Abstract
Introduction
The current study aimed to investigate the clinical features of and couple’s attitudes towards premature ejaculation (PE).
Methods
Qualified patients were continuously enrolled from 15 medical centers in different regions of China. Patient data were collected from March 1 2017 to July 31 2017. All men were assessed by the Premature Ejaculation Diagnostic Tool (PEDT) and Intravaginal Ejaculation Latency Time (IELT). Besides, sexual desire, force of ejaculation, and the five-item International Index of Erectile Function (IIEF-5) score were recorded. The couple’s attitudes towards PE were evaluated by a self-designed questionnaire.
Results
In total, 1033 males diagnosed with PE and their sexual partners and 3176 males without PE were enrolled. The mean PEDT and IELT scores of the patients with PE were 14.38 ± 3.68 and 1.59 ± 0.85, respectively. IIEF-5, sexual desire, and force of ejaculation significantly decreased in patients with PE. Among the 1033 couples, 44.3%, 21.39%, and 33.98% of the couples were seeking PE because of the dissatisfaction of the males, the females or both partners, respectively. In terms of the males who were dissatisfied with PE, 49.51% and 17.86% complained of short IELT and inability to control ejaculation. In terms of the females dissatisfied with PE, 41.61%, 19.93%, 21.68%, and 14.51% complained of arousal difficulty, weak sexual desire, failing to have organism and poor relationship, respectively.
Conclusions
PE has a negative impact on erectile function, sexual desire, and force of ejaculation. Sexual partners play important roles in the medical procedures for addressing PE.
Introduction
Premature ejaculation (PE) is one of the most common sexual disorders in males and can affect 4–39% of males in the general population [Citation1–3]. The definition and diagnosis of PE have been discussed and researched over the past few decades [Citation4]. In 2013, the International Society for Sexual Medicine (ISSM) defined PE as a male sexual dysfunction with the following characteristics: (1) ejaculation that always or nearly always occurs before or within 1 min of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often within 3 min (acquired PE), (2) the inability to delay ejaculation on all or nearly all vaginal penetrations, and (3) negative personal consequences [Citation5]. The ISSM definition of PE represents the first evidence-based definition of PE conditions, and this unified definition is of great importance for research into the treatment and epidemiology of PE.
Various biological and psychological theories have been suggested to explain the causes of PE, including hyposensitivity of 5-HT2c receptors and/or hypersensitivity of the 5-HT1a receptors, sexual performance anxiety, psychological or relationship problems, erectile dysfunction (ED), chronic prostatitis, metabolic syndrome (MetS), and hyperthyroidism [Citation6–11]. Notably, most of the causes are speculative and not evidence based. Several studies have attempted to analyze the risk factors for PE. However, the results were inconclusive. For instance, several studies reported a significant association between higher BMI and the occurrence of PE [Citation12,Citation13] while some studies demonstrated a contrary result [Citation14]. In terms of smoking and drinking habits, several studies demonstrated significant associations between these habits and the occurrence of PE [Citation12,Citation13]; however, a recent published meta-analysis indicated nonsignificant associations [Citation15]. Further epidemiological studies of high quality are required to verify the specific associations between these risk factors and PE.
Premature ejaculation can significantly impair sexual function in females [Citation16]. Several studies have reported that female sexual dysfunctions such as anorgasmia, hypoactive sexual desire, sexual aversion, sexual arousal disorders, and sexual pain disorders may be related to acquired PE [Citation17,Citation18]. While various studies have investigated the effects of PE on female sexual function, the role of females in the diagnosis and treatment of PE is usually ignored. According to our clinical experience, many patients seek PE due to the dissatisfaction of their sexual partners. Further studies are required to explore the role of females in the diagnosis and treatment of PE.
Considering the inconsistency of the risk factors and the important role of females in PE, the current multicenter cross-sectional study focused on the risk factors for PE in couples attending andrology outpatient clinics and the attitudes of the couples towards PE.
