Interrelationships among measures of premature ejaculation: the central role of perceived control

Updating, correcting, and calibrating the narrative about premature ejaculation

INTRODUCTION

The narrative surrounding premature ejaculation (PE) has developed and solidified over the past 25 years. Unfortunately, portions of that narrative are outdated and do not reflect more recent conceptualizations or empirical findings regarding this disorder.

OBJECTIVE

In this review we sought to identify existing narratives about PE in need of updating and to provide revised narratives based on the recent research literature.

METHOD

Five PE narratives in need of revision were identified, including: the prevalence of PE, age-related differences in PE prevalence, a validated ejaculation latency (EL) for diagnosing PE, differences between lifelong and acquired PE subtypes, and the application of PE definitions beyond penile-vaginal intercourse. Extensive literature searches provided information supporting both the original narrative and the need for a revised narrative based on both consideration of more recent studies and reinterpretation of studies conducted since the establishment of the original narratives.

RESULTS

For each selected topic, the prevailing narrative based on the extant literature was first presented, followed by discussion of accumulating evidence that challenges the existing narrative. Each section ends with a suggested revised PE narrative. In 2 instances, the revised narrative required significant corrections (eg, PE prevalence, validated EL for diagnosing PE); in 2 instances, it expanded on the existing narrative (eg, PE subtype differences, inclusion of partnered sexual activities beyond penile-vaginal intercourse); and in 2 other instances, it backed off prior conclusions that have since required rethinking (eg, age-related changes in PE, PE subtype differences). Finally, a brief review of the 3-pronged criteria for PE (EL, ejaculatory control, and bother/distress) is presented and discussed.

CONCLUSION

This review reiterates the dynamic state of research on PE and demonstrates the need for and value of ongoing research that not only addresses new issues surrounding this dysfunction but also challenges and revises some of the existing narratives about PE.

Do Ejaculation Latency and Other Sexual Measures Differ Between Men With Lifelong and Acquired Premature Ejaculation?

OBJECTIVE

To determine whether men with lifelong vs acquired premature ejaculation (PE) subtypes differ on their estimated ejaculation latencies (EL) and related sexual, relationship, and behavioral parameters.

METHODS

Of 2679 men who responded to an online multinational survey about sexual health and met inclusion criteria, 540 reported "probable" or "definite" PE, as assessed by the Premature Ejaculation Diagnostic Tool. Lifelong and acquired PE subtypes were compared on multiple measures related to EL, as well as on sets of demographic, diagnostic, relationship, sexual behavioral, and sexual functioning measures during both partnered sex and masturbation.

RESULTS

Nearly 73% of men with PE in this sample reported the lifelong subtype. No differences emerged in EL measures between subtypes, even when parsed according to age. Specifically, men 37years or under with either definite lifelong or acquired PE reported ELs of 1.9 minutes (SD=1.3). For men over 37, lifelong ELs were 2.0 minutes (SD=1.3), acquired ELs 2.4 minutes (SD=1.4). While the lifelong subgroup was younger and reported lower erectile functioning, these differences occurred only in the probable PE group and not the definite PE group.

CONCLUSION

Our data do not support different EL criteria for men with acquired vs lifelong PE, as suggested by several professional definitions. Furthermore, differences in age and erectile functioning between the groups, often reported in clinical samples though not in our definite PE group, may be an artifact of the general health/patient characteristics that lead such men to seek medical assistance.

Why Men Masturbate: Reasons and Correlates in Men with and without Sexual Dysfunction

Men purportedly masturbate for a variety of reasons, but systematic investigation of men's reasons has been lacking. We analyzed reasons why men masturbate (n = 2967, mean age = 37.7, SD = 12.9), whether men with and without sexual problems differ in their reasons, and whether those reasons vary with the frequency of masturbation and partnered sex. Results indicated that deriving pleasure, decreasing sexual tension, and reducing anxiety/stress were among the top motives, whereas partner issues were cited less frequently. Men with sexual dysfunctions showed only minor differences from men without sexual dysfunctions, the former more often citing anxiety/stress reduction as a motive. In addition, samples tapping participants from two world regions showed only minor differences in their patterns of responding. Motives for masturbation were also related to both the frequency of masturbation and the frequency of partnered sex. Overall, these findings indicate that men, like women, masturbate primarily for the positive reinforcing effects of pleasure, but in contrast with women, men are also more likely to use masturbation for the negatively reinforcing effects of reducing anxiety/distress. Unsatisfying sex with the partner and/or relationship issues were cited as a reason for masturbation in only a minority of men.

Progressive arousal: a new concept and definition for premature ejaculation

Background

Premature ejaculation (PE) is a nosologic entity with issues in its conceptualization and definition.

Aim

To understand if the altered sexual response in men with PE is in the orgasm phase, as currently assumed, or the arousal phase with difficulties in modulating, regulating, or decreasing sexual arousal.

Methods

Men were recruited who looked for help for PE and met the diagnostic criteria according to clinical standards. The participants completed a sociodemographic survey and the Premature Ejaculation Diagnostic Tool. They also performed a masturbation exercise with a maximum of 5 stops, with the intention of prolonging the arousal phase. The time of the exercise was measured from the beginning of genital masturbation to ejaculation.

Outcomes

We calculated the total time of the exercise, the median time at each start, and the number of dropouts. We performed a pairwise comparison analysis between starts and made a survival curve representing the percentage of men who remained in the exercise.

Results

A total of 481 men with PE participated (mean ± SD; age, 29.25 ± 8.72 years). We found that the expected median survival time until ejaculation was 317.00 seconds (95% CI, 288.34-345.65). However, the average time during stimulation decreased as the exercise progressed, and statistically significant differences were observed in their pairwise comparison (P < .001). Also, the chances of ejaculation increased as the exercise progressed, with 62.16% of the participants ejaculating before the end of the exercise. The results indicated increasing sexual arousal, where stops in stimulation were progressively less effective at maintaining ejaculation times at starts.

Clinical Implications

We showed that the arousal phase is altered in PE, not the orgasm phase, and this could finally have implications in the diagnosis and/or treatment of this condition.

Strengths and Limitations

The analysis of the times at starts and stops in a masturbation exercise in men with PE, had been barely addressed before. In the future, it would be important to verify the effect of stops during sexual intercourse and to incorporate a control group of men without PE.

Conclusions

We propose a new conceptualization and definition for PE: progressive arousal disorder is the inability to modulate, regulate, or decrease arousal during any sexual activity, even with brief stops during sexual stimulation, causing unwanted ejaculation.

Characteristics of men who report symptoms of delayed ejaculation: providing support for empirically derived diagnostic criteria

BACKGROUND

Little is known regarding the demographic, sexual, and relationship characteristics of men with symptoms of delayed ejaculation (DE).

AIM

To identify differences between men with and without DE symptomology to validate face-valid diagnostic criteria and to identify various functional correlates of DE.

METHODS

A total of 2679 men meeting inclusion criteria were partitioned into groups with and without DE symptomology on the basis of their self-reported "difficulty reaching ejaculation/orgasm during partnered sex." Men were then compared on a broad array of demographic and relationship variables, as well as sexual response variables assessed during partnered sex and masturbation.

OUTCOMES

Outcomes included the identified differences between men with and without DE symptomology.

RESULTS

Men with DE-whether having comorbid erectile dysfunction or not-differed from men without DE on 5 face-valid variables related to previously proposed diagnostic criteria for DE, including ones related to ejaculation latency (P < .001); self-efficacy related to reaching ejaculation, as assessed by the percentage of episodes reaching ejaculation during partnered sex (P < .001); and negative consequences of the impairment, including "bother/distress" and (lack of) "orgasmic pleasure/sexual satisfaction" (P < .001). All such differences were associated with medium to large effect sizes. In addition, men showed differences on a number of functional correlates of DE, including anxiety, relationship satisfaction, frequency of partnered sex and masturbation, and level of symptomology during partnered sex vs masturbation (P < .001).

CLINICAL IMPLICATIONS

Face-valid criteria for the diagnosis of DE were statistically verified, and functional correlates of DE relevant to guiding and focusing treatment were identified.

