Premature Ejaculation

Etiology

Overall, premature ejaculation is primarily psychological in nature. However, the precise cause of premature ejaculation remains largely undetermined. Several contributing risk factors, both biological and psychological, have been identified.[1] 

Biological factors:[7]

• Abnormal levels of the brain neurotransmitter serotonin (low serotonin levels shorten the time to ejaculation)[8]
• Abnormal hormonal levels, e.g., LH, prolactin, and TSH
• Hypogonadism
• Inflammation and/or infection of the prostate or urethra
• Erectile dysfunction (ED)
• Ejaculatory hyperreflexia
• Genetic predisposition
• Hyperthyroidism
• Neuropathy (such as multiple sclerosis)
• Alcoholism
• Diabetes
• Recreational drug use
• Sleep deprivation (leads to low serotonin levels)

Psychological factors:[7]

• Depression
• Anxiety
• Stress
• Guilt
• Narcissism
• Distorted thinking
• Unrealistic expectations about sexual performance
• Performance anxiety
• History of sexual repression
• Overall lack of confidence/poor body image
• History of sexual abuse or prior bad experience
• Relationship problems
• Control issues with partner
• Feeling of self-loathing
• Unrealistic fear of harm from vaginal penetration
• Hostility against women
• Other underlying mental health issues

Epidemiology

Premature ejaculation is the most frequently encountered sexual dysfunction worldwide.[9] Approximately 30% of adult men aged 18 to 59 report having problems with premature ejaculation, but some reports put the prevalence as high as 75%.[6][10] Additionally, 30% of men with premature ejaculation also report experiencing erectile dysfunction, in which case early ejaculation occurs in the absence of a full erection.[1]

Although premature ejaculation can occur at any adult age, it is most commonly reported in the 18 to 30-year-old age group and, together with erectile dysfunction, in the 45 to 65-year age group. Ethnically, premature ejaculation may be more prevalent among African Americans (34%) compared to Hispanics (27%) or Whites (29%).[11]

Internationally, the estimated incidence in Europe and India is similar to the United States.[11] The prevalence of premature ejaculation in Asia, Australia, Africa, and other parts of the world is not reported.

Pathophysiology

Ejaculation is controlled by the spinal ejaculatory generator center, located at the L1-L2 level. This center receives parasympathetic and sympathetic inputs from the penile nerves and communicates via sensory and motor nerves. In addition to the spinal ejaculatory center, the central, spinal, and peripheral nervous systems also work together for emission and ejaculation.[12]

Normal ejaculation is a complicated but well-coordinated series of physiological events typically involving three phases: emission, expulsion, and orgasm.

Emission involves the introduction of seminal fluid from the seminal vesicles, prostate, and vas into the posterior urethra. This action coordinates with the tightening of the internal sphincter, which closes the bladder neck and prevents retrograde ejaculation of semen into the bladder. This phase of ejaculation is dependent on smooth muscle contraction but generally has voluntary control. Neurological control is primarily via sympathetic nerves from the pelvic plexus (inferior hypogastric plexus), hypogastric nerves, and the caudal paravertebral sympathetic chain, which is located in the retroperitoneum on either side of the rectum and postero-lateral to the seminal vesicles.[1] Spinal control is at L2-L4. There is substantial central cerebral control of this phase of ejaculation.

Expulsion describes antegrade ejaculation, where the seminal fluid travels from the posterior urethra to the urethral meatus. This function is primarily a spinal reflex and occurs as the process reaches the "point of no return." The pressure for this comes from pelvic floor musculature contractions and the rhythmic contractile activity of the ischiocavernosus and bulbospongiosus muscles. The contractions typically occur at about 0.8-second intervals. These contractions increase the intraurethral pressure in the prostatic urethra, which results in the expression of semen from the urethral meatus. Neurological control is still basically a sympathetic reflex through the somatomotor efferent innervation of the pudendal nerve and the motor neurons located in the nucleus of Onuf, but the exact mechanism is not well defined. Spinal control is at S1-S2. One theory is that the expulsion reflex initiates by the presence of semen in the bulbar urethra, but clinical and experimental data on this are conflicting.[13][14][15] Normal pelvic floor muscle function and control are necessary for this process to operate properly.

