What are the recommended medications and measures for treating premature ejaculation in a male patient, including dosages, indications, and contraindications?

Medications and Measures for Premature Ejaculation

Daily paroxetine 10-20 mg is the single most effective pharmacological treatment for premature ejaculation, providing an 8.8-fold increase in ejaculatory latency time and should be your first-line choice for men with frequent sexual activity. 1, 2

First-Line Treatment Algorithm

For Frequent Sexual Activity (≥2-3 times per week)

• Start with paroxetine 10-20 mg daily, titrate to 40 mg after 2-4 weeks if needed 2, 3
• Alternative daily SSRIs if paroxetine is not tolerated:
  • Sertraline 50-200 mg daily (second-line, highly effective) 2, 3
  • Fluoxetine 20-40 mg daily (less potent alternative) 2
  • Citalopram 20-40 mg daily 2

Critical point: Daily SSRI dosing provides substantially greater ejaculatory delay compared to on-demand administration—this is not optional if you want optimal results. 1, 2

For Infrequent Sexual Activity (<2 times per week)

• Dapoxetine 30-60 mg taken 1-3 hours before intercourse (produces 2.5-3.0-fold IELT increase; 60 mg dose shows 3.0-fold increase) 1, 3, 4
  • In men with baseline IELT <30 seconds: 30 mg produces 3.4-fold increase, 60 mg produces 4.3-fold increase 1
  • Not FDA-approved in the USA but approved in many other countries 1, 3
• Alternative: Paroxetine 20 mg on-demand 3-4 hours before intercourse (less effective than daily dosing but viable option) 1

For Patients Concerned About Systemic Medication Effects

• Topical lidocaine/prilocaine spray (EMA-approved formulation: lidocaine 150 mg/ml + prilocaine 50 mg/ml) increases IELT up to 6.3-fold over 3 months with minimal systemic effects 1, 2, 3

Dosing Details and Expected Outcomes

Paroxetine (Most Effective)

• Starting dose: 10-20 mg daily 2
• Titration: Increase to 40 mg if inadequate response after 2-4 weeks 2
• Expected benefit: 8.8-fold increase in IELT 1, 2
• Onset: Full effect typically requires 2-3 weeks of daily dosing 5

Sertraline

• Dose range: 25-200 mg daily (typically start at 50 mg) 1, 2, 6
• Expected benefit: Significant IELT improvement, though less than paroxetine 2
• Sexual side effects: Ejaculation failure occurs in 14% of men (primarily delayed ejaculation), decreased libido in 6% 6

Dapoxetine (On-Demand Option)

• Dosing: 30 mg or 60 mg taken 1-3 hours before intercourse 1, 7, 4
• Expected benefit: Mean IELT increases from 0.9 minutes to 2.78 minutes (30 mg) or 3.32 minutes (60 mg) 4
• Onset: Effective on first dose 4
• Major limitation: 90% discontinuation rate at 2 years, mainly due to cost and disappointment with on-demand nature 1

Critical Contraindications and Safety Warnings

Absolute Contraindications

• Never prescribe SSRIs to men with bipolar depression due to risk of triggering mania 2, 3
• Never combine SSRIs with MAOIs due to serotonin syndrome risk 3
• Never combine SSRIs with other serotonergic drugs (tramadol, triptans, St. John's Wort) due to serotonin syndrome risk 2

Important Safety Monitoring

• Monitor patients under age 24 or those with comorbid depression for suicidal ideation 3
• Never abruptly discontinue SSRIs after daily dosing—taper to avoid SSRI withdrawal syndrome 3

Common Adverse Events Leading to Discontinuation

From sertraline data (representative of SSRI class):

• Nausea (3-4% discontinuation rate) 6
• Insomnia (2-3% discontinuation rate) 6
• Diarrhea (2% discontinuation rate) 6
• Ejaculation failure (1-2% discontinuation rate) 6

Clinical reality: Approximately 40% of patients refuse or discontinue SSRI treatment within 12 months—address concerns about antidepressant use upfront. 2

Special Clinical Scenarios

Coexisting Erectile Dysfunction

• Treat the ED first or concomitantly, as many men with ED develop secondary PE due to anxiety or need for intense stimulation to maintain erection 1, 2, 3
• Do not prescribe PDE5 inhibitors alone for PE in men with normal erectile function—they don't significantly improve IELT 1
• Consider combination therapy: SSRI plus PDE5 inhibitor shows superior results to SSRI monotherapy and enhances confidence and sexual satisfaction 1

Partial Responders to Monotherapy

• Combination therapy: Daily low-dose SSRI plus on-demand dosing 1, 3
• Alternative combination: SSRI plus PDE5 inhibitor (if ED coexists) 1

Alternative Agent (Use Cautiously)

• Tramadol on-demand: Up to 2.5-fold IELT increase 1, 3
• Major concern: Addiction potential and limited long-term safety data—reserve for refractory cases 1

Common Pitfalls to Avoid

1. Do not use on-demand SSRI dosing as first-line when daily dosing is feasible—the efficacy difference is substantial 2

2. Do not ignore psychological factors—anxiety, depression, and relationship issues may contribute to PE and should be addressed concurrently 1

3. Do not evaluate treatment success solely on IELT—patient and partner satisfaction and quality of life are the primary outcome targets 1, 3

4. Remember: None of these medications are FDA-approved specifically for PE in the USA—all doses and regimens deviate from FDA-approved indications 1

5. Warn patients about sexual side effects upfront—ejaculatory delay is therapeutic for PE but can become excessive; decreased libido occurs in 6% of men on sertraline 6