STRENGTHS AND LIMITATIONS

In this first comprehensive analysis of its kind, we have demonstrated widespread differences on sexual and relationship variables relevant to the diagnosis of DE and to its functional correlates between men with and without DE symptomology during partnered sex. Limitations include participant recruitment through social media, which likely biased the sample; the use of estimated rather than clocked ejaculation latencies; and the fact that differences between men with acquired and lifelong DE were not investigated.

CONCLUSION

This well-powered multinational study provides strong empirical support for several face-valid measures for the diagnosis of DE, with a number of explanatory and control covariates that may help shed light on the lived experiences of men with DE and suggest focus areas for treatment. Whether or not the DE men had comorbid erectile dysfunction had little impact on the differences with men having normal ejaculatory functioning.

Description of and Relationships among Potential Variables Supported for the Diagnosis of Delayed Ejaculation

The lack of empirically based diagnostic criteria for delayed ejaculation (DE) not only undermines confidence in the reported prevalence rates for this sexual dysfunction, but it has also resulted in a lack of validated patient reported outcomes (PROs) for assessing this condition. The current study was designed to describe and evaluate six face-valid variables previously shown to discriminate between men with and without DE for their utility as diagnostic measures for DE. A sample of 1285 men (mean age = 37.8, SD = 12.7) free of erectile problems and premature ejaculation completed an online sexual health survey that included potential questions intended for use in the diagnosis of DE. Questionnaire items included ones reflective of previously proposed diagnostic constructs related to DE: ejaculation timing/latency, ejaculation efficacy/control, and negative effects of DE. Results indicated that five of the six proposed items showed moderate intercorrelations, suggesting that each constituted a distinct (i.e., non-redundant) though relevant criterion related to the diagnosis of DE. Based on the level of interrelatedness, the better items representing each construct were included in commonality analysis to assess their unique contributions to the diagnosis of DE. Perceived lack of ejaculatory efficacy/control contributed the largest portion of the variance to the diagnosis of DE (58%), with bother/distress (an index of the negative effects of DE) contributing the second largest portion (25%), and ejaculation timing/latency contributing only a small portion of the variance (6%) to the diagnosis of DE. The relevance of these findings to developing a patient report outcome (PRO) for diagnosing DE that considers both empirically supported questions/items and an appropriate balance of items regarding the three constructs was discussed.

Comprehensive analysis of global research on overactive bladder: A scientometric approach

Background

Overactive bladder, a syndrome marked by an urgent need to urinate, is a globally prevalent ailment. Human health and quality of life are seriously affected. Therefore, it is essential to investigate the current progress and trends in this field.

Objective

No bibliometric analysis of overactive bladder has been conducted. Through the use of bibliometrics and visualization, this study intends to examine the current progress and development trend of this field.

Methods

Global publications on overactive bladder between January 2004 and August 2022 were extracted from the Web of Science core collection database. A bibliometric and visual analysis was carried out using VOSviewer software and CiteSpace.

Results

Over the last 20 years, publications have grown rapidly, but after 2019, they started to fall. According to the collaboration network, the United States, Univ Pittsburgh AND NEUROUROLOGY AND URODYNAMICS are the most active countries, institutes AND journals in the field, respectively. All keywords were categorized by the symbiosis analysis into four categories: experimental study, symptoms, clinical use, and quality of life. The most prevalent keyword across all clusters is "overactive bladder."

Conclusion

Year after year, there have been more publications in the field of overactive bladder research in many countries, and there has been a deeper level of cooperation and exchange. Researchers will still be interested in overactive bladder in the future. Currently, the clinical application of the disease and the safety and effectiveness of medications are being investigated. However, radical innovation in relevant experimental technologies is a significant obstacle in this field.

Does Bother/Distress Contribute to the Diagnosis of Premature Ejaculation?

Introduction

The role of bother/distress in the diagnosis of premature ejaculation (PE) has received minimal investigation compared with the 2 other diagnostic criteria, ejaculatory control and ejaculatory latency (EL).

Aim

This study assessed (i) the added variance explained by bother/distress to the diagnostic accuracy of PE and (ii) determined its overall contribution to a PE diagnosis.

Methods

The 3 diagnostic criteria for PE were assessed in 2,589 men (mean age = 38.2 years, SD = 13.5) in order to determine the contribution of each factor to a dysfunctional diagnosis. A series of regression and discriminant analyses were used to assess the value of bother/distress in explaining ejaculatory control and in predicting accuracy of PE group status. Commonality analysis was used to determine the relative contribution of each of these factors to the diagnosis of PE.

Main Outcome Measure

The major outcome was the quantified contribution of “bother/distress” to a PE diagnosis.

Results

Bother/distress accounted for about 3–4% of the variation in ejaculatory control and added only minimally to the prediction accuracy of PE group status (no, probable, definite PE). Commonality analysis indicated that bother/distress comprised about 3.6% of the unique explained variation in the PE diagnosis, compared with ejaculatory control and EL which contributed 54.5% and 26.7%, respectively. Common variance among factors contributed the remaining 15.5% to the PE diagnosis.

Clinical Translation

Bother/distress contributes least to the determination of a PE diagnosis. Its contribution is largely redundant with the unique and combined contributions of ejaculatory control and EL.

Strengths and Limitations

Using a well-powered and multivariate analysis, this study parsed out the relative contributions of the 3 diagnostic criteria to a PE diagnosis. The study is limited by its use of estimated EL, a single item assessment of bother/distress, and the lack of differentiation of PE subtypes, lifelong and acquired.

Conclusion

Bother/distress contributes minimally to the PE diagnosis, yet its assessment may be key to understanding the experiences of the patient/couple and to developing an effective treatment strategy.

Rowland DL, McNabney SM, Hevesi K. Does Bother/Distress Contribute to the Diagnosis of Premature Ejaculation?. Sex Med 2022;10:100548.

The Tenuous Role of Distress in the Diagnosis of Premature Ejaculation: A Narrative Review

BACKGROUND

Unlike the other 2 criteria for diagnosing premature ejaculation (PE), namely lack of ejaculatory control and short ejaculation latency (EL), the role of bother/distress has received only minimal consideration and investigation.

AIM

The specific aim was to determine both why distress is included in the PE diagnosis and whether such inclusion is advantageous to achieving better diagnostic outcomes. To this end, the review explored the historical and theoretical underpinnings of the inclusion of "bother/ distress" in the diagnosis of PE, with reference to the larger role that distress has played in the diagnosis of mental disorders, in an attempt to understand the utility (or lack thereof) of this construct in making a PE diagnosis.

METHODS

We reviewed the role of bother/distress across current professional definitions for PE and then expanded this discussion to include the role of distress in other sexual dysfunctions. We then included a brief historical perspective regarding the role that distress has played in the diagnosis of PE. This discussion is followed by a deeper look at 2 nosological systems, namely DSM and ICD, to allow perspective on the inclusion of the bother/distress construct in the diagnosis of mental and behavioral disorders, including the assumptions/arguments put forward to include or exclude bother/distress as an important criterion underlying various professional assumptions.

OUTCOME

Determination of the value and/or need of including bother/distress as a necessary criterion for the diagnosis of PE.

RESULTS

Based on the research literature, bother/distress does not appear to be as critical for a PE diagnosis as either the lack of ejaculatory control or short EL. It is the weakest of the differences among men with and without PE, and recent evidence suggests that its inclusion is generally redundant with the severity of the 2 other criteria for PE, ejaculatory control and EL.

CLINICAL TRANSLATION

Bother/distress appears to serve little purpose in the diagnosis of PE yet its assessment may be important for the treatment strategy and for assessing treatment effectiveness.

STRENGTHS AND LIMITATIONS

This review did not provide a critical analysis of the literature regarding the role of bother/distress in PE, but rather focused on its potential value in understanding and diagnosing PE.

CONCLUSION

Although bother/distress appears to add little to the improvement of accuracy for a PE diagnosis, understanding and assessing the man's or couple's experience of distress has important implications for the treatment strategy and focus, as well as for assessing treatment success. Rowland DL, Cooper SE. The Tenuous Role of Distress in the Diagnosis of Premature Ejaculation: A Narrative Review. Sex Med 2022;XX:XXXXXX.

Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?

Introduction

The criteria for premature ejaculation (PE) have generally been limited to the diagnosis of heterosexual men engaging in penile-vaginal intercourse and therefore the applicability of PE diagnostic criteria to gay men and to activities beyond penile-vaginal intercourse has yet to be explored in depth.

Aim

To compare the prevalence of PE in gay and straight men and to assess whether PE-related diagnostic measures (ejaculatory control, ejaculation latency [EL], and bother/distress) can be applied with confidence to gay men or to men engaging in sexual activities other than penile-vaginal intercourse.

Methods

Gay and straight participants (n = 3878) were recruited to take an online survey assessing sexual orientation, sexual function/dysfunction (including specific PE-related measures), sexual relationship satisfaction, and various other sexual behaviors during partnered sex or masturbation.

Outcomes

Comparison of ejaculatory control, EL, and bother/distress across gay and straight men, as well as across different types of sexual activities.

Results

A slightly lower PE prevalence among gay men became undetectable when other predictors of prevalence were included in a multivariate analysis (aOR = 0.87 [95% CI: 0.60–1.22]). Gay men with PE reported longer typical ELs (z_U = -3.35, P < .001) and lower distress (z_U = 3.68, P < .001) relative to straight men, but longer ELs and lower distress were also associated with anal sex.

Clinical Translation

Clinicians can feel confident about using existing criteria for the diagnosis of PE in gay men but should be aware of potentially longer ELs and lower PE-related bother/distress—probably related to the practice of anal sex—compared with straight men.

Strengths and Limitations

Although well-powered and international in scope, this study was limited by biases inherent to online surveys, the lack of a sizable sample of bisexual men, and a lack of differentiation between men with acquired vs lifelong PE.

Conclusions

Irrespective of sexual orientation, gay and straight men with PE reported shorter ELs, lower satisfaction, and greater bother/distress than functional counterparts. While PE-related diagnostic criteria (ejaculatory control, EL, and bother/distress) are applicable to gay men, accommodation for longer ELs and lower bother/distress in gay men should be considered.

McNabney SM, Weseman CE, Hevesi K, et al. Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?. Sex Med 2022;10:100516.

Premature Ejaculation Measures During Partnered Sex and Masturbation: What These Findings Tell Us About the Nature and Rigidity of Premature Ejaculation

Men with premature ejaculation (PE) during partnered sex (as defined by poor ejaculatory control) show significantly reduced PE symptomology during masturbation, but the reasons for this disparity are not clear. This study investigated the other two PE-related diagnostic criteria, namely ejaculatory latency (EL) and bother/distress, in order to explore possible explanations for this disparity between types of sexual activity. Specifically, 1,447 men with either normal or poor ejaculatory control were compared on EL parameters, bother/distress, and sexual satisfaction/pleasure during both partnered sex and masturbation. Results indicated that men with PE reported longer ELs during masturbation than partnered sex, in contrast with men without PE who reported shorter ELs during masturbation. Bother/distress was lower for both groups during masturbation, but bother/distress in men with PE during masturbation was comparable to that of men without PE during partnered sex. Minimal difference in these patterns was found across lifelong and acquired PE subtypes, whereas men with PE with comorbid erectile dysfunction appeared to represent a distinct group. These findings have implications for PE management or treatment as well as for the overall conceptualization of PE as a pathophysiological condition.

The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research

INTRODUCTION

Fifteen years have passed since the International Society of Sexual Medicine first established the 3-pronged criteria for premature ejaculation (PE): a short ejaculation latency, lack of ejaculatory control, and bother/distress. Although the process of establishing valid criteria for any condition or disorder is an ongoing one, a dearth of targeted research on these criteria has hindered professional societies from updating and revising them.

OBJECTIVES

To review and critique existing criteria used in the diagnosis of PE, to identify specific problems with them, and to recommend studies that will address shortcomings.

METHODS

Each of the PE criteria was evaluated and compared against standard procedures for establishing validated measures. Following each analysis, targeted research to address the gaps has been recommended.

RESULTS

Each PE criterion has shortcomings and each can be improved by using standard validation procedures, as noted by the targeted research outcomes. Professional societies can play an important role by encouraging broad participation in research that generates new and relevant data supporting, validating, or challenging the existing criteria.

CONCLUSION

The concepts underlying the diagnostic criteria for PE have both broad consensus and functional utility. Nevertheless, much of the research investigating PE has uncritically adopted these criteria without concomitantly recognizing their limitations. These limitations prevent determining accurate prevalence rates, interpreting research findings with confidence, and establishing efficacious treatment outcomes. Rowland DL, Althof SE, McMahon CG. The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research. Sex Med Rev 2021;XX:XXX-XXX.

Sexual Response Differs during Partnered Sex and Masturbation in Men With and Without Sexual Dysfunction: Implications for Treatment

BACKGROUND

It is unclear whether men who experience sexual difficulty during partnered sex experience similar difficulty during masturbation.

AIM

To determine whether sexual functionality and dysfunctionality were similar or different during masturbation vs partnered sex.

METHODS

We compared sexual responsivity during masturbation vs partnered sex in a multinational sample of 4,209 men with and without a sexual dysfunction to determine whether dysfunctionality was greater, less, or about the same during these 2 types of sexual activity.

OUTCOMES

Consistently lower impairment of sexual function was found during masturbation compared with partnered sex for all 3 sexual problems assessed: erectile dysfunction, premature ejaculation, and delayed ejaculation.

CLINICAL TRANSLATION

These findings reiterate the potential value of assessing sexual responsivity during masturbation as well as melding masturbation strategies with couples therapy in order to attenuate impaired response during partnered sex.

STRENGTH & LIMITATIONS

Although this study provides the first empirical evidence based on a large multinational sample indicating that sexual functionality is consistently higher during masturbation than partnered sex, it does not provide an empirically-derived explanation for this difference.

CONCLUSION

Understanding a man's response potential during masturbation may be important to improving sexual response during partnered sex, with the need for more targeted research that more directly evaluates the use of such strategies in the treatment of men's sexual problems. Rowland DL, Hamilton BD, Bacys KR et al. Sexual Response Differs during Partnered Sex and Masturbation in Men With and Without Sexual Dysfunction: Implications for Treatment. J Sex Med 2021;18:1835-1842.

Comorbidities Among Sexual Problems in Men: Results From an Internet Convenience Sample

INTRODUCTION

Men suffering from one sexual problem sometimes report having another sexual problem, but few studies have determined concordance rates among dysfunctions in non-clinical samples.

AIM

This study determined comorbidities among sexual dysfunctions based on an internet convenience sample of 4432 men from Hungary, the USA, and other world regions that visit social media fora.

METHOD

Participants completed an online 55-item questionnaire that included questions assessing erectile dysfunction (ED), premature ejaculation (PE), delayed ejaculation (DE), and lack of sexual interest (LSI).

MAIN OUTCOME MEASURES

Concordance rates and odds ratios among sexual dysfunctions.

RESULTS

Approximately 8% of men suffered from two or more sexual problems; men with a severe sexual problem were significantly more likely to suffer from a second sexual problem; concordance between PE and erectile dysfunction ranged from 23-29%, with subtypes of lifelong vs acquired PE showing patterns similar to one another; and most men with delayed ejaculation reported minimal problems with LSI, although LSI was generally key to understanding all other dysfunctions.

CONCLUSION

The percentage of men with one sexual problem having a second sexual problem was substantial, ranging from 23-40%. These findings will help clinicians better understand the intertwined nature of sexual problems and assist them in developing management protocols that address concomitant inadequacies in sexual response. Rowland DL, Oosterhouse LB, Kneusel JA, et al. Comorbidities Among Sexual Problems in Men: Results From an Internet Convenience Sample. Sex Med 2021;XX:XXXXXX.

