What are the treatment options for premature ejaculation?

From the Guidelines

Premature ejaculation can be effectively treated with a combination of daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics as first-line agents of choice, as recommended by the AUA/SMSNA guideline 1. The treatment of premature ejaculation (PE) involves a multifaceted approach, including pharmacological and behavioral therapies.

Pharmacological Therapies

• Daily SSRIs, such as paroxetine (10-40mg), sertraline (50-200mg), fluoxetine (20-40mg), and citalopram (20-40mg), are effective in delaying ejaculation, with paroxetine exerting the strongest ejaculation delay, increasing ELT a mean of 8.8-fold over baseline 1.
• On-demand administration of clomipramine, paroxetine, sertraline, and fluoxetine 3-6 hours before intercourse is modestly efficacious and well tolerated, but is associated with substantially less ejaculatory delay than daily treatment in most studies 1.
• Topical anesthetics, such as lidocaine and prilocaine, are moderately effective in delaying ejaculation, but may be associated with significant penile hypoesthesia and possible absorption by the receptive partner, resulting in discomfort and/or numbness 1.

Behavioral Therapies

• Behavioral strategies, such as the stop-start method and the squeeze technique, can be used in combination with pharmacological approaches to increase ELT and sexual satisfaction beyond that resulting from pharmacological treatment alone 1.
• Pelvic floor exercises, performed by contracting the muscles that stop urination for 10 seconds, repeated 10-15 times three times daily, can improve ejaculatory control. Combining behavioral and pharmacological approaches may be more effective than either modality alone, as recommended by the AUA/SMSNA guideline 1. It is essential to consult a healthcare provider to determine the most appropriate treatment plan based on individual circumstances, as some treatments may have side effects or interact with other medications.

From the FDA Drug Label

Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling, are likely to underestimate their actual incidence Table 5 below displays the incidence of sexual side effects reported by at least 2% of patients taking sertraline in placebo-controlled trials Table 5 Adverse Event Sertraline Hydrochloride Tablets Placebo Ejaculation Failure 1 (Primarily Delayed Ejaculation) 14% 1% Decreased Libido 26% 1%

Sertraline can be used to treat premature ejaculation due to its side effect of delayed ejaculation.

• The incidence of ejaculation failure, primarily delayed ejaculation, was 14% in patients taking sertraline compared to 1% in patients taking placebo 2.
• Sertraline is an SSRI, and SSRIs can cause untoward sexual experiences, including delayed ejaculation.
• Delayed ejaculation is a common side effect of sertraline, occurring in at least 2% of patients taking the medication.
• The exact mechanism of sertraline in treating premature ejaculation is not fully understood, but it is thought to be related to its effects on serotonin levels in the brain.
• Sertraline should be used with caution in patients with a history of sexual dysfunction, as it can exacerbate these conditions.
• Patients taking sertraline for premature ejaculation should be monitored for adverse effects, including decreased libido and ejaculation failure.

From the Research

Treatment Options for Premature Ejaculation

• Various treatment modalities are available for premature ejaculation, including behavioral modifications, medications, diet alterations, and surgery 3.
• Behavioral therapies, such as the stop-start technique, squeeze technique, and sensate focus, have been shown to be effective in extending the time between penetration and ejaculation 4.
• Pharmacological approaches, including dapoxetine, lidocaine/prilocaine spray, and selective serotonin reuptake inhibitors (SSRIs), are also commonly used to treat premature ejaculation 5.

Comparison of Treatment Outcomes

• A study comparing the stop-start technique with the stop-start technique and sphincter control training found that the combination of both techniques was more effective in increasing intravaginal ejaculatory latency time (IELT) and improving premature ejaculation diagnostic tool (PEDT) scores 6.
• Another study found that sildenafil was superior to other modalities, including clomipramine, sertraline, paroxetine, and the pause-squeeze technique, in terms of ejaculation latency and satisfaction 7.

Recommendations for Treatment

• The Post-University Interdisciplinary Association of Sexology (AIUS) recommends giving all patients with premature ejaculation psychosexological counseling and combining pharmacotherapies and sexually-focused cognitive-behavioral therapies, involving the partner in the treatment process 5.
• Dapoxetine is recommended as first-line, on-demand oral therapy for primary and acquired premature ejaculation, while lidocaine 150mg/mL/prilocaine 50mg/mL spray is recommended as local treatment for primary premature ejaculation 5.