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Distribution and Factors Associated with Four Premature Ejaculation Syndromes in Outpatients Complaining of Ejaculating Prematurely
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ORIGINAL RESEARCH—EJACULATORY DISORDERS Distribution and Factors Associated with Four Premature Ejaculation Syndromes in Outpatients Complaining of Ejaculating Prematurely Xiansheng Zhang, MD, PhD, Jingjing Gao, MB, Jishuang Liu, MM, Lei Xia, MM, Jiajia Yang, 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 DOI: 10.1111/jsm.12123
ABSTRACT
Introduction. Because available definitions of premature ejaculation (PE) were unable to encompass the various forms of PE, Waldinger et al. proposed a new classification that distinguished four PE syndromes. However, few studies have examined the prevalence rates of these four PE syndromes. Aims. The study aims to analyze the prevalence of and factors associated with four PE syndromes in outpatients who complained of ejaculating prematurely. Methods. Between December 2009 and December 2011, outpatients who complained of PE completed a detailed verbal questionnaire regarding their demographic data and medical and sexual history. Each patient was classified as having one of four PE subtypes: lifelong PE (LPE), acquired PE (APE), natural variable PE (NVPE), or prematurelike ejaculatory dysfunction (PLED). Main Outcome Measures. Based on the new classification scheme, PE was classified into four subtypes. The anxiety/depression status of patients was assessed by the Zung self-rating anxiety/depression scales, and erectile function was assessed by the International Index of Erectile Function-5 instrument. Results. This study included 1,988 male outpatients who complained of PE, with mean ages and body mass index (BMI) scores of 35.52 ⫾ 10.38 years and 25.34 ⫾ 4.51 kg/m2, respectively. Prevalence rates of PE syndromes were 35.66% for LPE, 28.07% for APE, 12.73% for NVPE, and 23.54% for PLED. Patients with APE had the highest mean ages and BMI scores, and they more frequently reported several comorbidities, including sexual desire disorder, hypertension, diabetes mellitus, chronic prostatitis, and erectile dysfunction. The PLED group had a lower mean frequency of sexual intercourse than other groups and higher rates of anxiety and depression. Conclusion. The prevalence of LPE was higher than that of other PE subtypes in an outpatient setting. Several comorbidities were more common in patients with APE and PLED. In particular, a lower frequency of intercourse and higher frequencies of anxiety and depression were found in patients with PLED. Zhang X, Gao J, Liu J, Xia L, Yang J, Hao Z, Zhou J, and Liang C. Distribution and factors associated with four premature ejaculation syndromes in outpatients complaining of ejaculating prematurely. J Sex Med 2013;10:1603–1611. Key Words. Premature Ejaculation; Syndromes; DSM-V; Distribution; Associated Factors
Introduction
P
remature ejaculation (PE) is one of the most common sexual complaints in men, affecting approximately 20% to 30% of the male population at one time [1–3]. Over the past decade, many studies have attempted to provide clearer guide-
© 2013 International Society for Sexual Medicine
lines for its definition and diagnosis and to explore new biomedical treatments for PE [4]. Although PE is generally understood, and associated diagnostic criteria have been proposed [5,6], the real prevalence of PE has been poorly understood until recently, due to the lack of a universally accepted definition of the disorder [7–9]. For instance, the J Sex Med 2013;10:1603–1611
1604 Diagnostic and Statistical Manual of Mental Disorders (DSM)-III definition of PE includes the criterion of control but not that of ejaculation time, whereas the converse is true in the DSM-IV-TR [10]. Most definitions of PE contain three parts, including: (i) short ejaculatory time; (ii) lack of perceived self-efficacy or control over the timing of ejaculation; and (3) personal distress and interpersonal difficulty related to ejaculatory dysfunction [11]. The International Society for Sexual Medicine ad hoc committee has defined lifelong PE as “a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy [6].” Based on these diagnostic criteria, a man would be diagnosed with this disorder if he experiences PE after vaginal penetration of ⱕ1 minute (intravaginal ejaculation latency time [IELT] of 0.5–1 minute), loss of control, and/or negative sexual consequences. In spite of these