Premature Ejaculation Treatment with SSRIs

Introduction to SSRIs for Premature Ejaculation

The use of SSRIs for premature ejaculation commonly causes ejaculatory delay, decreased libido, erectile dysfunction, and other sexual side effects, along with potential systemic effects including serotonin syndrome when combined with other serotonergic medications, as noted by The Journal of Urology 1

Anorgasmia (inability to achieve orgasm) is a potential side effect of SSRIs for premature ejaculation 2

Serotonin syndrome is a potentially serious complication most often associated with simultaneous use of multiple serotonergic drugs (SSRIs, TCAs, recreational drugs like amphetamine or cocaine), with symptoms including clonus, tremor, hyperreflexia, agitation, mental status changes, diaphoresis, and fever, and treatment includes cessation of serotonergic agents and possibly benzodiazepines for symptom management 1
SSRI withdrawal syndrome can occur with sudden cessation or rapid dose reduction of daily SSRIs, and patients should be advised to avoid abrupt discontinuation 1
Treatment with SSRIs should be avoided in men with a history of bipolar depression due to risk of triggering mania 1
There is a risk of suicidality in adolescents with premature ejaculation and comorbid depressive disorder, particularly when associated with suicidal ideation, and caution is suggested when prescribing SSRIs to this population 1

Approximately 40% of patients either refuse to begin or discontinue SSRI treatment within 12 months due to concerns about taking an antidepressant, treatment effects below expectations, and cost 1
Daily dosing of SSRIs is more effective for ejaculatory delay but may have more sustained side effects, with dosing regimens including paroxetine 10-40 mg/day, sertraline 50-200 mg/day, fluoxetine 20-40 mg/day, and citalopram 20-40 mg/day 1
On-demand dosing of SSRIs may have fewer side effects due to less cumulative exposure but also less ejaculatory delay, with dosing regimens including paroxetine 20 mg 3-4 hours before intercourse and sertraline 50 mg 4-8 hours before intercourse 2

The American Urological Association notes that SSRIs are favored over tricyclic antidepressants like clomipramine because of a better side effect profile, though both are effective for premature ejaculation treatment 1
For patients who cannot tolerate SSRI side effects, topical anesthetics (lidocaine/prilocaine) are an alternative first-line treatment, but may cause penile hypoesthesia (numbness) and possible absorption by the partner, resulting in discomfort/numbness, which can be mitigated by using a condom or washing the penis prior to penetration 1