Premature ejaculation is a common problem and it responds to treatment. The NHS is clear that occasional episodes are common and not a cause for concern, but that if it happens more than you would like and it is a problem for you, it is worth getting treated.

The part most often skipped is that it is not automatically a psychological issue. The NHS lists prostate problems, thyroid problems (either overactive or underactive) and recreational drug use among common physical causes. Two of those are diagnosed with a test and treated, which is why the first step is a doctor rather than a purchase.

Key takeaways

  • Occasional episodes are normal and not a cause for concern. The persistent pattern is what warrants treatment.
  • Physical causes are worth ruling out, notably prostate problems and thyroid problems in either direction.
  • Psychological causes are common too, including depression, stress, relationship problems and performance anxiety.
  • Dapoxetine (Priligy) is an SSRI designed specifically for this, and the only SSRI approved for on-demand use in PE. Other SSRIs are used off-label, on demand or daily.
  • Dapoxetine is taken 1 to 3 hours before sex, and not more than once a day.
  • Treatment response is reviewed after 4 weeks or 6 doses, and again every 6 months.
  • Ordinary SSRIs also work, off-label, usually taken daily, with full effect after 1 to 2 weeks.
  • See a doctor for a persistent problem, who may examine you or refer you to a specialist.

What counts as premature ejaculation?

Ejaculating sooner than you or your partner would wish, often enough that it is a problem for you.

The NHS defines it as where the male ejaculates sooner than he or his partner wishes during sexual arousal, and frames the threshold in terms of impact rather than a stopwatch: occasional episodes are common and not a cause for concern, but if it is happening more than you would like and is a problem, treatment may help.

That framing is more useful than a time in seconds, because distress and frequency are what actually determine whether something needs treating.

It is one of three main ejaculation problems, alongside delayed ejaculation and retrograde ejaculation, which have different causes and different treatments. The NHS advice for any persistent ejaculation problem is the same: see a doctor, who will discuss it, may examine you, and may refer you to a specialist.

What causes it?

A mix of physical and psychological factors, and the physical ones are the reason not to skip the appointment.

The NHS lists common physical causes:

  • prostate problems
  • thyroid problems, an overactive or underactive thyroid
  • using recreational drugs

And common psychological causes:

  • depression
  • stress
  • relationship problems
  • anxiety about sexual performance, particularly at the start of a new relationship or after previous difficulty

Thyroid problems appear on both lists. The NHS names overactive and underactive thyroid among common physical causes, and the EAU guideline lists hyperthyroidism among the conditions that can bring on acquired PE. The EAU is specific about priority: in acquired PE, treating the underlying cause, which it gives as erectile dysfunction, prostatitis, lower urinary tract symptoms, anxiety and hyperthyroidism, is the first goal of treatment. Thyroid disease is found by blood test and treated with a tablet, and its other symptoms are easily missed for years, as covered in thyroid problems.

The EAU guideline also places sexual performance anxiety among the causes of acquired PE, in the same list as psychological or relationship problems and comorbidities such as erectile dysfunction, prostatitis and hyperthyroidism. It adds that performance anxiety tied to erection difficulty can worsen PE and lead to a PE diagnosis when the erection is the underlying problem.

What is dapoxetine and how is it different?

Dapoxetine is the only SSRI approved for on-demand use in premature ejaculation. Other SSRIs are used for the same problem off-label, on demand or daily. The EAU Guidelines: disorders of ejaculation record that dapoxetine is the first on-demand oral agent approved for PE in many countries, though not in the USA.

The NHS describes dapoxetine (Priligy) as an SSRI specifically designed to treat premature ejaculation, licensed in the UK, which local NHS authorities can choose to prescribe. It acts much faster than the other SSRIs used for premature ejaculation and can be used “on demand”.

The practical instructions from the NHS:

  • Take it between 1 and 3 hours before sex.
  • Not more than once a day.
  • Response is reviewed after 4 weeks or after 6 doses, and again every 6 months.

The EAU guideline notes that the long-term outcomes of drug treatment for PE are unknown.

Dapoxetine is a prescription medicine, and whether it suits you depends on your other medicines and conditions. The NHS notes that it can interact with other medicines, including other antidepressants. It is worth being direct about one thing: because this is an embarrassing subject, it is a category where people buy informally. That is the same market where counterfeits concentrate, for the same reasons set out in erectile dysfunction.

A note on availability. Dapoxetine is approved in some countries and not others, and that is worth knowing before you go looking for it. The NHS describes it as licensed in the UK, where local NHS authorities can choose to prescribe it. The EAU guideline records that it is approved in European countries and elsewhere, but not in the USA, which is why it does not appear in the US drug label database at all. It is not currently listed in the UK electronic medicines compendium either. So if you cannot find it where you are, that is the reason rather than a supply problem.

Availability also decides what the alternatives are, and the licence picture is narrower than many men assume. The EAU guideline names two approved products: dapoxetine, the first on-demand oral agent approved for PE in many countries except the USA, and a metered-dose lidocaine/prilocaine spray, approved by the EMA for on-demand treatment of lifelong PE in the European Union. Every other medicine used in PE is off-label, including daily or on-demand SSRIs and clomipramine, which the same guideline says have consistently shown efficacy. A prescription or a product from one country also does not tell you what is permitted in another, and carrying prescription medicines across borders has its own rules. Not finding dapoxetine where you are does not leave you without treatment, but it does mean the alternatives are prescribed outside their licence.