Orgasm is involved in both ejaculation and the human sexual response cycle (desire, arousal, orgasm, and resolution). While extremely pleasurable, it is also quite short. It is primarily a brain or cerebral process associated with various physical events, including contractions of accessory sexual organs. Interestingly, the feeling of orgasm can occur even after radical prostatectomy and can occur without any genital sensory input or ejaculation.[1]

Classification

Premature ejaculation (PE) may be classified in several ways, such as the following:

• Primary PE is lifelong and begins as soon as the patient becomes sexually active; it typically involves an intravaginal ejaculation latency time (IELT) of <1 minute in 80% to 90%. 
• Secondary or acquired PE begins later in life and usually has an IELT of <3 minutes.[16]
• Variable PE is generally considered more or less a normal variant.
• Premature-like ejaculatory dysfunction occurs when patients become obsessed or unusually preoccupied with ejaculatory function or loss of control, but the IELT is normal.[17] 

A more helpful classification may be a clinical one:[18]

• Primary or Secondary:
  • Primary (Lifelong: present since the first sexual experience. Often due to conditioning, upbringing, or an early, traumatic sexual event.)
  • Secondary: (Acquired: developing after a period of relative normal sexual functioning)

• Global or Situational:
  • Global: (Constant: all the time, not limited to specific types of stimulation, partners, or situation)
  • Situational: (Intermittent: varies with partner, stimulation, situation, masturbation, location, or other factors)

• Severity:
  • Mild (occurs within approximately 30 seconds to 1 minute of vaginal penetration)
  • Moderate (occurs within approximately 15 to 30 seconds of vaginal penetration)
  • Severe (occurs before or during foreplay, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration)

History and Physical

The clinician must obtain a thorough history when assessing a male patient for sexual dysfunction. A detailed history includes inquiring about sexual history, libido, and erectile function.

It is essential to obtain a thorough medical history and perform a complete physical examination.

Physicians should be aware of the severe embarrassment many patients feel when discussing intimate details of their sexual problems with anyone, even their doctor. Overcoming this great difficulty can be challenging for physicians. To minimize this obstacle, physicians should remain professional and include an open-ended questions about sexual function and satisfaction during their routine intake discussion. It is suggested that this question be left until close to the end of the visit so there is some time to develop an interpersonal relationship before tackling this problematic issue.

If erectile dysfunction (ED) is present, it is crucial to determine the time of onset of the erectile dysfunction, evaluates possible performance anxiety as a contributing factor, and assess for any additional potential risk factors or reversible causes of ED if present. 

A sample question might be, "How is your sex life? Is everything working OK for you and your partner?" Anything other than a quick and emphatic "everything's fine" suggests a possible sexual problem and should prompt the physician to inquire further. A comment such as "Well, it's not like it used to be" could also indicate a sexual disorder such as erectile dysfunction or premature ejaculation. More focused and detailed questioning would then be able to identify the specific sexual problem correctly. The patient should be informed that these sexual disorders are common and can be treated.

Some helpful questions to ask a patient with suspected premature ejaculation might include the following:

• On average, how long does it take after vaginal penetration before ejaculation?
• How often do you experience premature ejaculation?
• Is it just once in a while or pretty much all the time?
• How long have you had this problem?
• Did it come on gradually or start suddenly?
• Have you ever had a bad sexual experience before the development of premature ejaculation?
• Does this happen with only one partner or with every partner?
• Do you experience premature ejaculation with every sexual encounter?
• What type of sexual activity (i.e., masturbation, foreplay, intercourse, use of visual cues, etc.) do you engage in, and how often?
• How has this affected your sexual activity?
• Does it happen with masturbation?
• Do your erections work OK? Some of the time or all the time?
• Do you lose your erection before ejaculation?
• Does an orgasm feel normal to you?
• How are your personal relationships?
• What does your partner think about this problem?
• Is it affecting your relationship?
• Do you and your partner avoid sexual intimacy because of this?
• Is your partner willing to work with you to help overcome this problem?
• What remedies have you tried already, and how did they work?
• How much does this problem bother you?
• Are you willing to consider any therapy or treatment that can resolve or improve this issue?
• Is there any particular treatment you have heard or read about that you wish to consider trying?
• Is there anything that makes it worse or better? (i.e., drugs, alcohol, etc.)

Evaluation

It is crucial to obtain a complete medical history of the patient. To properly diagnose premature ejaculation, the history should focus on any medical complaints or issues and his detailed sexual history. 

