Can sildenafil treat primary premature ejaculation? A prospective clinical study
In addition, a reduction in performance anxiety may exist on a subconscious level. Regardless of the mechanism, PDE5 inhibitors have been found to be safe and effective as a therapeutic adjunct for premature ejaculation in men for whom such therapy is not otherwise contraindicated. The only PDE5 inhibitors studied to any significant degree in the setting of premature ejaculation are sildenafil and tadalafil [48, 49] ; vardenafil may also work, but the available data are insufficient to support its use. A single-blind randomized placebo-controlled clinical study in 100 patients concluded that tadalafil, 5 mg once daily for 6 weeks, was significantly more effective than placebo (P=0.001) and was well tolerated in the treatment of premature ejaculation. [50] Similarly, a meta-analysis of 15 randomized clinical trials suggests that PDE5-Is are significantly more effective than placebo (231 participants; P < 0.00001), that there is no difference between PDE5-Is and selective serotonin reuptake inhibitors (SSRIs; 405 participants, P = 0.50), and that PDE5-Is combined with an SSRI are significantly more effective than SSRIs alone (521 participants, P = 0.001).
About this article
If the male always experiences ejaculation with initial sexual excitement or early foreplay, this is a serious problem and probably indicates lifelong premature ejaculation (the history should reveal this). Such cases will most likely call for treatment in conjunction with a mental health care professional. These more difficult cases should be screened out. Next, the couple should be instructed in sex therapy techniques, such as the stop-start or squeeze-pause technique popularized by Masters and Johnson. In this technique, the female partner slowly begins stimulation of the male but stops as soon as he senses a feeling of excessive excitement that may lead to ejaculatory inevitability.
Defining premature ejaculation for experimental and clinical investigations
She then administers firm compression to the penis just behind the glans, pressing mainly on the underside. This compression should be uncomfortable but not painful. Once the male has the feeling that ejaculation is no longer imminent, the female resumes stimulation. The process should be repeated and practiced at least 10 or more times. Over time, most males find that this technique helps decrease the impending inevitable need to ejaculate.
Authors and Affiliations
After practicing this technique for a while, the couple can move to another phase of the process. In this phase, the partners sit facing each other, with the woman’s legs crossing on top of the male’s legs. She stimulates him by manipulating his penis first close to and then with friction against her vulval area. Each time he senses excessive excitement, she applies the squeeze sildenafil citrate chewable tablets and stops all stimulation until he calms down enough for the process to be repeated. Finally, coitus may be attempted, with the female partner in the superior position so that she may withdraw immediately and again apply a squeeze to remove the male partner’s urge to climax. [51] The use of PDE5 inhibitors for the treatment of premature ejaculation is not approved by the FDA and is considered an off-label use. A study by Safarinejad demonstrated that a single daily high dose of pindolol (a nonselective beta-adrenergic antagonist with 5-HT1A autoreceptor antagonist properties [52] ) in combination with paroxetine (or possibly another SSRI) delayed ejaculation in patients in whom paroxetine therapy alone failed to provide benefit. [53] However, more studies must be performed before pindolol can be considered an ideal option for first- or second-line treatment of premature ejaculation. In studies by Safarinejad and Hosseini [54] and Salem et al, [55] the opioid analgesic tramadol was found to be significantly more effective than placebo in terms of increased time to ejaculation, increased sexual intercourse satisfaction, and tolerability.
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In a randomized double-blind, placebo-controlled clinical trial by Hamidi-Madani et al in 150 patients, 12 weeks of tramadol 50 20mg sildenafil mg on demand, paroxetine 20 mg on demand, and placebo all resulted in improvement, but the tramadol group experienced significantly greater benefit than the paroxetine and placebo groups (P < 0.0001). A systematic review and meta-analysis found that tramadol may be effective in treatment of premature ejaculation, especially when other therapies have failed, but that it remains necessary to consider the possibility of drug addiction and adverse effects before initial use or after long-term use. [57] A meta-analysis of on-demand use of tramadol noted that the available evidence was of low to moderate quality, but the drug appears to be effective in this setting, with a low rate of adverse events; the effective dose remains uncertain, but some data support the use of 50 mg.
