REVIEW
Behavioral Therapies for Management of Premature Ejaculation:A Systematic Review
Katy Cooper, PhD,* Marrissa Martyn-St James, PhD,* Eva Kaltenthaler, PhD,* Kath Dickinson, MA,*Anna Cantrell, MA,* Kevan Wylie, FRCP, FRCPsych, FECSM,† Leila Frodsham, MBChB, MRCOG,‡
and Catherine Hood, BMBCh§
*University of Sheffield, Sheffield, UK; †Porterbrook Clinic, Sheffield, UK; ‡Institute of Psychosexual Medicine, London,UK; §Imperial College, London, UK
DOI: 10.1002/sm2.65
A B S T R A C T
Introduction. Premature ejaculation (PE) is defined by short ejaculatory latency and inability to delay ejaculationcausing distress. Management may involve behavioral and/or pharmacological approaches.Aim. To systematically review the randomized controlled trial (RCT) evidence for behavioral therapies in themanagement of PE.Methods. Nine databases including MEDLINE were searched up to August 2014. Included RCTs comparedbehavioral therapy against waitlist control or another therapy, or behavioral plus drug therapy against drug treatmentalone. [Correction added on 10 September 2015, after first online publication: Search period has been amended fromAugust 2013 to August 2014.]Main Outcome Measure. Intravaginal ejaculatory latency time (IELT), sexual satisfaction, ejaculatory control, andanxiety and adverse effects.Results. Ten RCTs (521 participants) were included. Overall risk of bias was unclear. All studies assessed physicaltechniques, including squeeze and stop-start, sensate focus, stimulation device, and pelvic floor rehabilitation. Onlyone RCT included a psychotherapeutic approach (combined with stop-start and drug treatment). Four trialscompared behavioral therapies against waitlist control, of which two (involving squeeze, stop-start, and sensate focus)reported IELT differences of 7–9 minutes, whereas two (web-based sensate focus, stimulation device) reported nodifference in ejaculatory latency posttreatment. For other outcomes (sexual satisfaction, desire, and self-confidence),some waitlist comparisons significantly favored behavioral therapy, whereas others were not significant. Three trialsfavored combined behavioral and drug treatment over drug treatment alone, with small but significant differences inIELT (0.5–1 minute) and significantly better results on other outcomes (sexual satisfaction, ejaculatory control, andanxiety). Direct comparisons of behavioral therapy vs. drug treatment gave mixed results, mostly either favoring drugtreatment or showing no significant difference. No adverse effects were reported, though safety data were limited.Conclusions. There is limited evidence that physical behavioral techniques for PE improve IELT and other out-comes over waitlist and that behavioral therapies combined with drug treatments give better outcomes than drugtreatments alone. Further RCTs are required to assess psychotherapeutic approaches to PE. Cooper K, Martyn-StJames M, Kaltenthaler E, Dickinson K, Cantrell A, Wylie K, Frodsham L, and Hood C. Behavioral therapiesfor management of premature ejaculation: A systematic review. Sex Med 2015;3:174–188.
Key Words. Review; Systematic; Premature Ejaculation; Behavior Therapy; Psychological Therapy
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License,which permits use, distribution and reproduction in any medium, provided the original work is properly cited and
is not used for commercial purposes.
Introduction
P remature ejaculation (PE) is a male sexualdysfunction characterized by short ejacula-
tory latency. PE can be either lifelong (primary,present since first sexual experiences) or acquired(secondary, beginning later). The 2014 update ofthe International Society for Sexual Medicine(ISSM) Guidelines for the Diagnosis and Treat-ment of Premature Ejaculation define PE as acombination of (i) ejaculation usually occurringwithin about 1 minute of vaginal penetration (forlifelong PE) or a clinically significant reduction inlatency time, often to around 3 minutes or less (foracquired PE); (ii) inability to delay ejaculation;and (iii) negative personal consequences such asdistress, bother, frustration, and/or the avoidanceof sexual intimacy [1]. PE is similarly defined byDiagnostic and Statistical Manual of Mental Dis-orders 5 (DSM 5) (2013) as ejaculation usuallyoccurring within about 1 minute of vaginal pen-etration and before the individual wishes it andcausing clinically significant distress [1]. Estimat-ing the prevalence of PE is not straightforwarddue to the difficulty in defining what constitutesclinically relevant PE. Surveys have estimated theprevalence of Diagnostic and Statistical Manual ofMental Disorders IV-defined PE as 20–30%[2–4]; however, these estimates are likely toinclude men who have some concern about theirejaculatory function but do not meet the currentdiagnostic criteria for PE [1]. It has been sug-gested that the prevalence of lifelong PE accord-ing to the ISSM and DSM-5 definitions (with anejaculatory latency of about 1 minute) is unlikelyto exceed 4% [1]. Men with PE are more likely toreport lower levels of sexual functioning and sat-isfaction, and higher levels of personal distress andinterpersonal difficulty, than men without PE [5].They may also rate their overall quality of life aslower than that of men without PE [5]. In addi-tion, their partner’s satisfaction with the sexualrelationship has been reported to decrease withincreasing severity of the condition [6]. Manage-ment of PE may involve a range of interventions.These include systemic drug treatments (such asselective serotonin reuptake inhibitors, tricyclicantidepressants, phosphodiesterase type 5 inhibi-tors, and analgesics), topical anesthetic creams andsprays, and behavioral therapies (BTs) [7,8].
Behavioral and psychological therapies for PEinclude two main classes of therapy, with over-lapping elements [1]. The first consists of psy-chotherapy (such as psychosexual or relationship
counselling) for men and/or couples, to addresspsychological and interpersonal issues that maybe contributing to PE. The second consists ofphysical techniques to help men develop sexualskills to delay ejaculation and improve sexual self-confidence. Specific physical techniques includethe following. The “stop-start” technique, devel-oped by Semans, involves the man or his partnerstimulating the penis until he feels the urge toejaculate, then stopping until the sensationpasses; this is repeated a few times before allow-ing ejaculation to occur [9]. The aim is to learnto recognize the feelings of arousal in order toimprove control over ejaculation. With therelated “squeeze” technique, proposed by Mastersand Johnson, the man’s partner stimulates thepenis until he feels the urge to ejaculate, thensqueezes the glans of the penis until the sensationpasses; this is repeated before allowing ejacula-tion to occur [9]. Within sensate focus or sensatefocusing [7], the man and his partner begin byfocusing on touch, which excludes breasts, geni-tals, and intercourse, to encourage body aware-ness while reducing performance anxiety; this isfollowed by gradual reintroduction of genitaltouching and then full intercourse [10]. Pelvicfloor muscle rehabilitation exercises may alsoassist with ejaculatory control [11].
The aim of this study was to systematicallyreview the evidence base for BTs in the manage-ment of PE.
Methods
Review MethodsThe review was undertaken in accordance withthe general principles recommended in the Pre-ferred Reporting Items for Systematic Reviewsand Meta-Analyses statement (http://www.prisma-statement.org/). The review protocol is availablefrom the Health Technology Assessment Pro-gramme website (http://www.nets.nihr.ac.uk/projects/hta/131201).
Literature SearchesThe following databases were searched up toAugust 2014: MEDLINE; Embase; CumulativeIndex to Nursing and Allied Health Literature;The Cochrane Library including the CochraneSystematic Reviews Database, Cochrane Con-trolled Trials Register, Database of Abstracts ofReviews of Effects and the Health TechnologyAssessment database; ISI Web of Science,
Review Behaviour Therapy for Premature Ejaculation 175
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
including Science Citation Index, and the Confer-ence Proceedings Citation Index-Science. TheMedline search strategy is provided in Supplemen-tary Appendix S1; it should be noted that thesearch was undertaken as part of a wider projectassessing a variety of treatments for PE [12], andfor this reason, the search was not specific to BTs.The U.S. Food and Drug Administration websiteand the European Medicines Agency website werealso searched. Existing systematic reviews and rel-evant studies were also checked for eligible studies.
Eligibility CriteriaRandomized controlled trials (RCTs) in adult menwith PE that evaluated BTs were eligible for inclu-sion. Studies comparing a BT against a waitlistcontrol or against another therapy were eligible, aswere studies comparing a combination of BT plusdrug treatment against drug treatment alone.Studies were not included if the same BT wasprovided in both arms, as these were not consid-ered to be assessing the effect of the BT (e.g.,studies of drug plus behavioral treatment vs.behavioral alone). Theses and dissertations werenot included. Non-English publications wereincluded where sufficient data could be extractedfrom an English-language abstract or tables.
OutcomesRelevant outcomes included intravaginal ejacula-tory latency time (IELT), other measures of ejacu-latory latency, and other outcomes such as sexualsatisfaction, control over ejaculation, relationshipsatisfaction, self-esteem, quality of life, treatmentacceptability, and adverse events.
