Before prescribing

• Lifelong versus acquired PE, approximate intravaginal ejaculation latency time, perceived control, and distress
• Erectile dysfunction, low libido, genital pain, prostatitis symptoms, thyroid symptoms
• Anxiety, depression, relationship conflict, alcohol or recreational-drug use
• Current medications, especially antidepressants, tramadol, MAO inhibitors, PDE5 inhibitors, and CYP3A4 inhibitors
• Syncope, significant cardiac disease, arrhythmia, orthostatic hypotension, liver disease
• Blood pressure and pulse. Perform focused genital examination only if indicated.

Example outpatient prescription template

1. Dapoxetine 30 mg tablet
   • Take 1 tablet orally 1-3 hours before anticipated intercourse, with a full glass of water.
   • Maximum: one dose in 24 hours.
   • Review after 4 weeks or after 6 doses.
   • If there is inadequate benefit and it is tolerated, a clinician may consider 60 mg on demand, subject to local product labeling and reassessment.
   • Dispense: 6-12 tablets. No automatic refill.
   Counsel: nausea, dizziness, headache, diarrhea, dry mouth, and possible fainting can occur. Avoid alcohol, driving, heights, or hazardous tasks after dosing, particularly until individual response is known. Rise slowly from sitting/lying positions.
2. Behavioral and couple-based treatment
   • Start-stop method or squeeze technique, sensate-focus exercises, slower stimulation, and pelvic-floor relaxation/training.
   • Encourage joint counseling/sex therapy if relationship anxiety, performance anxiety, or communication difficulty is present.
   • Review in 4-6 weeks.

Do not prescribe dapoxetine if

• Taking another SSRI/SNRI, MAOI, linezolid, tramadol, St John's wort, or serotonergic recreational drugs, due to serotonin-toxicity risk
• History of mania/hypomania, severe depression with suicidality, or significant psychiatric instability
• History of syncope, significant structural heart disease, clinically important arrhythmia, or marked orthostatic hypotension
• Moderate or severe hepatic impairment
• Concurrent potent CYP3A4 inhibitors, depending on local labeling
• Heavy alcohol use or inability to avoid alcohol around dosing

If dapoxetine is unavailable or contraindicated

• Apply a small amount to the glans penis about 10-20 minutes before intercourse, then wash it off or use a condom before penetration to avoid penile over-numbness and transfer of anesthetic to the partner.
• Stop if either partner develops numbness, burning, rash, or reduced pleasure.

Do not recommend for PE

• Tribulus
• Ashwagandha
• Ginseng
• Maca
• Zinc
• L-arginine
• “Testosterone boosters”
• Unregulated “sexual enhancement” pills

If he also has erectile dysfunction

What is more useful

1. Behavioral treatment: start-stop method, sensate-focus exercises, anxiety reduction, and partner communication.
2. Pelvic-floor physiotherapy/training: may help some patients. A 2026 systematic review/meta-analysis evaluated physiotherapy for PE, though treatment protocols and evidence quality vary. Medrano-Sánchez et al., 2026, PMID 41990123
3. Evidence-based first-line options after assessment: on-demand dapoxetine where approved/appropriate, topical lidocaine-prilocaine, or selected SSRI therapy. The EAU guideline and AUA/SMSNA guideline recommend these approaches, not supplements.

Recent premature ejaculation guidelines and consensus statements

1. European Association of Urology - EAU Sexual and Reproductive Health Guidelines, 2026

• Diagnose based on sexual and medical history: estimated intravaginal ejaculation latency time, perceived control, distress, and interpersonal difficulty.
• Examine the patient initially, particularly for erectile dysfunction or genital/anatomical contributors.
• Do not order routine laboratory tests unless history or examination suggests a cause.
• For acquired PE, treat contributing conditions first, especially erectile dysfunction, other sexual dysfunction, or genitourinary infection such as prostatitis.
• For lifelong PE, first-line pharmacologic options are:
  • On-demand dapoxetine
  • Lidocaine/prilocaine spray
• Second-line alternatives: off-label daily SSRI therapy or daily/on-demand clomipramine.
• Tramadol may be considered only cautiously as a later-line option because of adverse effects, dependence, and interaction risks.
• Combine medication with behavioral, cognitive, couple, or psychosexual therapy when appropriate.

2. EAU 2025 peer-reviewed guideline publication

• Use the ISSM definition and distinguish lifelong from acquired PE.
• Discuss patient and partner expectations.
• Pharmacotherapy is generally first-line for lifelong PE.
• Identify and treat the underlying cause first in acquired PE.

3. Global Andrology Forum Clinical Practice Guidelines, 2025

• In research, lifelong PE is typically IELT <1 minute, and acquired PE is typically a clinically significant reduction, often to about <3 minutes, plus poor control and distress.
• In routine clinical care, do not use a time cutoff alone. A patient can have clinically important PE even when IELT is over one minute if there is persistent lack of control and distress.
• Multimodal treatment should be individualized.
• Screen for erectile dysfunction, anxiety/depression, relationship factors, diabetes, medication effects, and genitourinary disease.
• Surgical procedures and glans injections remain nonstandard or investigational, not routine care.

4. AUA/SMSNA Disorders of Ejaculation Guideline, published 2022

• Daily SSRI
• On-demand dapoxetine where available
• On-demand clomipramine
• Topical penile anesthetic

5. ISSM PE guideline

Practical guideline-based treatment sequence

1. Confirm PE and classify it as lifelong or acquired.
2. Assess distress, control, relationship impact, anxiety, erectile function, medication/substance use, and relevant medical conditions.
3. Treat erectile dysfunction, prostatitis/genitourinary infection, thyroid disease, or other identified cause first in acquired PE.
4. Offer behavioral and couple/psychosexual interventions.
5. For persistent lifelong PE, consider dapoxetine or lidocaine/prilocaine topical therapy where locally approved and clinically safe.
6. Use daily SSRI/clomipramine only with informed consent regarding off-label use, interactions, psychiatric history, and adverse effects.
7. Avoid routine supplements, testosterone boosters, unregulated sexual-enhancement products, surgery, or injections.