Treatment of Premature Ejaculation

Initial Assessment and Comorbidity Management

The American Urological Association recommends obtaining a detailed sexual history focusing on time to ejaculation, frequency and duration of premature ejaculation, relationship to specific partners, impact on sexual activity and quality of life, and presence of concomitant erectile dysfunction 1, 2
If erectile dysfunction coexists with premature ejaculation, the American Urological Association suggests treating the erectile dysfunction first, as premature ejaculation may improve when erectile dysfunction is effectively managed 1, 3, 2

The American Urological Association recommends daily selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacologic therapy, with the strongest evidence supporting daily paroxetine for maximal ejaculatory delay 3, 4
Daily paroxetine provides the greatest ejaculatory delay, increasing ejaculatory latency time (ELT) by a mean of 8.8-fold over baseline 4
Recommended daily dosing regimens include paroxetine 10-40 mg/day, sertraline 25-200 mg/day, fluoxetine 5-20 mg/day, citalopram 20-40 mg/day, and clomipramine 12.5-50 mg/day 5, 4, 6

The American Urological Association warns that SSRIs are not FDA-approved for premature ejaculation and may cause adverse effects such as ejaculation failure, decreased libido, nausea, insomnia, and dry mouth 4
The American Urological Association advises caution in adolescents and men with comorbid depression regarding suicidal ideation, though elevated risk has not been found in non-depressed men with premature ejaculation 4

The American Urological Association suggests considering alpha-1 adrenoceptor antagonists for men who have failed first-line therapy, though efficacy data remains limited 3, 7
Combining behavioral and pharmacological approaches is more effective than either modality alone, with a Moderate Recommendation and Evidence Level Grade B 3, 7

The American Urological Association states that patient and partner satisfaction is the primary target outcome for premature ejaculation treatment 1, 2, 8
The American Urological Association recommends discussing risks and benefits of all treatment options before intervention, including the off-label nature of pharmacologic therapies 1, 2, 8

The American Urological Association recommends starting treatment at the lowest effective dose compatible with reasonable success, according to studies published in The Journal of Urology 9, 10, 11
Lidocaine/prilocaine cream applied 20-30 minutes prior to intercourse increases ejaculatory latency time with minimal side effects, as reported in The Journal of Urology 10, 11

Topical anesthetics, such as lidocaine/prilocaine cream, can be applied to the penis 20-30 minutes before intercourse to increase ejaculatory latency time, with guidelines from The Journal of Urology 10, 11
Avoid prolonged application (30-45 minutes) as this causes loss of erection due to excessive penile numbness, according to The Journal of Urology 10, 11

Sildenafil citrate combined with paroxetine on a situational basis enhances efficacy of paroxetine alone, though increases headache and flushing, as reported in The Journal of Urology 9, 10, 11

Alpha-1 adrenoceptor antagonists, such as alfuzosin and terazosin, may be considered for men who have failed first-line therapy, though efficacy data remains limited, according to The Journal of Urology 11, 9

Patient and partner satisfaction is the primary target outcome for premature ejaculation treatment, not just ejaculatory latency time, with treatment choices based on patient and partner reports of efficacy, side effects, and acceptance, as recommended in The Journal of Urology 9, 10, 11