Treatment of Premature Ejaculation

Introduction to Premature Ejaculation

Premature ejaculation can be classified as primary (lifelong) or secondary (acquired), with understanding risk factors helping guide treatment, including erectile dysfunction, which often leads to secondary PE due to anxiety or need for intense stimulation 1, 2
Premature ejaculation is primarily a self-reported diagnosis based on sexual history, with key elements to assess including frequency and duration of PE, relationship to specific partners, and impact on sexual activity and relationships 2

The American Urological Association recommends fluoxetine at 5-20 mg/day as an effective and appropriate treatment option for premature ejaculation, though paroxetine (10-40 mg/day) is often considered more effective according to current guidelines 2
Daily SSRI therapy is recommended, with options including:
Medication Dosage
Sertraline 25-200 mg/day
Fluoxetine 5-20 mg/day
Paroxetine 10-40 mg/day
Clomipramine 12.5-50 mg/day
1, 2
Situational dosing is preferred by many clinicians, with options including:
Medication Dosage Timing
Paroxetine 20 mg 3-4 hours before intercourse
Sertraline 50 mg 4-8 hours before intercourse
Clomipramine 25 mg 4-24 hours before intercourse
1, 2
Topical anesthetics, such as Lidocaine/prilocaine cream (EMLA), can be applied 2.5%/2.5% cream 20-30 minutes before intercourse to prevent premature ejaculation, but should be washed off before intercourse to prevent numbness in the partner 2
PDE-5 inhibitors may be beneficial, especially in patients with comorbid erectile dysfunction, and α1-adrenoceptor antagonists may be considered for patients who have failed first-line therapy 1, 2

Long-term therapy is typically required, as premature ejaculation usually returns upon discontinuation of medication 2
None of the medications are FDA-approved specifically for premature ejaculation treatment in the US 2
Potential side effects of SSRIs include nausea, dry mouth, drowsiness, and reduced libido, and potential interactions with other medications, such as those metabolized by the cytochrome P450 system 1, 2
SSRIs should be avoided in patients with bipolar depression due to the risk of mania, and used with caution in adolescents and patients with depressive disorders 1

Treatment efficacy should be assessed using patient and partner satisfaction, Intravaginal Ejaculation Latency Time (IELT), and Premature Ejaculation Diagnostic Tool (PEDT) scores, with adjustments made to treatment based on response and side effects 1, 2
Regular follow-up is essential to assess treatment efficacy and adjust therapy as needed, as symptoms usually return upon discontinuing therapy 2
Patient and partner satisfaction should be the primary outcome measure for treatment success, and safety should be a primary consideration as premature ejaculation is not a life-threatening condition 2

Combining behavioral therapy with pharmacological approaches, particularly SSRIs, is the most effective treatment for premature ejaculation, providing greater improvement in ejaculation latency time than either modality alone, according to the American Urological Association 1
The American Urological Association recommends distinguishing PE from erectile dysfunction (ED), as these conditions frequently coexist, and treating ED first, as PE may improve once ED is effectively managed 1, 2