Research Design
[58] The first step is to attempt to relieve any underlying performance pressure on the male. If premature ejaculation occurs when intercourse is attempted, the couple should be instructed not to attempt intercourse until the ejaculatory problem is treated. In the meantime, the male may use manual stimulation, oral sex, or other means to satisfy the female partner. If the male always experiences ejaculation with initial sexual excitement or early foreplay, this is a serious problem and probably indicates lifelong premature ejaculation (the history should reveal this).
| Parameter | Data | Notes |
|---|---|---|
| Tolerance development | Rare, possible with prolonged use | Monitoring advised |
| Dependency risk | Low | Not considered addictive |
| Long-term side effects | Unclear, ongoing research | Regular medical check-ups recommended |
| Impact on cardiovascular health | Generally safe in healthy individuals | Caution in pre-existing cardiovascular conditions |
Such cases will most likely call for treatment in conjunction with a mental health care professional. These more difficult cases should be screened out. Next, the couple should be instructed in sex therapy techniques, such as the stop-start or squeeze-pause technique popularized by Masters and Johnson.
Author information
[61, 62] Currently, all those are considered experimental. Before the availability of nonsurgical methods for treating erectile dysfunction, a patient with premature ejaculation who was mistakenly diagnosed with erectile dysfunction might have undergone a penile prosthesis implantation, which would have yielded unsatisfactory results because of the incorrect initial diagnosis. In this scenario, the patient would be able to engage in sexual intercourse, because the penile implant would provide an adequate erection, but he would still climax prematurely. Currently, penile implants are placed much more rarely, and with the use of nonsurgical treatments for erectile dysfunction, any permanent harm resulting from diagnosing erectile dysfunction rather than premature ejaculation is unlikely. Consultation with a sex therapist, psychologist, or psychiatrist may prove helpful if the primary care physician or urologist cannot provide successful treatment or does not have the time to explore psychological issues and implement behavioral techniques (eg, squeeze-pause).
A new combination treatment for premature ejaculation: A sex therapist's perspective
If the primary care physician or urologist is inexperienced or uncomfortable with treating premature ejaculation, early referral to a sex therapist, psychologist, or psychiatrist is indicated. Some physicians are comfortable implementing pharmacologic therapy but not behavioral therapy. As with any medical condition, the patient should be offered all available treatment options, and the physician should proceed with referral for any option considered to require more specialized help than the physician can provide. For men who may have a severe emotional disturbance underlying the premature ejaculation, referral to a mental health professional is most appropriate. Diagnosis and treatment of the various psychological factors that manifest partly as premature ejaculation are beyond the scope of this discussion.
Efficacy of prilocaine-lidocaine cream in the treatment of premature ejaculation
Hossein Sadeghi-Nejad, MD, FACS, and Richard Watson, MD, FACS A B S T R A C TIntroduction. Premature ejaculation (PE) is the most common form of male sexual dysfunction. Until very recently, scientific investigation of PE has been hampered by a lack of standardized definitions and objective, validated questionnaires. Small numbers of randomized controlled studies evaluating various treatment options have also added to the challenges facing the clinicians who manage PE. This article provides a summary of some of the more relevant the peer-reviewed literature pertaining to the medical therapy of premature ejaculation. In this technique, the female partner slowly begins stimulation of the male but stops as soon as he senses a feeling of excessive excitement that may lead to ejaculatory inevitability. She then administers firm compression to the penis just behind the glans, pressing mainly on the underside. This compression should be uncomfortable but not painful. Once the male has the feeling that ejaculation is no longer imminent, the female resumes stimulation. The process should be repeated and practiced at least 10 or more times. Over time, most males find that this technique helps decrease the impending inevitable need to ejaculate. After practicing this technique for a while, the couple can move to another phase of the process. In this phase, the partners sit facing each other, with the woman’s legs crossing on top of the male’s legs. She stimulates him by manipulating his penis first close to and then with friction against her vulval area. Each time he senses excessive excitement, she applies the squeeze sildenafil citrate chewable tablets and stops all stimulation until he calms down enough for the process to be repeated. Finally, coitus may be attempted, with the female partner in the superior position so that she may withdraw immediately and again apply a squeeze to remove the male partner’s urge to climax.