Data Extraction and SynthesisOne reviewer performed data extraction of eachstudy; all numerical data were then checked by asecond reviewer. Where possible, data were pre-sented as forest plots using Cochrane RevMansoftware (version 5.2; The Nordic CochraneCentre, The Cochrane Collaboration, Copenha-gen, Denmark) (RevMan 2014) [13].
Assessment of Methodological Quality of StudiesMethodological quality of included RCTs wasassessed using the Cochrane Collaboration risk ofbias assessment criteria [14]. Completeness ofoutcome data was considered low risk if the per-centage of randomized participants excluded fromthe primary analysis was less than 30%. Selectivereporting was considered low risk if IELT orejaculatory latency was reported, and all outcomes
referred to in the study methods were reported.Overall risk of bias for each study was classed as“low” or “high” if they were rated as such for eachof three key domains: allocation concealment,blinding of outcome assessment, and completenessof outcome data; otherwise, overall risk of bias wasclassed as “unclear.”
Results
Quantity of EvidenceThe searches identified 2,283 citations (as part of awider project assessing a variety of treatments forPE). Eighteen full-text articles were obtained aspotentially relevant. A total of 10 RCTs (521 ran-domized participants) evaluating a BT for PE wereincluded in the review.
Characteristics of Included StudiesDetails of the included study characteristics arepresented in Table 1. As noted earlier, BTs for PEinclude two main types of therapy: first, psycho-therapeutic or counseling approaches, and secondphysical techniques. Interestingly, this reviewidentified only one RCT involving psychotherapyfor PE: a Chinese study [19] in which onegroup received a combination of drug treatment(chlorpromazine) plus psychotherapy (to reduceanxiety, sadness, and negative thoughts and rebuildconfidence) plus the stop-start technique, whereasthe other group received chlorpromazine alone.All other included RCTs focused on physical tech-niques, either individually or in combination. Thespecific BTs that were evaluated included: thesqueeze technique [22]; the stop-start technique[21,23]; the stop-start and squeeze techniques [15];the stop-start technique plus psychotherapy [19];functional-sexological treatment involving educa-tion on sensuality, movement of the body, speed ofsexual activity, muscular tension and breathing[15]; self-help material (covering squeeze tech-nique, pause technique, and sensate focusing) withor without therapist phone contact [17]; sexualtherapy for couples (sensate focus, stop-start tech-nique, and communication exercises) [17]; pelvicfloor muscle rehabilitation (awareness of musclecontraction) plus electrical stimulation of perinealfloor [11]; squeeze technique, sensate focus, andChinese traditional Qigong treatment (penisswinging and acupoint tapping) [20]; web-basedsex therapy based on sensate-focus [18]; and thestop-start technique using a handheld vibratingstimulation device [16].
176 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Tab
le1
Stu
dych
arac
teris
tics
and
risk
ofbi
as
RC
TC
ount
ryD
urat
ion
Nra
ndom
ized
Trea
tmen
ts(N
rand
omiz
ed)
PE
defin
ition
Life
long
/acq
uire
d
Ris
kof
bias
asse
ssm
ent
Ran
dom
sequ
ence
gene
ratio
nA
lloca
tion
conc
ealm
ent
Blin
ding
ofpa
rtic
ipan
ts/
pers
onne
l
Blin
ding
ofou
tcom
eas
sess
men
t
Com
plet
enes
sof
outc
ome
data
*S
elec
tive
repo
rtin
g†O
vera
llris
k‡
Beh
avio
ral
ther
apy
vs.
wai
tlis
tde
Car
ufel
and
Trud
el[1
5]C
anad
aN
Rn
=36
coup
les
—F
unct
iona
l-sex
olog
ical
ther
apy
(edu
catio
non
sens
ualit
y,bo
dym
ovem
ents
,sp
eed
ofac
tivity
,m
uscu
lar
tens
ion,
brea
thin
g)—
Beh
avio
ralt
hera
py(s
quee
ze,
stop
-sta
rt)
—W
aitli
st(t
otal
n=
36)
IELT
<2
min
utes
NR
Unc
lear
Unc
lear
Not
poss
ible
Unc
lear
Unc
lear
Low
Unc
lear
Jern
[16]
Fin
land
6w
eeks
n=
11
—S
top-
star
tte
chni
que
usin
gha
ndhe
ldvi
brat
iona
lstim
ulat
ion
devi
ce(n
=6)
—W
aitli
st(n
=5)
NR
Life
long
Unc
lear
Unc
lear
Not
poss
ible
Unc
lear
Low
Low
Unc
lear
Trud
elan
dP
roul
x[1
7]C
anad
a12
wee
ksn
=25
coup
les
—S
elf-
help
book
onbe
havi
oral
tech
niqu
es(b
iblio
ther
apy)
—S
elf-
help
book
+th
erap
ist
phon
eco
ntac
t—
Sex
ualt
hera
pyfo
rco
uple
s(s
ensa
tefo
cus,
stop
-sta
rt,
com
mun
icat
ion)
—W
aitli
st(t
otal
n=
25)
IELT
≤5
min
utes
NR
Unc
lear
Unc
lear
Not
poss
ible
Unc
lear
Unc
lear
Low
Unc
lear
van
Lank
veld
etal
.[1
8]N
ethe
rland
s12
wee
ksn
=40
—W
eb-b
ased
sex
ther
apy
(sen
sate
focu
s)(n
=22
)—
Wai
tlist
(n=
18)
NR
NR
Low
Unc
lear
Not
poss
ible
Unc
lear
Low
Low
Unc
lear
Co
mb
ined
ther
apie
svs
.m
on
oth
erap
yLi
etal
.[1
9]C
hina
6w
eeks
n=
90
—P
sych
othe
rapy
+st
op-s
tart
+ch
lorp
rom
azin
e50
mg/
d(n
=45
)—
Chl
orpr
omaz
ine
50m
g/d
(n=
45)
IELT
<1
min
ute
NR
Unc
lear
inE
nglis
hla
ngua
gete
xtU
ncle
arin
Eng
lish
lang
uage
text
Not
poss
ible
Unc
lear
inE
nglis
hla
ngua
gete
xtLo
wLo
wU
ncle
ar
Sha
oan
dLi
[20]
Chi
na8
wee
ksn
=12
0
—B
ehav
iora
lthe
rapy
(squ
eeze
,se
nsat
efo
cus,
Qig
ong,
acup
oint
s;8
wee
ks)
(n=
40)
—P
arox
etin
e20
mg/
d(8
wee
ks)
(n=
40)
—B
ehav
iora
lthe
rapy
(8w
eeks
)+
paro
xetin
e10
mg/
d(4
wee
ks)
(n=
40)
NR
NR
Unc
lear
inE
nglis
hla
ngua
gete
xtU
ncle
arin
Eng
lish
lang
uage
text
Not
poss
ible
Unc
lear
inE
nglis
hla
ngua
gete
xtLo
wLo
wU
ncle
ar
Yua
net
al.
[21]
Chi
na6
wee
ksn
=96
—B
ehav
iora
lthe
rapy
(sto
p-st
art)
(n=
32)
—C
italo
pram
20m
g/d
(n=
32)
—B
ehav
iora
lthe
rapy
+ci
talo
pram
(n=
32)
NR
NR
Unc
lear
inE
nglis
hla
ngua
gete
xtU
ncle
arin
Eng
lish
lang
uage
text
Not
poss
ible
Unc
lear
inE
nglis
hla
ngua
gete
xtLo
wLo
wU
ncle
ar
Beh
avio
ral
ther
apy
vs.
