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Prevalence and Factors Associated with the Complaint of Premature Ejaculation and the Four Premature Ejaculation Syndromes: A Large Observational Study in China
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ORIGINAL RESEARCH—EJACULATORY DISORDERS Prevalence and Factors Associated with the Complaint of Premature Ejaculation and the Four Premature Ejaculation Syndromes: A Large Observational Study in China Jingjing Gao, MB,* Xiansheng Zhang, MD, PhD,* Puyu Su, MD, PhD,† Jishuang Liu, MM,* Lei Xia, MM,* Jiajia Yang, MB,* Kai Shi, MB,* Dongdong Tang, MB,* Zongyao Hao, MD, PhD,* Jun Zhou, MM,* and Chaozhao Liang, MD, PhD* *Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; †Academy of Public Health, Anhui Medical University, Hefei, Anhui, China DOI: 10.1111/jsm.12180
ABSTRACT
Introduction. Although the new classification of premature ejaculation (PE) has been proposed by Waldinger et al., there have been few studies investigating the four PE syndromes in China. Aims. We investigated the prevalence and factors associated with the complaint of PE and the four PE syndromes in Anhui province, China. Methods. Between September 2011 and September 2012, subjects were selected from five cities in Anhui province, China. They participated in this survey by completing a detailed verbal questionnaire regarding their demographic data and medical and sexual history. Men with PE complaint were diagnosed as lifelong PE (LPE), acquired PE (APE), natural variable PE (NVPE), or premature-like ejaculatory dysfunction (PLED). Main Outcome Measures. PE complaint was divided into four PE syndromes. Anxiety, depression, and erectile dysfunction were independently assessed by the self-rating anxiety/depression scale and the international index of erectile function-5, respectively. Results. Of the 3,016 men evaluated, 25.80% complained of PE. The distribution of the four PE syndromes in men with PE complaint was in the order of NVPE (44.09%), PLPE (24.81%), APE (18.77%), and LPE (12.34%). Patients with PE complaint were older and more likely to smoke, had more comorbidities, and a higher body mass index (BMI) than patients without the complaint (P < 0.001 for all). Similar findings were also observed in patients with APE compared with other PE patients (depression P = 0.012, cardiovascular P = 0.003, others P < 0.001). In addition, the rates of counseling by a doctor in men with LPE and APE were higher than those in men with NVPE and PLED (P < 0.001). Conclusion. The prevalence of PE complaint in male population of Anhui province, China, was 25.80%, with the highest PE syndromes being NVPE and PLPE. Patients with PE complaint or APE were older and more likely to smoke, had more comorbidities, and a higher BMI. Gao J, Zhang X, Su P, Liu J, Xia L, Yang J, Shi K, Tang D, Hao Z, Zhou J, and Liang C. Prevalence and factors associated with the complaint of premature ejaculation and the four premature ejaculation syndromes: a large observational study in China. J Sex Med 2013;10:1874–1881. Key Words. Premature Ejaculation; Syndromes; Complaint; Prevalence; Associated Factors
Introduction
P
remature ejaculation (PE) is a common male sexual dysfunction [1,2]. Over the past few decades, intensified discussion and research efforts
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have attempted to provide clearer guidelines for its definition and diagnosis [3,4]. However, most of these definitions are considered to be authority based rather than evidence based [5]. Moreover, because of a lack of specific operational criteria, © 2013 International Society for Sexual Medicine
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Distribution for Premature Ejaculation Syndromes Table 1
Diagnostic criteria of four premature ejaculation syndromes Premature-like ejaculation dysfunction
Lifelong PE
Acquired PE
Natural variable PE
1. Early ejaculation occurs almost every time the patient has intercourse. 2. It occurs with nearly all women. 3. It begins at approximately the first sexual encounter. 4. Ejaculation occurs, in the majority of cases, within 30 seconds (70%), 60 seconds (90%), or 1–2 min (10%). 5. It persists throughout life (70%) and can even be aggravated with age (30%). 6. The ability to delay imminent ejaculation is diminished or absent.
1. Early ejaculation occurs at some point in a man’s life. 2. The man has usually had normal ejaculatory experience before the first complaint. 3. There is either a sudden or gradual onset. 4. The dysfunction may be due to: urological dysfunction (e.g., erectile dysfunction or prostatitis); thyroid dysfunction; or psychological or relationship problems. 5. The ability to delay imminent ejaculation is diminished or absent.
1. Early ejaculations are inconsistent and occur irregularly. 2. The ability to delay imminent ejaculation is diminished or absent. 3. A diminished ability to ejaculate is accompanied by either a short or normal ejaculation time.
1. There is a subjective perception of consistent or inconsistent early ejaculation during intercourse 2. There is a preoccupation with an imagined early ejaculation, or lack of ability to delay ejaculation 3. The actual intravaginal ejaculation latency time is in the normal range or may even be of longer duration (i.e., an ejaculation that occurs after 3–25 minutes) 4. The ability to delay imminent ejaculation is diminished or absent. 5. The preoccupation is not better explained by another mental disorder.
PE = premature ejaculation
they are vague in terms of operational specificity, and it is not possible to assess the accurate prevalence of PE [6]. In order to develop a contemporary, evidencebased definition of PE, a new PE definition has been proposed by the International Society for Sexual Medical ad hoc committee, which included three criteria of the intravaginal ejaculatory latency time (IELT) ⱕ1 min, loss of control, and/or negative sexual consequences [5,6]. However, this definition did not cover all aspects of PE, particularly characterizing the men who complain of PE but with a normal or extended IELT (e.g., an IELT of 3, 4, or even 5 minutes). To elucidate this issue, a new classification of PE has been suggested by Waldinger and Schweitzer [7,8], which states that PE diagnosis was based on three constructs: the duration of the ejaculation time, the frequency of complaints, and the course of the disorder over the lifetime of the patient. Besides the previously known lifelong PE (LPE) and acquired PE (APE) syndromes, the existence of two additional PE syndromes has been proposed: natural variable PE (NVPE) and premature-like ejaculatory dysfunction (PLED). NVPE is characterized by early ejaculations that occur irregularly and inconsistently with some subjective sense of diminished control of ejaculation, which is not considered a sexual dysfunction or psychopathology, but rather a normal variation in sexual performance. PLED is characterized by normal or extended IELT but with a diminished or
absent ability to delay imminent ejaculation, which should not be regarded as a symptom or manifestation of a true medical pathology and could be the result of psychological and/or relationship problems (Table 1). Based on the new classification, studies investigating the four PE syndromes were conducted by Serefoglu et al. [9–11]. A significant difference was found between the four PE syndromes with respect to their distribution and associated factors in the outpatient setting or general population of Turkey [9,10]. In addition, after assessing the severity of syndromes by patient-reported measures, they found that the complaint of PE was more severe in men with APE, whereas it was the least severe in men with PLED [11]. Although this new classification has provided a better view on the epidemiology, pathophysiology, etiology, and treatment of PE [12], the prevalence and factors associated with the four PE syndromes have not been widely investigated in China. Hence, in this survey, we randomly selected the male populations in the Anhui province of China, and then investigated the above issues. Aim
Based on the new classification of PE proposed by Waldinger [13], we investigated the prevalence and factors associated with the complaint of PE and the four PE syndromes in the general population of Anhui province, China. J Sex Med 2013;10:1874–1881
1876 Methods
Subjects This noninterventional, observational, crosssectional field survey was conducted from September 2011 to September 2012. Anhui is a province of China with more than 68 million inhabitants. Based on the stratified sampling, five cities (Huaibei City, Wangjiang City, Hefei City, Anqing City, and Chaohu City) were selected randomly to represent the northern, southern, middle, western, and eastern parts of Anhui province, China. A total of 4,000 men (ages ranging from 20 to 65 years) were selected from the health examination center, which represented the male population of Anhui province in terms of population distribution across urban and rural settings, geographic regions, and age groups. To be included in the study, participants had to meet the following criteria: (i) aged ⱖ18 years; (ii) in a heterosexual, stable, and monogamous sexual relationship with the same partner for at least 6 months; and (iii) able to comprehend and speak Chinese.
