Treatment of Premature Ejaculation in Men
Start with SSRIs as first-line pharmacotherapy, specifically daily paroxetine or sertraline, combined with behavioral therapy for optimal outcomes. 1
First-Line Treatment Approach
Pharmacological Management
SSRIs represent the most effective pharmacological intervention for premature ejaculation, though all use remains off-label as no FDA-approved treatments exist for this indication. 1, 2
- Daily SSRIs (paroxetine, sertraline, fluoxetine) are the primary pharmacological option, requiring continuous use to maintain efficacy 1, 2
- Sertraline causes ejaculatory delay in 14% of male patients (vs 1% placebo), with decreased libido in 6% 3
- Important caveat: Patients should avoid sudden cessation or rapid dose reduction of daily SSRIs, as this may precipitate SSRI withdrawal syndrome 1
- Expect 12-29% of patients to discontinue paroxetine within 12 months due to concerns about taking an antidepressant, treatment effects below expectations, or cost 1
Dapoxetine (a short-acting SSRI) allows on-demand dosing and is registered specifically for PE treatment in some countries, though not FDA-approved in the United States 2, 4
Behavioral Therapy
Behavioral interventions should be implemented alongside pharmacotherapy, as this combination produces superior outcomes compared to either modality alone. 1
- Behavioral therapy leads to significantly greater increases in ejaculatory latency time (ELT) when combined with pharmacological treatment 1
- Combination therapy produces greater improvement in validated PE assessment scores 1
- Techniques include arousal control methods that avoid interrupting sexual activity, which patients tolerate better than traditional squeeze or stop-start techniques 5
Second-Line Options
Topical Anesthetics
Topical lidocaine or prilocaine applied to the glans penis represents a well-established, moderately effective alternative for delaying ejaculation. 1, 2
- Critical pitfall: Significant penile hypoesthesia and possible absorption by the receptive partner can cause discomfort and numbness 1
- Prevention strategy: Use a condom or thoroughly wash the penis prior to penetration to prevent partner exposure 1
Tramadol (Use with Extreme Caution)
Tramadol may be considered for patients who have failed first-line therapy, but exercise significant caution given opioid crisis concerns, even though abuse rates are relatively low (0.7% vs 1.2% for hydrocodone). 1
Third-Line Considerations
Alpha-1 Adrenoreceptor Antagonists
Consider α1-blockers only after first-line therapy failure, as efficacy data remains very limited and additional controlled studies are needed. 1, 2
Essential Comorbidity Management
Erectile Dysfunction
If comorbid ED exists, thoroughly evaluate the temporal relationship between conditions to determine whether management should be concomitant or sequential. 1
- In some cases, acquired PE may be secondary to ED 1
- Some men with lifelong PE develop ED related to performance anxiety 1
- Treat ED according to AUA Guidelines on Erectile Dysfunction 1
Low Testosterone
Check morning testosterone levels, as progressively lower serum testosterone correlates with increased ejaculatory symptoms, and offer testosterone replacement per AUA guidelines if biochemically low. 6
What NOT to Do
Surgical management (including injection of bulking agents) should be considered experimental and only used in ethical board-approved clinical trials. 1
- Invasive treatments may cause permanent loss of penile sensation 1
- Procedures include selective dorsal nerve neurotomy, pulsed radiofrequency ablation of dorsal penile nerves, or hyaluronic acid gel glans augmentation 1
Partner Involvement
Include sexual partners in decision-making when possible, as this is fundamental to optimizing outcomes in ejaculatory disorders. 1, 6
Classification Context
Premature ejaculation is defined as ejaculation occurring sooner than desired (before or shortly after penetration), causing distress to either partner, with two subtypes: 1