How should premature ejaculation be evaluated and managed?

Evaluation and Management of Premature Ejaculation

Diagnose premature ejaculation through sexual history alone—focusing on ejaculatory latency time, loss of control, and personal/interpersonal distress—then initiate daily paroxetine 10-40 mg as first-line pharmacologic therapy, which provides the greatest ejaculatory delay with an 8.8-fold increase in ejaculatory latency time. 1, 2

Diagnostic Criteria

Lifelong vs. Acquired PE

Lifelong PE is defined by three essential components present since sexual debut: 1

• Ejaculation within approximately 2 minutes of penetration
• Poor ejaculatory control throughout sexual life
• Associated personal or interpersonal bother

Acquired PE requires either: 1

• Average ejaculatory latency time falling under 2-3 minutes (when previously normative), OR
• ≥50% reduction in ejaculatory latency time from prior baseline
• Must include loss of control and negative consequences

Essential History Components

Obtain a detailed sexual history documenting: 1, 3

• Time to ejaculation (self-estimated intravaginal ejaculatory latency time is appropriate for clinical practice) 1
• Perceived control over ejaculation 1, 3
• Personal distress and interpersonal difficulty caused by the dysfunction 1, 3
• Pattern: situational (specific partners) versus consistent (all attempts) 1, 3
• Frequency and duration of premature ejaculation 2

Critical differential diagnosis: Distinguish PE from erectile dysfunction, as ED patients frequently develop secondary PE from anxiety about maintaining erections. 1, 3

Physical Examination

Perform a focused physical examination to: 1, 3

• Identify anatomical abnormalities associated with PE or other sexual dysfunctions
• Reassure patients (though physical exam rarely changes management)
• Specifically assess for coexisting erectile dysfunction

Psychological Assessment

Query for: 1

• Ongoing or persistent anxiety
• Major depression and bipolar affective disorder
• Significant psychiatric problems over the past 6-12 months
• History of sexual abuse, decreased emotional intimacy, relationship conflict 1

Consider referral to a mental health professional depending on severity of mood disorder. 1

Laboratory Testing

Do NOT perform routine laboratory or physiological tests unless specific findings from history or physical examination suggest underlying conditions. 1, 3

For lifelong PE: Additional testing is not routinely necessary. 1

For acquired PE: Utilize additional testing only as clinically indicated, such as: 1

• Serum testosterone (if symptoms suggest hypogonadism)
• Thyroid function (if hyperthyroidism suspected)
• Glucose/HbA1c (if diabetes suspected)
• Urinalysis (if infection/inflammation suspected)

Validated Instruments

Patient-reported questionnaires may be used as an adjunct to diagnosis or to facilitate conversation about ejaculatory issues, but are not required for diagnosis. 1, 3

Treatment Algorithm

Step 1: Address Coexisting Erectile Dysfunction FIRST

If erectile dysfunction coexists with PE, treat the ED first—premature ejaculation may improve when erectile dysfunction is effectively managed. 2

Step 2: First-Line Pharmacologic Therapy

Daily SSRIs are first-line pharmacologic therapy, with paroxetine providing the greatest ejaculatory delay (8.8-fold increase in ejaculatory latency time): 2

Recommended daily dosing regimens: 2

• Paroxetine 10-40 mg/day (strongest evidence, maximal delay)
• Sertraline 25-200 mg/day
• Fluoxetine 5-20 mg/day
• Citalopram 20-40 mg/day
• Clomipramine 12.5-50 mg/day

Start at the lowest effective dose compatible with reasonable success. 2

Critical Safety Warnings

SSRIs are NOT FDA-approved for premature ejaculation and may cause: 2

• Ejaculation failure
• Decreased libido
• Nausea, insomnia, dry mouth

Exercise caution in adolescents and men with comorbid depression regarding suicidal ideation, though elevated risk has not been found in non-depressed men with PE. 2

Step 3: Topical Anesthetics (First-Line Alternative)

Lidocaine/prilocaine cream applied 20-30 minutes prior to intercourse increases ejaculatory latency time with minimal side effects. 2

Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness. 2

Step 4: Combination Therapy

Combining behavioral and pharmacological approaches is more effective than either modality alone. 2

Sildenafil citrate combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though increases headache and flushing. 2

Step 5: Second-Line Options

Alpha-1 adrenoceptor antagonists (alfuzosin, terazosin) may be considered for men who have failed first-line therapy, though efficacy data remains limited. 2

Treatment Goals

Patient and partner satisfaction is the primary target outcome—not just ejaculatory latency time. 2

Treatment choices should be based on patient and partner reports of efficacy, side effects, and acceptance. 2

Common Pitfalls to Avoid

• Do not rely solely on IELT: Control, distress, and interpersonal difficulty are equally important diagnostic criteria. 1, 3
• Do not miss coexisting ED: It requires treatment before addressing PE. 2, 3
• Do not order unnecessary laboratory tests in straightforward cases of PE. 1, 3
• Do not assume PE is purely psychological without ruling out organic causes. 4
• Discuss off-label nature of pharmacologic therapies and obtain informed consent before initiating treatment. 2