behavioral therapies for management of premature ... · premature ejaculation (pe) is deﬁned by...

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.

http://creativecommons.org/licenses/by-nc/4.0/

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.

http://www.prisma-statement.org/

http://www.prisma-statement.org/

http://www.nets.nihr.ac.uk/projects/hta/131201

http://www.nets.nihr.ac.uk/projects/hta/131201

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.


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.



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.


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)



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.


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



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.


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



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.


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



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

quee

ze)

Par

oxet

ine

Not

repo

rted

Dru

gS

ertr

alin

eN

otsi

gnifi

cant

Clo

mip

ram

ine

Not

sign

ifica

ntS

ilden

afil

Dru

gP

asto

reet

al.

[11]

40B

T(p

elvi

cflo

or)

Dap

oxet

ine

−1.2

2(−

1.65

to−0

.79)

,P

<0.

0000

1D

rug

Yua

net

al.

[21]

64B

T(s

top-

star

t)C

italo

pram

−3.5

5(−

3.88

to−3

.22)

,P

<0.

0000

1D

rug

Eja

cula

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186 Cooper et al.


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]



mailto:[email protected]

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.


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