Diagnostic Criteria for Premature Ejaculation: Clarifying the Role of “Ejaculatory Control” and “Bother/Distress”

“Ejaculatory control” and “bother/distress” are key criteria for diagnosing men with premature ejaculation (PE), yet compared with ejaculatory latency (EL), these constructs have received only minimal attention. In addition, they have not been characterized in men having different sexual orientations or subtypes of PE. This study aimed to characterize relationships among ejaculatory control, bother/distress, and EL; to assess differences across men having different sexual orientations, PE status, and PE subtypes (i.e., lifelong vs. acquired); and to determine the importance of ejaculatory control to men’s sexual partners. In total, 1071 men and sexual partners of men rated their ejaculatory control and bother/distress and estimated their EL; these measures were compared across sexual orientation, PE status, PE subtype, and male and female partners of men. Results revealed a monotonic though slightly curvilinear relationship between ejaculatory control and bother/distress. These PE criteria differed significantly between PE and non-PE men, to a lesser extent between gay and straight men, and not at all between men having lifelong vs. acquired PE. Female and male partners of men affirmed the importance of ejaculatory control during partnered sex, indicating lack of control as a potential reason for ending a relationship.

Premature ejaculation in couples using contraceptive withdrawal and associations with characteristics of its use: A cross-sectional study

This study aimed to investigate the Premature Ejaculation Profile (PEP) and its related factors in couples using contraceptive withdrawal (WD). The study sample was composed of 108 participants including 54 males and 54 females (their partners) who used WD. The data were collected via a questionnaire and the male and female forms of the PEP. The mean total PEP index score of the couples (female (F); 1.69 ± 0.55 and male (M); 1.65 ± 0.36) was below the average possible score. Although both males and their partners generally rated control over ejaculation (F; 57.4%, M; 61.1%) and satisfaction with sexual intercourse (F; 63%, M; 79.7%) as good/very good, they rate personal distress related to ejaculation (F; 64.8%, M; 83.4%) and interpersonal difficulty related to ejaculation (F; 81.5%, M; 92.6%) as 'extremely/quite a lot'. As the time of using WD increased, male control over ejaculation increased (p = .019); as the marriage duration (p = .045) and ages (F; p = .012, M; p = .045) of the couples increased, their problems related to ejaculation increased. According to the results, couples who use WD experience PE-related problems, and the problems they experience vary depending on the period of WD use, marriage duration and age.

Perceptions, Expectations, Preferences, and Attitudes Toward Premature Ejaculation, Its Diagnosis and Topical Treatment with Fortacin™ Spray: Results from an Expert Panel Discussion

INTRODUCTION

Premature ejaculation (PE) represents the most prevalent male sexual issue. Before beginning treatment, it is essential to discuss the patient's expectations thoroughly.

METHODS

Herein, we report the results of an expert panel discussion about perceptions, expectations, preferences, and attitudes towards PE, its diagnosis and treatment. The panel took place in October 2019 and involved 30 Italian urologists experienced in the management of male sexual dysfunction. It aimed at investigating physicians' points of view about selected aspects of PE management which emerged during the counselling of PE patients over the previous two years. Treatment-related questions were mainly focused on topical treatment with Fortacin™.

RESULTS

Overall, 83.3% of those interviewed declared that most of their patients perceive PE as a bother rather than a disease. The percentage of urologists interviewed perceived that improved subjective control over ejaculation and prolonged intravaginal ejaculatory latency time (IELT) as the main benefit expected by the majority of their patients was 56.5% and 10%, respectively. Eighty percent of urologists reported on-demand regimen as the dosage modality preferred by the majority of their patients and half of them reported the topical route to be the way of administration preferred in most cases. Moreover, 73.3% of urologists reported that adherence to treatment was higher in patients undergoing topical treatment. Finally, 80% of urologists perceived Fortacin to be efficacious in patients with acquired PE and 70% of them perceived its efficacy to be independent from IELT.

DISCUSSION

Most patients perceive PE as a bother rather than a disease and mainly advocate an improved control over ejaculation. Fortacin is perceived as efficacious in patients with acquired PE, and independent from IELT.

Premature Ejaculation Among Italian Men: Prevalence and Clinical Correlates From an Observational, Non-Interventional, Cross-Sectional, Epidemiological Study (IPER)

Introduction

There is a great variability in the prevalence of premature ejaculation (PE) worldwide and only few data are available about the Italian population.

Aim

To determine the prevalence of PE in the adult male population in Italy.

Methods

Adult men 18 to 80 years old who were sexually active were randomly sampled from patient lists of general practitioners in Italy and were included in this observational, non-interventional, cross-sectional epidemiologic study from January to July 2015.

Main Outcome Measures

Subjects were asked to complete general questionnaires on anthropometric data, lifestyle, education, occupation, economic conditions, general health status, comorbidities, and sexual habits: the Premature Ejaculation Diagnostic Tool (PEDT), the 5-item International Index of Erectile Function, and the Sexual Quality of Life Questionnaire–Male.

Results

1,104 subjects were recruited. Mean age was 45.6 years. Mean prevalence of PE based on PEDT score (≥11) was 18.5%, and 12.4% self-reported an intravaginal ejaculatory latency time shorter than 1 minute. Prevalence of PE proportionally increased with age. 64.6% of patients presented lifelong PE vs 35.4% of patients who reported acquired PE. Estimated prevalence of coexisting PE and erectile dysfunction was 7.0%. Furthermore, overall quality of sexual life was significantly worse in men with PE (P = .006). Enrolled men reported an overall rate of sexual problems in their partners of approximately 30%. 31.3% of patients with PE did not seek help for their dysfunction. No significant differences were noted between patients with and without PE for body mass index, alcohol consumption, smoking habits, physical activity, education, economic conditions, and marital status.

Conclusions

PE has a high prevalence in the Italian male population, increases with age, and heavily affects quality of life in patients and their partners. Encouraging data exist concerning the percentage of patients seeking help for their condition.

Verze P, Arcaniolo D, Palmieri A, et al. Premature Ejaculation Among Italian Men: Prevalence and Clinical Correlates From an Observational, Non-Interventional, Cross-Sectional, Epidemiological Study (IPER). Sex Med 2018;6:193–202.

Reexamining the Definitions of PE and DE

Evidence-based definitions improve clinical practice and research. Nonetheless, the International Society of Sexual Medicine (ISSM) and the American Psychiatric Association's (DSM-5) definitions regarding lifelong and acquired premature ejaculation (PE) and delayed ejaculation (DE) require reexamination. Existing Intravaginal Ejaculation Latency Time (IELT) evidence, the ISSM position papers, and articles both supporting and critiquing the ISSM's definitions were reviewed. Disproportionately, the findings from those studies document that the majority of men's IELT range is approximately 4 to 10 minutes. Such robust quantitative evidence should become the basis for determining the temporal criterion when defining both PE and DE. Any bilateral deviation from that majority's ∼4- to 10-minute IELT range should meet the qualification for the temporal diagnostic criterion. However, for a man to be diagnosed with a disorder, a licensed health-care clinician (HCC) must also determine that the man suffers from "lack of control" and "distress." Diagnosis would include subtyping Lifelong or Acquired, Global or Situational, similar to the ISSM guidelines and specifying mild, moderate, or severe-similar to DSM-5 requirements. "Control" and "distress" should trump latency and convey greater weight in the diagnostic process. Loosened latency criteria could result in false positive diagnoses; however, requiring a licensed HCC to evaluate control and distress reduces that risk.

Phosphodiesterase Type 5 Inhibitors for Premature Ejaculation: A Systematic Review and Meta-analysis

CONTEXT

Phosphodiesterase type 5 inhibitors (PDE5-Is) are prescribed off-label for the treatment of premature ejaculation (PE).

OBJECTIVE

To systematically review the evidence from randomised controlled trials (RCTs) for PDE5-Is in the management of PE.

EVIDENCE ACQUISITION

Medline and other databases were searched through September 2015. Quality of RCTs was assessed. Intravaginal ejaculatory latency time (IELT) data were pooled in a meta-analysis. Heterogeneity was assessed.

