SSRI Antidepressants and Their Role in PE

Prevalence estimates range between 22% and 38%. Defining premature ejaculation has proven to be a daunting task.

Class Summary

Dosing routines should be selected on a case-by-case basis after discussion of risks and benefits with the patient and his partner. Fluoxetine doses range from 5 to 20 mg/d and can be increased slowly to reach the desired response. Sertraline can be given in daily doses of 25, 50, 100, or 200 mg, or as a situational dose of 50 mg daily. Paroxetine dosing can be 10, 20, or 40 mg/d, increasing to the desired effect, or as a situational dose of 20 mg, 3 to 4 hours before sexual activity.1,11,12 Most evidence for paroxetine treatment suggests that a dosing regimen of 20 mg/d is the most effective.9 Paroxetine seems to exert the strongest ejaculatory delay, increasing IELT approximately 8.8-fold compared with the baseline in one study.13 The effects of SSRI medications, measured by ejaculatory delay, tend to occur 5 to 10 days after initiation, but may occur earlier.14 Ejaculoselective serotonin transport inhibitors (ESSTIs), which are not yet approved in the United States, are currently being tested for on-demand use in PE treatment. Some have suggested basing the definition on existing normative data on the average time of intercourse (7 to 10 minutes).

Others prefer to disregard this "stopwatch" approach because there is a lack of consensus as to what is a normal time period. Masters and Johnson define premature ejaculation as the inability to delay ejaculation long enough to allow the woman to reach orgasm in at least 50% of a couple's sexual encounters. This definition assumes absence of orgasmic dysfunction in the woman.

Further reading

Prevalence estimates range between 22% and 38%. Defining premature ejaculation has proven to be a daunting task. Some have suggested basing the definition on existing normative data on the average time of intercourse (7 to 10 minutes). Others prefer to disregard this "stopwatch" approach because there is a lack of consensus as to what is a normal time period. Masters and Johnson define premature ejaculation as the inability to delay ejaculation long enough to allow the woman to reach orgasm in at least 50% of a couple's sexual encounters.

Cite this article

This definition assumes absence of orgasmic dysfunction in the woman. The DSM-IVR defines premature ejaculation as "persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect the duration of the excitement phase such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity." Therefore, premature ejaculation may occur intravaginally or extravaginally. In addition, the DSM-IVR requires that the disturbance cause "marked distress or interpersonal difficulty" and that it not be due "exclusively to the direct effects of a substance (e.g., withdrawal from opioids)." Perhaps a more practical definition is the one that views premature ejaculation as a tendency to ejaculate at lower levels of sexual arousal. One possible mechanism is a lower rate of sexual intercourse as compared with control subjects, a notion with obvious therapeutic implications.

Biological causes

2003, Office Practice of Neurology (Second Edition) 2010, Primary Care: Clinics in Office PracticeVictor A. DiazJr MD, Jeremy D. Close MD Premature ejaculation (PE) is the most common type of male sexual dysfunction. Most clinicians use the broad definition of PE as ejaculation occurring sooner than desired (before or shortly after penetration), causing distress to one or both partners. No strict time parameters have been defined, but an intravaginal ejaculatory latency time (IELT; ie, penetration to ejaculation) of less than 2 minutes is generally accepted as defining PE.1 Use of this broad definition has contributed to the large range in prevalence, from 5% to 30%.2 New definitions for PE are being considered for the Diagnostic and Statistical Manual, Fifth Edition (DSM-V) and International Classification of Diseases (ICD)-11. The DSM-IVR defines premature ejaculation as "persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect the duration of the excitement phase such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity." Therefore, premature ejaculation may occur intravaginally or extravaginally.

