Premature Ejaculation: Treatment Options

Benzocaine/Lidocaine Delay Sprays & Creams

How they work: Local anesthetic reduces penile sensitivity, delaying ejaculation

Available products:

• Promescent (lidocaine 4%) - OTC spray, absorbed quickly, minimal transfer
• Roman Swipes - Pre-moistened wipes with benzocaine
• Stud 100 - Lidocaine spray
• SS Cream (EMLA) - Lidocaine/prilocaine cream (compound available by prescription)

How to use:

• Apply to glans and shaft 10-20 minutes before intercourse
• Wipe off excess before contact to minimize partner numbness
• Start with small amount, adjust as needed
• Use condom if partner experiences numbness

Pros:

• Works immediately (same day effectiveness)
• No systemic side effects
• Available over-the-counter
• Control over dosing

Cons:

• Must plan timing
• Possible partner transfer/numbness
• May reduce sensation too much if overdosed
• Some men dislike "medicated" approach

Start-Stop Technique

Learn to recognize the "point of no return" and pause stimulation before reaching it:

1. Begin sexual stimulation (alone or with partner)
2. Stop completely when approaching ejaculation
3. Wait for arousal to decrease (30-60 seconds)
4. Resume stimulation
5. Repeat cycle 3-4 times before allowing ejaculation
6. Practice regularly to build control

Squeeze Technique

Similar to start-stop, but adds physical squeeze to reduce arousal:

1. When approaching ejaculation, stop stimulation
2. Squeeze just below head of penis firmly for 10-20 seconds
3. Arousal and urge to ejaculate decrease
4. Wait 30 seconds, then resume
5. Repeat as needed

Edging (Extended Start-Stop)

Advanced technique for building ejaculatory control:

• Masturbate to point just before ejaculation
• Stop and let arousal decrease significantly
• Resume and approach edge again
• Repeat multiple times (5-10 cycles) before ejaculating
• Gradually learn precise control over ejaculatory reflex
• Practice 3-4 times per week for best results

Goal: Train yourself to maintain high arousal without ejaculating, increasing your control and stamina.

Pelvic Floor Exercises

Strengthening pelvic floor muscles can improve ejaculatory control:

• Kegel exercises for men: Contract muscles that stop urine flow
• Hold 3-5 seconds, relax 3-5 seconds
• Repeat 10-15 times, 3 sets per day
• Reverse Kegels: Push out gently (opposite of regular Kegel)
• Takes 2-3 months of consistent practice to see improvement

Working with a Sex Therapist

Professional therapy can address psychological and relationship factors:

What sex therapy includes:

• Psychosexual evaluation - identify contributing factors
• Performance anxiety reduction - cognitive behavioral techniques
• Couples counseling - involve partner in treatment
• Sensate focus exercises - structured touching without pressure
• Communication skills - discussing sexual needs with partner
• Homework assignments - graduated exposure to sexual situations

When therapy is especially helpful:

• Relationship stress contributing to PE
• Significant performance anxiety
• History of sexual trauma
• Partner communication issues
• Psychological factors primary cause

Finding a therapist:

• Look for AASECT-certified sex therapist
• Ask your urologist for referrals
• Verify expertise in male sexual dysfunction
• May require 6-12 sessions for benefit

Daily SSRIs (Off-Label Use)

Delayed ejaculation is a known side effect of SSRIs - we use this therapeutically for PE.

How SSRIs work for PE:

• Increase serotonin in brain, which inhibits ejaculatory reflex
• Daily dosing provides consistent effect
• Can increase ejaculatory latency 2-4 fold
• Most effective class of medications for PE

Benefits:

• Very effective (60-80% improvement)
• Predictable, consistent results
• Also treats anxiety/depression if present

Drawbacks:

• Must take daily (even on non-sexual days)
• Takes 1-2 weeks for full effect
• Systemic side effects possible (nausea, fatigue, decreased libido)
• Some men develop erectile dysfunction on SSRIs
• Discontinuation can be difficult (withdrawal symptoms)

On-Demand SSRIs

Dapoxetine (not available in US)

