The issue of treatment is a challenging one, especially if you’re in a relationship where you are stressed by your partner’s dissatisfaction with your sexual performance. On the one hand, you want a treatment that’s going to work as fast and effectively as possible.
Some men in this position search out a sexual therapist for one to one sessions, but the obvious disadvantage of this is that such sessions are potentially not only embarrassing but also expensive – ranging from $100 to $300 per hour. And do you really want to go through the experience of finding a sexual therapist, getting to know them, and then uncovering the most intimate secrets of your sex life in the consulting room?
Probably not. So here is a little about the various premature ejaculation treatments available, so you can make some kind of informed judgment about what you want to try – and, more importantly, which PE treatments simply don’t work, and are a waste of time and money.
Broadly speaking, for rapid ejaculators, the treatment methods fall into two main groups: firstly those which involve drugs, hypnosis, pills, lotions and potions, and secondly those which involve sexual therapy, behavioral modification, and dealing with relationship issues.
Therapy & Non-drug based treatments for premature ejaculation
One common recommendation for treatment of PE is to think of something non-sexual while you make love. But the problem here is that this is even more distracting – a man who ejaculates quickly needs all the feedback which his peripheral nervous system can provide, not less of it, as he is out of touch with the sensory feedback loop that makes him aware of how close he is to ejaculation. He therefore lacks the information needed to change his sexual behavior so that he does not actually reach the point of emission.
Non-sexual touching has also been recommended as a method of desensitization, but as a treatment approach this is now discredited. Non sexual touching can in fact be arousing, and it avoids the essential aspect of any PE treatment – which is to desensitize the man to sexual stimuli so that he is less aroused, able to prolong the length of time he spends on the plateau phase of his sexual arousal cycle, and therefore extend the time take for him to reach orgasm and ejaculate.
Another method of inhibition – that of squeezing the penis just below the frenulum as a man nears the point of ejaculation – is also not generally recommended nowadays by sexual therapists. This is painful, and although it causes a man’s erection to diminish and his arousal to decrease (perhaps not too surprisingly!), its efficacy in treating quick ejaculation remains doubtful.
It is surprising to hear that men were once advised to wear two condoms to reduce the amount of sexual stimulation they were receiving. This is an unsafe sexual practice, as friction between the two layers of latex can lead to the condom developing a tear or a hole. In any event, there are no reports of this ever having successfully treated a man’s PE.
The same applies to condoms containing benzocaine, which is reputed to anesthetize the penis and reduce the likelihood of premature ejaculation. In reality, men who try this treatment approach may find that they end up with a numb penis, do not feel the pleasurable sensations of penetration and the warmth of their partner’s body, and they may still ejaculate just as quickly.
Other approaches to the control of premature ejaculation have included the advice to change positions often during sex (which effectively works because of the interruption to the progressive increase in a man’s arousal); to use Kegel exercises to develop control of the pubococcygeal muscles which propel semen out of the penis – a forlorn hope since these muscles are almost impossible to control voluntarily – and a process of psychotherapy.
Goal oriented psychotherapy is one of the best and most effective treatments in a behavioral approach to control of rapid ejaculation. It may be premature to say it, before further definitive proof emerges, but any man who wishes to develop good ejaculatory control may be well advised to see a sexual/behavioral therapist to learn a behavioral control program, and a psychotherapist to discuss any underlying sexual issues which may be contributing to his premature ejaculation. Such issues include, but are not limited to: anxiety, fear of intimacy, hostility to women, lack of a sense of masculinity or male power, and doubts about body image, penis size and self-confidence.
Premature ejaculation treatment
Obviously it’s crucial for men who have premature ejaculation to accept that they have no voluntary control over ejaculation. But the reverse is true: a point many researchers miss is that men who cannot control their ejaculation may well not understand that it is in fact possible to exert voluntary control over such an apparently involuntary bodily function. In my view they may well be upset about the lack of control that they have in bed over their ejaculation, but they often do not appreciate that it is in fact possible to control ejaculation through voluntary effort.
