What are the recommended treatment options for an adult male without significant medical illness who presents with excessive masturbation?

Treatment of Excessive Masturbation in Men

Excessive masturbation in men should be managed primarily through referral to a mental health professional with expertise in sexual health, as this represents a psychological and behavioral issue rather than a medical disorder requiring pharmacological intervention.

Understanding the Clinical Context

The available urological guidelines do not recognize "excessive masturbation" as a distinct medical diagnosis requiring treatment. The AUA/SMSNA guidelines address ejaculatory disorders (premature ejaculation and delayed ejaculation) and erectile dysfunction, but excessive masturbation frequency alone is not classified as a pathological condition 1.

However, when masturbation becomes ego-dystonic (associated with guilt, distress, or functional impairment), clinical intervention is warranted 2.

Initial Assessment

Conduct a thorough sexual, psychological, and relational history to determine if the concern represents:

• Compulsive sexual behavior with associated psychological distress, relationship problems, or interference with daily functioning 2
• Underlying anxiety, depression, or stress for which masturbation serves as a maladaptive coping mechanism 3, 2
• Relationship dissatisfaction where masturbation substitutes for partnered sexual activity 3
• Comorbid sexual dysfunction such as erectile dysfunction or premature ejaculation that may be confused with or masked by masturbation patterns 1, 4

Key History Elements

• Frequency and context of masturbation behavior 1
• Degree of distress, guilt, or sense of loss of control 2
• Impact on relationships, work, and daily functioning 2, 5
• Presence of pornography use (highly correlated with masturbation frequency) 5
• Screening for depression, anxiety, and other psychiatric comorbidities using validated instruments 2
• Assessment of relationship quality and partner sexual satisfaction 3, 2
• Evaluation for concurrent erectile dysfunction or premature ejaculation 1, 4

Physical Examination and Laboratory Testing

• Morning serum total testosterone level should be measured, as low testosterone may contribute to sexual dysfunction patterns 1, 4
• Physical examination is generally not revealing unless evaluating for comorbid erectile dysfunction 1
• Additional laboratory testing (glucose, lipids) only if cardiovascular risk factors are present 1, 4

Primary Treatment Approach

Mental Health Referral (First-Line)

Referral to a mental health professional with expertise in sexual health is the cornerstone of treatment 1. This approach addresses:

• Psychological factors: Depression, anxiety, stress, and guilt associated with masturbation 1, 2
• Behavioral modification: Cognitive-behavioral therapy to address compulsive patterns 4
• Relationship issues: Couples therapy when masturbation impacts partner intimacy 1
• Underlying psychiatric conditions: Treatment of primary anxiety disorders, depression, or substance use 4

Psychotherapy Modalities

Psychological therapies integrate psychodynamic, systematic, behavioral, and cognitive approaches within a short-term model, delivered in individual, couples, group, or online formats 1.

When Pharmacotherapy May Be Considered

Pharmacological treatment is NOT indicated for excessive masturbation frequency alone. However, medication may be appropriate for specific comorbid conditions:

For Comorbid Premature Ejaculation

If the patient has premature ejaculation (ejaculation within 2 minutes of penetration with distress), consider:

• Daily SSRIs: Paroxetine 10-40 mg, sertraline 50-200 mg, fluoxetine 20-40 mg (off-label use) 1
• On-demand clomipramine: 25-50 mg, 4-24 hours before intercourse 1
• Topical penile anesthetics: Lidocaine/prilocaine cream 20-30 minutes before intercourse 1

Important caveat: SSRIs should be avoided in men with bipolar depression due to risk of mania 1

For Comorbid Erectile Dysfunction

If erectile dysfunction coexists (and is often confused with masturbation concerns in young men):

• Treat ED first before addressing other sexual concerns 4
• PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are first-line, requiring adequate trial of at least 5 occasions at maximum dose 4
• Testosterone replacement if documented low testosterone (<300 ng/dL with symptoms) 4

For Underlying Psychiatric Conditions

• Antidepressants or anxiolytics for primary depression or anxiety disorders (not for masturbation itself) 2
• Address substance use disorders that may be associated with compulsive sexual behaviors 2

Behavioral and Lifestyle Interventions

• Stress reduction techniques and anxiety management, as these are common motivations for masturbation 3
• Relationship counseling to improve partner intimacy and sexual satisfaction 1
• Reduction of pornography use, which is highly correlated with masturbation frequency 5
• Development of alternative coping strategies for stress and negative emotions 3

What NOT to Do

• Do not prescribe SSRIs solely to reduce masturbation frequency without a diagnosis of premature ejaculation or depression 1
• Do not perform surgical interventions for masturbation concerns 1
• Do not dismiss the patient's distress even though masturbation is a normal behavior; ego-dystonic masturbation causes significant psychological suffering 2, 5
• Do not overlook relationship dynamics that may be contributing to or resulting from the behavior 3, 2

Common Pitfalls

• Confusing excessive masturbation with premature ejaculation or erectile dysfunction: Young men frequently present with these concerns intertwined; careful history distinguishes them 4
• Failing to screen for psychological comorbidities: Men with ego-dystonic masturbation have higher rates of depression, anxiety, and relationship problems 2
• Ignoring the partner's perspective: Relationship satisfaction is often impaired and should be addressed 3, 2
• Premature pharmacological intervention: Mental health referral should occur first, not as a last resort 1