Premature Ejaculation

Treatment for Premature Ejaculation

There are currently no FDA-approved treatments for premature ejaculation. All medications prescribed for premature ejaculation are done so off-label, which means they are approved by the FDA to treat a different condition. This doesn't mean that there are no treatments for premature ejaculation, only that no drug has been specifically developed and approved for the purpose of treating it.

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Despite the absence of FDA approved treatments, there are a number of medications that are routinely prescribed. There are also a number of treatments that are considered "alternative", meaning that they either don't fit into the current mainstream treatment paradigm or there are mixed data concerning the efficacy.

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First-line Treatment for Premature Ejaculation

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The current standard of care first-line treatment for premature ejaculation is the prescription of oral medications called SSRIs (selective serotonin reuptake inhibitors). SSRIs are drugs primarily used to treat psychiatric illnesses like depression and anxiety. However, one of the most well-known side effects of SSRIs is erectile dysfunction and/or the inability to orgasm. 

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It usually takes 2 to 3 weeks after beginning treatment with an SSRI to determine if the treatment is effect. This adds to the drawbacks of treating premature ejaculation with SSRIs because SSRIs are typically tapered up with increasing doses to determine maximum clinical effect. It is also generally recommended not to stop SSRIs suddenly, therefore there would need to be a reverse taper just to discontinue the medication.

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SSRIs commonly prescribed for premature ejaculation include:

• Paroxetine (10 to 40mg per day)

• Sertraline (50 to 200mg per day)

• Fluoxetine (20 to 40mg per day)

• Citalopram (20 to 40mg per day)

• Escitalopram (10 to 20mg per day)

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A meta-analysis study that compared the relative effectiveness of SSRIs to delay ejaculation suggested that paroxetine may be the most effective. However, a determination of which medication to use, if any, should be the result of a discussion between the patient and his doctor.

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Second-line Treatment for Premature Ejaculation

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If SSRI medications are not effective in treating premature ejaculation or if a man is unable to tolerate the medication, clomipramine is considered the second-line treatment. Clomipramine is a tricyclic antidepressant that is typically used to treat depression and other psychiatric illnesses. Not only does clomipramine come with a huge list of side effects, one of the likely side effects includes loss of libido. Therefore, in addition to preventing premature ejaculation, it also keeps you from even wanting to have sex.

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Third-line Treatment for Premature Ejaculation

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If men fail treatments with the first- or second-line medications for premature ejaculation, they may be prescribed tramadol as an off-label treatment. Tramadol is an opioid pain medication and has the potential for addiction and abuse. 

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In randomized control trials comparing tramadol to placebo for premature ejaculation, tramadol was effective in prolonging ELT. However, it appears as though tramadol is not as effective as other oral medications such as the antidepressants listed above.

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Alternative Treatments for Premature Ejaculation

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There are several alternative treatments available for premature ejaculation. Some of the alternative treatments for premature ejaculation are only "alternative" because there's no widespread endorsement of the treatments use by any major medical organization. However, when treating a condition for which there is no FDA approved medication, the safe and medically supervised administration of alternative treatments by a physician should be considered.

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Phosphodiesterase Inhibitors for Premature Ejaculation

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Phosphodiesterase 5 (PDE5) inhibitors are drugs like Viagra or Cialis. These medications are FDA approved for erectile dysfunction. Some research suggests that there may be a benefit for men suffering from premature ejaculation. It is accepted that PDE5 inhibitors should be a first-line treatment consideration for men who have erectile dysfunction in addition to premature ejaculation.

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A meta-analysis published in Medicine in 2018 concluded that PDE5 inhibitors, with or without the use of an SSRI, worked better than a placebo for treating premature ejaculation. In fact, sildenafil was shown to be more effective than the SSRI sertraline for treating premature ejaculation. One study found that although PDE5 inhibitors were not more effective at prolonging ELT, sildenafil did have the effect of increasing the men's confidence during sex and increasing sexual satisfaction.

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Topical Anesthetics for Premature Ejaculation

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Topical anesthetics are creams, gels, and sprays that contain a numbing agent. The use of topical anesthetics to treat premature ejaculation may be the oldest form of treatment. The medications work by decreasing the sensation to the penis, thereby prolonging intercourse and delaying orgasm. Topical anesthetics have been shown in studies to perform better than placebo in delaying ejaculation. The topical agent is applied directly to the penis 5 to 10 minutes prior to sexual intercourse. 

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According to a meta-analysis published in Andrologia in 2020, topical anesthetics worked better than SSRIs, PDE5 inhibitors, and other antidepressants in treatment courses that were shorter than 8 weeks. For treatment courses that lasted longer than 8 weeks, PDE5 inhibitors with an SSRI was the most effective medication regimen.