dru
gtr
eatm
ent
Abd
el-H
amid
etal
.[2
2]E
gypt
Cro
ssov
er,
4w
eeks
each
,2-
wee
kw
asho
uts
n=
31
—B
ehav
iora
l(sq
ueez
ete
chni
que)
—C
lom
ipra
min
e25
mg
—S
ertr
alin
e50
mg
—P
arox
etin
e20
mg
—S
ilden
afil5
0m
g(a
ll3–
5ho
urs
pre-
coitu
s)(t
otal
n=
31)
IELT
≤2
min
utes
Life
long
Unc
lear
Low
Not
poss
ible
Unc
lear
Low
Low
Unc
lear
Ogu
zhan
glu
etal
.[2
3]Tu
rkey
8w
eeks
N=
32
—S
top-
star
tte
chni
que
(n=
16)
—F
luox
etin
e20
mg/
d(n
=16
)E
jacu
latio
nw
ithin
seve
ralm
inut
esLi
felo
ngan
dac
quire
d
Unc
lear
Unc
lear
Not
poss
ible
Unc
lear
Low
Hig
hU
ncle
ar
Pas
tore
etal
.[1
1]Ita
ly12
wee
ksn
=40
—P
elvi
cflo
orm
uscl
ere
habi
litat
ion
+el
ectr
ical
stim
ulat
ion
ofpe
rineu
m,
3se
ssio
ns/w
eek
(n=
19)
—D
apox
etin
e30
–60
mg
on-d
eman
d(n
=21
)
ISS
Mde
finiti
onP
ELi
felo
ngLo
wU
ncle
arN
otpo
ssib
leU
ncle
arLo
wLo
wU
ncle
ar
CIP
E-5
=C
hine
seIn
dex
ofP
rem
atur
eE
jacu
latio
n-5;
GR
ISS
=G
olom
bok
Rus
tIn
vent
ory
ofS
exua
lSat
isfa
ctio
n;IE
LT=
intr
avag
inal
ejac
ulat
ory
late
ncy
time;
ISS
M=
Inte
rnat
iona
lSoc
iety
for
Sex
ualM
edic
ine;
NR
=no
tre
port
ed;
PE
=pr
emat
ure
ejac
ulat
ion;
RC
T=
rand
omiz
edco
ntro
lled
tria
l.*C
ompl
eten
ess
ofou
tcom
eda
ta=
low
risk
if<3
0%ex
clud
edfr
ompr
imar
yan
alys
is.
† Sel
ectiv
ere
port
ing
=lo
wris
kif
repo
rted
IELT
/eja
cula
tory
late
ncy
and
allo
utco
mes
refe
rred
toin
met
hods
.‡ O
vera
llris
kof
bias
=“lo
w”
or“h
igh”
ifra
ted
assu
chfo
ral
loca
tion
conc
ealm
ent,
blin
ding
ofou
tcom
eas
sess
men
t,an
dco
mpl
eten
ess
ofou
tcom
eda
ta.
Review Behaviour Therapy for Premature Ejaculation 177
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Duration of the behavioral intervention inthe included studies ranged from 2 to 12 weeks.Four studies compared one or more behavioraltechniques with a waitlist control [15–18]. Threefurther studies compared a BT with one or moredrug treatments [11,22,23], whereas another threestudies compared combined therapy (behavioraland drug) vs. drug treatment alone [19–21].
Studies were conducted in a range of countries:three in China (published in Chinese language)[19–21], two in Canada [15,17], and one each inEgypt [22], Turkey [23], Italy [11], the Nether-lands [18], and Finland [16]. The definition of PEwas an IELT of <1 minute in one study [19], ≤2minutes in two studies [15,22], ≤5 minutes in onestudy [17], defined according to the ISSM defini-tion in one study [11], “before or within severalminutes” in one study [23], and was not reported(or not available in the English language text) infour studies [16,18,20,21]. Three studies reportedthat participants had lifelong PE [11,16,22],whereas in one study participants had lifelong oracquired PE [23]; for the remaining studies, thiswas not reported (or not available in the Englishlanguage text).
Of the 10 studies, one did not report IELT [23],whereas the remaining nine reported either IELT(in minutes) or another measure of ejaculatorylatency (Table 2). Of these, four studies reportedstopwatch-assessed IELT [11,15,16,22]; threestudies reported IELT in minutes, but the mea-surement method was not reported (or not avail-able in English-language text) [17,19,21]; onestudy reported tendency to ejaculate too soon asmeasured via the Golombok Rust Inventory ofSexual Satisfaction (GRISS) PE subscale [18]; andone study reported ejaculatory latency as measuredon the Chinese Index of Premature Ejaculation-5(CIPE-5) five-point Likert scale [20].
Risk of Bias in Included StudiesThe risk of bias within included studies is shown inTable 1. All 10 studies were classed as overallunclear risk of bias due to limited reporting ofmethodological details (three studies [19–21] werereported in Chinese, and some details wereunavailable from the English language text). Intotal, eight studies [15–17,19–23] were unclear interms of randomization sequence generation andnine [11,15–21,23] were unclear in terms of allo-cation concealment. Due to the nature of theinterventions, blinding of participants and person-nel was not possible in any study. Blinding ofoutcome assessment was unclear in all studies.
Eight studies [11,16,18–23] were considered at lowrisk of bias for completeness of outcome data(<30% excluded from primary analysis), whereastwo [15,17] were unclear on this point. All studiesscored low for selective reporting (based on thefact that they reported IELT or ejaculatory latencyas well as all outcomes referred to in the methodssections), with the exception of one study [23] thatdid not report IELT or ejaculatory latency.
Assessment of Effectiveness: IELT andEjaculatory Latency
BT vs.WaitlistFour studies assessed BTs vs. waitlist control[15–18]. Two significantly favored BTs in terms ofIELT, whereas one showed no difference onanother measure of ejaculatory latency (Table 2;Figures 1–3).
Functional-Sexological Treatment or Squeeze/Stop-Start vs.WaitlistA study by de Carufel and Trudel (2006; n = 36couples) [15] assessed two types of BT vs. waitlistcontrol: functional-sexological therapy (FS,involving education on sensuality, movement ofthe body, speed of sexual activity, muscular tensionand breathing) and BT (involving the squeeze andstop-start techniques). Duration of treatmentwas not reported. Both treatments improvedstopwatch-measured IELT significantly more thanwaitlist at posttreatment, by almost 7 minutes(Table 2; Figure 1). Follow-up data 3 months post-treatment was available for the FS and BT groups(though not for waitlist); in both groups, the sig-nificant change in IELT from baseline to post-treatment remained significant 3 months aftertreatment cessation.
Stop-Start Using Handheld Device vs.WaitlistA small study by Jern (n = 11 participants) [16]assessed the stop-start technique aided by a hand-held vibrating stimulation device vs. waitlistcontrol. Participants used the device, alone or witha partner, three times per week for 6 weeks. After6 weeks, ejaculatory latency improved slightlymore in the treatment group (improvement of 1.6minutes; P = 0.019 for change from baseline) thanin the waitlist group (0.9 minutes; P = 0.075 forchange); however, the posttreatment scores werenot significantly different (mean difference [MD]0.35 minutes, 95% confidence interval [CI] −2.26to 2.96; P = 0.79; Table 2 and Figure 1). Atfollow-up 6 months after all patients undertook
178 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Tab
le2
Res
ults
for
IELT
and
ejac
ulat
ory
late
ncy
RC
TC
ount
ryD
urat
ion
Nra
ndom
ized
Trea
tmen
ts(N
rand
omiz
edpe
rgr
oup)
Out
com
e:IE
LTor
ejac
ulat
ory
late
ncy
Res
ults
Effe
ctes
timat
e(9
5%C
I)S
igni
fican
tdi
ffere
nce?
Beh
avio
ral
ther
apy
vs.
wai
tlis
tD
eC
aruf
elan
dTr
udel
[15]
Can
ada
NR
n=
36co
uple
s
—F
unct
iona
l-sex
olog
ical
ther
apy
(FS
)—
Beh
avio
ralt
hera
py(B
T;sq
ueez
e,st
op-s
tart
)—
Wai
tlist
(tot
aln
=36
)
IELT
(sto
pwat
ch)
Pos
ttrea
tmen
tm
ean
(min
utes
):—
FS
:7.
80(S
D3.
74),
n=
18—
BT:
7.87
(SD
3.77
),n
=18
—W
aitli
st:
1.00
(SD
0.69
),n
=18
—3-
mon
thfo
llow
-up
mea
n(m
ins)
:—
FS
:6.
88(S
D4.
62),
n=
18—
BT:
8.18
(SD
5.41
),n
=18
BT
vs.
wai
tlist
(pos
ttrea
tmen
t):
—F
S:
MD
=6.
80(5
.04
to8.
56),
P<
0.00
001
—B
T:M
D=
6.87
(5.1
0to
8.64
),P
<0.
0000
1S
igni
fican
tch
ange
base
line
topo
st-t
reat
men
tm
aint
aine
dat
3-m
onth
follo
w-u
p(F
S,
BT
)
Yes
(fav
ors
BT
grou
ps)
Jern
[16]
Fin
land
6w
eeks
n=
11
—S
top-
star
tus
ing
hand
held
vibr
atin
gst
imul
atio
nde
vice
(n=
6)—
Wai
tlist
(n=
5)
IELT
(sto
pwat
ch)
Pos
ttrea
tmen
tm
ean
(min
s):
—B
T:2.
91(S
D1.
23),
n=
5;ch
ange
+1.6
0m
inut
es(P
=0.
019
for
chan
ge)
—W
L:2.
56(S
D2.
71),
n=
5;ch
ange
+0.9
0m
inut
es(P
=0.