EVIDENCE SYNTHESIS

Fifteen RCTs were included. The majority were of unclear methodological quality. Pooled IELT evidence suggests that PDE5-Is are significantly more effective than placebo (231 participants, p<0.00001), that there is no difference between PDE5-Is and selective serotonin reuptake inhibitors (SSRIs; 405 participants, p=0.50), and that PDE5-Is combined with an SSRI are significantly more effective than SSRIs alone (521 participants, p=0.001); however, high levels of statistical heterogeneity are evident (I2 ≥ 40%). Single-RCT evidence suggests that sildenafil is significantly more effective than the squeeze technique, but both lidocaine gel and tramadol are significantly more effective than sildenafil. Sildenafil combined with behavioural therapy is significantly more effective than behavioural therapy alone. Sexual satisfaction and ejaculatory control appear to be better with PDE5-Is compared with placebo and with PDE5-Is combined with an SSRI compared with an SSRI alone. Adverse events are reported with both PDE5-Is and other agents.

CONCLUSIONS

PDE5-Is are significantly more effective than placebo and PDE5-Is combined with an SSRI are significantly more effective than SSRIs alone at increasing IELT and improving other effectiveness outcomes; however, heterogeneity is evident across RCTs. The methodological quality of the majority of RCTs is unclear.

PATIENT SUMMARY

We reviewed phosphodiesterase type 5 inhibitors (PDE5-Is) for treating premature ejaculation. We found evidence to suggest that PDE5-Is are effective compared with placebo and that PDE5-Is combined with an SSRI are more effective than an SSRI alone. Adverse events are reported with PDE5-Is and other agents; however, the quality of the evidence is uncertain.

TRIAL REGISTRATION

PROSPERO registration number CRD42013005289.

The design and methodology of premature ejaculation interventional studies

Large well-designed clinical efficacy and safety randomized clinical trials (RCTs) are required to achieve regulatory approval of new drug treatments. The objective of this article is to make recommendations for the criteria for defining and selecting the clinical trial study population, design and efficacy outcomes measures which comprise ideal premature ejaculation (PE) interventional trial methodology. Data on clinical trial design, epidemiology, definitions, dimensions and psychological impact of PE was reviewed, critiqued and incorporated into a series of recommendations for standardisation of PE clinical trial design, outcome measures and reporting using the principles of evidence based medicine. Data from PE interventional studies are only reliable, interpretable and capable of being generalised to patients with PE, when study populations are defined by the International Society for Sexual Medicine (ISSM) multivariate definition of PE. PE intervention trials should employ a double-blind RCT methodology and include placebo control, active standard drug control, and/or dose comparison trials. Ejaculatory latency time (ELT) and subject/partner outcome measures of control, personal/partner/relationship distress and other study-specific outcome measures should be used as outcome measures. There is currently no published literature which identifies a clinically significant threshold response to intervention. The ISSM definition of PE reflects the contemporary understanding of PE and represents the state-of-the-art multi-dimensional definition of PE and is recommended as the basis of diagnosis of PE for all PE clinical trials.

Classification and definition of premature ejaculation

Premature ejaculation (PE) is a poorly understood condition and is considered as the most common sexual disorder in men. The ambiguity surrounding PE is in part due to the difficulty in conducting and interpreting research in the absence of a standardised definition that adequately encompasses the characteristics of these patients. An enhanced awareness of sexual dysfunctions in the recent decades has lead to an increase in scientific research that has challenged the traditional paradigm regarding PE. This has also enabled to establish a universal definition and classification of the disease. A move to a more evidence based approach has improved the clinicians' ability to define those who need medical treatment, as well as perform further research in this complex condition.

Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point model

The Sexual Tipping Point(®) (STP) model is an integrated approach to the etiology, diagnosis and treatment of men with delayed ejaculation (DE), including all subtypes manifesting ejaculatory delay or absence [registered trademark owned by the MAP Educational Fund, a 501(c)(3) public charity]. A single pathogenetic pathway does not exist for sexual disorders generally and that is also true for DE specifically. Men with DE have various bio-psychosocial-behavioral & cultural predisposing, precipitating, maintaining, and contextual factors which trigger, reinforce, or worsen the probability of DE occurring. Regardless of the degree of organic etiology present, DE is exacerbated by insufficient stimulation: an inadequate combination of "friction and fantasy". High frequency negative thoughts may neutralize erotic cognitions (fantasy) and subsequently delay, ameliorate, or inhibit ejaculation, while partner stimulation (friction) may prove unsatisfying. Assessment requires a thorough sexual history including inquiry into masturbatory methods. Many men with DE engage in an idiosyncratic masturbatory style, defined as a masturbation technique not easily duplicated by the partner's hand, mouth, or vagina. The clinician's most valuable diagnostic tool is a focused sex history (sex status). Differentiate DE from other sexual problems and review the conditions under which the man can ejaculate. Perceived partner attractiveness, the use of fantasy during sex, anxiety-surrounding coitus and masturbatory patterns require meticulous exploration. Identify important DE causes by juxtaposing an awareness of his cognitions and the sexual stimulation experienced during masturbation, versus a partnered experience. Assist the man in identifying behaviors that enhance immersion in excitation and minimize inhibiting thoughts, in order to reach ejaculation in his preferred manner. Discontinuing, reducing or altering masturbation is often required, which evokes patient resistance. Coaching tips are offered on how to ensure adherence to this suspension, manage resistance and facilitate success. Depending on motivation level, masturbation interruption may be compromised and negotiated. Encourage a man who continues to masturbate to alter style ("switch hands") and to approximate the stimulation likely to be experienced with his partner. Success will require most men to be taught to learn bodily movements and fantasies that approximate the thoughts and sensations experienced in masturbation. Fertility issues, as well as patient/partner anger are important causational factors, which often require individual and/or conjoint consultation. Drug treatment would benefit men particularly with severe DE, regardless of concomitant psychosocial-behavioral and cultural complications. When and if a safe effective medication for DE becomes available, this author's transdisciplinary perspective supports appropriate medication use when integrated with counseling. This approach emphasizes the utility of a biopsychosocial-cultural perspective combined with special attention to the patient's narrative. Treatment is patient-centered, holistic and integrates a variety of therapies as needed.

Interventions to treat premature ejaculation: a systematic review short report

BACKGROUND

Premature ejaculation (PE) is commonly defined as ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it. PE can be either lifelong and present since first sexual experiences (primary), or acquired (secondary), beginning later (Godpodinoff ML. Premature ejaculation: clinical subgroups and etiology. J Sex Marital Ther 1989;15:130-4). Treatments include behavioural and pharmacological interventions.

OBJECTIVE

To systematically review evidence for clinical effectiveness of behavioural, topical and systemic treatments for PE.

DATA SOURCES

The following databases were searched from inception to 6 August 2013 for published and unpublished research evidence: MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effects and the Health Technology Assessment database; ISI Web of Science, including Science Citation Index, and the Conference Proceedings Citation Index-Science. The US Food and Drug Administration website and the European Medicines Agency (EMA) website were also searched.

METHODS

Randomised controlled trials (RCTs) in adult men with PE were eligible (or non-RCTs in the absence of RCTs). RCT data were extrapolated from review articles when available. The primary outcome was intravaginal ejaculatory latency time (IELT). Data were meta-analysed when possible. Other outcomes included sexual satisfaction, control over ejaculation, relationship satisfaction, self-esteem, quality of life, treatment acceptability and adverse events (AEs).