What are the alternatives?

Off-label SSRIs, clomipramine, and non-drug approaches.

Ordinary SSRIs. The NHS notes that selective serotonin reuptake inhibitors are antidepressants that also delay ejaculation, and names paroxetine, sertraline and fluoxetine as used for this purpose. The EAU guideline adds citalopram and fluvoxamine, says all five have similar efficacy, and singles out paroxetine as producing the most substantial delay. Clomipramine, the most serotoninergic tricyclic antidepressant, was first reported as a PE treatment in 1977 and is also sometimes used.

These are usually taken daily rather than on demand, and they act more slowly than dapoxetine. Some men see improvement a few days after starting, but the full effect usually takes 1 to 2 weeks. Side effects are usually mild and should improve after 2 to 3 weeks, and include feeling or being sick, diarrhoea and excessive sweating.

The choice between on-demand and daily treatment is a real one. On demand suits infrequent or unpredictable need; daily suits regular activity and avoids having to plan hours ahead. That is a conversation to have with the prescriber rather than a ranking.

Non-drug approaches. The EAU guideline notes that psychosexual interventions alone for PE lack empirical support, but that start-stop exercises combined with psychoeducation and mindfulness techniques improve PE symptoms and the distress, anxiety and depression that come with them, and that behavioural therapy works best when added to medical treatment. The NHS describes psychosexual counselling, which can include a partner, and the squeeze and stop-go techniques, adding that these take a lot of practice.

Combinations. The EAU guideline notes that a significant proportion of men with erectile dysfunction also have PE, and that performance anxiety related to ED can worsen PE and lead to the wrong diagnosis. It also reports that many patients and doctors combine dapoxetine with a PDE-5 inhibitor: phase I studies found no pharmacokinetic interaction between dapoxetine and tadalafil or sildenafil, and a trial in men with PE but no ED found dapoxetine plus sildenafil improved latency more than either alone. Taking two prescription medicines together is a clinical decision, not a convenience purchase.

When should I see a doctor?

For a persistent problem, and sooner if anything else has changed.

The NHS position is that if you have a persistent problem with ejaculation you should visit your GP, who will discuss it, may examine you, and may refer you to a specialist.

Reasons to go sooner rather than later:

  • the problem started suddenly after years without it
  • there are urinary symptoms, which may point at the prostate
  • there is unexplained weight change, tiredness or heat intolerance, which may point at the thyroid
  • you also have erection difficulties
  • it is causing distress or affecting a relationship

Do and don’t

Do:

  • See a doctor for a persistent problem rather than self-treating. The NHS advises seeing a GP, who may examine you or refer you to a specialist.
  • Ask about thyroid and prostate as possible physical causes; the NHS lists both, thyroid in either direction, among the common physical causes.
  • Dapoxetine is taken 1 to 3 hours before sex and not more than once a day.
  • Keep the review points: after 4 weeks or 6 doses, then every 6 months.
  • Tell the prescriber about every other medicine, including anything bought abroad. Dapoxetine interacts with other antidepressants.
  • Consider the behavioural techniques the NHS describes, such as the squeeze and stop-go methods, alongside medication.

Don’t:

  • Treat occasional episodes as a medical problem; the NHS describes them as common and not a cause for concern.
  • Don’t take dapoxetine more than once a day.
  • Don’t add another prescription medicine on your own. Dapoxetine interacts with other antidepressants, and a PDE-5 inhibitor is a separate clinical decision.
  • Don’t buy informally. This category attracts counterfeits, and the NHS advises checking that an online pharmacy is registered with the General Pharmaceutical Council.
  • Don’t assume the cause is psychological: the NHS lists prostate problems, thyroid problems and recreational drug use as physical causes.

Frequently asked questions

How quickly does dapoxetine work? Dapoxetine is a short-acting SSRI with a profile built for on-demand use. The EAU guideline gives a time to peak plasma concentration of about 1.3 hours and a short half-life, and the NHS says it is taken between 1 and 3 hours before sex. Ordinary SSRIs delay ejaculation too, but they are taken daily; the EAU notes that the delay may start a few days after the first dose and becomes more evident after one to two weeks.

Will I need to take it forever? Often not. The EAU guideline reports cumulative discontinuation rates of dapoxetine reaching 90% at two years after starting, with cost (29.9%) and the on-demand nature of the drug (25%) the most common reasons. The NHS review points, at 4 weeks or 6 doses and then every 6 months, are where continuing is decided. Where a physical cause such as hyperthyroidism is treated, which the EAU makes the first goal in acquired PE, medication may not be needed long term.

Are the daily SSRIs the same as antidepressant treatment? They are the same medicines, used here for a different effect. The dosing and the purpose differ, and the boxed warning that applies to antidepressants is worth understanding either way, as covered in antidepressants.

Where to go next

The premature ejaculation category lists what is stocked here, and the ingredients index maps active ingredients to the brands containing them, which matters in a category sold under a very large number of brand names.

MedicForce option: our listings show active ingredient and strength, so a prescription written elsewhere can be matched precisely.