075
for
chan
ge)
—6-
mon
thfo
llow
-up
mea
n(m
ins)
:—
BT:
3.36
(SD
1.16
),n
=9;
chan
ge+1
.74
min
utes
(P=
0.00
8fo
rch
ange
)
BT
vs.
wai
tlist
(pos
ttrea
tmen
t):
—B
T:M
D=
0.35
(−2.
26to
2.96
),P
=0.
79S
igni
fican
tch
ange
from
base
line
to6-
mon
thfo
llow
-up
afte
ral
lpa
tient
sun
dert
ook
BT
No
(but
impr
oved
from
base
line)
Trud
elan
dP
roul
x[1
7]C
anad
a12
wee
ksn
=25
coup
les
—S
elf-
help
book
—S
elf-
help
book
+th
erap
ist
phon
eco
ntac
t—
Sex
ualt
hera
pyfo
rco
uple
s—
Wai
tlist
(tot
aln
=25
)
IELT
(met
hod
NR
)P
osttr
eatm
ent
mea
n(m
ins)
:—
Sel
f-he
lp:
11.0
5—
Sel
f-he
lp+
phon
e:9.
23—
Sex
ualt
hera
py:
10.7
8—
Wai
tlist
:1.
94
BT
vs.
wai
tlist
:—
Sel
f-he
lp:
MD
=9.
11—
Sel
f-he
lp+
phon
e:M
D=
7.29
—S
exua
lthe
rapy
:M
D=
8.84
Yes
(fav
ors
BT
grou
ps)
(No
SD
sre
port
ed)
Sig
nific
ant
chan
geba
selin
eto
post
trea
tmen
t,B
T(P
<0.
01)
but
not
wai
tlist
(P=
NS
).C
hang
es(B
T)
mai
ntai
ned
at3-
mon
thfo
llow
-up
van
Lank
veld
etal
.[1
8]N
ethe
rland
s12
wee
ksn
=40
—W
eb-b
ased
sex
ther
apy
(sen
sate
focu
s)(n
=22
)—
Wai
tlist
(n=
18)
Tend
ency
toej
acul
ate
too
soon
(GR
ISS
-PE
subs
cale
)
Pos
ttrea
tmen
tm
ean
(GR
ISS
-PE
):—
Sex
ther
apy:
13.2
(SD
2.5)
,n
=21
—W
aitli
st:
13.4
(SD
2.3)
,n
=16
BT
vs.
wai
tlist
:M
D=
−0.2
0(−
1.75
to1.
35),
P=
0.80
)
No
(but
impr
oved
from
base
line)
3-m
onth
follo
w-u
p(G
RIS
S-P
E):
—S
exth
erap
y:12
.9(S
D3.
2)6-
mon
thfo
llow
-up
(GR
ISS
-PE
):—
Sex
ther
apy:
13.4
(SD
3.1)
Sig
nific
ant
chan
gefr
omba
selin
e(P
<0.
001,
both
grou
ps).
Cha
nge
inse
xth
erap
ygr
oup
mai
ntai
ned
at3-
and
6-m
onth
follo
w-u
pB
ehav
iora
l+d
rug
ther
apie
svs
.d
rug
alo
ne
Liet
al.
[19]
Chi
na6
wee
ksn
=90
—P
sych
othe
rapy
+st
op-s
tart
+ch
lorp
rom
azin
e50
mg/
d(n
=45
)—
Chl
orpr
omaz
ine
50m
g/d
(n=
45)
IEL T
(met
hod
NR
)P
osttr
eatm
ent
mea
n(m
ins)
:—
BT
+ch
lor:
5.87
(SD
0.59
),n
=41
—C
hlor
:4.
76(S
D0.
54),
n=
40
Com
bine
dvs
.dr
ug:
MD
=1.
11(0
.86–
1.36
),P
<0.
0001
Yes
(fav
ors
com
bine
d)
Review Behaviour Therapy for Premature Ejaculation 179
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Tab
le2
Con
tinue
d
RC
TC
ount
ryD
urat
ion
Nra
ndom
ized
Trea
tmen
ts(N
rand
omiz
edpe
rgr
oup)
Out
com
e:IE
LTor
ejac
ulat
ory
late
ncy
Res
ults
Effe
ctes
timat
e(9
5%C
I)S
igni
fican
tdi
ffere
nce?
Sha
oan
dLi
[20]
Chi
na8
wee
ksn
=80
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(squ
eeze
,se
nsat
efo
cus,
Qig
ong,
acup
oint
;8
wee
ks)
+pa
roxe
tine
10m
g/d
(4w
eeks
)(n
=40
)—
Par
oxet
ine
20m
g/d
(8w
eeks
)(n
=40
)
Eja
cula
tory
late
ncy
(CIP
E-5
,fiv
e-po
int
scal
e,hi
gher
=im
prov
ed)
Pos
ttrea
tmen
tm
ean
(CIP
E-5
):—
BT
+pa
rox:
4.8
(SD
0.5)
,n
=40
—P
arox
:4.
4(S
D0.
5),
n=
40
Com
bine
dvs
.dr
ug:
MD
=0.
40(0
.18–
0.62
),P
=0.
0003
Yes
(fav
ors
com
bine
d)
Yua
net
al.
[21]
Chi
na6
wee
ksn
=64
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(sto
p-st
art)
+ci
talo
pram
(n=
32)
—C
italo
pram
20m
g/d
(n=
32)
IELT
(met
hod
NR
)P
ost-
trea
tmen
tm
ean
(min
s):
—B
T+
cita
l:6.
22(S
D0.
91),
n=
32—
Cita
lopr
am:
5.76
(SD
0.79
),n
=32
Com
bine
dvs
.dr
ug:
MD
=0.
46(0
.04–
0.88
),P
=0.
03Ye
s(f
avor
sco
mbi
ned)
Beh
avio
ral
ther
apy
vs.
dru
gtr
eatm
ent
Abd
el-H
amid
etal
.[2
2]E
gypt
Cro
ssov
er,
4w
eeks
each
,2-
wee
kw
asho
uts
n=
31
—B
ehav
iora
l(sq
ueez
ete
chni
que)
—C
lom
ipra
min
e25
mg
—S
ertr
alin
e50
mg
—P
arox
etin
e20
mg
—S
ilden
afil5
0m
g(a
ll3–
5ho
urs
pre-
coitu
s)(t
otal
n=
31)
IELT
(sto
pwat
ch)
Pos
ttrea
tmen
t,m
edia
n(m
ins)
:—
Beh
avio
ral(
sque
eze)
:3
—C
lom
ipra
min
e:4
—S
ertr
alin
e:3
—P
arox
etin
e:4
—S
ilden
afil:
15
Fav
ors
sild
enafi
lor
paro
xetin
evs
.pa
use-
sque
eze;
othe
rco
mpa
rison
sno
tsi
gnifi
cant
(no
furt
her
data
)
Yes
(fav
ors
drug
for
2of
4dr
ugs)
Pas
tore
etal
.[1
1]Ita
ly12
wee
ksn
=40
—P
elvi
cflo
orre
habi
litat
ion
+el
ectr
ical
stim
ulat
ion
(n=
19)
—D
apox
etin
e30
or60
mg
on-d
eman
d(n
=21
)
IEL T
(sto
pwat
ch)
Pos
ttrea
tmen
t,ge
omet
ricm
ean
(min
s):
—P
elvi
cflo
or:
2.10
(SD
0.62
),n
=17
—D
apox
etin
e:3.
32(S
D0.
62),
n=
15
BT
vs.
drug
:M
D=
−1.2
2(−
1.65
to−0
.79)
,P
<0.
0000
1
Yes
(fav
ors
drug
)
Sha
oan
dLi
[20]
Chi
na8
wee
ksn
=80
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(squ
eeze
,se
nsat
efo
cus,
Qig
ong,
acup
oint
)(n
=40
)—
Par
oxet
ine
20m
g/d
(n=
40)
Eja
cula
tory
late
ncy
(CIP
E-5
,fiv
e-po
int
scal
e,hi
gher
=im
prov
ed)
Pos
t-tr
eatm
ent
mea
n(C
IPE
-5):
—B
T:4.
2(S
D0.
4),
n=
40—
Par
ox:
4.4
(SD
0.5)
,n
=40
BT
vs.
drug
:M
D=
−0.2
0(−
0.40
to0.
00),
P=
0.05
Yes
(fav
ors
drug
)
Yua
net
al.
[21]
Chi
na2
wee
ksn
=64
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(sto
p-st
art)
(n=
32)
—C
italo
pram
20m
g/d
(n=
32)
IELT
(met
hod
NR
)P
osttr
eatm
ent
mea
n(m
ins)
:—
BT:
2.21
(SD
0.53
),n
=32
—C
italo
pram
:5.
76(S
D0.
