Medical treatments for premature ejaculation

No drug is approved by the FDA for the treatment of premature ejaculation. However, numerous studies have shown that selective serotonin reuptake inhibitors (SSRIs) and drugs with SSRI-like side effects are safe and effective to treat this condition, and many physicians use these agents for this purpose. SSRIs have been the most successful agents in delaying the too-rapid response in men who experience premature ejaculation. Desensitizing creams containing local anesthetic agents can also be useful for some men with premature ejaculation. These agents are not approved by the FDA specifically for this use, but they are believed to be of at least some efficacy and are a minimal-risk option for patients.

Premature ejaculation that relates to erectile dysfunction (ED) may resolve if ED is treated successfully. Drugs for the treatment of ED include sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), alprostadil (Caverject, Muse), and, possibly, SSRI antidepressants (if depression is causing the ED). Details on drugs for the treatment of ED are included in the article on impotence (see Erectile Dysfunction).

If a patient does not have premature ejaculation but has depression-related ED only, the use of a drug with minimal adverse sexual effects (incidence <1%) such as bupropion HCl (Wellbutrin) or venlafaxine HCL (Effexor) might be a consideration in an effort to avoid creating a problem with delayed ejaculation or even anorgasmia. However, if the patient has significant premature ejaculation, ED, and depression, an added benefit of an antidepressant with SSRI side effects is the possibility that the premature ejaculation is also helped.

Drug Category: Selective serotonin reuptake inhibitors -- Mechanism of action is linked to their inhibition of neuronal uptake of serotonin in the CNS. Various animal studies suggest that SSRIs have weak effects on norepinephrine and dopamine neuronal reuptake. They do not antagonize adrenergic (eg, alpha1-adrenergic, alpha2-adrenergic, beta-adrenergic), cholinergic, GABA, dopaminergic, histaminergic, serotonergic (5HT 1A, 5HT 1B, 5HT 2), or benzodiazepine receptors; therefore, they have fewer adverse anticholinergic effects than tricyclic antidepressants.

SSRIs have been observed to cause sexual side effects, the most common being delay in sexual climax for both males and females. In most cases, females require quite a bit more time to reach climax than males; therefore, delayed climax caused by an SSRI becomes an adverse effect in women. Often, the frustration and discouragement of the inability to reach orgasm induce a pattern of sexual avoidance in many females, and a corresponding decrease in libido or sexual excitement (lubrication) develops in these individuals. In males, too-rapid orgasm can cause some of the same patterns of sexual avoidance and decreased libido; thus, determining the primary problem when instituting therapy is important. Sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac) are useful SSRIs for treating premature ejaculation.

The optimal medical treatment for premature ejaculation has not been established, but, in the author's experience, single dosing prior to sexual relations can work for some males, while in others, achieving a blood level through daily use of the medication may be necessary, as in the treatment of clinical depression. Obviously, if single dosing is successful, therapy is simpler and is associated with fewer adverse effects. Therefore, this may be the preferred initial therapy. The dose may be increased in step-wise fashion until a therapeutic effect is achieved or until the maximum daily recommended dose is reached. No exact schedule of increased dosing has been determined, and the experience of the physician, response of the individual patient, adverse effects experienced by the patient, and other general medical considerations should be the guiding factors.

If one SSRI fails to help the patient, using a second choice certainly is reasonable. However, if the second choice fails, the author's experience is that a third choice is not likely to benefit the patient. As with treatment for depression, if a patient has been on the medication for 6 weeks at maximal dose with no improvement, then the likelihood is remote that a more prolonged course of therapy with a particular drug would be successful. No reason exists for not combining medication with behavioral modification therapy, desensitizing creams, or both; additive effects or even synergy from several simultaneous treatments can occur. If all treatment fails, then the only options are for the patient to see a different health care professional, if he wishes, or for him to accept his condition as being untreatable with currently available therapeutic options.

Drug Category: Topical anesthetic agents -- These agents may reduce penile sensitivity and excitability and delay ejaculation. Condoms also reduce male sensitivity, yet no evidence exists that wearing a condom helps successfully treat premature ejaculation. Topical anesthetic cream is probably the lowest-risk medication that can be used for premature ejaculation, with no adverse systemic effects in the absence of prior hypersensitivity to the medication (patient or partner). Usually, no contraindication exists for combined therapy with topical anesthetics, antidepressants, and behavioral therapy.

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