Historically, premature ejaculation was though of as a purely psychological problem and behavioral therapy was thought of as the best treatment. The so-called “stop-start technique” was the first and classic treatment for premature ejaculation – it requires a man’s partner to stimulate his penis until he is almost at the point of no return, then to stop the stimulation until he knows he is no longer near ejaculation (in other words, until his arousal has dropped below the point at which there is a danger of him ejaculating). The pattern of stimulation and stopping stimulation is repeated until there is a degree of control over ejaculation. A similar technique was put forward by Masters and Johnson in 1970, though they asked the man’s partner to squeeze his frenulum after she stopped stimulating him – presumably because such pressure can cause a loss of erection, so it will obviously take longer for him to get fully aroused again.
The reality, of course, is that many cases of premature orgasm are caused by a lack of sexual confidence, by psychosexual anxiety, and by interpersonal issues such as anger or lack of interest in the partner’s well-being, pleasure or satisfaction (what you might call a kind of sexual selfishness). Although teaching these techniques to delay ejaculation has been a main plank of psychosexual therapy, it may well be much more important in a psychodynamic sense for therapy to be directed at helping a man regain his sexual confidence, reduce his sexual performance anxiety, and more than anything else to resolve any interpersonal difficulties with his sexual partner. Treatment success is rather variable (although the methods on this website are about as successful as you can get), and the reasons for that appear to be that ejaculation is a spinal reflex which is strongly controlled by higher cortical centers – in other words, establishing voluntary control over it is difficult.
Well, that is a matter of opinion. I think that when the motivation to cure premature climax is there, establishing voluntary control is not actually that difficult. Sure, it takes time and practice, but the key thing is motivation. This control can be developed. It is influenced by past experiences and present context, but there are a very few men with what one might consider to be definitive premature ejaculation; that is to say, an ejaculation latency which is so short and difficult to control that they may be considered to have a genetic bias towards early ejaculation.
Needless to say, it has been suggested that rapid ejaculation is an evolutionary advantage: the faster you impregnate a woman, the safer you are, and the more likely are your genes to pass on to the next generation. This may be so, but it doesn’t alter the fact that today premature ejaculation is a social, if not an evolutionary, handicap.
Although conventional psychotherapeutic sex therapy is effective, it is long-term and slow – and you need a partner who is happy to help. This has led to a tendency to prescribe drugs, which, no doubt, represent a simple and easy approach to therapy in the eyes of many men and their doctors. Unfortunately the facts are that all the drugs which are used for the treatment of premature ejaculation were originally designed for other conditions, and they may therefore be inappropriate for this problem. They certainly do not have regulatory approval for this purpose.
Treating Premature Ejaculation With Drugs
The main treatments in this context are desensitizing agents applied to the skin of the penis and antidepressant drugs used “off label” for the treatment of premature ejaculation.
1 Desensitizing drugs
The oldest drug therapy for premature ejaculation is a local anesthetic which is applied to the penis – the idea being that premature ejaculation was caused by hypersensitivity of the penis. However, this has never been proven by experimental investigation and there are few benefits to this approach as a treatment. For one thing, the local anesthetic diminishes penile sensation and pleasure, which seem like high prices to pay for a slightly longer intravaginal time span. Furthermore, unless applied to the inside of a condom, they have the unfortunate side-effect of numbing the vagina, a somewhat distracting effect for the partner of the man concerned. There may be skin reactions, and there may be the delay in intercourse prompted by the need to apply the cream to the penis. However, this approach is still available in the form of a delay condom made by several of the large condom companies, and it may work for some men. There are various medications which have been used for this purpose, and they are listed below.
Lidocaine and prilocaine mixed together in equal amounts to form a preparation which is known as EMLA. This is widely used to treat rapid ejaculation, although accounts of its effectiveness are not widely available. It needs to be applied 20 minutes before insertion of the penis into the vagina; after 45 minutes, penile numbness and loss of erection are common effects. Overall, however, treatment results in a 5.6 fold increase in the length of intercourse (the time between insertion and ejaculation). Most men were very pleased with the treatment, though 16% of men had adverse effects including penile numbness and retarded ejaculation, penile irritation, and one man’s partner reporting decreased vaginal sensations.
