How to Increase Sexual Duration
If you are asking about erectile dysfunction (difficulty achieving or maintaining erections), start with a PDE5 inhibitor like tadalafil or sildenafil as first-line therapy; if you are asking about premature ejaculation (ejaculating too quickly), use selective serotonin reuptake inhibitors (SSRIs) or topical anesthetics as first-line treatment. 1, 2, 3
Clarifying the Problem: Two Different Conditions
The question "how to increase sexual time" typically refers to one of two distinct conditions:
- Erectile dysfunction (ED): Difficulty achieving or maintaining erections sufficient for intercourse 1
- Premature ejaculation (PE): Ejaculating before desired, typically within 1-2 minutes of penetration 1, 2
These require completely different treatment approaches and should not be confused.
For Erectile Dysfunction: Increasing Ability to Maintain Erections
First-Line Treatment: PDE5 Inhibitors
Start with either tadalafil or sildenafil—both have equivalent efficacy (~69% success rate vs 33% placebo) and should be chosen based on lifestyle preferences. 1, 4, 5
Choosing Between Medications
- Choose tadalafil if you value spontaneous sexual activity without timing medication (effective up to 36 hours), or if you have coexisting benign prostatic hyperplasia symptoms 4, 5
- Choose sildenafil if you prefer scheduled sexual activity with a predictable 4-5 hour window, or if there is concern about potential need for emergency nitrates (shorter waiting time of 24 hours vs 48 hours) 5, 6
Critical Safety Screening Before Starting
Verify the patient is NOT taking nitrates in any form—this combination causes potentially fatal hypotension. 4
- Ask if the patient can walk 1 mile in 20 minutes or climb 2 flights of stairs without symptoms—if unable, refer to cardiology before prescribing 4
- High-risk patients who should defer treatment include those with unstable angina, uncontrolled hypertension, recent MI, NYHA Class II-IV heart failure, or severe valvular disease 5
Dosing Strategy
- Tadalafil: Start 10 mg as-needed OR 2.5-5 mg daily for spontaneous activity 4
- Tadalafil does NOT show dose-dependent improvement between 5 mg, 10 mg, and 20 mg—choose dose based on tolerability, not expecting dramatically better efficacy at higher doses 4
- Sildenafil: Start 50 mg as-needed (more effective than 25 mg, though 100 mg shows minimal additional benefit over 50 mg) 5, 6
Ensuring an Adequate Trial Before Declaring Failure
Complete at least 5 separate attempts at maximum tolerated dose with proper technique before concluding the medication is ineffective. 4
Before escalating dose or switching medications, systematically address these modifiable factors:
- Verify adequate sexual stimulation is occurring—PDE5 inhibitors require sexual arousal to work; they do not create spontaneous erections 4
- Check timing and food intake—taking medication with large or fatty meals reduces efficacy 4
- Assess alcohol consumption—heavy alcohol use impairs erectile function independent of medication 4, 6
- Screen for hormonal abnormalities—check morning testosterone levels, as men with testosterone deficiency respond less robustly to PDE5 inhibitors alone 1, 4
- Evaluate relationship issues—depression, anxiety, and partner conflict significantly impact treatment response 4
- Review concomitant medications—antihypertensives, antidepressants, and opioids can worsen erectile dysfunction 4
When to Add Testosterone Therapy
For men with testosterone deficiency (typically <300 ng/dL), combining a PDE5 inhibitor with testosterone therapy is more effective than PDE5 inhibitor alone. 4, 5
- Check morning total testosterone, free testosterone, and SHBG levels 4
- Testosterone therapy alone is NOT effective monotherapy for ED 4
When to Switch to Another PDE5 Inhibitor
Switch from one PDE5 inhibitor to another only after:
- Completing maximum-dose regimen for at least 5 attempts 4
- All modifiable factors have been addressed 4
- Testosterone supplementation has been evaluated when levels are low 4
Some men who fail one PDE5 inhibitor achieve successful response with another, though head-to-head trials show comparable efficacy. 4
Second-Line Therapies
Proceed to second-line options only after failure of at least two different PDE5 inhibitors at maximum dose with proper technique: 4
- Intracavernosal injection therapy (alprostadil, papaverine, phentolamine)—most effective non-surgical option but highest risk of priapism 4
- Vacuum erection devices—mechanical solution with no systemic side effects 4
