Another RCT8 (N=84) compared EMLA cream applied 15 minutes prior to intercourse, sildenafil 50 mg orally 45 minutes prior to intercourse, EMLA cream plus sildenafil, and placebo. In the sildenafil-plus-EMLA group, 32% of the patients reported “improvement” and 54% reported “cure,” which was defined as ejaculation delayed until the patient wished it. In the EMLA-only group, 27% of the patients reported “improvement” and 50% reported “cure.” This was a statistically significant difference when compared with the placebo and sildenafil-only groups (number needed to treat [NNT]=3). There was no significant difference in reports of “improvement” or “cure” between the placebo and sildenafil-only groups.
One small RCT9 (N=24) compared placebo with the application of EMLA cream 20, 30, and 45 minutes prior to sexual intercourse. Improvement was seen in IELT in the 20- and 30-minute group, but penile numbness and erection loss increased in the 30- and 45-minute group.
PDE5 inhibitors: No convincing evidence
A review10 of 14 clinical trials concluded that there is no convincing evidence for PDE5 inhibitors in the treatment of men with lifelong premature ejaculation and normal erectile function. One RCT11 found no increase in IELT from baseline in men taking sildenafil when compared with placebo, although patients reported overall sexual satisfaction and confidence based on a questionnaire.
However, a study by Li et al12 treated 45 men with premature ejaculation and comorbid erectile dysfunction with sildenafil. Eighty-nine percent reported improved erectile function, and 60% reported decreased severity of premature ejaculation.
Recommendations from others
The American Urological Association13 recommends antidepressants as first-line systemic therapy for premature ejaculation, specifically the SSRIs fluoxetine, paroxetine, sertraline, and the tricyclic clomipramine. Topical EMLA cream is also recommended, but the reduction of penile sensation may limit the acceptability of this treatment option.
The British Association for Sexual Health and HIV Special Interest Group for Sexual Dysfunction14 also recommends SSRIs and clomipramine as they have the strongest evidence for their efficacy. The group emphasizes the importance of combining behavioral and pharmacologic therapies as the management approach should be tailored to the individual patient.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.