Chang J. et al., 2025: Management of male premature ejaculation: from past to future.

Jiaqing Chang, Weiwei Zhao, Lili Ma, Juan Zhao, Qiming Li, Xueyang Wang, Haichao Ju, Xinping Wang, Xing Xiping
Front Endocrinol (Lausanne). 2025 Dec 3;16:1718109. doi: 10.3389/fendo.2025.1718109

Abstract

Premature ejaculation (PE) is a common disease of the male reproductive system, which seriously affects the quality of life of patients and their partners. Currently, PE is regarded as a biopsychosocial disease with complex etiologies and diverse treatment methods. Oral selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PE, with advantages such as high safety, rapid onset of action, and non-invasiveness. However, topical anesthetics, behavioral and psychological therapies, device-assisted treatments, and traditional Chinese medicine (TCM) can also serve as alternative therapies for patients intolerant to SSRIs. With the rapid development of technology, some new methods-such as low-intensity extracorporeal shock wave therapy (Li-ESWT) and transcutaneous electrical nerve stimulation (TENS)-can even improve PE through mechanisms like regulating nerve conduction and improving local microcirculation. These are all important directions for the future treatment of male PE. In this mini-review, we will elaborate on these therapeutic approaches.

Comment Jens Rassweiler

Premature ejaculation (PE) is a prevalent male reproductive issue affecting about 20-30% of men globally, significantly impacting the quality of life for both patients and their partners. It is classified as a biopsychosocial disorder with multifaceted causes and treatment options.

Treatment Overview

1. First-Line Pharmacotherapy: Selective Serotonin Reuptake Inhibitors (SSRIs)

   - SSRIs, such as paroxetine and dapoxetine, are the primary medications used for PE. They increase serotonin levels in the brain, which helps delay ejaculation.

   - Daily use of SSRIs is more effective than on-demand use.

   - While SSRIs are generally safe, they can cause side effects like dizziness and nausea.

2. Alternative Therapies

   - Topical Anesthetics: Local anesthetics like lidocaine can reduce penile sensitivity and are effective for those intolerant to SSRIs.

   - Behavioral Therapy: Techniques such as cognitive-behavioral therapy (CBT) and various behavioral methods (e.g., the stop-start method) help manage anxiety and improve ejaculatory control.

   - Physical Therapy: Methods like low-intensity extracorporeal shock wave therapy (Li-ESWT) and transcutaneous electrical nerve stimulation (TENS) enhance local blood circulation and nerve function.

   - Traditional Chinese Medicine (TCM): TCM includes herbal treatments and acupuncture, showing potential in managing PE through holistic approaches.

3. Surgical Options

   - Surgical interventions like selective dorsal neurectomy and hyaluronic acid gel augmentation may be considered for patients who do not respond to other treatments. However, they require more evidence for widespread clinical adoption.

Future Directions

- Personalized Treatment: There is a growing emphasis on customizing treatment plans that consider individual psychological, physiological, and social factors.

- Emerging Therapies: Innovations such as gene therapy and stem cell therapy hold potential but require further research to establish their efficacy and safety.

Conclusion

PE is a complex condition that requires a multifaceted treatment approach. SSRIs remain the first-line therapy, but alternative treatments, including topical anesthetics and behavioral therapies, are essential for those who do not respond to SSRIs. Future research should focus on personalized treatment strategies and continue exploring innovative therapies to improve outcomes for patients with PE.

Discussion

Role of Low-Intensity Extracorporeal Shock Wave Therapy (Li-ESWT) in the Management of Premature Ejaculation

Low-Intensity Extracorporeal Shock Wave Therapy (Li-ESWT) is a non-invasive treatment method that has gained attention for its potential use in various urological conditions, including erectile dysfunction and, more recently, premature ejaculation (PE). The therapy utilizes acoustic waves to stimulate tissue regeneration, improve blood circulation, and modulate nerve function.

Mechanisms of Action

Li-ESWT is believed to exert therapeutic effects through several mechanisms.

1. Improvement of Local Microcirculation: Li-ESWT enhances blood flow to the penile region, which can improve overall penile health and function.

2. Nerve Regeneration: The therapy promotes the repair and regeneration of nerve tissues, which may counteract the hyperexcitability of the nerves associated with PE.

3. Reduction of Hyperactive Nerve Excitability: By modulating nerve function, Li-ESWT may help to elevate the ejaculatory threshold, thus delaying ejaculation.

Clinical Evidence

Recent studies have shown promising results regarding the effectiveness of Li-ESWT in the treatment of PE:

- Efficacy in Ejaculatory Latency: Clinical trials involving men with lifelong PE have demonstrated that Li-ESWT can significantly increase intravaginal ejaculatory latency time (IELT) and improve overall sexual satisfaction. For instance, a study with participants receiving Li-ESWT in conjunction with pharmacotherapy (like dapoxetine) showed marked improvements in IELT and related distress scales.

- Safety Profile: Li-ESWT is generally well-tolerated, with minimal side effects reported. This non-invasive nature makes it an attractive option for patients who may be reluctant to consider pharmacological treatments or surgical interventions.

Future Considerations

While the initial findings regarding Li-ESWT for PE are encouraging, further research is needed to:

- Establish Long-Term Efficacy: More extensive and longer-term studies are required to assess the durability of the treatment effects.

- Understand Mechanistic Pathways:Further exploration into the specific biological mechanisms by which Li-ESWT affects ejaculation is needed to optimize treatment protocols.

- Compare Against Other Modalities: Head-to-head trials comparing Li-ESWT to traditional treatments like SSRIs or behavioral therapies could provide insights into its relative effectiveness and ideal use cases.

Li-ESWT represents a promising adjunctive treatment for premature ejaculation, particularly for patients with underlying nerve sensitivity issues or those who prefer non-invasive options. Its ability to improve local blood flow and modulate nerve activity may offer a beneficial alternative or complement to existing treatment modalities in managing PE. Continued research will help clarify its role and optimize its application in clinical practice.

Jens Rassweiler