Study Design and Procedure Before the investigation, all men were informed about the procedure of the survey, and those participating were asked to provide written consent. In addition, because some subjective and sensitive personal questions (e.g., the development and experience of PE) were referred in this study, a presurvey (n = 30) was given to modify the originally designed items to ensure the accuracy and feasibility of the survey. This survey was reviewed and approved by the Anhui Medical University Research Subject review board. This survey was conducted by face-to-face interviews. Subjects were required to participate in this survey by completing a verbal questionnaire. The questionnaire collected the following data: (i) demographic information, e.g., age, body mass index (BMI), lifestyle, educational, and employment status; (ii) duration of PE, medical, and sexual history; (iii) the self-estimated IELT; (iv) the Zung self-rating anxiety/depression scales [14,15]; and (v) the International Index of Erectile Function-5 (IIEF-5) [16]. The reliability of these instruments (the Zung self-rating anxiety/ depression scales and IIEF-5) was assessed with Cronbach’s alpha coefficient. The internal consistencies of the Zung self-rating anxiety/depression scales and IIEF-5 were 0.80, 0.81, and 0.79, respectively. J Sex Med 2013;10:1874–1881
Gao et al. According to the outcomes of questionnaires, men who were not satisfied with their time to ejaculation were accepted as having the complaint of PE. Based on the new classification of PE (Table 1), each patient with a complaint of PE was diagnosed as one of the four PE syndromes, including LPE, APE NVPE, or PLED. Anxiety and depression, as the two indices reflecting the degree of negative psychological impact, were assessed by the Zung self-rating anxiety/ depression scales, in their Chinese version [17]. Each questionnaire contained 20 questions. After the questionnaire was completed, the total scores for the Zung self-rating anxiety/depression scales were combined, divided by 80, and then compared with a standard cutoff score for anxiety or depression. A standard cutoff of 0.5 was employed such that a score <0.5 indicated no anxiety/depression and a score ⱖ0.5 confirmed anxiety/depression. The erectile dysfunction was measured by the Chinese version of IIEF-5 [18], which is a validated five-item version of the 15-item IIEF questionnaire. It contains five questions, each of which is graded on a scale from 0 to 5 points. An IIEF-5 score ⱖ22 indicated normal erectile function, and <22 indicated ED.
Statistical Analysis All statistical analyses were performed using SPSS software (SPSS Inc., Chicago, IL, USA) version 13.0. Descriptive statistics were used to summarize the subject’s characteristics. Data were expressed as mean ⫾ standard deviation or number (percentage) when appropriate. Chi-square test, t-test, and one-way analysis of variance were used for intergroup comparisons, as appropriate. Statistical significance was defined as P < 0.05. Main Outcome Measures
Men with the complaint of PE in this survey were accepted as having the complaint of PE. Furthermore, based on the new classification of PE, men with PE complaint were diagnosed with one of four PE subtypes: LPE, APE, NVPE, and PLPE. Anxiety, depression, and erectile dysfunction were assessed by the Zung self-rating anxiety/ depression scales and IIEF-5, respectively. Results
A total of 3,016 men (mean age 33.67 ⫾ 9.89 years) completed the survey, giving a response rate of 75.40%. Men discontinued the study for the
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Distribution for Premature Ejaculation Syndromes
Table 2 Comparison of the demographic characteristics and presence of comorbidities in men with and without PE complaint Factors
All (n = 3016)
With PE (n = 778)
Without PE (n = 2238)
P*
Age, years BMI, kg/m2 Duration of the relationship, years Frequency of sexual intercourse, times/4 weeks Self-estimated IELT, minutes Monthly income, RMB Lifestyle Smoking Exercise Educational status Illiterate and literate Primary education High school Higher education Occupational status Student Unemployed Employed Retired Residence Urban Rural Comorbidities Anxiety Depression Sexual desire disorder Hypertension Diabetes mellitus Cardiovascular Varicocele Chronic prostatitis Erectile dysfunction
33.67 ⫾ 9.89 22.97 ⫾ 3.05 9.80 ⫾ 4.72 6.72 ⫾ 3.11 3.10 ⫾ 1.56 1,531.28 ⫾ 234.42
37.15 ⫾ 10.42 24.75 ⫾ 3.92 9.86 ⫾ 4.79 5.21 ⫾ 3.13 2.51 ⫾ 1.06 1,519.88 ⫾ 212.22
32.46 ⫾ 9.27 22.35 ⫾ 2.84 9.78 ⫾ 4.65 7.24 ⫾ 3.09 3.31 ⫾ 1.73 1,535.24 ⫾ 254.19
<0.001 <0.001 0.715 <0.001 <0.001 0.724 <0.001 <0.001 0.690
1,494 (49.54) 1,718 (56.96)
432 (55.53) 392 (50.39)
1,062 (47.45) 1,326 (59.25)
330 (10.94) 614 (20.36) 1,055 (34.98) 1,017 (33.72)
89 (11.44) 152 (19.54) 264 (33.93) 273 (35.09)
241 (10.77) 462 (20.64) 791 (35.34) 744 (33.24)
769 (25.50) 662 (21.59) 1,264 (41.91) 321 (10.64)
191 (24.55) 168 (21.59) 316 (40.62) 103 (13.24)
578 (25.83) 494 (22.07) 948 (42.36) 218 (9.74)
1,227 (40.68) 1,789 (59.32)
310 (39.85) 468 (60.15)
917 (40.97) 1,321 (59.03)
361 (11.97) 139 (4.61) 442 (14.66) 301 (9.98) 105 (3.48) 52 (1.72) 445 (14.57) 946 (31.37) 496 (16.45)
143 (18.38) 66 (8.48) 150 (19.28) 103 (13.24) 46 (5.91) 25 (3.21) 103 (13.24) 305 (39.20) 167 (21.47)
218 (9.74) 73 (3.26) 292 (13.05) 198 (8.85) 59 (2.64) 27 (1.21) 342 (15.28) 641 (28.64) 329 (14.70)
0.058
0.581
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.166 <0.001 <0.001
*Difference between men with and without the complaint of PE assessed by t-test or chi-square test, as appropriate PE = premature ejaculation; IELT = intravaginal ejaculatory latency time; RMB = renminbi
following reasons: “loss of follow-up” (n = 256), “incomplete information” (n = 473), and “other reasons” (n = 255). Among the entire male population, 778 (25.80%) complained of PE. The distribution of the four PE syndromes in men with PE complaint was as follows: NVPE (44.09%), PLPE (24.81%), APE (18.77%), and LPE (12.34%). Detailed demographic information and the presence of comorbidities for all subjects are summarized in Table 2. A significant difference was found between men with and without the complaint of PE, with respect to age, BMI, frequency of sexual intercourse, self-estimated IELT, smoking, exercise, and the presence of all comorbidities (except varicocele) (P < 0.001 for all). However, there was no significant difference between men with and without PE complaints when stratified according to duration of the relationship (P = 0.715), monthly income (P = 0.724), educational level (P = 0.690), occupational status (P = 0.058), residence (P = 0.581), and the presence of varicocele
(P = 0.166). Similarly, there was also a significant difference among the four PE syndromes with respect to the factors associated with the complaint of PE (Table 3). Compared with men without the complaint of PE, men with PE complaints presented a significantly higher age, BMI score, smoking rate, and presence of all comorbidities (except varicocele), whereas they reported a lower frequency of sexual intercourse, self-estimated IELT and exercise rate. Similarly, the mean age and BMI score and rates of smoking in men with APE were higher than those in men with other PE syndromes. All comorbidities (except varicocele) were also most prevalent in men with APE. However, their mean selfestimated IELT and the rate of exercise were lower than for other PE syndromes. Additionally, of the 778 men with a PE complaint, 88 men (11.31%) had sought treatment for PE, 175 men (22.49%) planned to seek treatment for PE, and 515 men (66.20%) had never considered consulting a doctor (Figure 1). There J Sex Med 2013;10:1874–1881
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Gao et al.