Ethics declarations
A retrospective review of peer reviewed publications relevant to the field of premature ejaculation and related medical therapies. Most couples find this technique to be highly successful. It can also help the female partner to be more aroused and can shorten her time to climax because it constitutes a form of extended foreplay in many cases.
- Early ejaculation is a normal variation for some men.
- Understanding personal sexual response helps manage PE.
- Sensory-enhancing devices may delay climax.
- Medications are not the only solution to PE.
- Regular exercise benefits erectile and ejaculatory health.
- Stress management techniques can improve PE outcomes.
- PE can be a sign of underlying medical issues.
- clinician-guided treatment yields better safety profiles.
- Support from partners encourages successful treatment.
- Combining therapy approaches often gives the best results.
- Healthy lifestyle choices support sexual function.
If the male is relatively young and can achieve another erection within a few minutes after a premature ejaculation, he may find that he is much less likely to experience a premature ejaculation the second time. The interval for achieving a second climax often includes a much longer period of latency, and the male can usually exert better control in this setting.
Additional information
Most couples find this technique to be highly successful. It can also help the female partner to be more aroused and can shorten her time to climax because it constitutes a form of extended foreplay in many cases. If the male is relatively young and can achieve another erection within a few minutes after a premature ejaculation, he may find that he is much less likely to experience a premature ejaculation the second time. The interval for achieving a second climax often includes a much longer period of latency, and the male can usually exert better control in this setting. Accordingly, some therapists advise young men to masturbate (or have their partner stimulate them rapidly to climax) 1-2 hours before sexual relations are planned.
Cite this article
In an older man, such a strategy may be less effective, because the older man may have difficulty achieving a second erection after his first rapid sexual release. If this occurs, it can damage his confidence and may result in secondary impotence. Kilinc et al reported that moderate physical activity longer than 30 min at least 5 times a week leads to ejaculation delay in patients with premature ejaculation. In their study, 35 patients were treated with dapoxetine, 30 mg on demand; 35 performed moderate physical activities; and 35 performed minimal physical activity. [59] Pastore et al reported long-term benefit from pelvic muscle floor rehabilitation (PFM) in patients with lifelong premature ejaculation.
