Dear Dr G,

I read with interest your article about the causes of premature ejaculation.

I have often assumed that premature ejaculation in men occurs because of anxiety and, as it is usually perceived as psychological, that there is no real medicine for a cure.

My wife and I have had an “acceptable” sexual relationship since we were married in our mid-twenties. Although the timing of my ejaculation is not ideal, we have accepted this shortcoming.

Although my wife has never complained about this condition, I cannot help thinking that I have shortchanged her in this relationship.

We have now been married for twelve years, and there is no better way to start the new year than by exploring ways to enhance the timing of our intimacy.

When I read about the causes of premature ejaculation, I could not help but check what medications are available for its treatment.

I also know my wife might be against medications, so I wonder whether any non-medical treatments are also available for premature ejaculation.

I am putting Dr G on the spot for clarification on how to overcome these sexual shortcomings!

First of all, what has been tried to enhance the timing of sex?

What medications are approved and effective in treating premature ejaculation?

Lastly, what are the shortcomings of these treatment modalities?

Yours truly,

Shortchanged Stephen

Premature ejaculation (PE) is one of the most common male sexual dysfunctions and has been reported across cultures and throughout history. Clinically, it is defined as ejaculation that occurs sooner than desired, accompanied by a lack of control and personal or interpersonal distress. PE may be lifelong, present from a man’s first sexual experiences, or acquired, developing later in life, often in association with other medical or psychological factors. Understanding its treatment requires an appreciation of how concepts of causation, therapy, and patient adherence have evolved.

Early and effective treatment of premature ejaculation is essential not only for sexual satisfaction but also for psychological well-being and relationship health. Untreated PE is associated with reduced self-esteem, performance anxiety, avoidance of intimacy, and partner distress. Modern management begins by determining whether PE is lifelong or acquired and by addressing contributing factors such as erectile dysfunction, anxiety disorders, thyroid disease or chronic pelvic symptoms.

Historically, premature ejaculation was mainly viewed through a psychological or moral lens. Before the mid-20th century, medical literature attributed PE to anxiety, excessive sexual desire, relationship conflict, or poor self-control. During the 1960s and 1970s, behavioural therapies such as the “stop–start” and “squeeze” techniques were introduced. These methods aimed to train men to recognise pre-ejaculatory sensations and delay climax through repeated practice. Their success depended heavily on sustained effort and partner cooperation, which limited long-term adherence.

A significant shift in treatment occurred in the late 20th century with the observation that certain antidepressants delayed ejaculation as an unintended side effect. Selective serotonin reuptake inhibitors (SSRIs) were found to significantly prolong intravaginal ejaculatory latency time, leading to their off-label use for PE. Daily SSRIs such as paroxetine, sertraline, fluoxetine, and escitalopram became widely used in clinical practice, although daily SSRI therapy is associated with systemic side effects.

In response to the need for a more targeted therapy, dapoxetine was developed as a short-acting SSRI specifically for PE. Unlike conventional SSRIs, dapoxetine is taken on demand, typically one to three hours before sexual activity, and is approved for the treatment of PE in many countries. Clinical trials have shown that dapoxetine produces modest to significant improvements in ejaculatory control and patient satisfaction. Common side effects include nausea, dizziness, headache and diarrhoea, with rare episodes of fainting related to vasovagal responses.

Topical anaesthetic therapies represent another long-standing and effective treatment strategy. Creams, sprays, or wipes containing agents such as lidocaine or a lidocaine–prilocaine combination reduce penile sensitivity and delay ejaculation. SS cream with similar anaesthetic qualities has also been used. These treatments act locally, avoid systemic side effects, and provide rapid benefit, often from the first use. Their main drawbacks include penile numbness, reduced sexual pleasure, local irritation, and the risk of transferring anaesthetic to a partner, potentially causing vaginal numbness unless precautions are taken.

Other pharmacological options have been explored off-label. Tramadol, an analgesic with serotonergic activity, has demonstrated efficacy in delaying ejaculation when taken on demand. However, its use is limited by side effects such as nausea, dizziness, sedation, constipation, and, importantly, the risk of dependence and drug interactions, particularly with antidepressants. For these reasons, tramadol is generally reserved for carefully selected cases and is not considered a first-line therapy.

Combination therapy has become increasingly common in clinical practice. Using behavioural techniques alongside pharmacological treatment, or combining topical anaesthetics with systemic medication, often yields better outcomes than any single modality alone. However, combination therapy also increases the likelihood of side effects and may further challenge patient adherence.

The treatment of premature ejaculation has evolved from purely psychological approaches to evidence-based behavioural and pharmacological strategies. Officially approved therapies, such as topical anaesthetics and dapoxetine in certain regions, coexist with widely used off-label treatments, including daily SSRIs and selected adjunctive medications. The most successful long-term outcomes are achieved through individualised treatment, realistic expectations, and a balanced approach that combines medical therapy with education and behavioural support. George Bernard Shaw famously said: “The greatest tragedy is not being opposed, but being shortchanged by low expectation!” Shortchanged men often put Dr G on the spot for treatment options. His view is: “The greatest tragedy is continuing to be shortchanged without any expectation of overcoming the shortcoming!”