Off-label nature of treatment
• Weak evidence base for some interventions
• Potential for known and unknown side effects
• SSRI adverse effects (sexual dysfunction, GI symptoms, weight changes)

Do not prescribe α1-adrenoreceptor antagonists (terazosin, tamsulosin, doxazosin) for PE unless treating comorbid BPH/LUTS, as efficacy data remains very limited and additional controlled studies are required 4.

Avoid surgical management (dorsal nerve neurotomy, radiofrequency ablation, hyaluronic acid augmentation) outside ethical board-approved clinical trials, as invasive treatment may cause permanent loss of penile sensation 4.

The primary treatment outcome is patient and partner satisfaction, not arbitrary physiological measures like specific IELT targets 1, 5. Goals include:

• Regaining sense of control over ejaculation timing
• Achieving satisfaction with sexual intercourse for both partners
• Reducing distress and interpersonal difficulties 1