Methods and materials
Study design and participants
The current multicentered and cross-sectional study focused on married heterosexual males with PE and their sexual partners. The diagnosis of PE was based on the criteria of the second Ad Hoc ISSM Committee. The participating patients were continuously recruited from 15 andrology outpatient clinics from March 1 2017 to July 31 2017. The 15 enrolled andrology outpatient clinics were in different regions of China (North China, Northeast China, Northwest China, Central China, and East China). Three hospitals in each province were chosen and expert andrologists or urologists from Tier 3 hospitals were asked to assist in the supervision of the survey. Patients with PE were included if they were: (1) married heterosexual men; (2) men living day-to-day with their female partners for at least 6 months; (3) men diagnosed with PE and their female partners who agreed to be involved in the study and had available medical histories. Married heterosexual men attending the andrology outpatient clinics were continuously enrolled in the non-PE group if they did not report PE and agreed to be involved. Participants were excluded if they were: (1) men with severe disease such as advanced malignant cancer, severe cardiovascular disease, and psychological disorders; (2) men without a visible genital malformation such as varicocele, testicular trauma, small testes, or cryptorchidism. All patients signed informed consent forms. The study was completely voluntary and anonymous and was approved by the Medical Research Ethics Committee of Peking Union Medical College Hospital, Beijing, China.
Questionnaire survey
All participants completed questionnaires covering the following basic information: age, height, weight, residence, education level, monthly income, occupation, marital status (first marriage or remarried), frequency of sexual intercourse, smoking, alcohol drinking, sexual desire (weak, moderate, or strong) and coexisting diseases (hypertension, diabetes, and chronic prostatitis). Besides, the Intravaginal Ejaculation Latency Time (IELT, which was measured by patients using a stopwatch), the Premature Ejaculation Diagnostic Tool (PEDT) and force of ejaculation (reduced or normal) were recorded for the evaluation of PE. The erectile function status of the males was assessed by the five-item International Index of Erectile Function (IIEF-5).
Additionally, attitudes towards PE were evaluated in patients with PE and their sexual partners through the following questions: (1) what prompted you to seek help with PE? (Man was not satisfied with PE; sexual partner was not satisfied with PE; both of them were not satisfied with PE); (2) what was the males most dissatisfied with? (short IELT; inability to control ejaculation; others); (3) what was the women most dissatisfied with? (arousal difficulty; weak sexual desire; failed to have orgasm; worse coupleboth of them were not sat (4) who was more concerned about the effects of PE treatments? (Man; woman; both of them).
Statistical analysis
Continuous and categorical values were presented as the mean ± standard deviation (SD) and frequency, respectively. All data were initially screened for homogeneity of variance and normality. Statistical significance was determined by the two-tailed Student’s t-test, Mann–Whitney’s U test and Chi-square test. Possible confounding factors associated with the occurrence of PE were identified by multivariable binary logistic regression analyses. Adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used to demonstrate the specific association. The results were considered significant when p values < .05. The statistical analysis was performed using Stata version 12 (StataCorp LP, College Station, TX).
Results
Basic characteristics of the enrolled participants
In total, 1033 males diagnosed with PE and their sexual partners and 3176 males without PE were enrolled. The basic characteristics of the enrolled participants are listed in and . The mean age was significantly higher (p < .001) and the BMI was significantly lower in patients with PE (p < .001). According to the results of the Chi-square test, occurrence of PE in men with higher education levels (p < .001) and monthly income (p < .001), office work (p < .001), primary married status (p < .001), lower frequency of sexual intercourse (p < .001), smoking (p < .001) and drinking habits (p < .001) was significantly higher. Additionally, the incidence of hypertension (p = .015), diabetes (p < .001) and chronic prostatitis (p < .001) were increased in patients with PE. Nonsignificant differences were identified in terms of residence.
Table 1. Basic characteristics of the enrolled participants.
The mean PEDT and IELT of the patients with PE were 14.38 ± 3.68 and 1.59 ± 0.85 min. Notably, IIEF-5 (p < .001), sexual desire (p < .001), and force of ejaculation (p < .001) significantly decreased in the patients with PE.
Table 2. Sexual function of the men with or without PE.