- Intraurethral alprostadil suppositories—less effective than injections but less invasive; first administration should be supervised due to ~3% risk of syncope 4
- Penile prosthesis implantation—definitive surgical solution for refractory cases 4
Common Adverse Effects
Most common side effects include headache, flushing, rhinitis, and dyspepsia; serious adverse events occur in <2% of patients. 1, 6
- Tadalafil has significantly lower rates of flushing compared to sildenafil 4
- Myalgia and back pain are more common with tadalafil 4
For Premature Ejaculation: Increasing Time to Ejaculation
Understanding the Condition
Premature ejaculation is defined as ejaculating within 1-2 minutes of penetration with associated distress; the median ejaculatory latency time in Western countries is 5-6 minutes. 1
Men with latencies beyond 25-30 minutes who report distress qualify for delayed ejaculation, which is a different condition. 1
First-Line Treatment Options
Pharmacologic Approaches
Selective serotonin reuptake inhibitors (SSRIs), topical anesthetics, and PDE5 inhibitors all demonstrate significant improvements of 1-5 minutes in intravaginal ejaculatory latency time. 2, 3
Dapoxetine (SSRI specifically approved for PE in Europe): Improves perceived control over ejaculation, with 36.3% of men on 30 mg and 44.5% on 60 mg reporting two-category or greater increase in control vs 15% with placebo 7
- However, discontinuation rates are high (up to 90%) due to side effects, cost, and need for scheduling sexual intercourse 2
Topical lidocaine/prilocaine spray (Fortacin): Officially approved in Europe as second medication for PE; offers easy handling and customer-friendly application 2
- May become real first-line therapy option due to unique galenic preparation and high patient acceptance 2
PDE5 inhibitors: Effective for PE, particularly when combined with other therapies 3
Tricyclic antidepressants and opioid analgesics: Also demonstrate efficacy but with different side effect profiles 3
Daily vs On-Demand Treatment
The majority of men with lifelong PE (81%) prefer daily drug treatment over on-demand medication, primarily because daily treatment does not interfere with spontaneity of sexual activity. 8
- Around 60% of men do not care that the medication is an antidepressant 8
- After receiving information about efficacy and side effects, even more men switch preference to daily treatment 8
Behavioral and Psychological Interventions
Refer men with lifelong or acquired delayed ejaculation to a mental health professional with expertise in sexual health. 1
- Psycho-behavioral strategies enhance psychosexual arousal and remove barriers that interfere with excitement 1
- Modifying sexual positions or practices to increase arousal may be beneficial 1
- Combined drug and behavioral therapies demonstrate significant improvements 3
Combination Therapy
Combining pharmacologic interventions (such as SSRIs or topical anesthetics) with behavioral therapy is more effective than either approach alone. 3
- Topical lidocaine-prilocaine spray has potential to become established second-line therapy for severe PE patients with ejaculatory latency <1-2 minutes when combined with oral therapy 2
Important Considerations
Pharmacologic interventions or combined therapies are more effective than non-pharmacologic interventions alone for treating sexual dysfunction in men. 3
- However, evidence for behavioral and psychological interventions is insufficient compared to drug trials, highlighting need for larger randomized controlled trials 3
- A range of treatment options should be presented to individual patients so they may consider risks and benefits differently 3
Addressing Underlying Issues
Review medications that may contribute to delayed ejaculation and consider replacement, dose adjustment, or staged cessation. 1
- Check morning testosterone levels, as lower serum testosterone is associated with increased prevalence of delayed ejaculation symptoms 1
- Basic serum studies including electrolytes, lipids, and glycosylated hemoglobin may identify medical conditions predisposing to neuropathy or vascular disease 1
Biopsychosocial Approach: Beyond Medication
Male sexuality becomes less predictable and more dependent on partner interaction with aging—this transition is normal and does not always require pharmacologic treatment. 9
A purely medical approach fails to address the multidimensional nature of male sexuality and reinforces sex as intercourse performance. 9