A Cochrane Review of four previously published studies of 253 men found insufficient evidence to support behavioral therapy for premature ejaculation, despite small studies and anecdotes proclaiming its success. But some experts maintain that the therapy, which aims to ease the anxiety surrounding the condition for both men and their partners, can be useful together with medication.
"The assumption behind psychosocial interventions is that when patients learn about [premature ejaculation] they begin to develop new sexual management strategies to deal with restrictive sexual patterns, such as avoidance of sexual activity and an unwillingness to discuss sex with a partner," said the review's lead author Tamara Melnik, a professor of internal medicine at the Federal University of Sao Paulo in Brazil. "There is a consensus that psychological aspects are very important to ensure success and maintenance of the results after discontinuation of medication."
Medications like Paxil, Zoloft and others in the selective serotonin reuptake inhibitor class of antidepressants can inhibit the ejaculatory reflex at low doses. And topical anesthetics like lidocaine cream can numb the penis, drawing out intercourse. But because none are FDA-approved for premature ejaculation, doctors are forced to prescribe drugs off-label and monitor patients closely for possible side effects.
"One of the greatest unmet needs in the field is the lack of FDA-approved treatments right now," said Dr. Wayne Hellstrom, a urologist at Tulane University Health Sciences Center in New Orleans, La. "But behavioral therapy does work in some people. And it does work in combination with other treatments, either oral or topical medications."
Premature ejaculation can crumble men's sexual self-confidence and make it difficult for them to establish comfortable sexual relationships. In up to 90 percent of cases, psychological factors are implicated as cause or a consequence.
"We often hear men only think with one brain, but there's still considerable thought and emotion that goes into sex," said Dr. Jeremy Close, a primary care physician at Jefferson University Hospitals in Philadelphia. "Behavioral therapy is to address the stress they may be having with not satisfying their partner because of premature ejaculation and feelings of inadequacy because of that."
The cause of premature ejaculation remains unknown, complicating the search for effective treatments. And outside of the four studies included in the Cochrane review, 13 others were too small or failed to sufficiently control biases or rule out the placebo effect resulting in their exclusion.
"We've got a lot of studies out there and, by and large, the majority show that most people are helped by psychotherapy. But the studies didn't meet the bar for evidence-based research that's set very high these days," said Dr. Stanley Althof, executive director of the Center for Marital and Sexual Health of South Florida and co-author of the Cochrane Review. "We really need to move into the 21st century with the kind of research we do."
Another barrier to behavioral therapy use is the cost. At up to $125 out-of-pocket per session for an eight-session treatment course, the peace of mind comes at a hefty price. And unlike medications, the psychological approach requires that both the man and his partner are on board.
Althof, a clinical psychologist who studies the effects of diseases and medications on sexuality, hopes ongoing research opens new doors for the treatment of sexual disorders in both men and women.
"This isn't about just enhancing your sex life or making you a better lover. This is about helping men or women with real problems," Althof said. "And we have ways to do that. We just have to be more rigorous in how we go about conducting research."