Premature ejaculation: clinical subgroups and etiology
The 154 participants in this retrospective study entered a 12-week program of PFM rehabilitation, including physio-kinesiotherapy treatment, electrostimulation, and biofeedback, with three sessions per week, with 20 min for each component completed at each session. Of the 122 participants who completed PFM rehabilitation, 111 gained control of their ejaculation reflex. Of the 95 participants who completed follow-up, 64% maintained satisfactory ejaculation control at 24 months sildenafil citrate tablets for female and 56% did so at 36 months. Surgical procedures that reduce penile sensation have been proposed as treatments for premature ejaculation. These include selective dorsal nerve neurotomy, pulsed radiofrequency ablation or cryoablation of dorsal penile nerves, and hyaluronic acid gelaugmentation of the glans penis. Accordingly, some therapists advise young men to masturbate (or have their partner stimulate them rapidly to climax) 1-2 hours before sexual relations are planned. In an older man, such a strategy may be less effective, because the older man may have difficulty achieving a second erection after his first rapid sexual release. If this occurs, it can damage his confidence and may result in secondary impotence. Kilinc et al reported that moderate physical activity longer than 30 min at least 5 times a week leads to ejaculation delay in patients with premature ejaculation. In their study, 35 patients were treated with dapoxetine, 30 mg on demand; 35 performed moderate physical activities; and 35 performed minimal physical activity. [59] Pastore et al reported long-term benefit from pelvic muscle floor rehabilitation (PFM) in patients with lifelong premature ejaculation. The 154 participants in this retrospective study entered a 12-week program of PFM rehabilitation, including physio-kinesiotherapy treatment, electrostimulation, and biofeedback, with three sessions per week, with 20 min for each component completed at each session. Of the 122 participants who completed PFM rehabilitation, 111 gained control of their ejaculation reflex. Of the 95 participants who completed follow-up, 64% maintained satisfactory ejaculation control at 24 months sildenafil citrate tablets for female and 56% did so at 36 months. Surgical procedures that reduce penile sensation have been proposed as treatments for premature ejaculation. These include selective dorsal nerve neurotomy, pulsed radiofrequency ablation or cryoablation of dorsal penile nerves, and hyaluronic acid gelaugmentation of the glans penis. [61, 62] Currently, all those are considered experimental. Before the availability of nonsurgical methods for treating erectile dysfunction, a patient with premature ejaculation who was mistakenly diagnosed with erectile dysfunction might have undergone a penile prosthesis implantation, which would have yielded unsatisfactory results because of the incorrect initial diagnosis. In this scenario, the patient would be able to engage in sexual intercourse, because the penile implant would provide an adequate erection, but he would still climax prematurely.
- Premature ejaculation is classified as lifelong or acquired.
- Lifelong PE begins from the first sexual experience.
- Acquired PE develops after a period of normal function.
- Sensory sensitivity might influence PE severity.
- Partner communication can improve PE management.
- Pelvic floor exercises may help control ejaculation.
- Squeeze techniques can delay climax.
- Pharmacological options include SSRIs, dapoxetine.
- Biofeedback therapy is an emerging PE treatment.
- Erectile dysfunction and PE can coexist.
- Proper diagnosis ensures effective treatment.
Currently, penile implants are placed much more rarely, and with the use of nonsurgical treatments for erectile dysfunction, any permanent harm resulting from diagnosing erectile dysfunction rather than premature ejaculation is unlikely.
Preparing for your appointment
Consultation with a sex therapist, psychologist, or psychiatrist may prove helpful if the primary care physician or urologist cannot provide successful treatment or does not have the time to explore psychological issues and implement behavioral techniques (eg, squeeze-pause). If the primary care physician or urologist is inexperienced or uncomfortable with treating premature ejaculation, early referral to a sex therapist, psychologist, or psychiatrist is indicated. Some physicians are comfortable implementing pharmacologic therapy but not behavioral therapy. As with any medical condition, the patient should be offered all available treatment options, and the physician should proceed with referral for any option considered to require more specialized help than the physician can provide. For men who may have a severe emotional disturbance underlying the premature ejaculation, referral to a mental health professional is most appropriate. Diagnosis and treatment of the various psychological factors that manifest partly as premature ejaculation are beyond the scope of this discussion.
- Sildenafil's role in PE is still under research.
- Off-label use requires informed consent.
- Behavioral techniques are first-line in many cases.
- The impact of psychological health on PE should not be ignored.
- Educating patients on realistic expectations is important.
- Sometimes, medication just masks underlying issues.
- Regular sexual activity can decrease PE severity.
- Consulting a urologist is recommended for persistent PE.
- Combining medication with therapy often improves outcomes.
- Delaying ejaculation involves both physical and mental strategies.
- Support and understanding enhance treatment adherence.
Hossein Sadeghi-Nejad, MD, FACS, and Richard Watson, MD, FACS A B S T R A C TIntroduction. Premature ejaculation (PE) is the most common form of male sexual dysfunction. Until very recently, scientific investigation of PE has been hampered by a lack of standardized definitions and objective, validated questionnaires.