79),
n=
32
BT
vs.
drug
:M
D=
−3.5
5(−
3.88
to−3
.22)
,P
<0.
0000
1)
Yes
(fav
ors
drug
)
BT
=be
havi
oral
ther
apy;
CI=
confi
denc
ein
terv
al;
CIP
E-5
=C
hine
seIn
dex
ofP
rem
atur
eE
jacu
latio
n-5;
FS
=fu
nctio
nal-s
exol
ogic
alth
erap
y;G
RIS
S=
Gol
ombo
kR
ust
Inve
ntor
yof
Sex
ual
Sat
isfa
ctio
n;IE
LT=
intr
a-va
gina
lej
acul
ator
yla
tenc
ytim
e;M
D=
mea
ndi
ffere
nce;
NR
=no
tre
port
ed;
PE
=pr
emat
ure
ejac
ulat
ion;
RC
T=
rand
omiz
edco
ntro
lled
tria
l;R
R=
rela
tive
risk;
SD
=st
anda
rdde
viat
ion.
180 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
treatment, IELT had improved by 1.7 minutesfrom baseline (P = 0.008 for change).
Self-Help Book with/Without Therapist Contactor Couples’ Sexual Therapy vs.WaitlistA further RCT by Trudel and Proulx (n = 25couples) [17] assessed three types of BT vs. waitlistcontrol: self-help book alone (described as
bibliotherapy); self-help book plus therapist phonecontact; and sexual therapy for couples. After 12weeks, all gave improvements in IELT of between7 and 9 minutes over that of the waitlist group,though the method of IELT measurement was notstated, with changes from baseline significant forall treatment groups (P < 0.01) but not for thewaitlist group (P value not reported; Table 2).
Figure 1 Behavioral therapies vs. waitlist: IELT and ejaculatory latency
Figure 2 Behavioral plus drug therapy vs. drug alone: IELT and ejaculatory latency
Review Behaviour Therapy for Premature Ejaculation 181
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
These data could not be presented on the forestplot as no standard deviations were reported.Changes from baseline in the treatment groupsremained significant 3 and 6 months after treat-ment cessation.
Web-Based Sex Therapy vs.WaitlistA third RCT by van Lankveld et al. [18] (n = 40participants) assessed web-based sex therapy (usingsensate focus) vs. waitlist. The GRISS-PE subscalewas used to measure the extent to which a man hasthe tendency to ejaculate too soon. There wasalmost no difference between groups at 12 weeks(score of 13 in both groups; P = 0.80; Table 2 andFigure 1). Both groups improved from baseline(P < 0.001), and the change in the sex therapygroup remained significant at 3 and 6 months aftertreatment cessation (no follow-up data were avail-able for waitlist).
Combined Behavioral and Drug Therapy vs.Drug AloneThree studies compared behavioral and drug com-bination therapy vs. drug treatment alone; allshowed small but significant differences in IELTor ejaculatory latency favoring the combinedapproach [19–21].
BT Plus Chlorpromazine vs. ChlorpromazineOne RCT by Li et al. (n = 90 participants)[19] assessed combined therapy (BT pluschlorpromazine, a dopamine antagonist; 50 mg/day) vs. chlorpromazine alone. BT consisted of thestop-start technique plus psychotherapy (to reduce
anxiety, sadness, and negative thoughts and rebuildconfidence). Combined therapy gave a greaterincrease in IELT at 6 weeks, though the differencewas only 1 minute, and the measurement methodwas not reported (MD 1.11 minutes, 95% CI 0.86to 1.36; P < 0.00001; Table 2 and Figure 2).
BT Plus Paroxetine vs. ParoxetineAnother RCT by Shao et al. (n = 80 participantsfor this comparison) [20] assessed BT plusparoxetine (a selective serotonin reuptake inhibi-tor [SSRI]) vs. paroxetine alone. BT includedsqueeze technique, sensate focus, Qigong andacupoint tapping and was provided for 8 weeks.The paroxetine dose was 10 mg/day for 4 weeks inthe combined therapy group and 20 mg/day for 8weeks in the paroxetine-only group. Combinedtherapy was superior to paroxetine alone inincreasing ejaculatory latency at 8 weeks as mea-sured on a five-point Likert scale via the CIPE-5,though the difference was small (MD 0.40,95% CI 0.18 to 0.62; P = 0.0003; Table 2 andFigure 2).
BT Plus Citalopram vs. CitalopramA further RCT by Yuan et al. (n = 64 participantsfor this comparison) [21] reported that BT (stop-start technique) plus citalopram (an SSRI; 20 mg/day) was superior to citalopram alone inincreasing IELT at 6 weeks, though the IELTdifference was only 0.5 minutes, and the mea-surement method was not reported (MD 0.46minutes, 95% CI 0.04 to 0.88; P = 0.03; Table 2and Figure 2).
Figure 3 Behavioral therapy vs. drug treatment: IELT and ejaculatory latency
182 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
BT vs. Drug TreatmentFour studies compared BT alone vs. drug treat-ment alone; all showed small but significant differ-ences in IELT or ejaculatory latency favoring drugtreatment [11,20–22].
Pelvic Floor Rehabilitation vs. DapoxetineOne RCT by Pastore et al. (n = 40 participants)[11] compared pelvic floor rehabilitation (pluselectrical stimulation of the perineum) vs.dapoxetine (an SSRI, 30 or 60 mg taken prior tointercourse). The between-group difference ingeometric mean stopwatch-assessed IELT at 12weeks was 1.22 minutes in favor of dapoxetine(MD 1.22, 95% CI 0.79 to 1.65; P < 0.0001;Table 2 and Figure 3).
BT vs. ParoxetineThe RCT by Shao et al. (n = 80 participants forthis comparison) [20] compared paroxetine(20 mg/day) against BT (squeeze technique,sensate focus, Qigong and acupoint tapping). Thebetween-group difference in the CIPE-5 ejacula-tory latency score at 8 weeks significantly favoredparoxetine (MD 0.20, 95% CI 0.00 to 0.40;P = 0.05; Table 2 and Figure 3).
BT vs. CitalopramThe RCT by Yuan et al. (n = 64 participants forthis comparison) [21] reported a between-groupdifference in IELT at 6 weeks of 3.55 minutes infavor of citalopram (20 mg/day) compared withBT (stop-start technique); MD 3.55, 95% CI 3.22to 3.88; P < 0.00001; Table 2 and Figure 3). Themeasurement method was not reported.
Squeeze Technique vs. SSRIs or TricyclicAntidepressants (TCA)The between-group difference in medianstopwatch-measured IELT following a 4-week ran-domized crossover comparison (Abdel-Hamidet al.; n = 31 participants) [22] significantly favoredsildenafil or paroxetine over BT (pause-squeezetechnique), whereas comparisons with sertralineand clomipramine were not significant (Table 2).Data were not presented on the forest plot due tothe reporting of median rather than mean values.
Assessment of Effectiveness: Non-IELT Outcomes
With the exception of the RCT by Pastore et al.[24], all of the included trials were reported asevaluating one or more outcomes other than IELT(Table 3). However, these were diverse across the
included trials and were not reported in sufficientdetail to permit any pooling across trials.
BT vs.Waitlist ControlFour RCTs assessed non-IELT outcomes for BTsvs. waitlist control; one significantly favored BTs[15], whereas the other two were unclear as towhether there was a significant difference betweengroups [16–18]. One RCT (de Carufel and Trudel)[15] showed significant improvements in male per-ception of duration of intercourse and couples’sexual satisfaction with either functional sexologi-cal treatment (sensual education) or BT (stop-starttechnique and squeeze technique) compared withwaitlist control. Another RCT (Trudel and Proulx)[17] reported a significant increase from baselinein sexual satisfaction for all three BT groups (self-help book, self-help book plus therapist phonecontact, and sexual therapy) with better results forself-help plus phone contact vs. self-help alone;however, no data were reported for the waitlistgroup. A further RCT (van Lankveld et al.) [18]reported that sexual desire improved significantlymore with web-based sensate focus than waitlistcontrol, whereas sexual satisfaction improved frombaseline but showed no significant differencebetween groups; conversely, self-confidenceshowed no significant difference either betweengroups or from baseline. A small RCT using thestop-start technique aided by a handheld stimula-tion device (Jern) [16] showed no significantimprovement over waitlist or from baseline post-treatment (via a composite score for ejaculatorylatency, control and relationship problems);however, a significant improvement from baselinewas observed at 6-month follow-up (at whichpoint all patients had received treatment so therewas no waitlist comparison).