• Dapoxetine is taken as needed, usually 1-3 hours before sex for rapid action.
• Topical anesthetics should be used sparingly to avoid numbness of partner.
• SSRIs may cause side effects like nausea, dizziness, or decreased libido.
• Tramadol carries potential for abuse and should only be used under medical supervision.
• Daily use of certain medications may be recommended for persistent PE.
• Psychological counseling helps address performance anxiety contributing to PE.
• Pelvic floor exercises improve control and delay ejaculation naturally.
• Partner involvement in therapy can improve treatment adherence.
• Discontinuing medication abruptly may cause withdrawal symptoms or rebound.
• For some men, combining therapy with lifestyle changes yields better results.
• Over-the-counter remedies should be approached cautiously and discussed with a doctor.
• Research continues into new pharmacological and non-pharmacological treatments.

In addition, the DSM-IVR requires that the disturbance cause "marked distress or interpersonal difficulty" and that it not be due "exclusively to the direct effects of a substance (e.g., withdrawal from opioids)." Perhaps a more practical definition is the one that views premature ejaculation as a tendency to ejaculate at lower levels of sexual arousal. One possible mechanism is a lower rate of sexual intercourse as compared with control subjects, a notion with obvious therapeutic implications. 2003, Office Practice of Neurology (Second Edition) 2010, Primary Care: Clinics in Office PracticeVictor A.

Analgesic, Opioid

PE is difficult to diagnosis because there is no universally accepted definition. The American Urological Association (AUA) recommends that PE be diagnosed wholly on sexual history. Four key factors need to be considered when making the diagnosis. IELT refers to the time between vaginal insertion of the penis and the start of intravaginal ejaculation. IELT has been assessed by patient and partner recall, and by stopwatch evaluation.

Definition of Premature Ejaculation

Men with PE have a shortened or nonexistent IELT, tending to ejaculate in a few seconds to minutes. Normal IELT values have been somewhat difficult to define, as there is substantial variation in patient and partner recall, leading to self-reported IELTs that are inaccurately longer than actual stopwatch times.6 One multinational study of men without PE revealed self-reported times ranging from nearly 7 minutes in Germany to more than 13 minutes in the United States.7 There appears to be considerable overlap in times between PE and non-PE groups, suggesting that, until better normative values are available, the diagnosis cannot be made on an individual's IELT alone. Three additional self-reported factors that may be present include poor control over ejaculation, dissatisfaction with intercourse by the patient or partner, and perceived distress about the condition by the patient or partner. Not all of these factors need to be present to identify PE. A focused sexual history will help elicit many of these complaints to establish a diagnosis.8 Sexual history should include questions regarding frequency and duration of PE (primary vs acquired) and relationship to specific partners (global vs situational).

Tadalafil (Cialis)