No specific laboratory or radiographic tests are necessary to evaluate for premature ejaculation. Some tests, such as serum testosterone and prolactin, may be appropriate if there is concomitant erectile dysfunction or loss of libido, with a clinical picture suggesting possible hypogonadism. While low testosterone is increased in patients with premature ejaculation, treatment of hypogonadism does not help cure the ejaculatory problem.

Hyperthyroidism has been linked to premature ejaculation, so obtaining a thyroid-stimulating hormone level may be reasonable in selected patients with reasonable suspicion of excess thyroid hormone levels.[19] Treating hyperthyroidism can improve premature ejaculation symptoms, unlike hypogonadism, where testosterone supplementation is ineffective.[20]

Penile biothesiometry (vibrational skin sensation threshold testing), nerve conduction studies, somatosensory nerve latency testing, and hormonal evaluations (testosterone, FSH, LH, prolactin, melatonin) are being done selectively by some specialists. None of these tests are necessary or currently recommended for routine clinical practice and should be considered investigational. 

Mental Health Evaluation

As premature ejaculation is primarily a psychological disorder, it is important to include a psychological/psychosexual assessment as part of the overall evaluation. A consultation with a mental health professional experienced in male sexual dysfunction (psychiatrist, psychologist, or certified sex therapist)  should be made. Convincing a patient to see such a mental health professional for an evaluation can be challenging. Here are a few suggested talking points for discussion with the patient:

• Inform the patient that this is part of the usual routine for evaluating this problem.
• The consultation is just a simple assessment for an opinion.
• The request for the consultation is not a judgment; it's part of the usual routine workup for premature ejaculation.
• The evaluation is done by healthcare professionals who do this all the time.
• It's just like doing a blood test. We test the blood because we don't otherwise know the test results, good or bad. Same thing here.
• A mental health consultation report will help me offer you the best treatment with the best chance of a successful outcome. Isn't that what you said you wanted?
• If there are underlying psychological issues that need to be dealt with or are contributing to the problem, which is common, then identifying and treating them is the best way to achieve an optimal result; and maybe even a cure!
• Premature ejaculation is not a physical problem; everything works. It's a problem of control related to stress, anxiety, and nervousness. It's necessary to explore this to optimally deal with the problem.
• We rarely encounter individuals with this type of sexual disorder who are completely unaffected emotionally.
• Most men will demonstrate some negative emotional health effects such as extreme stress, anxiety, depression, loss of self-esteem, feelings of inadequacy, or something similar. 
• Such issues cannot be dealt with and eliminated until they are identified and treated, which needs a mental health evaluation by an experienced professional.

Many potential psychological and emotional issues can account for premature ejaculation.[21] These include:

• A disconnect between the level of sexual excitement and sensory awareness/perception
• A feeling of worthlessness, self-loathing
• A need to manage control of the relationship through emotional and sexual means
• Conditioned response from early negative experiences
• Distorted thinking, such as overgeneralization, mental catastrophizing, etc.
• Excessive narcissism
• Fear of harm from vaginal penetration
• Lack of sensory awareness
• Obtaining pleasure from debasing or soiling women
• Power and control issues regarding the relationship
• Tendency to overgeneralization
• Unconscious hostile emotions toward women

Mental health professionals experienced in dealing with male sexual disorders recognize that these and other ideas or concepts from various schools of psychology may be involved.

Treatment / Management

Treating premature ejaculation often requires a multimodal approach incorporating behavioral, psychological, and pharmacological therapies. In general, the physiology of the sexual act is not impaired to damaged in pure premature ejaculation. As such, it is not an actual disease, and there is no physiological function to "fix" or surgery to repair the damage as there is no injury to repair. Sexual activity other than vaginal intercourse can be used to produce female orgasm, which rarely results from purely vaginal intercourse.[22]

It is important to note that there is no surgery for premature ejaculation. In the past, penile implants were sometimes empirically inserted in men with premature ejaculation, generally leading to disastrous results.

Behavioral Therapy

Several behavioral therapies may be options to increase tolerance and delay ejaculation; in essence, training the patient to learn how to recognize that ejaculation is imminent and teach him, through habituation and training, how to delay ejaculation. Two of the most frequently recommended examples include the stop-and-start technique and the squeeze method.