Combined Behavioral + Drug Therapy vs. Drug AloneThree RCTs reported better results for combinedtherapy (behavioral plus drug) than drug treatmentalone on a range of non-IELT outcomes [19–21].BT (stop-start plus psychotherapy) combined withchlorpromazine was reported by one RCT asbeing more effective than chlorpromazine aloneon a self-rated measure of anxiety and CIPE mea-sures of sexual anxiety, sexual satisfaction, andejaculatory control (Li et al.) [19]. Another RCT(Shao et al.) [20] reported that combined treat-ment with paroxetine plus BT (squeeze, sensatefocus, Qigong and acupoint tapping) was superiorto paroxetine alone on CIPE measures of ejacula-tory control, patient/partner satisfaction, and
Review Behaviour Therapy for Premature Ejaculation 183
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Tab
le3
Res
ults
for
outc
omes
othe
rth
anIE
LT
RC
TC
ount
ryD
urat
ion
Nra
ndom
ized
Trea
tmen
ts(N
rand
omiz
edpe
rgr
oup)
Out
com
em
easu
reR
esul
tsS
igni
fican
tdi
ffere
nce?
Beh
avio
ral
ther
apy
vs.
wai
tlis
tD
eC
aruf
elan
dTr
udel
[15]
Can
ada
NR
n=
36co
uple
s
—F
unct
iona
l-sex
olog
ical
ther
apy
—B
ehav
iora
lthe
rapy
(squ
eeze
,st
op-s
tart
)—
Wai
tlist
(tot
aln
=36
)
Sex
uals
atis
fact
ion
(Hud
son’
sin
dex)
Bot
htr
eatm
ent
grou
psha
dsi
gnifi
cant
impr
ovem
ents
over
wai
tlist
(men
and
part
ners
)Ye
s(f
avor
sB
Tgr
oups
)
Per
cept
ion
ofdu
ratio
nof
inte
rcou
rse
Impr
oved
sign
ifica
ntly
with
both
trea
tmen
ts(m
en;
P<
0.05
)bu
tno
tw
aitli
stYe
s(f
avor
sB
Tgr
oups
)
Jern
[16]
Fin
land
6w
eeks
n=
11
—S
top-
star
tus
ing
hand
held
vibr
atin
gst
imul
atio
nde
vice
(n=
6)—
Wai
tlist
(n=
5)
Eja
cula
tory
cont
rol,
late
ncy,
rela
tions
hip
prob
lem
s(C
HE
ES
)P
osttr
eatm
ent,
nosi
gnifi
cant
betw
een-
grou
pdi
ffere
nce
orch
ange
from
base
line
No
(als
ono
impr
ovem
ent
from
base
line)
At
6m
onth
s,si
gnifi
cant
impr
ovem
ent
from
base
line
afte
ral
lpa
tient
sun
dert
ook
BT
(P=
0.00
6)S
igni
fican
tim
prov
emen
tfr
omba
selin
e
Trud
elan
dP
roul
x[1
7]C
anad
a12
wee
ksn
=25
coup
les
—S
elf-
help
book
—S
elf-
help
book
+th
erap
ist
phon
eco
ntac
t—
Sex
ualt
hera
pyfo
rco
uple
s—
Wai
tlist
(tot
aln
=25
)
Sex
uals
atis
fact
ion
(SII)
Impr
oved
inal
lthr
eetr
eatm
ent
grou
psfo
rm
enan
dpa
rtne
rs(P
<0.
05);
noda
tafo
rw
aitli
stgr
oup
Unc
lear
(BT
vs.
wai
tlist
)
Sel
f-he
lpbo
ok+
phon
eco
ntac
tbe
tter
than
self-
help
book
alon
e(P
<0.
05)
Bet
ter
with
phon
eco
ntac
t
van
Lank
veld
etal
.[1
8]N
ethe
rland
s12
wee
ksn
=40
—W
eb-b
ased
sex
ther
apy
(sen
sate
focu
s)(n
=22
)—
Wai
tlist
(n=
18)
Sex
uald
esire
(IIE
F)
Fav
ored
sex
ther
apy
vs.
wai
tlist
(P<
0.05
).Im
prov
edfr
omba
selin
eac
ross
grou
ps(P
<0.
05);
mai
ntai
ned
at3-
and
6-m
onth
follo
w-u
p
Yes
(als
oim
prov
edfr
omba
selin
e)
Ove
rall
satis
fact
ion
(IIE
F)
No
betw
een-
grou
pdi
ffere
nce.
Impr
oved
from
base
line
acro
ssgr
oups
(P=
0.00
5);
mai
ntai
ned
at3-
and
6-m
onth
follo
w-u
pN
o(b
oth
grou
psim
prov
edfr
omba
selin
e)S
elf-
confi
denc
e(S
EA
R)
No
betw
een-
grou
pdi
ffere
nce.
No
sign
ifica
ntch
ange
from
base
line
topo
st-t
reat
men
tN
o(a
lso
noim
prov
emen
tfr
omba
selin
e)B
ehav
iora
l+d
rug
ther
apie
svs
.d
rug
alo
ne
Liet
al.
[19]
Chi
na6
wee
ksn
=90
—P
sych
othe
rapy
+st
op-s
tart
+ch
lorp
rom
azin
e50
mg/
d(n
=45
)—
Chl
orpr
omaz
ine
50m
g/d
(n=
45)
Sex
uals
atis
fact
ion
(pat
ient
&pa
rtne
r),
ejac
ulat
ory
cont
rol,
ejac
ulat
ory
late
ncy
(CIP
E)
Chl
orpr
omaz
ine
+B
Tsu
perio
rto
chlo
rpro
maz
ine
alon
efo
ral
lou
tcom
es(P
<0.
05)
Yes
(fav
ors
com
bine
d)
Anx
iety
(SA
San
dC
IPE
)C
hlor
prom
azin
e+
BT
supe
rior
toch
lorp
rom
azin
eal
one
(CIP
EP
<0.
05,
SA
SP
<0.
01)
Yes
(fav
ors
com
bine
d)
Sha
oan
dLi
[20]
Chi
na8
wee
ksn
=80
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(squ
eeze
,se
nsat
efo
cus,
Qig
ong,
acup
oint
;8
wee
ks)
+pa
roxe
tine
10m
g/d
(4w
eeks
)(n
=40
)—
Par
oxet
ine
20m
g/d
(8w
eeks
)(n
=40
)
Eja
cula
tory
cont
rol(
CIP
E-5
)B
T+
paro
xetin
ebe
tter
than
paro
xetin
e(P
<0.
01)
Yes
(fav
ors
com
bine
d)P
atie
nt/p
artn
ersa
tisfa
ctio
n(C
IPE
-5)
BT
+pa
roxe
tine
bette
rth
anpa
roxe
tine
(P<
0.05
)Ye
s(f
avor
sco
mbi
ned)
Sex
uala
nxie
ty(C
IPE
-5)
BT
+pa
roxe
tine
bette
rth
anpa
roxe
tine
(P<
0.01
)Ye
s(f
avor
sco
mbi
ned)
Yua
net
al.
[21]
Chi
na2
wee
ksn
=64
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(sto
p-st
art)
+ci
talo
pram
(n=
32)
—C
italo
pram
20m
g/d
(n=
32)
Sex
uals
atis
fact
ion
(mea
sure
NR
)F
avor
edB
T+
cita
lopr
amvs
.ci
talo
pram
alon
e(P
=N
R)
Unc
lear
Beh
avio
ral
ther
apy
vs.
dru
gtr
eatm
ent
Abd
el-H
amid
etal
.[2
2]E
gypt
Cro
ssov
er,
4w
eeks
each
,2-
wee
kw
asho
uts
n=
31
—B
ehav
iora
l(sq
ueez
e)—
Clo
mip
ram
ine
25m
g—
Ser
tral
ine
50m
g—
Par
oxet
ine
20m
g—
Sild
enafi
l50
mg
(all
3–5
hour
spr
e-co
itus)
Sex
uals
atis
fact
ion
(mod
ified
ED
ITS
)M
edia
ns:
sque
eze
tech
niqu
e,6;
clom
ipra
min
e,11
;se
rtra
line,
10si
lden
afil,
30;
paro
xetin
e,12
Yes
(sild
enafi
lor
paro
xetin
esu
perio
rto
BT;
othe
rsno
tsi
gnifi
cant
)A
nxie
ty(A
AI,
scal
e0
to30
)M
edia
ns:
sque
eze
tech
niqu
e,12
;cl
omip
ram
ine,
11;
sert
ralin
e,11
;si
lden
afil,
8;pa
roxe
tine,
9N
o
Ogu
zhan
glu
etal
.[2
3]Tu
rkey
8w
eeks
N=
32
—S
top-
star
tte
chni
que
(n=
16)
—F
luox
etin
e20
mg/
d(n
=16
)S
exua
lsat
isfa
ctio
n(la
tenc
yan
dco
ntro
lin
75%
coitu
s)N
odi
ffere
nce
betw
een
grou
ps(P
>0.