RESULTS

A total of 103 studies (102 RCTs, 65 from reviews) were included. RCTs were available for all interventions except yoga. The following interventions demonstrated significant improvements (p < 0.05) in arithmetic mean difference in IELT compared with placebo: topical anaesthetics - eutectic mixture of local anaesthetics (EMLA(®), AstraZeneca), topical eutectic mixture for PE (Plethora Solutions Ltd) spray; selective serotonin reuptake inhibitors (SSRIs) - citalopram (Cipramil(®), Lundbeck), escitalopram (Cipralex(®), Lundbeck), fluoxetine, paroxetine, sertraline, dapoxetine (Priligy(®), Menarini), 30 mg or 60 mg; serotonin-noradrenaline reuptake inhibitors - duloxetine (Cymbalta(®), Eli Lilly & Co Ltd); tricyclic antidepressants - inhaled clomipramine 4 mg; phosphodiesterase-5 (PDE5) inhibitors - vardenafil (Levitra(®), Bayer), tadalafil (Cialis(®), Eli Lilly & Co Ltd); opioid analgesics - tramadol (Zydol SR(®), Grünenthal). Improvements in sexual satisfaction and other outcomes compared with placebo were evident for SSRIs, PDE5 inhibitors and tramadol. Outcomes for interventions not compared with placebo were as follows: behavioural therapies - improvements over wait list control in IELT and other outcomes, behavioural therapy plus pharmacotherapy better than either therapy alone; alpha blockers - terazosin (Hytrin(®), AMCO) not significantly different to antidepressants in ejaculation control; acupuncture - improvements over sham acupuncture in IELT, conflicting results for comparisons with SSRIs; Chinese medicine - improvements over treatment as usual; delay device - improvements in IELT when added to stop-start technique; yoga - improved IELT over baseline, fluoxetine better than yoga. Treatment-related AEs were evident with most pharmacological interventions.

LIMITATIONS

Although data extraction from reviews was optimised when more than one review reported data for the same RCT, the reliability of the data extraction within these reviews cannot be guaranteed by this assessment report.

CONCLUSIONS

Several interventions significantly improved IELT. Many interventions also improved sexual satisfaction and other outcomes. However, assessment of longer-term safety and effectiveness is required to evaluate whether or not initial treatment effects are maintained long term, whether or not dose escalation is required, how soon treatment effects end following treatment cessation and whether or not treatments can be stopped and resumed at a later time. In addition, assessment of the AEs associated with long-term treatment and whether or not different doses have differing AE profiles is required.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005289.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effects of adult male circumcision on premature ejaculation: results from a prospective study in China

The purpose of this study is to investigate the effects of adult male circumcision on premature ejaculation (PE). Therefore, between December 2009 and March 2014, a total of 575 circumcised men and 623 uncircumcised men (control group) were evaluated. Detailed evaluations (including circumcision and control groups) on PE were conducted before circumcision and at the 3-, 6-, 9-, and 12-month follow-up visits after circumcision. Self-estimated intravaginal ejaculatory latency time (IELT), Patient-Reported Outcome measures, and 5-item version of the International Index of Erectile Function were used to measure the ejaculatory and erectile function for all subjects. The results showed that, during the one-year follow-up, men after circumcision experienced higher IELT and better scores of control over ejaculation, satisfaction with sexual intercourse, and severity of PE than men before circumcision (P < 0.001 for all). Similarly, when compared with the control group, the circumcised men reported significantly improved IELT, control over ejaculation, and satisfaction with sexual intercourse (P < 0.001 for all). These findings suggested that circumcision might have positive effects on IELT, ejaculatory control, sexual satisfaction, and PE severity. In addition, circumcision was significantly associated with the development of PE.

An evidence-based unified definition of lifelong and acquired premature ejaculation: report of the second international society for sexual medicine ad hoc committee for the definition of premature ejaculation

Introduction

The International Society for Sexual Medicine (ISSM) Ad Hoc Committee for the Definition of Premature Ejaculation developed the first evidence-based definition for lifelong premature ejaculation (PE) in 2007 and concluded that there were insufficient published objective data at that time to develop a definition for acquired PE.

Aim

The aim of this article is to review and critique the current literature and develop a contemporary, evidence-based definition for acquired PE and/or a unified definition for both lifelong and acquired PE.

Methods

In April 2013, the ISSM convened a second Ad Hoc Committee for the Definition of Premature Ejaculation in Bangalore, India. The same evidence-based systematic approach to literature search, retrieval, and evaluation used by the original committee was adopted.

Results

The committee unanimously agreed that men with lifelong and acquired PE appear to share the dimensions of short ejaculatory latency, reduced or absent perceived ejaculatory control, and the presence of negative personal consequences. Men with acquired PE are older, have higher incidences of erectile dysfunction, comorbid disease, and cardiovascular risk factors, and have a longer intravaginal ejaculation latency time (IELT) as compared with men with lifelong PE. A self-estimated or stopwatch IELT of 3 minutes was identified as a valid IELT cut-off for diagnosing acquired PE. On this basis, the committee agreed on a unified definition of both acquired and lifelong PE as a male sexual dysfunction characterized by (i) ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE); (ii) the inability to delay ejaculation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.

Conclusion

The ISSM unified definition of lifelong and acquired PE represents the first evidence-based definition for these conditions. This definition will enable researchers to design methodologically rigorous studies to improve our understanding of acquired PE. Serefoglu EC, McMahon CG, Waldinger MD, Althof SE, Shindel A, Adaikan G, Becher EF, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An evidence-based unified definition of lifelong and acquired premature ejaculation: Report of the second International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation. Sex Med 2014;2:41–59.

An evidence-based unified definition of lifelong and acquired premature ejaculation: report of the second International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation

INTRODUCTION

The International Society for Sexual Medicine (ISSM) Ad Hoc Committee for the Definition of Premature Ejaculation developed the first evidence-based definition for lifelong premature ejaculation (PE) in 2007 and concluded that there were insufficient published objective data at that time to develop a definition for acquired PE.

AIM

The aim of this article is to review and critique the current literature and develop a contemporary, evidence-based definition for acquired PE and/or a unified definition for both lifelong and acquired PE.

METHODS

In April 2013, the ISSM convened a second Ad Hoc Committee for the Definition of Premature Ejaculation in Bangalore, India. The same evidence-based systematic approach to literature search, retrieval, and evaluation used by the original committee was adopted.

RESULTS

The committee unanimously agreed that men with lifelong and acquired PE appear to share the dimensions of short ejaculatory latency, reduced or absent perceived ejaculatory control, and the presence of negative personal consequences. Men with acquired PE are older, have higher incidences of erectile dysfunction, comorbid disease, and cardiovascular risk factors, and have a longer intravaginal ejaculation latency time (IELT) as compared with men with lifelong PE. A self-estimated or stopwatch IELT of 3 minutes was identified as a valid IELT cut-off for diagnosing acquired PE. On this basis, the committee agreed on a unified definition of both acquired and lifelong PE as a male sexual dysfunction characterized by (i) ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE); (ii) the inability to delay ejaculation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.

CONCLUSION

The ISSM unified definition of lifelong and acquired PE represents the first evidence-based definition for these conditions. This definition will enable researchers to design methodologically rigorous studies to improve our understanding of acquired PE.

Female partner's perception of premature ejaculation and its impact on relationship breakups, relationship quality, and sexual satisfaction

INTRODUCTION

Women's perceptions of the men's ejaculatory behavior, as well as the impact premature ejaculation (PE) has on the couple's functioning, are important factors that need to be considered.

AIM

This survey investigated women's perception and importance of ejaculatory function, as well as the specific aspects of PE that cause distress. In addition, the survey further identified the factors with a greater impact on intimacy, relationship, and sexual behavior.

METHODS

The 1,463 females belonging to a web panel from three different countries (Mexico, Italy, and South Korea), aged 20-50 years, participated in the survey. A combination of validated and self-constructed questionnaires to assess women's perception of PE, relationship satisfaction and quality, and sexual functioning and satisfaction were used.

MAIN OUTCOME MEASURES

Descriptive statistics in form of proportions and percentages, correlation, and regression analyses.

RESULTS

A significant correlation between the importance of ejaculatory control and felt distress could be observed (rho = 0.55, P < 0.001). Women reporting less sexual problems considered ejaculatory control more important and reported more PE-related distress (rho = 0.23 and 0.11, respectively; P < 0.001 for both). The male's lack of attention and focus on performance was the most frequently reported reasons for sexual distress (47.6%) followed by "the short time between penetration and ejaculation" (39.9%), and "the lack of ejaculatory control" (24.1%). Almost a quarter of women reported that the man's ejaculatory problem had previously led to relationship breakups (22.8%). Women considering duration to be important were more likely to report breakups.

CONCLUSIONS

The study highlights the detrimental effects of PE on relationship and sexual satisfaction in the female partner and how it can lead to the termination of the relationship. Most notably, this is the first study to report that an important source of female distress are not only parameters related to performance such as control or duration but rather inappropriate attention focus and the negligence of other forms of sexual activities.