• Start-and-Stop Technique: Engage in usual sexual activity until there is the beginning of a feeling of ejaculation. Immediately stop all sexual activity and mentally focus on something different, such as reading a book. When sexual excitement has waned sufficiently, resume sexual activity. When performed consistently, it can help train and habituate the system to delay ejaculation naturally.[23]

• Squeeze Method: Like the Stop-and-Start technique, the patient is instructed to start normal sexual activity until there is a sensation that ejaculation will be coming. At that point, the patient or his partner will grasp the head of the penis and gently squeeze the area where the glans joins the shaft. This is not painful and typically reduces the erection very quickly. After a suitable pause when sexual excitement has sufficiently declined, sexual intercourse may be resumed. Over time, when performed consistently, this can cause a delay in subsequent ejaculation. The squeeze technique allows 64% of patients to regain ejaculatory control, but this success declines to about 1/3 after three years.[24]

Both of these approaches are repeatable as necessary. (As described by Masters and Johnson in their 1970 book Human Sexual Inadequacy.) The goal, according to Masters and Johnson, is to eventually reach a point where there is vaginal penetration but no ejaculation for about 15 minutes. While effective in many cases, at least in the short term, these behavioral methods primarily focus on distraction along with the forced reduction in sexual stimulation and excitement, which many couples find unnatural and disturbing as it reduces their overall sexual satisfaction and intimacy. 

Masturbation and "Second Try" coitus can help delay ejaculation by taking advantage of the refractory period after an initial ejaculation. The first ejaculation occurs as it normally does, either through intercourse or masturbation. The should be about 1 hour before the next attempt. For most men, there is a refractory period immediately after an ejaculation where sexual stimulation takes longer, and ejaculation is naturally delayed. These methods take advantage of this natural effect. The actual optimal timing of the refractory period will vary, so the 1 hour period suggested is just a starting point and can be adjusted for each individual. These techniques may overcompensate and result in the loss of libido (sexual interest) or an inability to become aroused a second time, especially if the "second try" is attempted too soon. If that happens, the timing should be adjusted, or alternative techniques should be used.

Stress reduction techniques can be helpful. These include using a non-verbal signal to indicate an interest in sexual activity that evening. This could be as simple as moving a centerpiece or vase on the dining table. A "yes" or "no" response would be a countermove of some sort. The couple agrees that if the signal is "no," there is no guilt, shame, or blame.

Having an ED remedy available on "standby" can be helpful in some situations to reduce performance anxiety, even if it's never actually utilized.

Thickened condoms have been found to prolong penile hyperemia, improve erectile rigidity, increase erection time, lengthen pre-ejaculatory time after vaginal penetration, and help overcome premature ejaculatory problems.[25] Thickened condoms can prolong the time between vaginal penetration and ejaculation. Patient satisfaction rates were higher with thicker condoms compared to standard prophylactics.[25] The use of two standard condoms can simulate the effect of a single, thicker one. 

Exercise for both men and women has been reported to help prevent premature ejaculation.[26] Kegel exercises, pelvic muscle rehabilitation,[27] and physical therapy have also been shown to help treat, minimize, or prevent premature ejaculation.[28][29][30] (A1)

Other behavioral techniques include cognitive distraction, alternate sexual positions, adjusting the interval between sexual encounters, increasing the frequency of intercourse, and extending foreplay.

Behavioral therapy can help delay ejaculation but does not "cure" the disorder. It does not directly deal with any underlying psychological causes or consequences and will not fix all relationship issues. Associated medical or biological conditions such as ED or hyperthyroidism must be addressed separately. Behavioral therapy should be included in the treatment plan for treating premature ejaculation as it has no side effects and offers some immediate help.

Pharmacological Therapy

Topical anesthetics applied to the penis have been used with some success. This involves the self-application of topical desensitizing medications such as lidocaine sprays/creams to the tip and shaft of the penis 10 to 15 minutes before the initiation of sexual activity. This avoids potential systemic side effects compared to SSRIs.[31] However, many patients report temporary loss of sensitivity and decreased sexual pleasure; their female partners have also reported similar symptoms. Condoms may be used simultaneously to decrease sensation and minimize any sensitivity loss in female partners when using topical male anesthetic penile therapies.(B3)

In Europe, a dose-metered anesthetic spray is approved and available for premature ejaculation. It uses a combination of local anesthetics, lidocaine, and prilocaine and seems to offer reasonably satisfactory results in the most severe cases.[32] It is best used with a condom to avoid desensitization in the female partner. In the US and elsewhere, where the spray is not available, topical anesthetic creams or gels can be used to decrease penile tactile sensitivity instead.