It should be determined whether PE occurs with all or some sexual attempts, and what degree of stimulus results in PE. Inquiries about the type and frequency of current and past sexual activity (eg, foreplay, masturbation, intercourse, use of visual clues) should include feelings toward these behaviors, to help elucidate any underlying guilt or poor sexual education that may be playing a role. It is also important to explore the effect of PE on current and past sexual activity, types and quality of personal relationships, and general quality of life, as well as aggravating or alleviating factors and any relationship to drug use or abuse. Awareness of the issues surrounding PE may affect treatment considerations and, ultimately, treatment success. Physical examination should include a complete general examination and a genital examination. DiazJr MD, Jeremy D. Close MD Premature ejaculation (PE) is the most common type of male sexual dysfunction. Most clinicians use the broad definition of PE as ejaculation occurring sooner than desired (before or shortly after penetration), causing distress to one or both partners. No strict time parameters have been defined, but an intravaginal ejaculatory latency time (IELT; ie, penetration to ejaculation) of less than 2 minutes is generally accepted as defining PE.1 Use of this broad definition has contributed to the large range in prevalence, from 5% to 30%.2 New definitions for PE are being considered for the Diagnostic and Statistical Manual, Fifth Edition (DSM-V) and International Classification of Diseases (ICD)-11. PE can be divided into primary PE, which begins when the patient becomes sexually active, and secondary PE, which is acquired later in life.3 Additional subclasses include global and situational PE. Global PE is present in all circumstances, whereas situational PE occurs only with certain partners and situations.4 There are 3 distinct components to antegrade, or normal, ejaculation: emission, ejaculation, and orgasm. Emission is the contraction of seminal vesicles and the prostate with expulsion of sperm and seminal fluid into the posterior urethra. Ejaculatory inevitability, or the medicine for erectile dysfunction point at which ejaculation cannot be stopped, occurs in response to distention of the posterior urethra. The ejaculatory phase may or may not be followed by orgasm, defined as the centrally experienced conclusion of sexual excitation.4 The intricacies of these biologic sequences have made it difficult to understand the pathophysiology of PE. Historically, PE has been attributed to psychological causes such as early sexual experience, sexual conditioning, sexual technique, frequency of sex, and anxiety. Newer research is focused on neurobiological explanations, such as hyposensitivity of 5-hydroxytryptamine 2C (5-HT2c) receptors or hypersensitivity of 5-HT1a receptors. Men with low 5-HT levels reach the ejaculatory threshold earlier, resulting in more rapid ejaculation, whereas men with high 5-HT levels may have delayed or absent ejaculation. This idea is supported by the successful use of selective serotonin reuptake inhibitor (SSRIs), which increase 5-HT levels, in patients with PE.

It has also been suggested that men with PE have a hyperexcitable ejaculatory reflex that prevents them from controlling ejaculation.4 PE often goes undiagnosed because many men are reluctant to discuss sexual issues, and clinicians generally do not initiate these conversations. Time constraints and provider uneasiness with the topic compound the problem.5 The importance of dialog cannot be overemphasized, given that the diagnosis of PE is mostly based on sexual history. Many men do not realize that loss of erection after ejaculation is normal.

• Topical anesthetic creams temporarily desensitize the penis to delay ejaculation.
• SSRI medications like paroxetine are prescribed off-label for premature ejaculation.
• Dapoxetine is a short-acting SSRI specifically approved for PE treatment.
• Tramadol, an opioid, can help delay ejaculation but carries dependency risks.
• Topical sprays offer quick, localized numbing effects to control ejaculation timing.
• PDE5 inhibitors like sildenafil may improve performance in men with PE and ED.
• Behavioral therapies include the stop-start and squeeze techniques to extend duration.
• Kegel exercises strengthen pelvic muscles, potentially delaying ejaculation.
• Counseling and sex therapy can address psychological causes of PE.
• Combining medication with behavioral techniques enhances treatment effectiveness.
• Herbal supplements lack robust clinical evidence but are used by some for PE.
• Consultation with a healthcare provider is essential to tailor appropriate therapy.

Some men confuse PE with erectile dysfunction (ED). However, a skilled interviewer can help the patient clearly describe his true concerns. Including the partner in the discussion is often helpful, but this should be the patient's choice. PE is difficult to diagnosis because there is no universally accepted definition. The American Urological Association (AUA) recommends that PE be diagnosed wholly on sexual history. Four key factors need to be considered when making the diagnosis. IELT refers to the time between vaginal insertion of the penis and the start of intravaginal ejaculation. IELT has been assessed by patient and partner recall, and by stopwatch evaluation. Men with PE have a shortened or nonexistent IELT, tending to ejaculate in a few seconds to minutes. Normal IELT values have been somewhat difficult to define, as there is substantial variation in patient and partner recall, leading to self-reported IELTs that are inaccurately longer than actual stopwatch times.6 One multinational study of men without PE revealed self-reported times ranging from nearly 7 minutes in Germany to more than 13 minutes in the United States.7 There appears to be considerable overlap in times between PE and non-PE groups, suggesting that, until better normative values are available, the diagnosis cannot be made on an individual's IELT alone. Three additional self-reported factors that may be present include poor control over ejaculation, dissatisfaction with intercourse by the patient or partner, and perceived distress about the condition by the patient or partner. Not all of these factors need to be present to identify PE. A focused sexual history will help elicit many of these complaints to establish a diagnosis.8 Sexual history should include questions regarding frequency and duration of PE (primary vs acquired) and relationship to specific partners (global vs situational).