Prevalence and impact of premature ejaculation in outpatients complaining of ejaculating prematurely: using the instruments of intravaginal ejaculatory latency time and patient-reported outcome measures

This study was designed to assess the impact of premature ejaculation (PE) on a large population of men and their female partners using the instruments of intravaginal ejaculatory latency time (IELT) and patient-reported outcome (PRO) measures. A non-interventional, observational and cross-sectional field survey enrolled 2704 men with self-reported PE and their female partners from January 2010 to January 2012. PE was diagnosed by the International Society for Sexual Medicine (ISSM) criterion. IELT and sexual dysfunction were measured using a stopwatch and PRO measures, respectively. The incidence of PE in this study was 19.27%. PE negatively impacted on subjects and their partners, including reduced ejaculatory control and sexual satisfaction, and increased personal distress and interpersonal difficulty (P<0.001 for all). The severity of PE was considered worse by subjects than by their female partners (P<0.001). Reduced ejaculatory control and sexual satisfaction were considered the central themes of PE. Furthermore, a correlation was observed among the outcomes of IELT and PRO measures for subjects and their partners (absolute correlation coefficient ranged from 0.33 to 0.67). This in-depth qualitative study provides valuable insight into the PE status in Chinese men. Further research is needed to confirm and extend these results.

Efficacy and safety of dapoxetine in men with premature ejaculation and concomitant erectile dysfunction treated with a phosphodiesterase type 5 inhibitor: randomized, placebo-controlled, phase III study

INTRODUCTION

Men with comorbid erectile dysfunction (ED) and premature ejaculation (PE) may be concomitantly prescribed a phosphodiesterase type 5 (PDE5) inhibitor and dapoxetine.

AIM

Evaluate efficacy and safety of dapoxetine 30 mg and 60 mg on demand (prn) in men with PE and ED who were being treated with PDE5 inhibitors.

METHODS

This randomized, double-blind, placebo-controlled, flexible-dose, multicenter study enrolled men ≥18 years who met diagnostic criteria for PE including intravaginal ejaculatory latency time (IELT) of ≤2 minutes in ≥75% of sexual intercourse episodes; were on stable regimen of a PDE5 inhibitor; and had International Index of Erectile Function-erectile function domain score ≥21. Subjects received placebo, dapoxetine 30 mg, or dapoxetine 60 mg prn (1-3 hours before intercourse) for 12 weeks.

MAIN OUTCOME MEASURE

Stopwatch-measured average IELT, Clinical Global Impression of Change (CGIC) in PE, Premature Ejaculation Profile (PEP), and treatment-emergent adverse events (TEAEs).

RESULTS

Of 495 subjects randomized, 429 completed the study. Arithmetic mean average IELT significantly increased with dapoxetine vs. placebo at end point (5.2 vs. 3.4 minutes) and weeks 4, 8, and 12 (P ≤ 0.002 for all). Men who described their PE at least "better" using the CGIC were significantly greater with dapoxetine vs. placebo at end point (56.5% vs. 35.4%) and weeks 4, 8, and 12 (P ≤ 0.001 for all). Significantly better outcomes were also reported with dapoxetine vs. placebo on PEP measures. Incidence of TEAEs was 20.0% and 29.6% in placebo- and dapoxetine-treated subjects, respectively (P = 0.0135). TEAEs led to discontinuation in 1.6% of subjects in both groups. Most frequent TEAEs were known adverse drug reactions of dapoxetine treatment including nausea (9.2%), headache (4.4%), diarrhea (3.6%), dizziness (2.4%), and dizziness postural (2.4%).

CONCLUSIONS

In men with PE and comorbid ED on a stable regimen of PDE5 inhibitor, dapoxetine provided meaningful treatment benefit and was generally well tolerated.

Functional and psychological characteristics of belgian men with premature ejaculation and their partners

Physiological, behavioral, cognitive, and emotional factors are generally acknowledged to play a role in premature ejaculation (PE). However, the nature and the extent of their etiological impact remain largely imprecise. The present study examined functional and psychometric dynamics at work in a PE population. A total of 461 men with PE and 80 partners completed an online questionnaire. The main outcome measures were self-reported ejaculatory latency time, the feeling of control upon ejaculation, sexual satisfaction, distress related to PE, trait anxiety (STAI-B), sexual cognitions (Sexual Irrationality Questionnaire [SIQ]), social anxiety (Liebowitz's Social Anxiety Scale [LSAS] and Social Interaction Self-Statement Test [SISST]), and personality traits (Temperament and Character Inventory-Revised [TCI-R]). In our sample, the median latency time to ejaculation was between 1 and 2 min. Sexual satisfaction and distress correlated more strongly with the feeling of control than with the self-reported latency time. Men experienced more distress and dissatisfaction related to PE than did their partners, while overestimating their partners' distress and dissatisfaction. PE participants' scores differed significantly, albeit slightly, from STAI-B, SIQ, LSAS, and SISST norms. The differences were negligible on TCI-R. Some differences became stronger when subtypes were considered. Participants combining generalized and lifelong PE with self-reported latency times of <30 s reported lower sexual satisfaction and control, higher distress, higher social anxiety, and harm avoidance (TCI-R/HA) scores. By contrast, the situational subtype of PE was found to be characterized by a higher level of satisfaction, a greater feeling of control, less distress, and higher trait anxiety scores. However, the trends remained statistically discrete.

Psychological impact of premature ejaculation and barriers to its recognition and treatment

BACKGROUND

Premature ejaculation (PE) is the most common male sexual dysfunction, occurring in 20-30% of men. Unlike erectile dysfunction, which increases with age, rates of PE remain constant across the adult life span.

OBJECTIVE

To review the prevalence of PE, its psychological sequelae and barriers to effective treatment, treatment options, and the effects of treatment on the psychological burden of PE.

METHODS

PubMed and Embase databases were searched to identify primary papers related to PE published between 1980 and 2010. Key words included premature ejaculation, prevalence, quality of life, interpersonal relationships, psychotherapy, drug therapy, and treatment barriers.

RESULTS

Men with PE often suffer from significant psychological distress including anxiety, depression, lack of sexual confidence, poor self-esteem, impaired quality of life, sexual dissatisfaction, and interpersonal difficulties. Due to various reasons, however, most men do not seek treatment for PE. Many physicians are unaware of the distressful nature of PE and might be reluctant to ask patients about their sexual function. Nevertheless, increasing clinical research on pharmacologic treatment of PE, and the use of on-demand orally administered short-acting selective serotonin reuptake inhibitors or topically applied local anesthetics, appears promising. Although few rigorous studies assessing psychotherapeutic treatments have been conducted, many clinicians report the success of psychological treatments for PE.

SUMMARY AND CONCLUSIONS

Conclusions drawn from this review are limited due to inherent variations across studies, including criteria to define PE, study designs, outcome measures, populations, survey instruments, and study settings. While the psychological distress associated with PE suggests the appropriateness of at least minimal counseling for couples, limited data are available to support a combined psychotherapeutic and pharmacologic treatment approach. The paucity of well-designed psychotherapy or combination studies represents an important unmet need in the treatment of PE.