SSRIs are considered a first-line medical treatment in most cases of premature ejaculation. In the United States, there are no drugs specifically approved for the treatment of premature ejaculation, but SSRIs such as fluoxetine, paroxetine, sertraline, citalopram, escitalopram, and clomipramine have been commonly used successfully off-label to treat primary and secondary premature ejaculation. These drugs delay ejaculation by inhibiting the serotonin transporter, thereby increasing serotonin's action at the post-synaptic cleft, which delays ejaculation. 

Typical drug selection and dosage ranges include fluoxetine 20 to 40 mg/day, paroxetine 10 to 40 mg/day, sertraline 50 to 200 mg/day, citalopram 20 to 40 mg/day, and escitalopram 10-20 mg/day. A meta-analysis review suggests that paroxetine may be the most effective of these medications in treating premature ejaculation.[33] SSRIs should be initiated at the lowest possible dose and titrated upward accordingly over 3 to 4-week intervals. Patients have reported 6 to 20 times greater ejaculatory delay with medication, and improvement is seen in as little as one week.[21] However, full therapeutic effects are typically observable only after 2 to 3 weeks of therapy. (B2)

Unfortunately, SSRIs need to be taken daily for optimal efficacy and carry the potential for side effects, including decreased libido, anorgasmia, and erectile dysfunction.[34][35] Sometimes the patient is instructed to take the medication on an "as needed" basis about 3 to 5 hours before sexual activity to decrease the side effects experienced with daily drug use. However, this intermittent method does not seem as effective in controlling the disorder. (A1)

Premature ejaculation can return upon discontinuation of the medication, so most men need to take these drugs on an ongoing basis. Some men who respond to SSRI therapy may have to remain on SSRI medication indefinitely.

Clomipramine, which is chemically a dibenzazepine tricyclic antidepressant and a serotonin reuptake inhibitor, is used as a second-line therapy for premature ejaculation and can be tried when other SSRIs have failed.[36][37] Clomipramine appears to have a stronger affinity for the cellular serotonin transporter than other SSRIs.[36] Its serotonergic effect can be enhanced by fluvoxamine, a CYP450 1A2 inhibitor.[38] As with other SSRIs, clomipramine should be initiated at the lowest possible dose and titrated up accordingly over 3- to 4-week intervals. It is typically dosed between 12.5 to 50 mg/day.[36] When used for premature ejaculation, 15 to 25 mg taken 4 hours before sexual activity has shown success.[37][39][40][41](A1)

Full therapeutic benefits are typically apparent after 2 to 3 weeks of therapy. Potential side effects include erectile dysfunction and decreased libido. As with other SSRIs, clomipramine can be taken on an "as needed" basis 3 to 5 hours prior to sexual activity, which mitigates the potential side effects of daily use; however, this may not be as effective for premature ejaculation as daily therapy. It is FDA-approved only for use in adult obsessive-compulsive disorder but has many off-label uses.[36]

Dapoxetine is an SSRI recently developed specifically for premature ejaculation, which is now available in Europe. It is effective when taken 1 to 3 hours prior to sexual activity. However, the drug has not yet been approved in the US. European data indicate that its side-effect profile is poor and discontinuation rates are extreme at up to 90%. This is due to its high rate of side effects (diarrhea, dizziness, fatigue, headache, insomnia, nausea, and orthostatic hypotension), high cost, sub-optimal performance, and the need to schedule intercourse.[32] 

Tramadol is generally used as a pain medication as it has activity at opioid receptors, which may affect penile sensation. It also inhibits the reuptake of serotonin reuptake. These combined effects can be useful in treating premature ejaculation as a second-line agent.[42][43] Tramadol has been shown to substantially lengthen IELT, improve ejaculatory control, and increase sexual satisfaction when taken 2 hours prior to initiating sexual activity.[44] It is typically only considered when SSRIs, clomipramine, and combination therapy have failed due to its potential for opioid-like side effects and addiction potential.(A1)

Non-selective beta-adrenergic blockers have also been tried with partial success in patients who failed to respond to SSRIs.

