Treatment of Premature Ejaculation

Initial Assessment and Concomitant Conditions

The American Urological Association recommends obtaining a detailed sexual history assessing frequency and duration of premature ejaculation, relationship to specific partners, degree of stimulus causing premature ejaculation, impact on sexual satisfaction, and quality of life before initiating treatment 1
The European Association of Urology suggests that if erectile dysfunction coexists with premature ejaculation, treating the erectile dysfunction first is a critical step, as many patients develop secondary premature ejaculation due to anxiety about maintaining erections or the need for intense stimulation 1

The American Urological Association recommends treating premature ejaculation with either selective serotonin reuptake inhibitors (SSRIs) or topical anesthetics as first-line pharmacotherapy, with the choice based on patient preference for daily versus on-demand dosing 2, 3
Paroxetine, sertraline, and fluoxetine are the most effective SSRIs for premature ejaculation, with paroxetine showing the strongest efficacy, according to the European Association of Urology 2, 1
The European Association of Urology suggests that dapoxetine is specifically approved for on-demand premature ejaculation treatment at 30-60 mg doses, showing 2.5-4.3 fold increases in intravaginal ejaculatory latency time, particularly effective in men with baseline ejaculatory latency <30 seconds 3
The American Urological Association notes that none of these medications are FDA-approved for premature ejaculation in the United States; all use is off-label, with common side effects including ejaculatory delay, decreased libido, dry mouth, nausea, and somnolence 2, 1

The American Urological Association recommends lidocaine 2.5%/prilocaine 2.5% cream (EMLA) applied 20-30 minutes before intercourse as an effective alternative to oral therapy, according to the European Association of Urology 2, 3
The European Association of Urology suggests that EMA-approved lidocaine/prilocaine sprays are also available and may offer more convenient application 3

The European Association of Urology recommends considering referring patients for psychosexual counseling in conjunction with medication, particularly in complicated cases or unstable partnerships, as combined behavioral and pharmacological treatment produces significantly greater increases in ejaculatory latency than pharmacotherapy alone 3
The European Association of Urology suggests that for patients with severe premature ejaculation, combination therapy with both topical and oral medications can considerably increase latency compared to monotherapy 3
The European Association of Urology notes that in patients with comorbid premature ejaculation and erectile dysfunction, PDE5 inhibitors can be safely combined with dapoxetine or other premature ejaculation medications after erectile dysfunction treatment is initiated 3

The American Urological Association recommends avoiding surgical interventions, including neurectomy and penile prosthesis implantation, as their risks far outweigh any potential benefits, according to the European Association of Urology 2

The American Urological Association suggests that patient and partner satisfaction is the primary target outcome, not arbitrary physiological measures, and discussing all risks and benefits before initiating treatment, reassuring patients that premature ejaculation is common and treatable, is essential 2, 1

The American Urological Association recommends a combination of behavioral therapy and pharmacological approaches as the best treatment for premature ejaculation, as this combination is more effective than either modality alone 4, 5, 6

The use of Selective Serotonin Reuptake Inhibitors (SSRIs), such as paroxetine, sertraline, and fluoxetine, is a recommended pharmacological option for premature ejaculation, with common side effects including ejaculatory delay, decreased libido, dry mouth, and nausea 7, 8
Topical anesthetics, such as lidocaine/prilocaine cream, can be used to delay ejaculation, but may cause penile hypoesthesia and transfer to partners, and should be used with a condom or thorough penis washing to prevent partner numbness 7, 8, 9

Combined behavioral and pharmacological treatment leads to a significantly greater increase in ejaculatory latency time compared to pharmacological therapy alone, and improves scores on validated instruments for assessment of premature ejaculation 4, 6

α1-Adrenoreceptor antagonists may be considered for men who have failed first-line therapy, but have limited efficacy data available and require additional controlled studies to determine their true role in premature ejaculation management 4, 5
For premature ejaculation with comorbid erectile dysfunction, the American Urological Association recommends treating erectile dysfunction first, then addressing premature ejaculation with appropriate therapy 5

For treatment-resistant cases, combining multiple therapeutic approaches, including α1-adrenoreceptor antagonists as add-on therapy, may be considered 5, 7

Surgical interventions should be avoided, as they are considered experimental and may result in permanent loss of penile sensation, and should only be used in the context of ethical board-approved clinical trials 4, 6
Up to 40% of patients may refuse to begin or discontinue SSRI treatment within 12 months due to concerns about taking antidepressants, treatment effects below expectations, or cost 5, 7, 8
Tramadol should be used with caution due to its opioid-like properties and risk of dependency, particularly in the context of the opioid crisis 5, 10