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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 SSRIs, success rates exceed 80%.

Eligibility: Suitable for almost all patients. Most effective when partner is involved and supportive. Less effective for severe lifelong 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 those who can't tolerate SSRIs.

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.

For severe lifelong PE or patients who haven't responded adequately to on-demand options, daily low-dose SSRI therapy is highly effective. SSRIs are not licensed for PE but are widely used off-label based on strong clinical evidence.

Common regimens: Low-dose paroxetine (10-20 mg daily) is the most studied. Sertraline (25-100 mg daily) is also commonly used. Other SSRIs including citalopram and escitalopram have similar effects.

How they work: Persistent elevation of serotonin signalling produces sustained increases in ejaculatory threshold. Effects build over 2-4 weeks of daily use.

Effectiveness: Studies show 4-8-fold increases in ejaculation latency, often achieving near-normal or normal timing (see source 5 below). Highly effective for severe lifelong PE.

Side effects: Common: nausea, drowsiness, reduced libido, occasional erectile difficulty. Most resolve with continued use or dose adjustment. Sexual side effects are sometimes dose-limiting.

Considerations: Daily SSRI requires gradual onset (don't expect immediate effect), gradual discontinuation if stopping (to avoid withdrawal symptoms), and structured monitoring. Generally avoided in patients with bipolar disorder, recent suicide ideation, or significant interactions with other medications.

Combination therapy: SSRIs are sometimes combined with PDE5 inhibitors (if ED also present) or topical anaesthetics for synergistic effect. Combination protocols are individually tailored.