SS cream, which is made and sold in Korea, is applied to the glans about sixty minutes before intercourse, then washed off. There is an unfortunate smell with the product which makes it less desirable than some other products, due no doubt to the fact that it is made of a cocktail of nine ingredients, including those with local anesthetic and vasodilatatory qualities. It seems to be effective in extending the length of intercourse, although it also produces considerable irritation of the penis (one in five men).
This mixture (known as TEMPE) for the treatment of PE is delivered as a metered-dose spray combination of lidocaine and prilocaine. The formulation is designed to maximize tissue penetration and therefore produce a fast reaction in the penis, enabling intercourse to proceed without a condom. Unfortunately the compound does not penetrate keratinized skin, and its effectiveness on circumcised men is therefore somewhat questionable (circumcised men often have a keratinized glans). Treatment consists of three applications squirted onto the glans penis a quarter of an hour before sex: this regime produces a significant increase in time between penetration and ejaculation, and is reported to produce a significant improvement in a man’s control over the time when he ejaculates. There are few side-effects, although 12% of men reported numbness of the penis and erectile dysfunction (the latter only being experienced by one man). TEMPE produces an average increase in intra-vaginal time from 1 minute to 4.9 minutes. It is not as effective as EMLA cream but apparently produces fewer side-effects.
Dyclonine / Alprostadil
A mixture of local anesthetic called dyclonine and the vasodilator alprostadil (used in men with erectile dysfunction to stimulate and maintain erection), is being developed – as yet, no data are available for the success rate of the product.
2 Anti-depressants for premature ejaculation treatment
Drug treatments by mouth for premature ejaculation include selective serotonin reuptake inhibitors (SSRIs) and clomipramine, which is a tricyclic antidepressant. There are a few other compounds, like Viagra (PDE-5 inhibitors) and tramadol, which are also included since they are the subject of current research.
Clomipramine is a tricyclic antidepressant whose effectiveness in the treatment of premature ejaculation was demonstrated as long ago as the mid 1970s. As reported elsewhere on this website, Waldinger has shown that if it is used on a daily basis, clomipramine has the ability to increase the length of time between penetration and ejaculation by 4.6 times. This mirrors the results from sertraline or fluoxetine. Clomipramine must be used between three and six hours before intercourse: clomipramine 25 mg produces a 4 times increase in intra-vaginal ejaculatory latency time. Unfortunately, an adverse side effect is nausea which lasts for two days – the day the drug is taken and the day after. There are also certain criteria which apply to the men who take this drug, and which have been shown to be the conditions which make it most effective (i.e. they are satisfied with sex as demonstrated by a self-rating of five on a seven point scale, and they ejaculate twice or more each week).
SSRIs for premature ejaculation treatment
SSRIs are not approved for the treatment of PE, although they are commonly prescribed. They delay ejaculation in between 30 and 50% of men, and at the moment, there are four varieties which find a sue in this way: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citralopram (Celexa). Other SSRI’s are not effective at increasing the duration of sexual intercourse; the producers of Dapoxetine – a related compound – have tried (but been denied) formal approval for the drug to be listed as a treatment for this sexual dysfunction.
The delaying effect of paroxetine on ejaculation was first recorded in 1994 and has been confirmed many times since. The absence of regulatory approval may well relate to the fact that a drug should not be marketed for the effectiveness of its side-effects rather than its main treatment purpose (which is, of course, depression).
Having said that, this set of drugs is pretty well tolerated by men with premature ejaculation, who seem to have a different side effect profile than men with depression on these drugs. However, one has to ask if these are desirable side-effects: yawning, nausea, perspiration, fatigue and loose bowel movements! Even if, as is claimed, these adverse effects gradually disappear with use, ingesting these antidepressives seems like one of the most dramatic ways possible to try and prevent premature ejaculation! Furthermore, some men using these drugs to gain a longer period of sex will experience much worse symptoms, which include SSRI discontinuation syndrome, diabetes, bleeding, and so on.