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Alprostadil for Premature Ejaculation

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Alprostadil is approved by the FDA to treat erectile dysfunction. It is sold under the brand names Caverject (an injectable) and Muse (a suppository cream). Aprostadil is a prostaglandin analog which means it causes dilation of the blood vessels in the penis by increasing inflammation.

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Several studies have suggested that alprostadil is worth consideration as a treatment for premature ejaculation. The potential drawback for the use of alprostadil is the ability to expose one's partner to the medication during intercourse. A small percentage of partners experienced vaginal burning and/or itching from a man's use of alprostadil prior to sexual intercourse.

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Therapy for Premature Ejaculation

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There is evidence to suggest that behavioral therapy may be effective is improving premature ejaculation in men. For men who have a significant psychological component or social issues with their partner, combining therapy with medication has shown to be more effective in treating premature ejaculation. This should be no surprise, given that one of the diagnostic criteria for PE is psychological distress.

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Psychological therapy can also help deal with the psychological component of PE - namely the loss of control. The loss of control factor in premature ejaculation can be thought of as a combination of psychological factors with physical ones. What this means is that the brain, being a powerful organ, is capable of changing the physiological response.

 

For example, being suddenly startled or scared during sexual intercourse will likely lead to immediate orgasm. These reactions activate what is known as the sympathetic nervous system (the fight or flight response). The sympathetic nervous system is what becomes activated during ejaculation and orgasm. Ultimately, encouraging activation of the parasympathetic nervous system (rest and digest) could potentially counteract the sympathetic nervous system, leading to a delayed orgasm response.

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Hyaluronic Acid Injections for Premature Ejaculation

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Several studies have described a technique of injecting hyaluronic acid into the penis to treat premature ejaculation. The hyaluronic acid formulation used is typically one used for dermal fillers in aesthetic practices. The technique involves the injection of the filler using a fan technique into the glans of the penis. The theory behind the effectiveness of this treatment seems to be the desensitization of the glans itself, a part of the penis known to be rich in sensory nerve endings.

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Transcutaneous Electrical Nerve Stimulation (TENS) for Premature Ejaculation

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The use of electrical stimulation to treat genital and sexual issues goes back to the days of acupuncture. Practitioners of Traditional Chinese Medicine (TCM) historically alleged that issues with the bladder and pelvic floor could be treated with acupuncture. Later on, it was identified that the area where the acupuncture needles were placed was the anatomic location of the tibial nerve at the ankle. Electrical stimulation of this nerve became common practice to treat overactive bladder syndrome, especially in Europe. It has only become an accepted medical practice in the U.S. in the past two decades.

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In 2022, the Asian Journal of Urology published a study in which the author described the use of a TENS unit to treat premature ejaculation. The author depicts the placement of TENS electrodes directly on the penis, theoretically treating premature ejaculation through direct stimulation of the dorsal penile nerve.

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A different study published in the International Journal of Impotence Research reported the use of TENS to stimulate the posterior tibial nerve and successfully treated premature ejaculation. Posterior Tibial Nerve Stimulation (PTNS) is a known second-line treatment for overactive bladder syndrome and it can be assumed  that the potential mechanism for the treatment of premature ejaculation is somewhat similar. Unfortunately, the exact mechanism is unknown at this time.

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One proposed mechanism of action involves the reflex arch provided by the nerves exiting at the level of the sacrum. Evidence of this function can be seen when eliciting the cremasteric reflex. Stroking the skin on the inner thigh of a man will cause the skin of the scrotum to elevate. These two areas have different nerve distributions, so there is not a direct superficial link. The two areas must be connect at a higher level of the nervous system, such as the spinal cord.

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Electroacupuncture for Premature Ejaculation

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A randomized control trial published in the Journal of Healthcare Engineering in 2022 studied the effects of electroacupuncture on as a treatment for premature ejaculation. The study attempted to see if electroacupuncture had an effect on serum testosterone. The researchers found a significant increase in life satisfaction scores of patients treated with electroacupuncture. They also found that electroacupuncture was effective at prolonging IELT. The authors concluded that electroacupuncture can be an effective treatment for premature ejaculation.

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A randomized control trial published in The Chinese Journal of Physiology in 2020 studied the effects of low-frequency electroacupuncture on the sexual performance of rats. The researchers compared the use of low-frequency acupuncture (2 Hz) with high-frequency acupuncture (80 Hz). They found increase levels of serotonin and luteinizing hormone in those treated with low-frequency acupuncture. The authors concluded that low-frequency acupuncture might be an effective treatment for premature ejaculation.