- Sildenafil enhances blood flow but doesn't directly delay ejaculation.
- PE is often linked with heightened genital sensitivity.
- Timed use of sildenafil may improve sexual confidence.
- Medication dose should be carefully managed.
- PDE5 inhibitors may have a role in PE enhancement.
- Regular sexual activity can help reduce PE symptoms.
- Psycho-sexual therapy addresses underlying issues.
- Identifying triggers can help manage PE episodes.
- Drugs are part of a comprehensive PE management plan.
- Pharmacotherapy may require adjustment over time.
- Always follow medical advice regarding medication use.
Small numbers of randomized controlled studies evaluating various treatment options have also added to the challenges facing the clinicians who manage PE. This article provides a summary of some of the more relevant the peer-reviewed literature pertaining to the medical therapy of premature ejaculation.
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In addition, a reduction in performance anxiety may exist on a subconscious level. Regardless of the mechanism, PDE5 inhibitors have been found to be safe and effective as a therapeutic adjunct for premature ejaculation in men for whom such therapy is not otherwise contraindicated. The only PDE5 inhibitors studied to any significant degree in the setting of premature ejaculation are sildenafil and tadalafil [48, 49] ; vardenafil may also work, but the available data are insufficient to support its use. A single-blind randomized placebo-controlled clinical study in 100 patients concluded that tadalafil, 5 mg once daily for 6 weeks, was significantly more effective than placebo (P=0.001) and was well tolerated in the treatment of premature ejaculation. [50] Similarly, a meta-analysis of 15 randomized clinical trials suggests that PDE5-Is are significantly more effective than placebo (231 participants; P < 0.00001), that there is no difference between PDE5-Is and selective serotonin reuptake inhibitors (SSRIs; 405 participants, P = 0.50), and that PDE5-Is combined with an SSRI are significantly more effective than SSRIs alone (521 participants, P = 0.001).
Key Takeaways
[51] The use of PDE5 inhibitors for the treatment of premature ejaculation is not approved by the FDA and is considered an off-label use. A study by Safarinejad demonstrated that a single daily high dose of pindolol (a nonselective beta-adrenergic antagonist with 5-HT1A autoreceptor antagonist properties [52] ) in combination with paroxetine (or possibly another SSRI) delayed ejaculation in patients in whom paroxetine therapy alone failed to provide benefit. [53] However, more studies must be performed before pindolol can be considered an ideal option for first- or second-line treatment of premature ejaculation. In studies by Safarinejad and Hosseini [54] and Salem et al, [55] the opioid analgesic tramadol was found to be significantly more effective than placebo in terms of increased time to ejaculation, increased sexual intercourse satisfaction, and tolerability. In a randomized double-blind, placebo-controlled clinical trial by Hamidi-Madani et al in 150 patients, 12 weeks of tramadol 50 20mg sildenafil mg on demand, paroxetine 20 mg on demand, and placebo all resulted in improvement, but the tramadol group experienced significantly greater benefit than the paroxetine and placebo groups (P < 0.0001).
Neurobiology of sexual behavior
A systematic review and meta-analysis found that tramadol may be effective in treatment of premature ejaculation, especially when other therapies have failed, but that it remains necessary to consider the possibility of drug addiction and adverse effects before initial use or after long-term use. [57] A meta-analysis of on-demand use of tramadol noted that the available evidence was of low to moderate quality, but the drug appears to be effective in this setting, with a low rate of adverse events; the effective dose remains uncertain, but some data support the use of 50 mg. [58] The first step is to attempt to relieve any underlying performance pressure on the male. If premature ejaculation occurs when intercourse is attempted, the couple should be instructed not to attempt intercourse until the ejaculatory problem is treated. In the meantime, the male may use manual stimulation, oral sex, or other means to satisfy the female partner. A retrospective review of peer reviewed publications relevant to the field of premature ejaculation and related medical therapies.