It should be determined whether PE occurs with all or some sexual attempts, and what degree of stimulus results in PE.

Additional info

PE can be divided into primary PE, which begins when the patient becomes sexually active, and secondary PE, which is acquired later in life.3 Additional subclasses include global and situational PE. Global PE is present in all circumstances, whereas situational PE occurs only with certain partners and situations.4 There are 3 distinct components to antegrade, or normal, ejaculation: emission, ejaculation, and orgasm. Emission is the contraction of seminal vesicles and the prostate with expulsion of sperm and seminal fluid into the posterior urethra. Ejaculatory inevitability, or the medicine for erectile dysfunction point at which ejaculation cannot be stopped, occurs in response to distention of the posterior urethra. The ejaculatory phase may or may not be followed by orgasm, defined as the centrally experienced conclusion of sexual excitation.4 The intricacies of these biologic sequences have made it difficult to understand the pathophysiology of PE.

Key Takeaways

Historically, PE has been attributed to psychological causes such as early sexual experience, sexual conditioning, sexual technique, frequency of sex, and anxiety. Newer research is focused on neurobiological explanations, such as hyposensitivity of 5-hydroxytryptamine 2C (5-HT2c) receptors or hypersensitivity of 5-HT1a receptors. Men with low 5-HT levels reach the ejaculatory threshold earlier, resulting in more rapid ejaculation, whereas men with high 5-HT levels may have delayed or absent ejaculation. This idea is supported by the successful use of selective serotonin reuptake inhibitor (SSRIs), which increase 5-HT levels, in patients with PE. It has also been suggested that men with PE have a hyperexcitable ejaculatory reflex that prevents them from controlling ejaculation.4 PE often goes undiagnosed because many men are reluctant to discuss sexual issues, and clinicians generally do not initiate these conversations.

Sildenafil (Viagra®) for PE

Time constraints and provider uneasiness with the topic compound the problem.5 The importance of dialog cannot be overemphasized, given that the diagnosis of PE is mostly based on sexual history. Many men do not realize that loss of erection after ejaculation is normal. Some men confuse PE with erectile dysfunction (ED). However, a skilled interviewer can help the patient clearly describe his true concerns. Including the partner in the discussion is often helpful, but this should be the patient's choice. Inquiries about the type and frequency of current and past sexual activity (eg, foreplay, masturbation, intercourse, use of visual clues) should include feelings toward these behaviors, to help elucidate any underlying guilt or poor sexual education that may be playing a role. It is also important to explore the effect of PE on current and past sexual activity, types and quality of personal relationships, and general quality of life, as well as aggravating or alleviating factors and any relationship to drug use or abuse.

How to prevent premature ejaculation

Antidepressant medications have been the most studied, because their well-known side effects, including anorgasmia and delayed ejaculation, make them ideal for treating PE. The most commonly used agents are the SSRIs. Tricyclic antidepressants (TCAs), such as clomipramine, have also been used, but TCAs have fallen out of favor because of safety concerns, especially in the elderly. Options include once-daily dosing or situational dosing regimens. Daily dosing increases IELT more than situational dosing. Awareness of the issues surrounding PE may affect treatment considerations and, ultimately, treatment success. Physical examination should include a complete general examination and a genital examination. The provider should always be sexual tablets for women reassuring when normal findings are present. The examiner should look for signs of underlying chronic disease or endocrine dysfunction (eg, gynecomastia, muscle wasting). Laboratory evaluation is rarely necessary in men with lifelong PE, unless there are complicating factors or concerning physical examination findings.9 Secondary PE may need additional laboratory work, specifically focused on risk factors such as vascular disease, obesity, diabetes, and depression. Specific attention should be given to the possibility of underlying ED. Recent data show that almost half of men with PE also have ED.10 Men with ED may hurry their sexual experience to prevent loss of erection, leading to rapid ejaculation. This behavior may inappropriately lead to the diagnosis of PE, when ED may be the true diagnosis. Options for treatment of PE include pharmacologic, psychological, and behavioral therapies. The primary goal should be patient and partner satisfaction and should not focus on the IELT. Options should be discussed with the patient (and partner) to best fit their desired outcome, and should include discussion of how common and treatable PE is, to help normalize this problem. Each treatment modality can be used individually or in combination with others.

