Premature Ejaculation Guidelines

Updated: May 25, 2021
  • Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines for Management of Premature Ejaculation

International Society of Sexual Medicine

The International Society of Sexual Medicine (ISSM) has developed evidence-based guidelines for patients suffering from lifelong premature ejaculation (PE), which include definitions of lifelong and acquired PE; discussions of the epidemiology, etiology, diagnosis, and treatment of PE; and a flow chart for the management of PE. The guidelines were most recently reviewed and revised in 2013. [60]

American Urologic Association

The American Urologic Association (AUA) published guidelines on the pharmacologic management of PE in 2004; the guidelines were reviewed and validated in 2010. [61] Guideline statements were as follows:

  • The diagnosis of PE is based on sexual history. A detailed sexual history should be obtained from all patients with ejaculatory complaints.
  • In patients with concomitant PE and erectile dysfunction (ED), the ED should be treated first.
  • Before initiating any intervention, clinicians should discuss the risks and benefits of all treatment options. Patient and partner satisfaction is the primary target outcome for the treatment of PE.
  • Any of several serotonin reuptake inhibitors or topical anesthetics can provide effective treatment for PE. The optimal treatment choice should be based on both physician judgment and patient preference.

The AUA also noted the following:

  • Although not approved by the US Food & Drug Administration for treatment of PE, oral antidepressants and topical anesthetic agents are effective and have minimal side effects when used for this purpose.
  • Oral antidepressants should be started at the lowest possible dose that is compatible with a reasonable chance of success
  • The choice of additional therapy is based on the patient and partner reports of efficacy, side effects, and acceptance of the therapy as well as on a regular review of alternative approaches
  • Support and education of the patient and, when possible, the partner are an integral part of PE therapy.

Italian Society of Andrology and Sexual Medicine

The Italian Society of Andrology and Sexual Medicine (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, ingested 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 a selective serotonin reuptake inhibitor (SSRI; ie, 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