Table 3 Comparison of the demographic characteristics and presence of comorbidities in men with different PE syndromes Factors Age, years BMI, kg/m2 Duration of the relationship, years Frequency of sexual intercourse, times/4 weeks Self-estimated IELT, minutes Monthly income, RMB Lifestyle Smoking Exercise Educational status Illiterate and literate Primary education High school Higher education Occupational status Student Unemployed Employed Retired Residence Urban Rural Comorbidities Anxiety Depression Sexual desire disorder Hypertension Diabetes mellitus Cardiovascular Varicocele Chronic prostatitis Erectile dysfunction
LPE* (n = 96) 40.72 ⫾ 12.03b,c,d 23.25 ⫾ 4.05b 9.25 ⫾ 5.02 4.23 ⫾ 2.05c,d 1.33 ⫾ 0.74b,c,d 1,524.24 ⫾ 207.15
APE* (n = 146) 48.29 ⫾ 10.67a,c,d 28.14 ⫾ 3.13a,c,d 10.01 ⫾ 4.28 4.49 ⫾ 2.25c,d 1.65 ⫾ 0.82a,c,d 1,510.45 ⫾ 198.87
NVPE* (n = 343)
PLED* (n = 193)
P†
32.46 ⫾ 9.02a,b,d 24.07 ⫾ 3.89b 9.82 ⫾ 4.19 6.45 ⫾ 3.72a,b
35.28 ⫾ 8.24a,b,c 24.13 ⫾ 4.02b 10.12 ⫾ 5.11 4.05 ⫾ 2.17a,b
<0.001 <0.001 0.675 <0.001
2.73 ⫾ 1.24a,b,d 1,498.82 ⫾ 234.33
3.36 ⫾ 1.18a,b,c 1,562.28 ⫾ 219.48
<0.001 0.802
52 (54.17)b 44 (45.83)c
119 (81.51)a,c,d 53 (36.30)c,d
169 (49.27)b 197 (57.43)a,b
92 (47.67)b 98 (50.78)b
13 (13.54) 18 (18.75) 35 (36.46) 30 (31.25)
18 (12.33) 27 (18.49) 51 (34.93) 50 (34.25)
34 (9.91) 71 (20.70) 113 (32.94) 125 (36.44)
24 (12.44) 36 (18.65) 65 (33.68) 68 (35.23)
23 (23.96) 20 (20.83) 41 (42.71) 12 (12.50)
37 (25.34) 32 (21.92) 60 (41.10) 17 (11.64)
83 (24.20) 72 (20.99) 138 (40.23) 50 (14.58)
48 (24.87) 44 (22.80) 77 (39.90) 24 (12.44)
40 (41.67) 56 (58.33)
59 (40.41) 87 (59.59)
131 (38.19) 212 (61.81)
80 (41.45) 113 (58.55)
26 (27.08)b,c,d 11 (11.46)c 19 (19.79)b 16 (16.67)b,c 4 (4.17)b 4 (4.17) 14 (14.58) 33 (34.38)b 23 (23.96)b,c,d
52 (35.62)a,c,d 19 (13.01)c 53 (36.30)a,c,d 40 (27.40)a,c,d 21 (14.38)a,c,d 11 (7.53)c 17 (11.64) 92 (63.01)a,c,d 56 (38.36)a,c,d
30 (8.75)a,b,d 17 (4.96)a,b,d 43 (12.54)b 18 (5.25)a,b,d 10 (2.92)b 4 (1.17)b 46 (13.41) 110 (32.07)b 51 (14.87)a,b
<0.001 <0.001 0.975
0.998
35 (18.13)a,b,c 19 (9.84)c 35 (18.13)b 27 (13.99)b,c 11 (5.70)b 6 (3.11) 26 (13.47) 70 (36.27)b 37 (19.17)a,b
0.861 <0.001 0.012 <0.001 <0.001 <0.001 0.003 0.921 <0.001 <0.001
Data are expressed as the mean ⫾ standard deviation or number (percentage), as appropriate. *Difference between two subgroups assessed by t-test or chi-square test, as appropriate †Difference among four PE syndromes assessed by one-way analysis of variance or chi-square test, as appropriate a Significant difference compared with LPE bSignificant difference compared with APE cSignificant difference compared with NVPE d Significant difference compared with PLPE PE = premature ejaculation; IELT = intravaginal ejaculatory latency time; RMB = renminbi; LPE = lifelong PE; APE = acquired PE; NVPE = natural variable PE; PLED = premature-like ejaculatory dysfunction
Figure 1 Distribution of men who sought treatment or planned to seek treatment for the complaint of premature ejaculation (PE) based on the four PE syndromes.
J Sex Med 2013;10:1874–1881
Distribution for Premature Ejaculation Syndromes was a significant difference among the four PE syndromes when grouped according to the rates of seeking treatment of PE (P < 0.001). Men with LPE (41.67%) and APE (53.42%) were more likely to seek treatment for PE than men with NVPE (28.57%) and PLPE (24.35%).
Discussion
Although the new classification of PE has played an important role in the epidemiology, diagnosis, and treatment of PE, the four PE syndromes have not been well investigated, particularly in China. Furthermore, the distribution of and factors associated with the four PE syndromes in an outpatient setting and the general population have only been reported by Serefoglu et al. [9–11]. Results from the study of 261 male patients who sought treatment for the complaint of PE [9] have shown that the distribution of the four PE syndromes was in the order of LPE (62.45%), APE (28.70%), NVPE (14.56%), and PLED (6.90%). The majority of men were diagnosed as having LPE. However, the opposite findings have been observed in another study of the general population of Turkey [10]. Of the 2,593 male subjects, approximately 20% complained of PE. Furthermore, among the entire study population, 2.3%, 3.9%, 8.5%, and 5.1% were classified as LPE, APE, NVPE, and PLED, respectively. The prevalence of NVPE in their study population was higher than those of other subtypes. Moreover, the rate of patients consulting a doctor was higher in men with LPE (12.77%) and APE (26.53%), whereas it was lower in men with NVPE (6.47%) and PLPE (1.75%). Similarly, in our study, 25.80% of the male population complained of ejaculating prematurely. The incidence of LPE, APE, NVPE, and PLED in men with the complaint of PE was 12.34%, 18.77%, 44.09%, and 24.81%, respectively. The highest prevalence was also observed in men with NVPE. In addition, the rates of those having sought treatment and those planning to seek treatment in men with LPE (41.67%) and APE (53.42%) were higher than those in men with NVPE (28.57%) and PLED (24.35%). As a result, Waldinger [13] suggested that the subtypes of NVPE and PLED often accounted for the apparently very high prevalence previously reported in general population surveys of 20–30%, whereas the prevalence of LPE and APE was only 2–5%.