It seems ironic that all of this can lead to a claim that these drugs are known to be efficient in controlling rapid ejaculation. But there are still researchers asking whether they should be taken daily or on-demand (i.e. when sex is planned)!
Dr Gerald Brock, a prominent Canadian sexual health doctor and renowned urologist, has made the observation that prescribing SSRIs for premature ejaculation treatment is now becoming more common in Canada. In the absence of specifically approved treatment methodologies and drugs approved for this purpose, SSRIs such as sertraline and paroxetine are now offered to patients as well as some non-SSRIs such as clomipramine.
Many men do not seek treatment for this potentially embarrassing condition, and many others are not offered good treatment when they do…….so are prescription drugs an appropriate therapy anyway?
SSRIs & side effects
Dr Brock has observed that SSRIs can be effective, but like many others working in the field points out the side effects. For one thing, they have long half-lives – a measure of how fast the drug decays in the body – and of course they are not designed for premature ejaculation ejaculation. The side-effects can include nausea and fatigue. Much worse, though, these drugs can apparently cause ejaculation failure and even complete impotence. The Annals of Pharmacotherapy has reported that citralopram withdrawal can actually cause a man to ejaculate faster!
Clearly, therefore, drug treatment is only part of the answer. Dr Brock states that a three-pronged approach is needed: this is an important medical issue and needs careful treatment and the men who have it deserve to be taken seriously. This three pronged approach involves education, so any stigma attached to seeking treatment is removed; then the recognition that sexual therapies and psychotherapy can be effective in helping to cure PE; and finally, the carefully considered administration of SSRI prescriptions, perhaps with psychological therapy.
Needless to say the drug companies are working hard in finding a side-effect free drug to treat PE, though as yet they do not seem to have made much progress.
Do drugs really help cure premature ejaculation – an effective treatment?
Yet there are some experts who think drug therapy should be more widely used. An article in Current Opinion in Investigational Drugs called for increased use of SSRI therapy, on the grounds that its overview of these drugs had established that paroxetine was the most effective treatment for PE; they also observed that daily intake gives better ejaculation control (by which we mean delay between penetration and ejaculation) than treatment on an ad hoc basis. (This means of course that the drugs are permanently in the patient’s body, which has implications for tolerance and raises concerns about possible side-effects.)
A study reported in The Journal of Clinical Psychopharmacology concluded that the time between penetration and ejaculation could be extended from one minute or less to about two minutes in men who had received treatment with paroxetine, fluoxetine, and sertraline. In my opinion, the risks of drug treatment far outweigh the rewards for an improvement of such a short time – especially when more conventional sexual-therapy-based methods can effectively provide complete control. The problem seems to be that we are in a society where the drug treatment of PE potentially rewards the drug companies with massive profits and the patients with little effort.
UroToday.com defines PE, quite correctly, as the recurrent approach of orgasm and ejaculation with little or no sexual stimulation, shortly before or after penetration and certainly before the sexual partners wish for it to happen. The journal then observes that while the established view is that PE is a psychological condition, recent opinion suggests that disturbances of serotonergic 5-hydroxytrptamine (5-HT) neurotransmission might be a causative factor – and hence drug therapies which target the 5-HT system might be an effective treatment. Francisco Giuliano has studied the efficiency of Dapoxetine in the treatment of premature ejaculation and published his results in the July 2007 European Urology Supplements.