05);
sign
ifica
ntly
impr
oved
inbo
thgr
oups
No
(impr
oved
from
base
line)
Anx
iety
(STA
I)A
nxie
ty(s
tate
and
trai
t)im
prov
edfr
omba
selin
ein
both
grou
ps(P
<0.
05)
No
(impr
oved
from
base
line)
Pas
tore
etal
.[1
1]Ita
ly12
wee
ksn
=40
—P
elvi
cflo
orre
habi
litat
ion
+el
ectr
ical
stim
ulat
ion
(n=
19)
—D
apox
etin
e30
–60
mg
(n=
21)
No
othe
rou
tcom
esre
port
ed—
—
Sha
oan
dLi
[20]
Chi
na8
wee
ksn
=80
for
this
com
paris
on
—B
ehav
iora
lthe
rapy
(squ
eeze
,se
nsat
efo
cus,
Qig
ong,
acup
oint
)(n
=40
)—
Par
oxet
ine
20m
gpe
rda
y(n
=40
)
Eja
cula
tory
cont
rol(
CIP
E-5
)P
arox
etin
ebe
tter
than
BT
(P<
0.01
)Ye
s(f
avor
sdr
ug)
Pat
ient
/par
tner
satis
fact
ion
(CIP
E-5
)B
Tbe
tter
than
paro
xetin
e(P
<0.
01)
Yes
(fav
ors
BT
)S
exua
lanx
iety
(CIP
E-5
)B
Tvs
.pa
roxe
tine,
P=
nons
igni
fican
t(v
alue
NR
)N
odi
ffere
nce
Yua
net
al.
[21]
Chi
na2
wee
ksn
=64
—B
ehav
iora
lthe
rapy
(sto
p-st
art)
(n=
32)
—C
italo
pram
20m
g/d
(n=
32)
Sex
uals
atis
fact
ion
(mea
sure
NR
)C
italo
pram
sign
ifica
ntly
supe
rior
toB
T(P
=0.
015)
Yes
(fav
ors
drug
)
AA
I=A
rabi
cA
nxie
tyIn
vent
ory;
BT
=be
havi
oral
ther
apy;
CH
EE
S=
Che
cklis
tfo
rE
arly
Eja
cula
tion
Sym
ptom
s;C
IPE
-5=
Chi
nese
Inde
xof
Pre
mat
ure
Eja
cula
tion-
5;E
DIT
S=
Ere
ctile
Dys
func
tion
Inve
ntor
yof
Trea
tmen
tS
atis
fact
ion;
IIEF
=In
ter-
natio
nalI
ndex
ofE
rect
ileF
unct
ion;
NR
=no
tre
port
ed;
RC
T=
rand
omiz
edco
ntro
lled
tria
l;S
AS
=S
elf-
ratin
gA
nxie
tyS
cale
;S
EA
R=
Sel
f-E
stee
man
dR
elat
ions
hip;
SII
=S
exua
lInt
erac
tion
Inve
ntor
y;S
TAI=
Sta
te-T
rait
Anx
iety
Inde
x.
184 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
sexual anxiety. A further RCT (Yuan et al.) [21]reported that BT (stop-start technique) combinedwith citalopram was more effective at improvingsexual satisfaction than citalopram alone, thoughsignificance level was not reported.
BT vs. Drug TreatmentFour RCTs [20–23] comparing BTs vs. drug treat-ment reported non-IELT outcomes, with mixedresults (some outcomes favoring drug treatment,some behavioral, and some showing no differ-ence). One RCT (Shao et al.) [20] reported mixedresults; results for CIPE-assessed ejaculatorycontrol significantly favored paroxetine over BT,whereas results for patient/partner satisfaction sig-nificantly favored BT, and there was no significantdifference in sexual anxiety. Yuan et al. [21]reported that citalopram significantly improvedsexual satisfaction compared with BT (stop-start).Oguzhanglu et al. [23] reported no significantbetween-group difference in sexual satisfaction forstop-start technique compared with fluoxetine(though both groups improved from baseline). Acrossover RCT (Abdel-Hamid et al.) [22] reportedsignificantly better sexual satisfaction withsildenafil or paroxetine compared with the squeezetechnique but no significant differences comparedwith clomipramine or sertraline, whereas anxietywas not significantly different between groups.
Assessment of Adverse Effects and Withdrawalsfrom Treatment
Adverse effect data were available for six of 10studies [11,16,17,20,22,23]. None reported anyadverse effects for BTs. One study (Trudel andProulx) [17] reported that dropout rates fromtreatment were higher for the group receiving self-help material alone (45%) than for the two groupswith therapist contact (14% and 33%; unclearwhich data relate to which of the two therapist-contact groups).
Adverse event rates reported for groups receiv-ing drug treatment or combined drug and behav-ioral treatment were as follows: 10% forparoxetine 10 mg/day (plus BT) [20]; 40% forparoxetine 20 mg/day [20]; 17% for paroxetine20 mg taken pre-coitus [22]; 10% for sertraline50 mg pre-coitus [22], 13% for fluoxetine [23];13% for dapoxetine 30 mg pre-coitus [11]; 29%for dapoxetine 60 mg pre-coitus [11]; 25% for clo-mipramine 25 mg pre-coitus [22]; and 18% forsildenafil 50 mg pre-coitus [22]. Where reported,adverse effects of SSRIs included nausea, diarrhea,
dry mouth, anorexia, drowsiness, and yawning[11,22,23], whereas adverse effects of sildenafil(phosphodiesterase type 5 inhibitors) includedheadache, flushing, and nasal congestion [22].
Summary of Effectiveness Results
The effectiveness results across trials are summa-rized in Table 4. Four trials compared BTs againstwaitlist [15–18]. Of these, two trials assessing fivetypes of BT reported posttreatment differences inIELT of 7–9 minutes compared with the waitlistgroups, with changes in the treatment groupsmaintained 3 months after treatment cessation[15,17]. However, a further trial showed no differ-ence in ejaculatory latency via the GRISS-PE scalebetween web-based sensate focus and waitlist,though both groups improved from baseline [18].Another trial showed no posttreatment differencein IELT between the stop-start technique aided bya stimulation device vs. waitlist, though there was asignificant improvement from baseline at 6-monthfollow-up [16]. Results were mixed for otheroutcomes (sexual satisfaction, desire, and self-confidence), with some waitlist comparisons sig-nificantly favoring BT while others were notsignificant [15–18].
Three trials favored combined behavioral anddrug treatment over drug treatment alone [19–21], with small but significant differences in IELTfavoring combined treatment (0.5–1 minute acrosstwo trials) [19,21] and significantly better resultsfor combined treatment on other outcomes(sexual satisfaction, ejaculatory control, andanxiety) [19–21]. Direct comparisons of BT aloneor drug treatment alone gave mixed results bothfor IELT and other outcomes, with most findingseither favoring drug treatment or showing no sig-nificant difference.
Discussion
This systematic review assesses the effectiveness ofBTs for the treatment of PE, based on RCT evi-dence. Ten trials were identified; these were con-ducted across various countries and the overall riskof bias was unclear in all studies. The includedstudies assessed various types of BT either indi-vidually or in combination, including the squeezeand stop-start techniques, stop-start aided by astimulation device, education on sensuality andmovement, sensate focus, and pelvic floor musclerehabilitation. All the above showed some evi-dence of effectiveness either over waitlist or as an
Review Behaviour Therapy for Premature Ejaculation 185
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Tab
le4
Sum
mar
yof
resu
lts
Out
com
eR
CTs
Npt
psIn
terv
entio
nC
ompa
rato
rM
ean
diff.
(95%
CI)
,P
valu
eF
avor
s
Beh
avio
ral
ther
apy
vs.
wai
tlis
tIE
LT(m
inut
es)
deC
aruf
elan
dTr
udel
[15]
36B
T(s
quee
ze,
stop
-sta
rt)
Wai
tlist
6.87
(5.1
0to
8.64
),P
<0.
0000
1B
TB
T(F
S)
Wai
tlist
6.80
(5.0
4to
8.56
),P
<0.
0000
1B
TTr
udel
and
Pro
ulx
[17]
25B
T(s
elf-
help
)W
aitli
st9.
11(N
R)
BT
BT
(sel
f-he
lp+
phon
e)W
aitli
st7.
29(N
R)
BT
BT
(cou
ples
ther
apy)
Wai
tlist
8.84
(NR
)B
TJe
rn[1
6]11
BT
(sto
p-st
art+
devi
ce)
Wai
tlist
0.35
(−2.
26to
2.96
),P
=0.
79N
otsi
gnifi
cant
Eja
cula
tory
late
ncy
(GR
ISS
-PE
)va
nLa
nkve
ldet
al.