1879 Moreover, men with NVPE and PLED were not likely to seek treatment because their PE is irregular and their IELT is usually within the normal range. Hence, our findings further confirmed the view of Waldinger [13] and the data found by Serofoglu et al. [10] that the prevalence rates of NVPE and PLPE in the general population are higher than those of LPE and APE, but the rates of consulting a doctor were lower in men with NVPE and PLPE. However, the cultural and religious differences between the Chinese and Western patient populations should be taken into account. The difference in prevalence rates can be explained by these factors, and further research is needed to confirm and extend these results. PE was known to be a multifactorial sexual dysfunction [19–22]. Several demographic factors were found to be associated with the complaint of PE [10,23]. Results from Park et al.’s study [24] showed that patients with the complaint of PE were in higher age and had a lower frequency of sexual intercourse and IELT than patients without PE complaint. Similarly, Porst et al. [2] found a significant association between PE and no PE groups with respect to age, smoking, exercise, and the presence of comorbidities. Besides higher mean age and lower exercise level, men with PE were more likely to smoke and self-report other sexual dysfunctions (e.g., low libido and erectile dysfunction) and psychological disturbances (e.g., depression and anxiety) than men without PE. In addition, Patrick and Giuliano et al. [25,26] reported that PE was significantly associated with ejaculatory control, personal distress, sexual satisfaction, and interpersonal difficulty. Moreover, there was a significant difference among the four PE syndromes when regarding the presence of comorbidities (e.g., diabetes mellitus and chronic prostatitis). These comorbidities were more prevalent in men with APE. In another study for assessing the PE status by three different PE scales (Premature Ejaculation Diagnostic Tool [PEDT], Arabic Index of Premature Ejaculation [AIPE], and Premature Ejaculation Profile [PEP]), Serofoglu et al. [11] also found that there was a significant difference among each of the PEP measures, PEP index scores, and PEDT and AIPE scores of PE patients who described LPE, APE, NVPE, and PLED. The mean scores obtained from each item of the PEP and mean PEP index score were significantly better in men with PLED, whereas they were worse in men with APE. In addition, the mean AIP and PEDT scores in men with NVPE and PLED were better than those in men with J Sex Med 2013;10:1874–1881
1880 LPE and APE. These findings indicated that the PE complaint was more severe in men with APE, whereas it was least severe in men with PLED. Results from our survey confirmed their findings. We found that the complaint of PE was associated with age, BMI, frequency of sexual intercourse, self-estimated IELT, lifestyle, and all comorbidities (except varicocele). Men with the complaint of PE presented a higher mean age and BMI score and an incidence of all comorbidities (except varicocele). However, they reported a lower mean frequency of sexual intercourse and self-estimated IELT and rate of exercise. Similarly, the PE syndromes were associated with the above factors. Mean age, mean BMI score, smoking rate, and incidence of all comorbidities (except varicocele) were higher in men with APE, whereas their mean self-estimated IELT and exercise rate were lower. Accordingly, based on our findings, we speculate that the four PE syndromes have different characteristics and should be managed separately. Overall, the results of the current study have provided a framework for understanding the prevalence and factors associated with the four PE syndromes in the male population of Anhui province, China. Our observed findings were essentially in agreement with those previously reported by Serefoglu et al. [9–11]. However, several limitations of this survey should be considered. First, we cannot compare each of the PE syndromes with its control group, and the factors associated with each PE subtype were not assessed. Second, the patient-reported outcomes have not been used in our study to evaluate the status of different PE syndromes, and further studies should include them. Third, although 4,000 men have been selected, approximately 24.60% discontinued the study. Potential sampling bias should be considered. Finally, because face-to-face interviews were used in the study, respondents might feel obliged to give socially acceptable answers when some private, sensitive, and subjective questions were at issue. Other methods (e.g. Internet-based surveys) would address these problems.
Gao et al. the distribution of the four PE syndromes was in the order of NVPE (44.09%), PLED (24.81%), APE (18.77%), and LPE (12.34%). The complaint of PE and PE syndromes were associated with some demographic factors (e.g., age, BMI, and frequency of sexual intercourse) and comorbidities (e.g. anxiety, depression, and hypertension). Moreover, men with LPE and APE were more likely to seek treatment for the PE complaint than men with NVPE and PLED. These findings further confirm the view of Waldinger [13] and the data found by Serefoglu et al. [10] that the prevalence rates of NVPE and PLPE in the general population are higher than those of LPE and APE, but the rates of consulting a doctor were lower in men with NVPE and PLPE. Further research is needed to confirm and extend these results. Acknowledgment
The authors would like to thank Dr. Zheng Peng for his expertise in statistical analysis. Corresponding Author: Xiansheng Zhang, MD, PhD, Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei city, Anhui, China. Tel: 86 551 2922046; Fax: +86-551-2922046; E-mail: [email protected] Conflicts of Interest: The author(s) report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Xiansheng Zhang; Chaozhao Liang; Jingjing Gao (b) Acquisition of Data Jingjing Gao; Puyu Su; Jishuang Liu; Lei Xia; Jiajia Yang; Kai Shi; Dongdong Tang; Zongyao Hao; Jun Zhou (c) Analysis and Interpretation of Data Jingjing Gao; Puyu Su
Category 2 (a) Drafting the Article Jingjing Gao; Xiansheng Zhang; Chaozhao Liang (b) Revising It for Intellectual Content Jingjing Gao; Xiansheng Zhang; Chaozhao Liang
Conclusions
Category 3
This is the first population-based study to systematically evaluate the prevalence and factors associated with the complaint of PE and the four PE syndromes in the Anhui province of China. The prevalence of PE complaints in our study was 25.80%. Among the subjects with PE complaints,
References
J Sex Med 2013;10:1874–1881
(a) Final Approval of the Completed Article Chaozhao Liang; Xiansheng Zhang; Jingjing Gao
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Distribution for Premature Ejaculation Syndromes 2 Porst H, Montorsi F, Rosen RC, Gaynor L, Grupe S, Alexander J. The Premature Ejaculation Prevalence and Attitudes (PEPA) survey: Prevalence, comorbidities, and professional help-seeking. Eur Urol 2007;51:816–23. 3 American Psychiatric Association. Diagnostic criteria from DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000:370. 4 World Health Organization. The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva: World Health Organization; 1993. 5 McMahon CG, Althof SE, Waldinger MD, Porst H, Dean J, Sharlip ID, Adaikan PG, Becher E, Broderick GA, Buvat J, Dabees K, Giraldi A, Giuliano F, Hellstrom WJ, Incrocci L, Laan E, Meuleman E, Perelman MA, Rosen RC, Rowland DL, Segraves R. An evidence-based definition of lifelong premature ejaculation: Report of the International Society for Sexual Medicine (ISSM) ad hoc committee for the definition of premature ejaculation. J Sex Med 2008;5:1590– 606. 6 Althof SE, Abdo CH, Dean J, Hackett G, McCabe M, McMahon CG, Rosen RC, Sadovsky R, Waldinger M, Becher E, Broderick GA, Buvat J, Goldstein I, El-Meliegy AI, Giuliano F, Hellstrom WJ, Incrocci L, Jannini EA, Park K, Parish S, Porst H, Rowland D, Segraves R, Sharlip I, Simonelli C, Tan HM. International Society for Sexual Medicine’s guidelines for the diagnosis and treatment of premature ejaculation. J Sex Med 2010;7:2947–69. 7 Waldinger MD, Schweitzer DH. Changing paradigms from a historical DSM-III and DSM-IV view toward an evidencebased definition of premature ejaculation. Part I—Validity of DSM-IV-TR. J Sex Med 2006;3:682–92. 8 Waldinger MD, Schweitzer DH. Changing paradigms from a historical DSM-III and DSM-IV view toward an evidencebased definition of premature ejaculation. Part II—Proposals for DSM-V and ICD-11. J Sex Med 2006;3:693–705. 9 Serefoglu EC, Cimen HI, Atmaca AF, Balbay MD. The distribution of patients who seek treatment for the complaint of ejaculating prematurely according to the four premature ejaculation syndromes. J Sex Med 2010;7:810–5. 10 Serefoglu EC, Yaman O, Cayan S, Asci R, Orhan I, Usta MF, Ekmekcioglu O, Kendirci M, Semerci B, Kadioglu A. Prevalence of the complaint of ejaculating prematurely and the four premature ejaculation syndromes: Results from the Turkish Society of Andrology Sexual Health Survey. J Sex Med 2011;8:540–8. 11 Serefoglu EC, Yaman O, Cayan S, Asci R, Orhan I, Usta MF, Ekmekcioglu O, Kendirci M, Semerci B, Kadioglu A. The comparison of premature ejaculation assessment questionnaires and their sensitivity for the four premature ejaculation syndromes: Results from the Turkish society of andrology sexual health survey. J Sex Med 2011;8:1177–85.