Dapoxetine hydrochloride is a selective serotonin reuptake inhibitor (SSRI), but it has the benefit of having a short half life, which means it stays in the body for a much shorter time. It’s been developed specifically for the treatment of men with PE. “Older” SSRI’s work by increasing the level of 5-HT neurotransmission but the majority of SSRI’s such as fluoxetine, sertraline, and paroxetine (all of which can increase the time delay between intromission or penetration and ejaculation) don’t reach the maximum level in the bloodstream for several hours after they have been taken. This means that men who wish to try this remedy for premature ejaculation cannot take these SSRI drugs just before sex (as is possible with Viagra in cases of erectile dysfunction). By contrast, Dapoxetine inhibits serotonin reuptake and takes only one hour to reach maximum concentration in the bloodstream. In addition, it is eliminated quickly from the body and it therefore has the profile of an on-demand medication which gives it both greater commercial possibilities and greater effectiveness for the man who, together with his doctor, wishes to adopt this as a treatment for premature ejaculation.
The studies which demonstrated the potential effectiveness of Dapoxetine involved over 2600 men who were given between 30 and 60 mg of Dapoxetine between one and three hours before sex. The average age of the men taking part in the drug treatment trial was forty years – surprisingly old, for I have always had the impression that men lose their tendency to premature ejaculation as they get older. It would therefore seem likely that these men were suffering from both long-standing and sever premature ejaculation. Indeed, almost two-thirds of the men reported life-long problems with premature ejaculation, and about a third of the men has developed premature ejaculation after a period of normal sexual relationships (i.e. satisfactory vaginal intercourse).
The researchers measured the time between intromission and ejaculation and found that although a placebo did lead to an increase in the length of intercourse, it was nowhere near as significant as the increased length of intercourse with dapoxetine. At 30 mg dosage, intercourse increased from an average of 0.92 minutes to 2.78minutes. With 60 mg of dapoxetine, it increased from an average of 0.92 minutes to 3.32 minutes. This improvement was maintained over the twelve weeks of the study. Of course, the issue of side-effects always comes up: but the Dapoxetine produced relatively few side-effects, which included nausea and headache. Nausea occurred in 8.7% of men given 30 mg and 20.1% of men given 60 mg. Headaches occurred in 5.9% of the men given 30 mg and 6.8% of the men given 60 mg. Unfortunately 4% of men taking the lower dose had sufficiently severe effects to require the cessation of treatment, as did 10% of men given the higher dose. These are rather high figures for a drug which seems to have limited use as a premature ejaculation treatment and only produces a relatively short increase in vaginal intercourse duration.
Giuliano F Eur Urol Supp. 6(13):780-6, July 2007
A drug developed for treatment of premature ejaculation
The New Scientist has reported the outcome of this study of the effectiveness of Dapoxetine treatment on nearly 2000 men who were diagnosed with either moderate or sever premature ejaculation. Before taking the drug, these men had an average time before ejaculation of less than one minute after penetration. Again, they were given either a placebo “treatment” or 30 or 60 mg of dapoxetine, which was taken between one and three hours before intercourse.
After twelve weeks of taking the drug treatment, the average time before ejaculation had gone up from less than a minute to 2.8 minutes for the lower dose and 3.3 minutes for the higher dose.
Even better, the authors of the study suggested that the men’s subjective view of how well they could control their ejaculation and how satisfied they were with sex had improved markedly, as had their partner’s level of satisfaction.
No license for drug treatment of premature ejaculation
Dapoxetine was developed for controlling premature ejaculation, but although the researchers have claimed it to be safe and effective, the FDA has not given it a license. The side effects include nausea, diarrhea, headaches and dizziness. And the other problem is this: according to Marcel Waldinger, a neuropsychiatrist at Leyenburg Hospital in The Hague, existing SSRIs have already found a place in the treatment regime for premature ejaculation, and work with greater efficiency. He says that the best way to prevent PE is by continual use of existing SSRIs. he observes that these drugs produce an increase in time between intromission and ejaculation of about nine times, while Dapoxetine only increases the time by a factor of three. According to Waldinger, one also has to ask about the motives of the drug companies in developing a drug specifically to treat PE.