Risk factors associated with PE
Possible risk factors for PE were identified by multivariate analysis. The result indicated that the occurrence of PE was positively associated with lower body mass index (body mass index >25, OR: 0.67, 95%CI: 0.56–0.80, p < .001), higher age (age > 35 years, OR: 1.22, 95%CI: 1.01–1.47, p = .038), higher education level (education level > university, OR: 1.36, 95%CI: 1.12–1.64, p = .002) and monthly income (monthly income > 5000 ¥, OR: 1.34, 95%CI: 1.10–1.63, p = .003), office work (OR: 1.66, 95%CI: 1.38–1.99, p < .001), primary married status (OR: 2.83, 95%CI: 2.06–3.90, p < .001), a lower frequency of sexual intercourse (intercourse < 5 per month, OR: 2.31, 95%CI: 1.93–2.79, p < .001), drinking habits (OR: 1.75, 95%CI: 1.44–2.13, p < .001), diabetes (OR: 2.39, 95%CI: 1.48–3.88, p < .001), chronic prostatitis (OR: 2.22, 95%CI: 1.80–2.75, p < .001), ED (IIEF < 21, OR: 4.57, 95%CI: 3.83–5.46, p < .001), weak sexual desire (OR: 2.11, 95%CI: 1.53–2.92, p < .001), and reduced force of ejaculation (OR: 6.36, 95%CI: 5.20–7.78, p < .001) ().
Table 3. Multivariate analysis of the association between study variables and PE occurrence.
Couple’s attitudes towards PE
Among the 1033 couples, 44.3%, 21.39%, and 33.98% of the couples were seeking PE because of the dissatisfaction of the man, the woman, and both partners, respectively. Among the men who were dissatisfied with PE, 49.51% and 17.86% reported short IELT and inability to control ejaculation, respectively, as the aspects causing the greatest dissatisfaction. In terms of women who were dissatisfied with PE, 41.61%, 19.93%, 21.68%, and 14.51% complained of arousal difficulty, weak sexual desire, failure to have an organism, and worse couple’s relationship, respectively, as the aspects causing the greatest dissatisfaction. In 30.69% of the couples, only the males and not the females were concerned about the treatment effects. In 9.97% of the couples, only the females and not the males were concerned about the treatment effects. In 59.34% of the couples, both the males and their sexual partners were concerned about the effects of PE treatment. Detailed information regarding the couple’s attitudes towards PE is listed in .
Table 4. Couple's attitude towards diagnosis and treatment of PE.
Discussion
Over the past decades, many clinical studies have investigated the risk factors in associated patients with PE; however, the results were controversial. The inconsistency may arise partly from differences in definitions of PE, the basic characteristics of the enrolled participants, the inclusion criteria and the exclusion criteria. To obtain a more comprehensive understanding of PE, more researches of high quality are required to investigate the specific roles of these risk factors. The current study focused on the risk factors for PE in patients attending andrology outpatient clinics. According to the existing data, PE is associated with the following factors: lower body mass index, higher age, education level and monthly income, office work, primary married status, lower frequency of sexual intercourse, drinking habits, diabetes, chronic prostatitis, ED, weak sexual desire, and decreased force of ejaculation.
The association between age and PE is still not clear. According to the results of the National Health and Social Life Survey (NHSLS), the occurrence of PE (diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) did not differ across the analyzed age categories [Citation19]. However, several recently published studies demonstrated a positive association between higher age and PE [Citation14,Citation20]. One possible reason for this is decreased penile sensitivity and nerve conduction in elderly participants. Besides, the different definitions used in these studies may influence the results. Similarly, the current study indicated that higher age can be a potential risk factor for PE.
Recent studies reported a higher prevalence of ED among patients with MetS. Several components of MetS were also found to be associated with ED [Citation21]. Although a large number of studies revealed an association between ED and PE [Citation22], PE has not received the same attention as ED in the study of patients with MetS. Knowledge is still limited regarding the real prevalence of PE in such patients, and only a few studies have investigated the role of obesity in PE. Salama et al. and Jeh et al. reported that PE was more common in patients with MetS [Citation23,Citation24]. Notably, the components of MetS such as hypertension and diabetes and subsequent treatment may influence the occurrence of PE. A recent study indicated that the visceral adiposity index (VAI), a novel indicator for the assessment of visceral obesity, was negatively correlated with PE [Citation25]. One possible cause is the lower testosterone in obese males. Lower testosterone may affect the level of 5-HT in the brain and subsequently result in PE [Citation26]. Consistent with these studies, the current study also demonstrated a negative association between obesity (higher body mass index) and PE. In addition, the components of MetS, such as hypertension and diabetes, were also reported to be risk factors of PE in the current study.