Alpha-adrenergic blockers, such as tamsulosin and silodosin, can help with premature ejaculation by increasing IELT, but they often lead to other ejaculatory problems, such as retrograde ejaculation or anejaculation.[45]

There is currently no FDA-approved medical therapy for premature ejaculation, although there is substantial information on the off-label efficacy of SSRIs for the disorder.

Psychological Treatment

Psychotherapy may be used to address the negative thoughts and emotions that can lead to problems with sexual relationships. It can help the patient become less anxious about sexual performance and give them enhanced sexual confidence.[21] It is the preferred first-line therapy in patients who have underlying psychological problems or subjective premature ejaculation (where the intravaginal latency time is actually normal).

Current psychotherapy for premature ejaculation tends to be short-term and integrates behavioral, cognitive, systems, and psychodynamic approaches. The intention is to help the patient learn to control ejaculation and resolve the cascade of negative psychological effects and feelings this causes. (low self-esteem, performance anxiety, lowered libido, sexual avoidance, negative relationship issues, self-loathing, increased partner's hostility, etc.)

Effective therapy includes three general principles.[21] These are:

• Patient empowerment, in which men feel that they can create, change and impact contextual factors.
• Creating a friendly, safe environment where issues, choices, obstacles, and meanings of the patient's behavioral, psychological, and relationship issues can be explored.
• Providing hopefulness as well as establishing realistic expectations regarding outcomes.

Specific psychological treatment of premature ejaculation incorporates multiple goals:

• Learning and practicing behavioral modification techniques that can delay ejaculation and provide more control.
• Improving confidence in the patient's sexual performance.
• Reducing performance anxiety.
• Modifying habitual or rigid sexual practices that lead to poor performance.
• Overcoming obstacles to improved intimacy.
• Resolving ongoing relationship and interpersonal issues that help maintain the sexual disorder.
• Identifying and resolving any thoughts, perceptions, or feelings that interfere with normal sexual function.
• Increasing communication.

Sex therapy is the specific branch of psychotherapy devoted to managing sexual problems. They extensively use behavioral techniques (Stop-and Start, Squeeze Technique) but also address relationship issues, emotional factors, performance anxiety, unrealistic expectations, and partner concerns. Many PE patients fear sexual excitement and may not realize the restrictive impact this has on their partner and the relationship. There is a tendency to excessively focus solely on his own sexual performance and lack of ejaculatory control, which results in a lack of adequate attention to his partner.[46] (B2)

One technique used by sex therapists is to eliminate the performance anxiety issue by forbidding full intercourse for a limited period, only allowing limited intimate touching but no intercourse or ejaculation. The degree and type of this touching are gradually expanded as control is achieved. Combined with other techniques, this approach can be successful as well as sensate focus therapy.

Overall, the combination of psychosexual therapy together with behavioral modification techniques and pharmacological treatment has seen the most success.[47][48][49][50] This is because all aspects of the problem are dealt with, including the underlying psychological, interpersonal, cognitive, and relationship issues that created and maintained the disorder.[21] Psychotherapy offers the only true potential for a "cure" for premature ejaculation and should not be overlooked when preparing a treatment plan for a patient with this disorder. The cooperation and involvement of the sexual partner in the psychological evaluation and treatment process greatly improve the success and effectiveness of psychotherapy.(A1)

Combination Therapy

Combination therapy with SSRI medications, ejaculatory delay techniques, local desensitization methods, psychological help, and behavioral (sex) therapy can successfully treat most cases of premature ejaculation and has seen the most success.[48][49][50] This is because all aspects of the problem are dealt with, including the underlying psychological, interpersonal, cognitive, and relationship issues that created and maintained the disorder.[21] Psychotherapy offers the only true potential for a "cure" for premature ejaculation and should not be overlooked when preparing a treatment plan for patients with this disorder.(A1)

In committed relationships, success rates with combination therapy are reported to be as high as 85%. However, the likelihood of a relapse is also high, as reported recurrence rates are 20% to 50%.[20] (B3)

• Numerous case reports indicate that combination medical therapy is far more effective than solo drug treatment for premature ejaculation.
• A phosphodiesterase type 5 inhibitor and an SSRI medication are recommended, especially in cases where there is concomitant ED.
• Combining pharmacologic and behavioral treatment is more efficient than pharmacotherapy alone.  