1881 12 Serefoglu EC, Saitz TR. New insights on premature ejaculation: A review of definition, classification, prevalence and treatment. Asian J Androl 2012;14:822–9. 13 Waldinger MD. Premature ejaculation: Advantages of a new classification for understanding etiology and prevalence rates. Sexologies 2008;17:30–5. 14 Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371–9. 15 Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63–70. 16 Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999;11: 319–26. 17 Zhang MY. Manual of psychiatric rating scale (in Chinese). Hunan: Hunan Science and Technology Press; 1993. 18 Huang YF, Li HJ. Practical andrology (in Chinese). Beijing: Science Press; 2009. 19 Liang CZ, Hao ZY, Li HJ, Wang ZP, Xing JP, Hu WL, Zhang TF, Ge WW, Zhang XS, Zhou J, Li Y, Zhou ZX, Tang ZG, Tai S. Prevalence of premature ejaculation and its correlation with chronic prostatitis in Chinese men. Urology 2010;76: 962–6. 20 Lee SW, Lee JH, Sung HH, Park HJ, Park JK, Choi SK, Kam SC. The prevalence of premature ejaculation and its clinical characteristics in Korean men according to different definitions. Int J Impot Res 2012;25:12–7. 21 Shindel AW, Nelson CJ, Naughton CK, Mulhall JP. Premature ejaculation in infertile couples: Prevalence and correlates. J Sex Med 2008;5:485–91. 22 Serefoglu EC, Direk N, Hellstrom WJ. Premature ejaculation and erectile dysfunction prevalence and attitudes in the Asia-pacific region—a comment. J Sex Med 2012;9:1488–9. 23 McMahon CG, Lee G, Park JK, Adaikan PG. Premature ejaculation and erectile dysfunction prevalence and attitudes in the Asia-Pacific region. J Sex Med 2012;9:454–65. 24 Park HJ, Park JK, Park K, Lee SW, Kim SW, Yang DY, Moon G, Min KS, Moon KH, Yang SK, Hyun JS, Park NC. Prevalence of premature ejaculation in young and middle-aged men in Korea: A multicenter internet-based survey from the Korean Andrological Society. Asian J Androl 2010;12:880–9. 25 Giuliano F, Patrick DL, Porst H, La Pera G, Kokoszka A, Merchant S, Rothman M, Gagnon DD, Polverejan E, Study G. Premature ejaculation: Results from a five-country European observational study. Eur Urol 2008;53:1048– 57. 26 Patrick DL, Althof SE, Pryor JL, Rosen R, Rowland DL, Ho KF, McNulty P, Rothman M, Jamieson C. Premature ejaculation: An observational study of men and their partners. J Sex Med 2005;2:358–67.
J Sex Med 2013;10:1874–1881
ORIGINAL RESEARCH—EJACULATORY DISORDERS Prevalence and Factors Associated with the Complaint of Premature Ejaculation and the Four Premature Ejaculation Syndromes: A Large Observational Study in China Jingjing Gao, MB,* Xiansheng Zhang, MD, PhD,* Puyu Su, MD, PhD,† Jishuang Liu, MM,* Lei Xia, MM,* Jiajia Yang, MB,* Kai Shi, MB,* Dongdong Tang, MB,* Zongyao Hao, MD, PhD,* Jun Zhou, MM,* and Chaozhao Liang, MD, PhD* *Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; †Academy of Public Health, Anhui Medical University, Hefei, Anhui, China DOI: 10.1111/jsm.12180
ABSTRACT
Introduction. Although the new classification of premature ejaculation (PE) has been proposed by Waldinger et al., there have been few studies investigating the four PE syndromes in China. Aims. We investigated the prevalence and factors associated with the complaint of PE and the four PE syndromes in Anhui province, China. Methods. Between September 2011 and September 2012, subjects were selected from five cities in Anhui province, China. They participated in this survey by completing a detailed verbal questionnaire regarding their demographic data and medical and sexual history. Men with PE complaint were diagnosed as lifelong PE (LPE), acquired PE (APE), natural variable PE (NVPE), or premature-like ejaculatory dysfunction (PLED). Main Outcome Measures. PE complaint was divided into four PE syndromes. Anxiety, depression, and erectile dysfunction were independently assessed by the self-rating anxiety/depression scale and the international index of erectile function-5, respectively. Results. Of the 3,016 men evaluated, 25.80% complained of PE. The distribution of the four PE syndromes in men with PE complaint was in the order of NVPE (44.09%), PLPE (24.81%), APE (18.77%), and LPE (12.34%). Patients with PE complaint were older and more likely to smoke, had more comorbidities, and a higher body mass index (BMI) than patients without the complaint (P < 0.001 for all). Similar findings were also observed in patients with APE compared with other PE patients (depression P = 0.012, cardiovascular P = 0.003, others P < 0.001). In addition, the rates of counseling by a doctor in men with LPE and APE were higher than those in men with NVPE and PLED (P < 0.001). Conclusion. The prevalence of PE complaint in male population of Anhui province, China, was 25.80%, with the highest PE syndromes being NVPE and PLPE. Patients with PE complaint or APE were older and more likely to smoke, had more comorbidities, and a higher BMI. Gao J, Zhang X, Su P, Liu J, Xia L, Yang J, Shi K, Tang D, Hao Z, Zhou J, and Liang C. Prevalence and factors associated with the complaint of premature ejaculation and the four premature ejaculation syndromes: a large observational study in China. J Sex Med 2013;10:1874–1881. Key Words. Premature Ejaculation; Syndromes; Complaint; Prevalence; Associated Factors
Introduction
P
remature ejaculation (PE) is a common male sexual dysfunction [1,2]. Over the past few decades, intensified discussion and research efforts
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have attempted to provide clearer guidelines for its definition and diagnosis [3,4]. However, most of these definitions are considered to be authority based rather than evidence based [5]. Moreover, because of a lack of specific operational criteria, © 2013 International Society for Sexual Medicine
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Distribution for Premature Ejaculation Syndromes Table 1
Diagnostic criteria of four premature ejaculation syndromes Premature-like ejaculation dysfunction
Lifelong PE
Acquired PE
Natural variable PE
1. Early ejaculation occurs almost every time the patient has intercourse. 2. It occurs with nearly all women. 3. It begins at approximately the first sexual encounter. 4. Ejaculation occurs, in the majority of cases, within 30 seconds (70%), 60 seconds (90%), or 1–2 min (10%). 5. It persists throughout life (70%) and can even be aggravated with age (30%). 6. The ability to delay imminent ejaculation is diminished or absent.
1. Early ejaculation occurs at some point in a man’s life. 2. The man has usually had normal ejaculatory experience before the first complaint. 3. There is either a sudden or gradual onset. 4. The dysfunction may be due to: urological dysfunction (e.g., erectile dysfunction or prostatitis); thyroid dysfunction; or psychological or relationship problems. 5. The ability to delay imminent ejaculation is diminished or absent.
1. Early ejaculations are inconsistent and occur irregularly. 2. The ability to delay imminent ejaculation is diminished or absent. 3. A diminished ability to ejaculate is accompanied by either a short or normal ejaculation time.
1. There is a subjective perception of consistent or inconsistent early ejaculation during intercourse 2. There is a preoccupation with an imagined early ejaculation, or lack of ability to delay ejaculation 3. The actual intravaginal ejaculation latency time is in the normal range or may even be of longer duration (i.e., an ejaculation that occurs after 3–25 minutes) 4. The ability to delay imminent ejaculation is diminished or absent. 5. The preoccupation is not better explained by another mental disorder.