Waldinger has studied the time that men last between penetration and ejaculation on average: his findings make interesting reading. The study was carried out in 2005 and he discovered that – in the general population – not just among men seeking treatment or cure for premature ejaculation – the average length of intercourse was just 5.4 minutes in The Netherlands, the UK, the US and Spain. In Turkey the average time to ejaculation was 3.7 minutes.
So where does this leave us? Men who identify as having premature ejaculation, and who seek treatment for it, may actually be in the normal range of sexual activity for men in their general population. This does not mean that treatment should be denied, for as we have seen, the definition of PE these days is tailored specifically to include a factor of the man’s subjective satisfaction (or lack thereof) with his sexual performance. But the danger is that the drug companies create a pathology out of a normal condition so that they can sell drugs to deal with it. And most men will sometimes experience a rapid ejaculation – it is normal.
This of course brings back into play the difficulty of definition: PE has been described as the most common male sexual problem, affecting between a fifth and a third of all men. But what does that mean, if it is so common? Isn’t it then a “normal” condition? Waldinger concludes by observing that he believes only men who have experienced lifelong PE should receive drugs. As he (in my opinion correctly) observes, lifelong PE is a much rarer problem, and probably only affects 1% to 5% of men. New Scientist 8 September 2006 and The Lancet (volume 368, p 929)
More scientific reviews of drug treatment of premature ejaculation
What follows is a summary of treatment of premature ejaculation adapted from Medscape.
SSRIs have been administered to increase ejaculatory delay; because they are associated with inability to ejaculate and erectile dysfunction. Unfortunately, continual administration of SSRIs is linked to dry mouth, nausea, drowsiness, and reduced libido. Dapoxetine hydrochloride (DPX) has been studied and indeed has undergone Phase III trials. DPX is a serotonin transport inhibitor (STI) which has a pharmokinetic profile suitable for “on-demand” usage in the treatment of PE. Unlike other oral agents, DPX works quickly and is effective from the first dose. [Editor: as previously mentioned, FDA approval has not yet been forthcoming.] The worst side-effects of SSRIs is that they not only cause decreased libido but they can cause erectile dysfunction.
Another category of drugs which have been studied as possible candidates for the management of premature ejaculation are Phosphodiesterase-5 (PDE-5) inhibitors. The somewhat tenuous connection with quick climax is their ability to prolong erections. It’s been established that PDE-5 inhibitors are useful in the treatment of men who have premature ejaculation secondary to erectile dysfunction, and that they can be used in association with other drugs such as SSRIs.
Anesthetic substances which can be administered to the surface of the penis have been tested in the treatment of premature ejaculation. [Editor: though some studies have shown an increase in ejaculatory delay times, evidence from my own experience with men who have premature ejaculation is that these creams, whether administered to the surface of the penis or contained in a condom, do not have much impact on PE, but they do remove sensation, thereby making sex even less satisfactory for both partners.]
Clomipramine: at 25 – 50 mg per day increases sexual latency from 1 minute to 3 to 6 minutes
Fluoxeline: at 5 – 60 mg per day increases sexual latency from 1 minute to 2 to 9 minutes
Paroxeline: at 20 – 40 mg increases sexual latency from 1 minute to 3 to 10 minutes
Sertraline: at 25 – 100 mg increases sexual latency from 1 minute to 3 to 6 minutes
The higher the dose, the longer the ejaculatory delay. But at high does, there are unpleasant psychotropic side-effects. These drugs stay in the body for a long time, and they cannot be given on-demand. As soon as the drugs are reduced, the man’s inability to control his ejaculation returns. The summary of this treatment regime, therefore, is that it is “woefully inadequate”.
Obviously the ideal drug for controlling premature ejaculation is going to interfere with the signal from the brain to the penis in a way that allows on-demand treatment (i.e. you take it just before sex), be fast-acting with a short half-life, and deal with the specific serotonin receptors that deal with ejaculation.
It’s worth making the observation at this point that the behavioral therapies are effective but they do require a co-operative partner. The simple fact is that premature ejaculation is underdiagnosed and undertreated. None of the current drug treatments are FDA-approved.