Treatment of Premature Ejaculation
Premature ejaculation should be treated with either selective serotonin reuptake inhibitors (SSRIs) or topical anesthetics as first-line pharmacotherapy, with the choice based on patient preference for daily versus on-demand dosing. 1
Initial Assessment and Concomitant Conditions
Before initiating treatment, obtain a detailed sexual history assessing frequency and duration of PE, relationship to specific partners, degree of stimulus causing PE, impact on sexual satisfaction, and quality of life. 1
Critical first step: If erectile dysfunction coexists with premature ejaculation, treat the ED first. 1, 2 Many patients develop secondary PE due to anxiety about maintaining erections or the need for intense stimulation, and PE often improves once ED is effectively managed.
First-Line Pharmacological Treatment Options
SSRIs (Most Effective Oral Agents)
Paroxetine, sertraline, and fluoxetine are the most effective SSRIs for PE, with paroxetine showing the strongest efficacy. 1 These can be dosed either daily or on-demand:
Daily dosing regimens: 1
- Paroxetine: 10-40 mg/day
- Sertraline: 25-200 mg/day
- Fluoxetine: 5-20 mg/day
- Clomipramine (tricyclic): 25-50 mg/day
On-demand dosing (taken 3-8 hours before intercourse): 1
- Paroxetine: 20 mg taken 3-4 hours pre-intercourse
- Sertraline: 50 mg taken 4-8 hours pre-intercourse
- Clomipramine: 25 mg taken 4-24 hours pre-intercourse
Dapoxetine (where available outside the USA) is specifically approved for on-demand PE treatment at 30-60 mg doses, showing 2.5-4.3 fold increases in intravaginal ejaculatory latency time. 1 It is particularly effective in men with baseline ejaculatory latency <30 seconds.
Important caveat: None of these medications are FDA-approved for PE in the United States; all use is off-label. 1 Common side effects include ejaculatory delay (14% with sertraline, 13% with paroxetine), decreased libido (3-6%), dry mouth, nausea, and somnolence. 3, 4, 5 Up to 40% of patients discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, cost, or disappointment with on-demand efficacy. 2
Topical Anesthetics
Lidocaine 2.5%/prilocaine 2.5% cream (EMLA) applied 20-30 minutes before intercourse is an effective alternative to oral therapy. 1
Critical application instructions: The cream must be washed off thoroughly or used with a condom to prevent transfer to the partner causing vaginal numbness. 2 Penile hypoesthesia is a common side effect. 2
EMA-approved lidocaine/prilocaine sprays are also available and may offer more convenient application. 1
Combination and Augmentation Strategies
Combined behavioral and pharmacological treatment produces significantly greater increases in ejaculatory latency than pharmacotherapy alone. 2 Consider referring patients for psychosexual counseling in conjunction with medication, particularly in complicated cases or unstable partnerships. 1, 6
For patients with severe PE (ejaculatory latency <30-60 seconds or anteportal ejaculation), combination therapy with both topical and oral medications can considerably increase latency compared to monotherapy. 6
In patients with comorbid PE and ED, PDE5 inhibitors can be safely combined with dapoxetine or other PE medications after ED treatment is initiated. 1, 2
Second-Line Options
α1-adrenoceptor antagonists may be considered for men who have failed first-line therapy, though efficacy data remains limited. 2, 7 These require additional controlled studies to determine their true role in PE management.
Behavioral Modifications
While pharmacotherapy is most effective, behavioral techniques can augment treatment:
- Stop-start technique and squeeze method have limited long-term efficacy data but may help some couples 8, 9
- Modifying sexual positions or practices to increase arousal 9
- Functional-sexological treatment teaching arousal control without interrupting sexual activity shows effectiveness comparable to traditional behavioral techniques 9
Treatments to Avoid
Surgical interventions including neurectomy and penile prosthesis implantation should be avoided—their risks far outweigh any potential benefits. 1, 2 These are considered experimental and may cause permanent loss of penile sensation.
Tramadol should be used with extreme caution due to opioid-like properties and dependency risk. 2
Shared Decision-Making
Patient and partner satisfaction is the primary target outcome, not arbitrary physiological measures. 1 Discuss all risks and benefits before initiating treatment, reassuring patients that PE is common and treatable. 1 Safety should be the primary consideration given PE is not life-threatening. 1