[18]
40B
T(w
eb-b
ased
sens
ate
focu
s)W
aitli
st−0
.20
(−1.
75to
1.35
),p=
0.80
Not
sign
ifica
nt
Sex
uals
atis
fact
ion
deC
aruf
elan
dTr
udel
[15]
36B
T(t
wo
type
s;se
eab
ove)
Wai
tlist
P=
NR
BT
Trud
elan
dP
roul
x[1
7]25
BT
(thr
eety
pes;
see
abov
e)W
aitli
stP
=N
RU
ncle
arva
nLa
nkve
ldet
al.
[18]
40B
T(w
eb-b
ased
sens
ate
focu
s)W
aitli
stP
=N
RN
otsi
gnifi
cant
Per
cept
ion
ofdu
ratio
nde
Car
ufel
and
Trud
el[1
5]36
BT
(tw
oty
pes;
see
abov
e)W
aitli
stP
<0.
05B
T
Sex
uald
esire
van
Lank
veld
etal
.[1
8]40
BT
(web
-bas
edse
nsat
efo
cus)
Wai
tlist
P<
0.05
BT
Sel
f-co
nfide
nce
van
Lank
veld
etal
.[1
8]40
BT
(web
-bas
edse
nsat
efo
cus)
Wai
tlist
P=
NR
Not
sign
ifica
nt
Eja
cula
tory
cont
rol,
late
ncy,
prob
lem
sJe
rn[1
6]11
BT
(sto
p-st
art+
devi
ce)
Wai
tlist
P=
NR
Not
sign
ifica
nt
Beh
avio
ral+
dru
gth
erap
ies
vs.
dru
gal
on
eIE
LT(m
inut
es)
Liet
al.
[19]
90B
T(P
S+
SS
)+
chlo
rpro
maz
ine
Chl
orpr
omaz
ine
1.11
(0.8
6to
1.36
),P
<0.
0001
BT
+dr
ugY
uan
etal
.[2
1]64
BT
(sto
p-st
art)
+ci
talo
pram
Cita
lopr
am0.
46(0
.04
to0.
88),
P=
0.03
BT
+dr
ug
Eja
cula
tory
late
ncy
(CIP
E-5
)Li
etal
.[1
9]90
BT
(PS
+S
S)
+ch
lorp
rom
azin
eC
hlor
prom
azin
eP
<0.
05B
T+
drug
Sha
oan
dLi
[20]
80B
T(v
ario
us)
+pa
roxe
tine
Par
oxet
ine
0.46
(0.0
4to
0.88
),P
=0.
03B
T+
drug
Sex
uals
atis
fact
ion
Liet
al.
[19]
90B
T(P
S+
SS
)+
chlo
rpro
maz
ine
Chl
orpr
omaz
ine
P<
0.05
BT
+dr
ugS
hao
and
Li[2
0]80
BT
(var
ious
)+
paro
xetin
eP
arox
etin
eP
<0.
05B
T+
drug
Yua
net
al.
[21]
64B
T(s
top-
star
t)+
cita
lopr
amC
italo
pram
P=
NR
(sta
tes
favo
rsB
T+
drug
)U
ncle
ar
Eja
cula
tory
cont
rol
Liet
al.
[19]
90B
T(P
S+
SS
)+
chlo
rpro
maz
ine
Chl
orpr
omaz
ine
P<
0.05
BT
+dr
ugS
hao
and
Li[2
0]80
BT
(var
ious
)+
paro
xetin
eP
arox
etin
eP
<0.
01B
T+
drug
Anx
iety
Liet
al.
[19]
90B
T(P
S+
SS
)+
chlo
rpro
maz
ine
Chl
orpr
omaz
ine
P<
0.05
BT
+dr
ugS
hao
and
Li[2
0]80
BT
(var
ious
)+
paro
xetin
eP
arox
etin
eP
<0.
01B
T+
drug
Beh
avio
ral
ther
apy
vs.
dru
gtr
eatm
ent
IELT
(min
utes
)A
bdel
-Ham
idet
al.
[22]
31B
T(s
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rol
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[20]
80B
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ario
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oxet
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80B
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ifica
nt
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havi
oral
ther
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ndom
ized
cont
rolle
dtr
ial;
RR
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kra
tio;
SS
=st
op-s
tart
.
186 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
addition to drug treatment. No adverse effectswere reported for BTs, though these were not wellreported across trials. There were generally onlyone or two trials of each specific type of therapy,which limits the conclusions that can be drawn.Results of two trials each comparing either two orthree different types of BT indicated that all weresimilarly effective [15,17].
Only one RCT, Li et al. [19], included a psycho-therapeutic approach, comparing chlorpromazineplus the stop-start technique plus psychotherapyagainst chlorpromazine alone. The effectiveness ofpsychotherapy in this study was unclear due to thecombined intervention and the use of an activecontrol. All remaining RCTs focused on physicaltechniques as outlined above. Indeed, current PEguidelines note that the majority of psychotherapystudies are uncontrolled and nonblinded [1].Therefore, there remains a need for well-conducted RCTs of psychotherapeutic approachesto PE.
Study treatments were relatively well-describedin most studies, though some simply referred to anestablished technique (such as stop-start or sensatefocus). Three of the included studies were inChinese language. This review used robust meth-odology including thorough literature searchingand data checking by two reviewers. Non-RCTstudies were not included within this review asthese were considered to be of lower methodologi-cal quality and would have provided limited infor-mation on effectiveness.
Duration of the behavioral interventions in theincluded studies ranged from 2 to 12 weeks. Threestudies reported that IELT improvements weremaintained 3–6 months after treatment cessation;however, in general, there is limited data regardinghow long any positive effects would be maintainedafter treatment finishes and whether additionalfollow-up treatments might be required. This is aconsideration both for BTs and for drug treat-ments within PE studies.
The majority of RCTs included an assessmentof either IELT or another measure of ejaculatorylatency, though the method of IELT measurement(e.g., via stopwatch) was not always reported.Many RCTs also reported other outcomes such asejaculatory control, sexual satisfaction, and anxiety,though various different measures were used toassess these, and data were not always clearlyreported. It is important that clinical studies aim toassess non-IELT aspects of PE, as highlighted inthe recently updated ISSM definition of PE, whichincludes inability to delay ejaculation and negative
personal consequences in addition to reducedlatency time [1].
In comparison with a pharmacological treat-ment, most BTs require a willingness of the manand his partner to engage with the therapy andpractice the relevant techniques. The suitability ofa BT is likely to depend on individual patient (andpartner) preference; some people may prefer abehavioral option, whereas others may prefera pharmacological approach. Combinations ofmedical and psychological approaches may beuseful where there is a clear psychosocial or rela-tionship issue [1].
In order to increase consistency in outcomedata and facilitate meta-analyses, future studiesshould aim to recruit men meeting the ISSM defi-nition of PE, measure stopwatch-assessed IELT,and report other aspects of PE in addition to IELTusing validated instruments.
Further research may focus on psychotherapeu-tic or counseling approaches for PE, for which fewRCTs were identified in the current evidence base.Combination therapy may also be worthy offurther study; this may include combinations ofphysical techniques and counseling approaches,and/or behavioral and drug treatments. Additionalareas for further study may include assessment ofdifferences between types of BT, optimum dura-tion of therapy, and how effects might best bemaintained long-term.
Conclusions
There is limited evidence that physical behavioraltechniques for PE improve IELT and other out-comes over waitlist control. There is also someevidence that BTs combined with drug treat-ments improve IELT and other outcomes com-pared with drug treatments alone. Areas forfurther research might include: RCTs of psycho-therapeutic or counseling approaches to PE;further studies of combination therapy (physical/behavioral and/or counseling and/or drug); andassessment of how effects of therapy might bemaintained long-term.
Acknowledgments
Thanks to Shijie Ren for translation of articles.
Corresponding Author: Katy Cooper, PhD,ScHARR, University of Sheffield, Regent Court, 30Regent Street, Sheffield S1 4DA, UK. Tel: +44 (0)114222 0773; Fax: +44 (0)114 272 4095; E-mail:[email protected]
Review Behaviour Therapy for Premature Ejaculation 187
Sex Med 2015;3:174–188© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.
Conflict of Interest: No conflicts of interest occurred forany author.
Funding
This work was funded by the UK National Insti-tute for Health Research (NIHR) Health Technol-ogy Assessment (HTA) Programme, projectnumber 13-12.
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Supporting Information
Additional Supporting Information may be found in the onlineversion of this article at the publisher’s website:
Appendix S1 Medline search strategy (August 2014).
188 Cooper et al.
Sex Med 2015;3:174–188 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc.on behalf of International Society for Sexual Medicine.