Interestingly, the current study indicated that the incidence of PE was higher in patients with higher education levels, those with a higher monthly income and those who performed office work. In contrast, previous published studies have demonstrated nonsignificant results, which may be due to the differences in cultures and customs in different populations. It is presumed that the higher prevalence of anxiety and depression in patients with higher education levels, higher monthly income and office work may contribute to PE. Further studies are required to explore the specific associations between these social factors and PE.
Several studies have explored the association between prostate diseases and PE [Citation11,Citation27]. Chronic prostatitis was reported to be positively associated with PE [Citation11]. However, the detailed mechanisms were not clear. The prevalence of anxiety and depression in patients with chronic prostatitis is high, and these psychological disorders can contribute to PE. In addition to chronic prostatitis, it is postulated that the local effect of an enlarged prostate on the nerves supplying the penis may induce PE. However, a recent study demonstrated that there was no significant association between prostate volume and PE [Citation27]. One possible reason is that PE is thought to be a disorder of the central nervous system rather than the peripheral nervous system. In the current study, a significant association between chronic prostatitis and PE was revealed, which was consistent with a previous study [Citation11]. Unfortunately, the incidences of psychological disorders were not analyzed, and further studies are required to explore relevant factors.
Various studies have investigated the correlation between ED and PE. In 2015, a meta-analysis identified an association between ED and PE [Citation22]. It is suggested that ED and PE are not separate entities, but should be considered from a dimensional point of view. The prevalence of ED was higher in patients with PE in the current study. Besides, multivariate analysis indicated that ED is a potential risk factor for PE. Sexual desire and force of ejaculation were reported to be decreased in patients with PE and the distress arising from PE and ED may be one possible cause.
Testosterone plays an important role in male sexual disorders. Long-term testosterone therapy can improve urinary and sexual function and quality of life in men with hypogonadism [Citation28]. Fundamental studies have demonstrated that lower testosterone may affect the level of 5-HT in the brain and subsequently result in PE [Citation26]; however, studies exploring the role of testosterone in patients with PE are limited. Unfortunately, sexual hormones were not analyzed because of the various standards used in different hospitals, and further studies are required to investigate the role of testosterone in patients with PE.
Data concerning the role of females in the diagnosis and treatment of PE are limited. Females’ feelings are usually ignored during the diagnosis and treatment of PE in China. There may be two possible reasons for this. First, many clinicians in China believe that almost all patients seek treatment for PE because of their own dissatisfaction; Second, patients will not voluntarily tell their doctors that they came to the clinic because of the dissatisfaction of their sexual partners. Based on these situations, the percentage of dissatisfaction among females can be underestimated. The current study demonstrated that in 21.39% of the couples, the males were seeking treatment for PE because of the dissatisfaction of the females while the males themselves were not concerned about their sexual intercourse. Including those couples in which both partners were dissatisfied with sexual intercourse (33.98%), a total of 55.37% females were dissatisfied with their sexual intercourse. The percentage was relatively higher compared with the traditional perspective. After consulting doctors, nearly half of the females were concerned about the treatment effects (9.97% couples). The percentage decreased because after education by clinicians, the psychological obstacles on the part of the females disappeared. Basic psychosexual education or coaching is necessary not only for patients with PE, but also for their sexual partners.
The current study has several strengths: (1) a large number of patients with PE and patients without PE were enrolled, which enabled adjustment for potential confounders in the multivariate binary logistic regression analysis. (2) Attitudes towards PE were measured in both the males with PE and their sexual partners. There were several limitations that should be addressed in the current cross-sectional study: (1) psychological disorders were not analyzed due to the various standards used in different medical centers. (2) Although the diagnosis of PE was strictly based on the definition developed by ISSM, acquired PE and lifelong PE were not analyzed independently, and further studies are required to investigate the associated risk factors and the role of sexual partners in different subtypes of PE.
Conclusions
PE has a negative impact on erectile function, sexual desire, and force of ejaculation. Sexual partners play important roles in the medical procedures for treating PE.
Acknowledgements
The following individuals are acknowledged for their contribution in this study: Yu Liu, Wenjun Bai, Jialun Guo, Zhiming Hong, Weitian Chen, Da Chen, Chunying Zhang, Yong Yang, Jianhui Wu, Chunyang Wang, Jianjun Cheng, Haixiang Hu, and Xuejun Shang.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
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