• Short-acting SSRI developed specifically for PE
• Taken 1-3 hours before intercourse
• FDA-approved in many countries (not US)
• Avoids daily dosing requirement

Off-label on-demand approach:

• Some doctors prescribe regular SSRIs 4-6 hours before sex
• Less predictable than daily dosing
• May work for some patients

Clomipramine (Anafranil) - Off-Label

Dosing: 25-50 mg daily, or 12.5-25 mg taken 4-6 hours before intercourse

How it works:

• Strong serotonergic activity delays ejaculation
• Can be as effective as SSRIs
• Option for those who can't tolerate SSRIs

Benefits:

• Very effective for PE
• Can use daily or on-demand
• Alternative to SSRIs

Drawbacks:

• More side effects than SSRIs (dry mouth, constipation, drowsiness)
• Anticholinergic effects
• Not first-line due to side effect profile
• Requires careful dosing

Tramadol (Ultram) for PE

Dosing: 25-50 mg taken 2-4 hours before anticipated intercourse

How it works:

• Weak opioid with serotonin/norepinephrine reuptake inhibition
• Multiple mechanisms delay ejaculation
• Can increase ejaculatory latency 2-3 fold

Benefits:

• On-demand dosing (not daily)
• Effective for many men
• Works relatively quickly (2-4 hours)
• Alternative when SSRIs fail or cause ED

Important cautions:

• ⚠️ Opioid medication - potential for dependence/abuse
• ⚠️ Cannot use with alcohol - dangerous combination
• ⚠️ Side effects: Nausea, dizziness, drowsiness
• ⚠️ Seizure risk in susceptible individuals
• ⚠️ Drug interactions with many medications
• ⚠️ Not for everyone - careful patient selection required

Tramadol should be used cautiously and only under close medical supervision. Discuss risks thoroughly with your doctor. Many urologists prefer SSRIs as safer first-line option.

For PE with Concurrent Erectile Dysfunction

If PE is accompanied by ED or difficulty maintaining erection:

Options:

• Sildenafil (Viagra) - 50-100 mg before intercourse
• Tadalafil (Cialis) - 10-20 mg as needed, or 5 mg daily
• Vardenafil (Levitra) - 10-20 mg before intercourse
• Avanafil (Stendra) - 100-200 mg before intercourse

How they help PE:

• Reduce anxiety about maintaining erection
• Enable second erection more quickly (shorter refractory period)
• Can combine with SSRIs safely
• Many men last longer during second intercourse

Combination therapy: SSRI for PE + PDE5 inhibitor for ED often works well together.

Step 1: Conservative Measures (Try First)

1. Behavioral techniques - start-stop, squeeze, edging (2-3 months)
2. Topical delay spray - immediate option while learning techniques
3. Lifestyle optimization - stress reduction, adequate sleep
4. Partner communication - discuss together, reduce pressure

Success rate: 30-50% of men improve significantly with conservative measures alone

Step 2: Add Medication if Needed

1. Daily SSRI - paroxetine or sertraline as first choice
2. Start low dose, increase gradually if needed
3. Give 2-3 weeks for full effect
4. Adjust dose based on response and side effects
5. Continue behavioral techniques alongside medication

Success rate: 60-80% significant improvement with daily SSRIs

Step 3: Alternative Medications

If SSRIs cause unacceptable side effects:

• Clomipramine (TCA) - if SSRIs not tolerated
• Tramadol on-demand - carefully selected patients only
• Combination topical + behavioral - maximize conservative approach

Step 4: Consider Sex Therapy

• If psychological factors prominent
• If relationship issues contributing
• If medications only partially effective
• Can combine with any medical treatment

Reasonable Expectations:

• Goal is NOT "lasting forever" - unrealistic and unnecessary
• Goal IS achieving satisfactory duration for you and your partner
• Average improvement: 2-4x increase in ejaculatory latency
• Most men go from <1 minute to 3-5 minutes or more
• Improved confidence and reduced anxiety
• Better sexual satisfaction for both partners

Don't Suffer in Silence

PE is a common, treatable condition. Most men see significant improvement with appropriate treatment. There's no need to be embarrassed - urologists treat this regularly and have many effective options to help you.