Premature and delayed ejaculation: two ends of a single continuum influenced by hormonal milieu

Although it is well established that all the aspects of male reproduction are hormonally regulated, the endocrine control of the ejaculatory reflex is still not completely clarified. Sex steroids, thyroid and pituitary hormones (oxytocin and prolactin) have been proposed to control the ejaculatory process at various levels; however, only a few reports are currently available. The aim of this study was to evaluate the contribution of testosterone, thyrotropin (TSH) and prolactin (PRL) in the pathogenesis of ejaculatory dysfunction in a large series of subjects consulting for sexual dysfunction. Among the 2652 patients studied, 674 (25.2%) and 194 (7.3%) reported premature and delayed ejaculation (PE and DE), respectively. Categorizing ejaculatory difficulties on an eight-point scale starting from severe PE and ending with anejaculation (0 = severe PE, 1 = moderate PE, 2 = mild PE, 3 = no difficulties, 4 = mild DE, 5 = moderate DE, 6 = severe DE and 7 = anejaculation), PRL as well as TSH levels progressively increased from patients with severe PE towards those with anejaculation. Conversely, the opposite was observed for testosterone levels. All of these associations were confirmed after adjustment for age (adjusted r = 0.050, 0.053 and -0.038 for PRL, TSH and testosterone, respectively; all p < 0.05). When all hormonal parameters were introduced in the same regression model, adjusting for age, ΣMHQ (an index of general psychopathology) and use of selective serotonin reuptake inhibitor antidepressants, they were independently associated with ejaculatory problems (adjusted r = 0.056, 0.047 and -0.059 for PRL, TSH and testosterone, respectively; all p < 0.05). This study indicates endocrine system is involved in the control of ejaculatory function and that PRL, TSH and testosterone play an independent role.

Determinants of sexual dysfunction among clinically diagnosed diabetic patients

BACKGROUND

Diabetes mellitus is a chronic disease that can result in various medical, psychological and sexual dysfunctions (SD) if not properly managed. SD in men is a common under-appreciated complication of diabetes. This study assessed the prevalence and determinants of SD among diabetic patients in Tema, Greater Accra Region of Ghana.

METHOD

Sexual functioning was determined in 300 consecutive diabetic men (age range: 18-82 years) visiting the diabetic clinic of Tema General Hospital with the Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaire, between November, 2010 and March, 2011. In addition to the socio-demographic characteristics of the participants, the level of glycosylated haemoglobin, fasting blood sugar (FBS) and serum testosterone were assessed. All the men had a steady heterosexual relationship for at least 2 years before enrolment in the study.

RESULTS

Out the 300 participants contacted, the response rate was 91.3% after 20 declined participation and 6 incomplete data were excluded All the respondents had at least basic education, 97.4% were married, 65.3% were known hypertensive, 3.3% smoked cigarettes, 27% took alcoholic beverages and 32.8% did some form of exercise. The 69.3% SD rate observed in this study appears to be related to infrequency (79.2%), non-sensuality (74.5%), dissatisfaction with sexual acts (71.9%), non-communication (70.8%) and impotence (67.9%). Other areas of sexual function, including premature ejaculation (56.6%) and avoidance (42.7%) were also substantially affected. However, severe SD was seen in only 4.7% of the studied population. The perceived "adequate", "desirable", "too short" and "too long intra-vaginal ejaculatory latency time (IELT) are 5-10, 5-10, 1-2 and 15-30 minutes respectively. Testosterone correlates negatively with glycated haemoglobin (HBA1c), FBS, perceived desirable, too short IELT, and weight as well as waist circumference.

CONCLUSION

SD rate from this study is high but similar to that reported among self-reported diabetic patients in Kumasi, Ghana and vary according to the condition and age. The determinants of SD from this study are income level, exercise, obesity, higher perception of "desirable" and "too short" IELT.

Premature ejaculation: bother and intravaginal ejaculatory latency time in Iran

INTRODUCTION

Complaints of premature ejaculation (PE) and its repercussions are culture-dependent.

AIM

To report the measured intravaginal ejaculatory latency time (IELT) and the impact of PE in Kermanshah, Iran.

METHODS

From November 1996 through October 2008, 3,458 patients presented to us with self-diagnosed PE. In the first visit, after obtaining a psychosocial and sexual history, PE-specific bother was self-rated by the patients and the patients were advised to measure their IELTs over the next 2-3 weeks. In the second visit, the measured IELTs were reported by the patients.

MAIN OUTCOME MEASURES

Patients' measured IELT and bother score.

RESULTS

Age range was 17-80 years (mean 34.1, standard deviation [SD] 9.1, median 32). Sixty-five percent were married. Primary and secondary PE was reported by 2,105 (60.8%) and 1,353 (39.1%) patients, respectively. Occasional PE was reported by 36 (0.01%). Of those with multiple partners, 6% had partner-specific PE. IELT distribution was positively skewed. Anteportal ejaculation was reported by 97 (2.8%). In 3,458 self-reported PE patients, IELT was 1-15 seconds in 542 (15.7%), 16-30 seconds in 442 (12.8%), 31-60 seconds in 978 (28.3%), > 1 <or= 2 minutes in 551 (15.9%), > 2 <or= 5 minutes in 712 (20.6%), and >5 minutes in 136 (3.9%). IELTs of <or=1 minutes and <or=2 minutes were reported by 59.5% and 75.5%, respectively. Median bother score was 3 of 4. Pearson's correlation between IELT and bother (r = -0.607) was highly negative, with shorter IELTs being correlated with more bother. Six hundred forty-three patients (18.6%) always consumed opium to lengthen their IELTs. All 21 patients who started to use Tramadol as a PE treatment became addicted to it. Of 168 divorced couples due to PE, 23 divorced because the sexually dissatisfied wives became involved in extramarital affairs. Applying the Diagnostic and Statistical Manual of Mental Disorders criteria for PE and a cutoff IELT point of <or=2 minutes, and thus excluding the patients with IELTs of longer than 2 minutes, the patients with occasional PE, and the patients who reported no personal bother, of 3,458 self-reported PE patients, 2,571 (74.3%) had PE. Including the 97 patients with anteportal ejaculation, arithmetic mean IELT in 2,571 patients was 45.87 seconds, SD 36.1, median 40, and range 0-120. Excluding the anteportal ejaculation, arithmetic mean IELT in the remaining 2,474 patients was 47.67 seconds, SD 35.71, median 42, range 1-120, and geometric mean 31.06.

CONCLUSION

PE has a devastating impact. In clinical practice, primary lifelong PE is by far the most common variety of PE. Occasional PE is a very rare cause of presentation. A significant proportion of the patients who consider themselves as premature ejaculators have IELTs of more than 2 minutes; the sexual medicine community should reach a consensus on the clinical diagnostic and therapeutic approach to these patients who consider themselves as premature ejaculators. The most important cause of bother in PE is the briefness of the ejaculatory latency, rather than the lack of control. Second-round ED (pseudoED) was reported for the first time. The worst type of PE, i.e., anteportal ejaculation, is not very rare; thus, geometric mean that excludes anteportal ejaculation is not suitable statistics to report the ejaculatory latency time; instead, median is the best measure of IELT reporting. Cutoffs of 0.5-2.5 percentiles are not suitable means to diagnose PE.

Neural regulation of ejaculation

INTRODUCTION

Delineation of the underlying neurophysiological mechanisms of ejaculatory behavior is crucial for the treatment of male sexual dysfunction, including premature ejaculation. Recent studies provide compelling evidence that a population of lumbar spinothalamic (LSt) cells may play a role in the regulation of the ejaculatory response. Subsequent to ejaculation, LSt cells exhibit markers of activation that are not only highly correlated with ejaculatory behavior, but are also absent following the expression of other components of sexual behavior, such as mounts or intromissions. Similarly, targeted chemical lesion of LSt cells using substance P-saporin abolishes ejaculatory behavior explicitly. Early evidence suggests that pharmacological manipulation of LSt cells may offer additional evidence of crucial LSt cell involvement in the generation of ejaculation.

AIM

This review is intended to summarize what has currently been revealed regarding the role of LSt cells in the regulation and generation of ejaculatory behavior, and also to discuss the direction of future behavioral investigations.

METHODS

Information presented in this discussion was derived from analysis of numerous recent articles detailing the delineation of anatomical and physiological correlates of sexual behavior, as well as numerous literature searches using the National Library of Medicine PubMed Services.

RESULTS

A great deal of the work that has led to the implication of LSt cells in ejaculatory behavior is reviewed in the present article, including clinical data, as well as anatomical, physiological, and behavioral examinations. The rationale for ongoing pharmacological studies is also discussed.

CONCLUSION

LSt cells appear to play a vital role in the generation and regulation of ejaculatory behavior. Additional elucidation of this "ejaculation generator" could prove invaluable for the future treatment of male sexual dysfunction. Studies are currently in progress to further reveal the precise function of these cells and mechanisms of action through which they operate.