Premature Ejaculation Guidelines

Updated: May 19, 2023
  • Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines for Management of Premature Ejaculation

Guidelines on premature ejaculation (PE) have been published by the following organizations:

  • International Society of Sexual Medicine (ISSM)
  • American Urological Association (AUA) and Sexual Medicine Society of North American (SMSNA)
  • Italian Society of Andrology and Sexual Medicine (SIAMS)

International Society of Sexual Medicine

The ISSM has developed evidence-based guidelines for patients suffering from lifelong PE. The guidelines were most recently reviewed and revised in 2013. [63] The guidelines include the following:

  • Definitions of lifelong and acquired PE
  • Discussions of the epidemiology and etiology of PE
  • Recommended and optional questions to establish the diagnosis of PE and direct treatment
  • Use of validated questionnaires
  • Psychological/behavioral, combined medical and psychological, and educational interventions
  • Pharmacologic treatment
  • A flow chart for the management of PE

American Urological Association and Sexual Medicine Society of North America

The AUA/SMSNA published joint guidelines on disorders of ejaculation in 2020. Guideline statements regarding the definition of PE were as follows [61] :

  • Lifelong PE is defined as poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut.
  • Acquired PE is defined as consistently poor ejaculatory control, associated bother, and ejaculation latency that is markedly reduced from prior sexual experience during penetrative sex. 

Other guideline statements on the diagnosis of PE included the following [61] :

  • The diagnosis of PE is based on medical, relationship, and sexual history and a focused physical examination.
  • Validated patient-reported questionnaires may be useful in diagnosis but are not required.
  • Laboratory testing should not be routinely used for the diagnosis of lifelong PE.
  • Laboratory testing may be useful when clinically indicated for the diagnosis of acquired PE.
  • Patients should be advised that circumcision status is unrelated to PE.
  • Consider referral to a mental health professional with expertise in sexual health; patients should be advised that combination behavioral and pharmacologic therapy is more effective than either therapy alone.
  • In patients with concomitant PE and erectile dysfunction (ED), the ED should be treated according to AUA guidelines on erectile dysfunction.
  • First-line pharmacologic treatments include daily selective serotonin reuptake inhibitor (SSRI) use, on-demand clomipramine or dapoxetine (where available), and topical penile anesthetics.
  • If first-line pharmacotherapy fails, consider on-demand dosing of tramadol or, possibly, alpha-1 adrenergic receptor blockers.
  • Patients should be advised that there is insufficient evidence to support the use of alternative therapies (eg, intracavernous self-injection,  duloxetine, venlafaxine, herbal therapies, acupuncture, botulinum toxin, modafanil, oxytocin antagonists).
  • Patients should be advised that surgical treatments (eg, selective dorsal nerve neurotomy, pulsed radiofrequency ablation of dorsal penile nerves, hyaluronic acid gel glans penis augmentation) are considered experimental and should only be delivered as part of a clinical trial.

Italian Society of Andrology and Sexual Medicine

The SIAMS issued guidelines on the management of PE in 2020. [22] In addition to recommendations regarding definitions and diagnosis, SIAMS recommends use of the following medications, which are approved in Europe for treatment of PE:

  • Dapoxetine as first-line on-demand oral therapy for both lifelong and acquired PE; the suggested starting dose is 30 mg, taken with a full glass of water 1–3 h before intercourse, with no titration to 60 mg or addition of other treatment until after at least 6–8 full sexual attempts in a congruous erotic environment
  • Eutectic lidocaine/prilocaine spray as local therapy for lifelong PE

SIAMS recommendations regarding off-label therapy include the following:

  • Obtain written and signed informed consent before initiating off-label treatment.
  • Use dapoxetine and a phosphodiesterase type 5 (PDE5) inhibitor to improve ejaculatory control in patients with comorbid erectile dysfunction (ED) and PE (loss of control of erection and ejaculation [LCEE]).
  • Consider the combination of dapoxetine and lidocaine/prilocaine in patients with PE refractory to a single therapy.
  • Use a PDE5 inhibitor in patients with ED or subclinical ED and PE (LCEE).
  • Consider on-demand use of an SSRI (paroxetine or fluoxetine) for PE refractory to first-line treatments and in the absence of psychiatric contraindications, as confirmed by a psychiatric consultation and psychometry.
  • Consider daily use of clomipramine or an SSRI (paroxetine or fluoxetine) for PE refractory to first line-treatments or to on-demand SSRI use, in the absence of psychiatric contraindications, as confirmed by a psychiatric consultation and psychometry.

SIAMS recommends against the following:

  • Prescription of an antidepressant without a careful screening for depression and determination of the endogenous or reactive nature of the depression
  • Use of alpha-1 adrenergic receptor blockers as second-line therapy in men with PE/lower urinary tract symptoms (LUTS)
  • Use of tramadol for PE