Summary of Treatments

Behavioral

• Seek ways to reduce performance pressure on the male.
• Consider using alternate sexual activities other than vaginal intercourse to produce female sexual satisfaction.
• Using a non-verbal signal for one partner to indicate interest in sexual activity to the other can help reduce stress.
• A standby ED therapy can help reduce performance anxiety.
• Teach the "top-and-start" or the "squeeze" techniques as described by Masters and Johnson.
• Use a condom with or without a topical local anesthetic to diminish penile sensation.
• Consider using a second condom to further reduce penile tactile sensation.
• Use the "second try" trick, where the second attempt at coitus will usually enjoy significantly delayed ejaculation.
• Consider masturbation 1 to 2 hours before sexual intercourse. This will tend to delay ejaculation, similar to the "second try" technique above.

Pharmacological 

• Treat any underlying associated physical or medical problems such as ED.
• In cases where premature ejaculation and erectile dysfunction are both present, treat the ED first.
• Medical therapy for premature ejaculation is primarily with SSRIs which are used off-label.
• Daily drug therapy appears more effective than intermittent or "as-needed" treatment.
• Drugs for erectile dysfunction, such as phosphodiesterase type 5 inhibitors, have only limited effectiveness for premature ejaculation when used alone but will help with associated ED.
• Non-selective beta-adrenergic blockers or clomipramine can be used in cases where SSRIs have failed.
• Tramadol may be considered when all the above therapies are inadequate or unsuccessful.

Psychological

• Discuss issues with both partners.
• Inform the couple that although there is no physical damage or injury, it is still a real problem that requires medical help to overcome.
• Teach them that premature ejaculation is a very real and common disorder.
• It is not possible to overcome the problem without help.
• Relieve unrealistic feelings of guilt or blame.
• Premature ejaculation is nobody's "fault" and will respond to treatment.
• The commitment and involvement of the partner in treatment will significantly improve the outcome.
• Obtain a mental health consultation to identify underlying psychological problems and relationship issues that may need attention.
• Consider a referral to a certified sex therapist or another mental health professional with experience in premature ejaculation.
• Psychological treatment and "sex therapy" is often the preferred treatment as it deals with the underlying causes and may permanently cure the disorder without drugs.

A combination of treatments, including behavioral modification techniques, psychosexual (sex) therapy, an ED drug, and a daily SSRI medication, is more effective and provides better overall outcomes than any single therapeutic modality treatment.

Investigational therapies include:

• Surgical circumcision in selected patients
• Dorsal penile nerve cryoablation
• Neuromodulation
• Hyaluronic acid gel glans augmentation
• Botulinum toxin injection (into pelvic floor musculature)
• Dopamine receptor antagonists
• Oxytocin receptor antagonists

Differential Diagnosis

Other conditions require consideration before a diagnosis of premature ejaculation can be made, including severely delayed orgasm in the female partner. The average time to climax in females varies between 12 to 25 minutes; in extreme cases of delayed female orgasm, almost any male would be considered to have premature ejaculation, so the partner’s sexual response is a factor that merits evaluation. Adverse effects of psychotropic drugs must also be a contributing factor.

Prognosis

Lifelong premature ejaculation has no definitive cure. However, management of the condition can be successful via a multimodal combination treatment approach in the majority of cases.

Acquired premature ejaculation can often be corrected by treating the underlying cause. For example, if a man has erectile dysfunction and ejaculates prematurely to compensate for his inability to maintain an erection, treating the erectile dysfunction may also eliminate his premature ejaculation. At the very least, it will reduce performance anxiety and lead to a more successful outcome.

In many cases, pharmacological therapy must be continued indefinitely, as discontinuation may lead to the recurrence of premature ejaculation.

Success rates after treatment vary from 30% to 70%, but relapses are common, and some men need lifelong therapy.

Premature ejaculation takes an enormous toll on male self-esteem, often leading to serious marital difficulties, divorce, and depression.

Complications

• Premature ejaculation can potentially cause couples to have difficulty conceiving if ejaculation does not occur intravaginally. It can also lead to increased stress, anxiety, and significant relationship issues.[6]
• Performance anxiety and erectile dysfunction are often associated with premature ejaculation. 
• Underlying psychological issues contributing to or resulting from premature ejaculation may not be adequately addressed in all cases.
• If treatment fails, this can further reinforce feelings of depression, defeatism, and low self-esteem.