PE = premature ejaculation
they are vague in terms of operational specificity, and it is not possible to assess the accurate prevalence of PE [6]. In order to develop a contemporary, evidencebased definition of PE, a new PE definition has been proposed by the International Society for Sexual Medical ad hoc committee, which included three criteria of the intravaginal ejaculatory latency time (IELT) ⱕ1 min, loss of control, and/or negative sexual consequences [5,6]. However, this definition did not cover all aspects of PE, particularly characterizing the men who complain of PE but with a normal or extended IELT (e.g., an IELT of 3, 4, or even 5 minutes). To elucidate this issue, a new classification of PE has been suggested by Waldinger and Schweitzer [7,8], which states that PE diagnosis was based on three constructs: the duration of the ejaculation time, the frequency of complaints, and the course of the disorder over the lifetime of the patient. Besides the previously known lifelong PE (LPE) and acquired PE (APE) syndromes, the existence of two additional PE syndromes has been proposed: natural variable PE (NVPE) and premature-like ejaculatory dysfunction (PLED). NVPE is characterized by early ejaculations that occur irregularly and inconsistently with some subjective sense of diminished control of ejaculation, which is not considered a sexual dysfunction or psychopathology, but rather a normal variation in sexual performance. PLED is characterized by normal or extended IELT but with a diminished or
absent ability to delay imminent ejaculation, which should not be regarded as a symptom or manifestation of a true medical pathology and could be the result of psychological and/or relationship problems (Table 1). Based on the new classification, studies investigating the four PE syndromes were conducted by Serefoglu et al. [9–11]. A significant difference was found between the four PE syndromes with respect to their distribution and associated factors in the outpatient setting or general population of Turkey [9,10]. In addition, after assessing the severity of syndromes by patient-reported measures, they found that the complaint of PE was more severe in men with APE, whereas it was the least severe in men with PLED [11]. Although this new classification has provided a better view on the epidemiology, pathophysiology, etiology, and treatment of PE [12], the prevalence and factors associated with the four PE syndromes have not been widely investigated in China. Hence, in this survey, we randomly selected the male populations in the Anhui province of China, and then investigated the above issues. Aim
Based on the new classification of PE proposed by Waldinger [13], we investigated the prevalence and factors associated with the complaint of PE and the four PE syndromes in the general population of Anhui province, China. J Sex Med 2013;10:1874–1881
1876 Methods
Subjects This noninterventional, observational, crosssectional field survey was conducted from September 2011 to September 2012. Anhui is a province of China with more than 68 million inhabitants. Based on the stratified sampling, five cities (Huaibei City, Wangjiang City, Hefei City, Anqing City, and Chaohu City) were selected randomly to represent the northern, southern, middle, western, and eastern parts of Anhui province, China. A total of 4,000 men (ages ranging from 20 to 65 years) were selected from the health examination center, which represented the male population of Anhui province in terms of population distribution across urban and rural settings, geographic regions, and age groups. To be included in the study, participants had to meet the following criteria: (i) aged ⱖ18 years; (ii) in a heterosexual, stable, and monogamous sexual relationship with the same partner for at least 6 months; and (iii) able to comprehend and speak Chinese.
Study Design and Procedure Before the investigation, all men were informed about the procedure of the survey, and those participating were asked to provide written consent. In addition, because some subjective and sensitive personal questions (e.g., the development and experience of PE) were referred in this study, a presurvey (n = 30) was given to modify the originally designed items to ensure the accuracy and feasibility of the survey. This survey was reviewed and approved by the Anhui Medical University Research Subject review board. This survey was conducted by face-to-face interviews. Subjects were required to participate in this survey by completing a verbal questionnaire. The questionnaire collected the following data: (i) demographic information, e.g., age, body mass index (BMI), lifestyle, educational, and employment status; (ii) duration of PE, medical, and sexual history; (iii) the self-estimated IELT; (iv) the Zung self-rating anxiety/depression scales [14,15]; and (v) the International Index of Erectile Function-5 (IIEF-5) [16]. The reliability of these instruments (the Zung self-rating anxiety/ depression scales and IIEF-5) was assessed with Cronbach’s alpha coefficient. The internal consistencies of the Zung self-rating anxiety/depression scales and IIEF-5 were 0.80, 0.81, and 0.79, respectively. J Sex Med 2013;10:1874–1881
Gao et al. According to the outcomes of questionnaires, men who were not satisfied with their time to ejaculation were accepted as having the complaint of PE. Based on the new classification of PE (Table 1), each patient with a complaint of PE was diagnosed as one of the four PE syndromes, including LPE, APE NVPE, or PLED. Anxiety and depression, as the two indices reflecting the degree of negative psychological impact, were assessed by the Zung self-rating anxiety/ depression scales, in their Chinese version [17]. Each questionnaire contained 20 questions. After the questionnaire was completed, the total scores for the Zung self-rating anxiety/depression scales were combined, divided by 80, and then compared with a standard cutoff score for anxiety or depression. A standard cutoff of 0.5 was employed such that a score <0.5 indicated no anxiety/depression and a score ⱖ0.5 confirmed anxiety/depression. The erectile dysfunction was measured by the Chinese version of IIEF-5 [18], which is a validated five-item version of the 15-item IIEF questionnaire. It contains five questions, each of which is graded on a scale from 0 to 5 points. An IIEF-5 score ⱖ22 indicated normal erectile function, and <22 indicated ED.
Statistical Analysis All statistical analyses were performed using SPSS software (SPSS Inc., Chicago, IL, USA) version 13.0. Descriptive statistics were used to summarize the subject’s characteristics. Data were expressed as mean ⫾ standard deviation or number (percentage) when appropriate. Chi-square test, t-test, and one-way analysis of variance were used for intergroup comparisons, as appropriate. Statistical significance was defined as P < 0.05. Main Outcome Measures
Men with the complaint of PE in this survey were accepted as having the complaint of PE. Furthermore, based on the new classification of PE, men with PE complaint were diagnosed with one of four PE subtypes: LPE, APE, NVPE, and PLPE. Anxiety, depression, and erectile dysfunction were assessed by the Zung self-rating anxiety/ depression scales and IIEF-5, respectively. Results
