Dr. med. Dirk Manski

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Premature Ejaculation: Definition, Diagnosis and Treatment

Definition of Premature Ejaculation

Premature ejaculation is one of the most common sexual complaints. It is characterized by an unwanted early ejaculation before or after minimal sexual stimulation, this may interfere with sexual or emotional well-being in patient or partner and may possibly disturbe the (sexual) relationship. There are many different definitions of premature ejaculation. Most definitions refer to the following components of the disease:

Epidemiology of Premature Ejaculation

The prevalence rate of premature ejaculation in sexually active men is around 3–6%; it varies between studies and due to different definitions of premature ejaculation. Premature ejaculation is equally prevalent in all age groups.

Etiology (Causes) of Premature Ejaculation

Psychogenic causes:

Anxiety, poor communication between partners, lack of ejaculation techniques, and psychodynamic causes.

Physical causes:

Penile hypersensitivity, 5-hydroxytryptamine (5-HT) receptor hyper- or hyposensitivity (depending on the receptor subtype), and erectile dysfunction.

Signs and Symptoms

The clinical course of the disease is variable. Primary premature ejaculation is usually a lifelong disease and is caused by physical causes (see above). Secondary premature ejaculation is the acquired form; psychogenic causes are more prevalent.

Diagnostik Workup of Premature Ejaculation


In addition to a detailed sexual history (vaginal latency time, partners, techniques), further questions aim to exclude erectile dysfunction or to assess other sexual complaints.

Treatment of Premature Ejaculation

Sexual Therapy

The benefits of sexual therapy are the lack of side effects, its improvement in the communication of sexual partners, and may result in the treatment of premature ejaculation in a more satisfying partnership. Disadvantages are the delayed and inconstant effects of behavioral therapy. In addition, it requires a high human and financial burden to patients (or society), and the cooperation of the sexual partner is mandatory.

Stop-Squeeze Method [Masters and Johnson, 1970]:

Shortly before ejaculation, the sexual stimulation is paused until the decreased sexual arousal allows further stimulation without ejaculation.

Stop-Pause Method [Kaplan 1983]:

Shortly before ejaculation, the sexual stimulation is paused, until the decreased sexual arousal allows further stimulation without ejaculation.

Local treatment:

The use of ointments or sprays with local anesthetics (e.g., lidocaine or lidocaine-prilocaine combination) decreases the hypersensitivity of the penis. Application 20 minutes before intercourse, if necessary, in combination with a condom.

Pharmacological Treatment of Premature Ejaculation

Pharmacological therapy of premature ejaculation is possible with the use of serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. The problem are the side effects of the antidepressants and the lack of approval for the indication premature ejaculation. Since 2009, dapoxetine (a short-acting SSRI) received approval for on-demand treatment of premature ejaculation (Porst et al., 2010).


Dapoxetine is a short-acting selective serotonin reuptake inhibitor (SSRI), which has been approved for an on-demand therapy. A 30 mg dose is taken 1–3 hours before planned sexual activity. Dapoxetine should be taken only once a day. In the case of inefficiency without side effects, the dose may be increased to 60 mg. Please see section dapoxetine for pharmacology, side effects, and contraindications.


Paroxetine is a long-acting SSRI; the dosage is 20–40 mg daily. The onset of action begins after 1–2 weeks.


Fluoxetine is a long-acting SSRI; the dosage is 20–40 mg daily. The onset of action begins after 1–2 weeks.


Clomipramine is a tricyclic antidepressant that can be used (off-label) as an on-demand treatment. The dosage is 10–50 mg five hours before sexual intercourse.

Phosphodiesterase inhibitors:

PDE5 inhibitors do not increase IELT, but they do increase confidence in achieving a second erection and thereby improve sexual experience. In addition, PDE5 inhibitors are indicated for the treatment of erectile dysfunction, which may also be the cause for the premature ejaculation.


Besides the activity on the opioid receptor, tramadol also influences the cholinergic and serotonergic nervous systems. Tramadol increased IELT in a randomized phase-3 study (Bar-Or u.a., 2012): 1,2 min (with 62 mg Tramadol) versus 0,6 min (with placebo). Side effects of tramadol were acceptable. Regarding the addictive potential, regular use can only be discouraged.

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AUA, “Guideline: Disorders of Ejaculation,” 2020. [Online]. Available: https://www.auanet.org/guidelines-and-quality/guidelines/disorders-of-ejaculation.

S. E. Althof. Prevalence, characteristics and implications of premature ejaculation/rapid ejaculation.
J Urol, 175 (3 Pt 1): 842–848, Mar 2006.

Bar-Or, D.; Salottolo, K. M.; Orlando, A.; Winkler, J. V. & Group, T. O. S. A randomized double-blind, placebo-controlled multicenter study to evaluate the efficacy and safety of two doses of the tramadol orally disintegrating tablet for the treatment of premature ejaculation within less than 2 minutes.
Eur Urol, 2012, 61, 736-743.

Buvat, J.; Tesfaye, F.; Rothman, M.; Rivas, D. A. & Giuliano, F. Dapoxetine for the Treatment of Premature Ejaculation: Results from a Randomized, Double-Blind, Placebo-Controlled Phase 3 Trial in 22 Countries.
Eur Urol, 2009.

EAU-Guidelines: Sexual and Reproductive Health

H. Porst et al., “Baseline characteristics and treatment outcomes for men with acquired or lifelong premature ejaculation with mild or no erectile dysfunction: integrated analyses of two phase 3 dapoxetine trials.,” J Sex Med., vol. 7, no. 6, pp. 2231–2242, 2010.

  Deutsche Version: Vorzeitige Ejakulation