Expected duration

The provider should always be sexual tablets for women reassuring when normal findings are present. The examiner should look for signs of underlying chronic disease or endocrine dysfunction (eg, gynecomastia, muscle wasting). Laboratory evaluation is rarely necessary in men with lifelong PE, unless there are complicating factors or concerning physical examination findings.9 Secondary PE may need additional laboratory work, specifically focused on risk factors such as vascular disease, obesity, diabetes, and depression. Specific attention should be given to the possibility of underlying ED. Recent data show that almost half of men with PE also have ED.10 Men with ED may hurry their sexual experience to prevent loss of erection, leading to rapid ejaculation.

Topical Treatments for Premature Ejaculation

This behavior may inappropriately lead to the diagnosis of PE, when ED may be the true diagnosis. Options for treatment of PE include pharmacologic, psychological, and behavioral therapies. The primary goal should be patient and partner satisfaction and should not focus on the IELT. Options should be discussed with the patient (and partner) to best fit their desired outcome, and should include discussion of how common and treatable PE is, to help normalize this problem. Each treatment modality can be used individually or in combination with others. Antidepressant medications have been the most studied, because their well-known side effects, including anorgasmia and delayed ejaculation, make them ideal for treating PE. The most commonly used agents are the SSRIs. Tricyclic antidepressants (TCAs), such as clomipramine, have also been used, but TCAs have fallen out of favor because of safety concerns, especially in the elderly. Options include once-daily dosing or situational dosing regimens. Daily dosing increases IELT more than situational dosing.

• Dapoxetine is specifically designed for on-demand use in PE.
• Topical anesthetics require minimal use to avoid excessive numbness.
• SSRIs impact neurotransmitters involved in ejaculation control.
• Tramadol's side effects limit its routine use for PE.
• Non-drug approaches include psychological counseling and exercises.
• Pelvic strengthening exercises aid in delay of ejaculation.
• Partner education enhances understanding and support.
• Managing stress and anxiety can significantly improve PE.
• Some therapies combine medication with sex therapy sessions.
• Medical evaluation is essential before initiating treatment.
• Lifestyle factors like smoking can influence sexual performance.
• Patient adherence to treatment plans improves outcomes.

Dosing routines should be selected on a case-by-case basis after discussion of risks and benefits with the patient and his partner. Fluoxetine doses range from 5 to 20 mg/d and can be increased slowly to reach the desired response. Sertraline can be given in daily doses of 25, 50, 100, or 200 mg, or as a situational dose of 50 mg daily. Paroxetine dosing can be 10, 20, or 40 mg/d, increasing to the desired effect, or as a situational dose of 20 mg, 3 to 4 hours before sexual activity.1,11,12 Most evidence for paroxetine treatment suggests that a dosing regimen of 20 mg/d is the most effective.9 Paroxetine seems to exert the strongest ejaculatory delay, increasing IELT approximately 8.8-fold compared with the baseline in one study.13 The effects of SSRI medications, measured by ejaculatory delay, tend to occur 5 to 10 days after initiation, but may occur earlier.14 Ejaculoselective serotonin transport inhibitors (ESSTIs), which are not yet approved in the United States, are currently being tested for on-demand use in PE treatment.