A total of 3,016 men (mean age 33.67 ⫾ 9.89 years) completed the survey, giving a response rate of 75.40%. Men discontinued the study for the
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Distribution for Premature Ejaculation Syndromes
Table 2 Comparison of the demographic characteristics and presence of comorbidities in men with and without PE complaint Factors
All (n = 3016)
With PE (n = 778)
Without PE (n = 2238)
P*
Age, years BMI, kg/m2 Duration of the relationship, years Frequency of sexual intercourse, times/4 weeks Self-estimated IELT, minutes Monthly income, RMB Lifestyle Smoking Exercise Educational status Illiterate and literate Primary education High school Higher education Occupational status Student Unemployed Employed Retired Residence Urban Rural Comorbidities Anxiety Depression Sexual desire disorder Hypertension Diabetes mellitus Cardiovascular Varicocele Chronic prostatitis Erectile dysfunction
33.67 ⫾ 9.89 22.97 ⫾ 3.05 9.80 ⫾ 4.72 6.72 ⫾ 3.11 3.10 ⫾ 1.56 1,531.28 ⫾ 234.42
37.15 ⫾ 10.42 24.75 ⫾ 3.92 9.86 ⫾ 4.79 5.21 ⫾ 3.13 2.51 ⫾ 1.06 1,519.88 ⫾ 212.22
32.46 ⫾ 9.27 22.35 ⫾ 2.84 9.78 ⫾ 4.65 7.24 ⫾ 3.09 3.31 ⫾ 1.73 1,535.24 ⫾ 254.19
<0.001 <0.001 0.715 <0.001 <0.001 0.724 <0.001 <0.001 0.690
1,494 (49.54) 1,718 (56.96)
432 (55.53) 392 (50.39)
1,062 (47.45) 1,326 (59.25)
330 (10.94) 614 (20.36) 1,055 (34.98) 1,017 (33.72)
89 (11.44) 152 (19.54) 264 (33.93) 273 (35.09)
241 (10.77) 462 (20.64) 791 (35.34) 744 (33.24)
769 (25.50) 662 (21.59) 1,264 (41.91) 321 (10.64)
191 (24.55) 168 (21.59) 316 (40.62) 103 (13.24)
578 (25.83) 494 (22.07) 948 (42.36) 218 (9.74)
1,227 (40.68) 1,789 (59.32)
310 (39.85) 468 (60.15)
917 (40.97) 1,321 (59.03)
361 (11.97) 139 (4.61) 442 (14.66) 301 (9.98) 105 (3.48) 52 (1.72) 445 (14.57) 946 (31.37) 496 (16.45)
143 (18.38) 66 (8.48) 150 (19.28) 103 (13.24) 46 (5.91) 25 (3.21) 103 (13.24) 305 (39.20) 167 (21.47)
218 (9.74) 73 (3.26) 292 (13.05) 198 (8.85) 59 (2.64) 27 (1.21) 342 (15.28) 641 (28.64) 329 (14.70)
0.058
0.581
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.166 <0.001 <0.001
*Difference between men with and without the complaint of PE assessed by t-test or chi-square test, as appropriate PE = premature ejaculation; IELT = intravaginal ejaculatory latency time; RMB = renminbi
following reasons: “loss of follow-up” (n = 256), “incomplete information” (n = 473), and “other reasons” (n = 255). Among the entire male population, 778 (25.80%) complained of PE. The distribution of the four PE syndromes in men with PE complaint was as follows: NVPE (44.09%), PLPE (24.81%), APE (18.77%), and LPE (12.34%). Detailed demographic information and the presence of comorbidities for all subjects are summarized in Table 2. A significant difference was found between men with and without the complaint of PE, with respect to age, BMI, frequency of sexual intercourse, self-estimated IELT, smoking, exercise, and the presence of all comorbidities (except varicocele) (P < 0.001 for all). However, there was no significant difference between men with and without PE complaints when stratified according to duration of the relationship (P = 0.715), monthly income (P = 0.724), educational level (P = 0.690), occupational status (P = 0.058), residence (P = 0.581), and the presence of varicocele
(P = 0.166). Similarly, there was also a significant difference among the four PE syndromes with respect to the factors associated with the complaint of PE (Table 3). Compared with men without the complaint of PE, men with PE complaints presented a significantly higher age, BMI score, smoking rate, and presence of all comorbidities (except varicocele), whereas they reported a lower frequency of sexual intercourse, self-estimated IELT and exercise rate. Similarly, the mean age and BMI score and rates of smoking in men with APE were higher than those in men with other PE syndromes. All comorbidities (except varicocele) were also most prevalent in men with APE. However, their mean selfestimated IELT and the rate of exercise were lower than for other PE syndromes. Additionally, of the 778 men with a PE complaint, 88 men (11.31%) had sought treatment for PE, 175 men (22.49%) planned to seek treatment for PE, and 515 men (66.20%) had never considered consulting a doctor (Figure 1). There J Sex Med 2013;10:1874–1881
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Table 3 Comparison of the demographic characteristics and presence of comorbidities in men with different PE syndromes Factors Age, years BMI, kg/m2 Duration of the relationship, years Frequency of sexual intercourse, times/4 weeks Self-estimated IELT, minutes Monthly income, RMB Lifestyle Smoking Exercise Educational status Illiterate and literate Primary education High school Higher education Occupational status Student Unemployed Employed Retired Residence Urban Rural Comorbidities Anxiety Depression Sexual desire disorder Hypertension Diabetes mellitus Cardiovascular Varicocele Chronic prostatitis Erectile dysfunction
LPE* (n = 96) 40.72 ⫾ 12.03b,c,d 23.25 ⫾ 4.05b 9.25 ⫾ 5.02 4.23 ⫾ 2.05c,d 1.33 ⫾ 0.74b,c,d 1,524.24 ⫾ 207.15
APE* (n = 146) 48.29 ⫾ 10.67a,c,d 28.14 ⫾ 3.13a,c,d 10.01 ⫾ 4.28 4.49 ⫾ 2.25c,d 1.65 ⫾ 0.82a,c,d 1,510.45 ⫾ 198.87
NVPE* (n = 343)
PLED* (n = 193)
P†
32.46 ⫾ 9.02a,b,d 24.07 ⫾ 3.89b 9.82 ⫾ 4.19 6.45 ⫾ 3.72a,b
35.28 ⫾ 8.24a,b,c 24.13 ⫾ 4.02b 10.12 ⫾ 5.11 4.05 ⫾ 2.17a,b
<0.001 <0.001 0.675 <0.001
2.73 ⫾ 1.24a,b,d 1,498.82 ⫾ 234.33
3.36 ⫾ 1.18a,b,c 1,562.28 ⫾ 219.48
<0.001 0.802
52 (54.17)b 44 (45.83)c
119 (81.51)a,c,d 53 (36.30)c,d
169 (49.27)b 197 (57.43)a,b
92 (47.67)b 98 (50.78)b
13 (13.54) 18 (18.75) 35 (36.46) 30 (31.25)
18 (12.33) 27 (18.49) 51 (34.93) 50 (34.25)
34 (9.91) 71 (20.70) 113 (32.94) 125 (36.44)
24 (12.44) 36 (18.65) 65 (33.68) 68 (35.23)
23 (23.96) 20 (20.83) 41 (42.71) 12 (12.50)
37 (25.34) 32 (21.92) 60 (41.10) 17 (11.64)
83 (24.20) 72 (20.99) 138 (40.23) 50 (14.58)
48 (24.87) 44 (22.80) 77 (39.90) 24 (12.44)
40 (41.67) 56 (58.33)
59 (40.41) 87 (59.59)
131 (38.19) 212 (61.81)
80 (41.45) 113 (58.55)
26 (27.08)b,c,d 11 (11.46)c 19 (19.79)b 16 (16.67)b,c 4 (4.17)b 4 (4.17) 14 (14.58) 33 (34.38)b 23 (23.96)b,c,d
52 (35.62)a,c,d 19 (13.01)c 53 (36.30)a,c,d 40 (27.40)a,c,d 21 (14.38)a,c,d 11 (7.53)c 17 (11.64) 92 (63.01)a,c,d 56 (38.36)a,c,d
30 (8.75)a,b,d 17 (4.96)a,b,d 43 (12.54)b 18 (5.25)a,b,d 10 (2.92)b 4 (1.17)b 46 (13.41) 110 (32.07)b 51 (14.87)a,b
<0.001 <0.001 0.975
0.998
35 (18.13)a,b,c 19 (9.84)c 35 (18.13)b 27 (13.99)b,c 11 (5.70)b 6 (3.11) 26 (13.47) 70 (36.27)b 37 (19.17)a,b
0.861 <0.001 0.012 <0.001 <0.001 <0.001 0.003 0.921 <0.001 <0.001
Data are expressed as the mean ⫾ standard deviation or number (percentage), as appropriate. *Difference between two subgroups assessed by t-test or chi-square test, as appropriate †Difference among four PE syndromes assessed by one-way analysis of variance or chi-square test, as appropriate a Significant difference compared with LPE bSignificant difference compared with APE cSignificant difference compared with NVPE d Significant difference compared with PLPE PE = premature ejaculation; IELT = intravaginal ejaculatory latency time; RMB = renminbi; LPE = lifelong PE; APE = acquired PE; NVPE = natural variable PE; PLED = premature-like ejaculatory dysfunction
Figure 1 Distribution of men who sought treatment or planned to seek treatment for the complaint of premature ejaculation (PE) based on the four PE syndromes.
