Premature ejaculation: assessed properly, treated to the pattern.

Behavioural therapy is the foundational first-line approach for many patients, particularly those with mild-to-moderate PE, no co-occurring conditions, or preferences against pharmacological treatment. It's also a powerful complement when added to pharmacological treatment.

The start-stop technique: During sexual activity, stimulation is paused before the point of ejaculatory inevitability. After 30 seconds of rest, stimulation resumes. Practising this builds awareness of ejaculatory thresholds and trains the body to tolerate higher arousal without climaxing.

The squeeze technique: Similar principle, but firm pressure is applied to the base of the penis just before ejaculation point, reducing arousal. Used during practice initially, then less needed as control develops.

Pelvic floor strengthening: Specific exercises (Kegels for men) strengthen the muscles involved in ejaculatory control. Studies show pelvic floor training improves ejaculation latency by approximately 60% in many patients over 12 weeks (see source 2 below).

Effectiveness: Behavioural techniques alone improve PE in 50-60% of patients over 8-12 weeks of consistent practice. Combined with topical anaesthetics or on-demand dapoxetine, outcomes improve further.

Eligibility: Suitable for almost all patients. Most effective when partner is involved and supportive. Less effective for severe lifelong (primary) PE in the absence of pharmacological support.

Topical anaesthetics reduce penile sensitivity through local action - the simplest pharmacological approach with minimal systemic effects.

Lidocaine-prilocaine cream (EMLA, off-label): Applied 15-20 minutes before intercourse, then wiped off before condom use. Available as cream or spray formulations.

Lidocaine spray (TEMPE, licensed): Sprayed 5-10 minutes before intercourse. Convenient and discreet; faster onset than cream.

How they work: Reduce sensitivity in the glans, raising the threshold for ejaculation without affecting libido, erection, or partner sensation (when applied and removed correctly).

Effectiveness: Studies show 2-3-fold increases in ejaculation latency for most users (see source 3 below). Effects are reliable and on-demand.

Potential side effects: If not removed before intercourse, can cause partner numbness or reduced sensation. Some experience reduced sensitivity or pleasure - dose and timing adjustment usually resolves this. Rare allergic reactions.

Eligibility: Suitable for most patients. Particularly useful when preferring non-systemic treatment, occasional use, or where oral medication is unsuitable.

Dapoxetine is the only SSRI licensed specifically for PE. It's short-acting - taken on-demand 1-3 hours before sexual activity, with effects fading within hours.

How it works: Increases serotonin signalling in brain regions controlling ejaculation, raising the ejaculatory threshold. Designed specifically for short half-life so it doesn't cause persistent SSRI effects.

Dosing: 30 mg or 60 mg, 1-3 hours before intercourse. Not for daily use.

Effectiveness: Approximately 2-3-fold increases in ejaculation latency in clinical trials (see source 4 below). Effective for most patients within the first few doses.

Side effects: Nausea (most common, usually reduces with use), headache, dizziness. Less common: orthostatic hypotension. Generally well-tolerated.

Contraindications: Concurrent MAOIs, severe heart conditions, severe hepatic impairment. Caution with other antidepressants.

Eligibility: Suitable for most patients who prefer on-demand pharmacological control. Particularly useful when occasions are planned or anticipated.

In secondary (acquired) PE, an identifiable contributor is often present. Where one is found, treating it is the priority, and symptomatic options are used alongside it where the doctor considers that appropriate.

Medical and physical contributors: erectile dysfunction is common in acquired PE, and treating the ED often improves the PE. Thyroid dysfunction, particularly hyperthyroidism, is associated with acquired PE and thyroid function is checked where indicated (see source 6 below). Prostatitis and lower urinary tract symptoms are assessed where pelvic discomfort or urinary symptoms accompany PE.

Medication and substance review: some prescribed medications, recreational drugs and heavy alcohol use affect ejaculatory control. A full medication review is part of every consultation.

Psychological and relationship contributors: performance anxiety, stress, low mood and relationship difficulty are frequent drivers. These are addressed through structured counselling and partner-inclusive behavioural work, with onward referral where formal psychosexual therapy or mental health care is indicated.

How it works in practice: history, focused examination and targeted investigations (testosterone, thyroid function, glucose, urinalysis where prostatic symptoms are present) identify what is contributing. The plan then treats the cause rather than the symptom alone.

Eligibility: relevant to any patient whose PE began after a period of normal control, and to patients with primary PE who also have a treatable co-occurring condition. The doctor advises at consultation which elements apply to you.