Premature ejaculation: A common problem with a promising future

The distress of this condition is actually felt by both partners (see, "Not men only: PE adversely affects female partners"). For a man, the tendency is to be concerned about disappointing his mate and leaving her unfulfilled. The woman achieves less pleasure from the shortened duration of intercourse and realizes he is depressed for failing her.

Although PE is a widespread problem, few couples have sought treatment, believing that no therapy is available. Physicians, in general, know little about this topic and often are startled when patients broach the subject.

Investigational topical medications applied to the penis as sprays or creams have reportedly shown some success. These include two anesthetics-a cream combining 2.5% lidocaine plus 2.5% prilocaine (EMLA) and a spray combining lidocaine, 7.5 mg, plus prilocaine, 2.5 mg (TEMPE)-and a compound composed of multiple herbs, known as SS cream.

Off-label use of the selective serotonin reuptake inhibitors (SSRIs), especially paroxetine (Paxil), sertraline hydrochloride (Zoloft), and fluoxetine (Prozac), mostly with on-demand dosing, has shown good results as well. The slight reduction in libido and penile rigidity and the risk of suicide in patients on such medications, although rare, has mandated that they be used with caution.

Dapoxetine, a short-acting SSRI not yet available in the United States, is currently in clinical trials as a treatment for PE (see, "Investigational PE Rx improves QoL in men, partners"). Compared to other SSRIs, which must be taken many hours prior to coitus, it reaches peak levels within an hour. Modest success in prolonging intravaginal ejaculatory latency time (IVELT) has been seen with dapoxetine, and no suicide has been seen.

Other medications that have been shown to be successful in treating PE include clomipramine hydrochloride (Anafranil), a tricyclic antidepressant, and tramadol hydrochloride (Ultram), a synthetic opioid analgesic. The success of the phosphodiesterase type-5 inhibitors has been variable in treating PE.

The future holds great promise in this area. Paradigms of combination therapy will likely be the standard approach, as none of these medications is a "wonder drug" for this problem. A number of other short-acting SSRIs are under study. When one or more of these drugs gain FDA approval, a marketing blitz comparable to that seen with the introduction of PDE-5 inhibitors will occur. This will create awareness of the magnitude of the problem, educate physicians on its treatment, and ultimately improve marital harmony for the large number of couples affected by PE.

Dr. Mulcahy, a member of the Urology Times editorial council, is in private urology practice in Phoenix.