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Distribution for Premature Ejaculation Syndromes was a significant difference among the four PE syndromes when grouped according to the rates of seeking treatment of PE (P < 0.001). Men with LPE (41.67%) and APE (53.42%) were more likely to seek treatment for PE than men with NVPE (28.57%) and PLPE (24.35%).
Discussion
Although the new classification of PE has played an important role in the epidemiology, diagnosis, and treatment of PE, the four PE syndromes have not been well investigated, particularly in China. Furthermore, the distribution of and factors associated with the four PE syndromes in an outpatient setting and the general population have only been reported by Serefoglu et al. [9–11]. Results from the study of 261 male patients who sought treatment for the complaint of PE [9] have shown that the distribution of the four PE syndromes was in the order of LPE (62.45%), APE (28.70%), NVPE (14.56%), and PLED (6.90%). The majority of men were diagnosed as having LPE. However, the opposite findings have been observed in another study of the general population of Turkey [10]. Of the 2,593 male subjects, approximately 20% complained of PE. Furthermore, among the entire study population, 2.3%, 3.9%, 8.5%, and 5.1% were classified as LPE, APE, NVPE, and PLED, respectively. The prevalence of NVPE in their study population was higher than those of other subtypes. Moreover, the rate of patients consulting a doctor was higher in men with LPE (12.77%) and APE (26.53%), whereas it was lower in men with NVPE (6.47%) and PLPE (1.75%). Similarly, in our study, 25.80% of the male population complained of ejaculating prematurely. The incidence of LPE, APE, NVPE, and PLED in men with the complaint of PE was 12.34%, 18.77%, 44.09%, and 24.81%, respectively. The highest prevalence was also observed in men with NVPE. In addition, the rates of those having sought treatment and those planning to seek treatment in men with LPE (41.67%) and APE (53.42%) were higher than those in men with NVPE (28.57%) and PLED (24.35%). As a result, Waldinger [13] suggested that the subtypes of NVPE and PLED often accounted for the apparently very high prevalence previously reported in general population surveys of 20–30%, whereas the prevalence of LPE and APE was only 2–5%.
1879 Moreover, men with NVPE and PLED were not likely to seek treatment because their PE is irregular and their IELT is usually within the normal range. Hence, our findings further confirmed the view of Waldinger [13] and the data found by Serofoglu et al. [10] that the prevalence rates of NVPE and PLPE in the general population are higher than those of LPE and APE, but the rates of consulting a doctor were lower in men with NVPE and PLPE. However, the cultural and religious differences between the Chinese and Western patient populations should be taken into account. The difference in prevalence rates can be explained by these factors, and further research is needed to confirm and extend these results. PE was known to be a multifactorial sexual dysfunction [19–22]. Several demographic factors were found to be associated with the complaint of PE [10,23]. Results from Park et al.’s study [24] showed that patients with the complaint of PE were in higher age and had a lower frequency of sexual intercourse and IELT than patients without PE complaint. Similarly, Porst et al. [2] found a significant association between PE and no PE groups with respect to age, smoking, exercise, and the presence of comorbidities. Besides higher mean age and lower exercise level, men with PE were more likely to smoke and self-report other sexual dysfunctions (e.g., low libido and erectile dysfunction) and psychological disturbances (e.g., depression and anxiety) than men without PE. In addition, Patrick and Giuliano et al. [25,26] reported that PE was significantly associated with ejaculatory control, personal distress, sexual satisfaction, and interpersonal difficulty. Moreover, there was a significant difference among the four PE syndromes when regarding the presence of comorbidities (e.g., diabetes mellitus and chronic prostatitis). These comorbidities were more prevalent in men with APE. In another study for assessing the PE status by three different PE scales (Premature Ejaculation Diagnostic Tool [PEDT], Arabic Index of Premature Ejaculation [AIPE], and Premature Ejaculation Profile [PEP]), Serofoglu et al. [11] also found that there was a significant difference among each of the PEP measures, PEP index scores, and PEDT and AIPE scores of PE patients who described LPE, APE, NVPE, and PLED. The mean scores obtained from each item of the PEP and mean PEP index score were significantly better in men with PLED, whereas they were worse in men with APE. In addition, the mean AIP and PEDT scores in men with NVPE and PLED were better than those in men with J Sex Med 2013;10:1874–1881
1880 LPE and APE. These findings indicated that the PE complaint was more severe in men with APE, whereas it was least severe in men with PLED. Results from our survey confirmed their findings. We found that the complaint of PE was associated with age, BMI, frequency of sexual intercourse, self-estimated IELT, lifestyle, and all comorbidities (except varicocele). Men with the complaint of PE presented a higher mean age and BMI score and an incidence of all comorbidities (except varicocele). However, they reported a lower mean frequency of sexual intercourse and self-estimated IELT and rate of exercise. Similarly, the PE syndromes were associated with the above factors. Mean age, mean BMI score, smoking rate, and incidence of all comorbidities (except varicocele) were higher in men with APE, whereas their mean self-estimated IELT and exercise rate were lower. Accordingly, based on our findings, we speculate that the four PE syndromes have different characteristics and should be managed separately. Overall, the results of the current study have provided a framework for understanding the prevalence and factors associated with the four PE syndromes in the male population of Anhui province, China. Our observed findings were essentially in agreement with those previously reported by Serefoglu et al. [9–11]. However, several limitations of this survey should be considered. First, we cannot compare each of the PE syndromes with its control group, and the factors associated with each PE subtype were not assessed. Second, the patient-reported outcomes have not been used in our study to evaluate the status of different PE syndromes, and further studies should include them. Third, although 4,000 men have been selected, approximately 24.60% discontinued the study. Potential sampling bias should be considered. Finally, because face-to-face interviews were used in the study, respondents might feel obliged to give socially acceptable answers when some private, sensitive, and subjective questions were at issue. Other methods (e.g. Internet-based surveys) would address these problems.
Gao et al. the distribution of the four PE syndromes was in the order of NVPE (44.09%), PLED (24.81%), APE (18.77%), and LPE (12.34%). The complaint of PE and PE syndromes were associated with some demographic factors (e.g., age, BMI, and frequency of sexual intercourse) and comorbidities (e.g. anxiety, depression, and hypertension). Moreover, men with LPE and APE were more likely to seek treatment for the PE complaint than men with NVPE and PLED. These findings further confirm the view of Waldinger [13] and the data found by Serefoglu et al. [10] that the prevalence rates of NVPE and PLPE in the general population are higher than those of LPE and APE, but the rates of consulting a doctor were lower in men with NVPE and PLPE. Further research is needed to confirm and extend these results. Acknowledgment
The authors would like to thank Dr. Zheng Peng for his expertise in statistical analysis. Corresponding Author: Xiansheng Zhang, MD, PhD, Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei city, Anhui, China. Tel: 86 551 2922046; Fax: +86-551-2922046; E-mail: [email protected] Conflicts of Interest: The author(s) report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Xiansheng Zhang; Chaozhao Liang; Jingjing Gao (b) Acquisition of Data Jingjing Gao; Puyu Su; Jishuang Liu; Lei Xia; Jiajia Yang; Kai Shi; Dongdong Tang; Zongyao Hao; Jun Zhou (c) Analysis and Interpretation of Data Jingjing Gao; Puyu Su
Category 2 (a) Drafting the Article Jingjing Gao; Xiansheng Zhang; Chaozhao Liang (b) Revising It for Intellectual Content Jingjing Gao; Xiansheng Zhang; Chaozhao Liang
Conclusions
Category 3
This is the first population-based study to systematically evaluate the prevalence and factors associated with the complaint of PE and the four PE syndromes in the Anhui province of China. The prevalence of PE complaints in our study was 25.80%. Among the subjects with PE complaints,
References
J Sex Med 2013;10:1874–1881
(a) Final Approval of the Completed Article Chaozhao Liang; Xiansheng Zhang; Jingjing Gao
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