definitions, clinicians reported that men who did not meet the diagnostic criteria for lifelong PE (i.e., men with IELT of 5–10 minutes) were seeking treatment for the complaint of PE. This circumstance suggested that the available definitions of PE did not encompass all of the forms of PE. To address this issue, Waldinger and Schweitzer [12,13] proposed a new classification scheme of PE that was based on the duration of ejaculation time, frequency of complaints, and course of the disorder over the lifetime of the patient. In addition to the subtypes of lifelong PE (LPE) and acquired PE (APE), they added the natural variable PE (NVPE) and premature-like ejaculatory dysfunction (PLED) subtypes [9,12]. The NVPE subtype is characterized by inconsistent and irregular early ejaculation. At other times, most patients in the NVPE group have normal or extended ejaculation times. Therefore, this type of PE is considered to be a manifestation of the normal variation of ejaculatory performance. In contrast, PLED is characterized by normal or extended IELT, but with a diminished or absent ability to delay imminent ejaculation. The PLED subtype should not be regarded as a symptom or manifestation of a true medical pathology. Psychological or relationship problems may underlie complaints of PLED [9]. Waldinger posited that men with the NVPE and PLED subtypes were often captured as having PE in epidemiological studies, because of the J Sex Med 2013;10:1603–1611
Zhang et al. broad definition used. However, these patients would not likely seek medical treatment, because their PE syndromes were irregular, and the IELT was usually within the normal range [13]. Serefoglu et al. [14] performed a populationbased study to investigate the prevalence of the four PE syndromes according to the new classification. They found that the prevalences of LPE, APE, NVPE, and PLED were 2.3%, 3.9%, 8.5%, and 5.1%, respectively. Moreover, 10.0% of men with PE complaints had seen a doctor, most of whom described acquired PE. In another study, Serefoglu et al. [15] evaluated the distribution of patients who were admitted to an outpatient clinic with the complaint of ejaculating prematurely. They reported that the majority of the men were diagnosed as having LPE (62.5%); the remaining men were diagnosed as having APE (16.1%), NVPE (14.5%), or PLED (6.9%). These studies confirmed the assertions of Waldinger [13] that patients suffering from LPE and APE were those who were most likely to seek treatment. Although this new classification scheme provides a better perspective of the epidemiology, pathophysiology, etiology, and treatment of PE, few studies have investigated the four PE syndromes, particularly in China. Therefore, the present study was designed to analyze the prevalence of and factors associated with the four PE syndromes in outpatients who sought treatment for the complaint of ejaculating prematurely.
Aim Based on the classification of PE proposed by Waldinger [13], we evaluated the prevalence of and factors associated with four PE syndromes in outpatients who sought treatment for the complaint of ejaculating prematurely. Methods
Subjects A noninterventional, observational, cross-sectional field survey was carried out between December 2009 and December 2011. Subjects were selected from male patients who complained of PE and were referred to the Andrology Clinic of the First Affiliated Hospital of Anhui Medical University in Hefei, Anhui, China. To be included in the study, subjects had to meet the following criteria: (i) male patient aged ⱖ18 years who comprehended and spoke Chinese; (ii) in a heterosexual, stable, and monogamous sexual relationship with the same female partner for >6 months.
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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 minutes (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 a 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.
Before study enrollment, patients were informed about the research. Those who participated were asked to complete a consent document. Prior to the survey, a presurvey was completed by a small number of subjects and their partners to refine the survey questions and improve their clarity. This study was reviewed and approved by the Anhui Medical University Research Subject Review Board.
Study Design The survey was conducted by face-to-face interview. A careful medical and sexual history was taken by an experienced clinician. Eligible subjects participated in the survey by completing a verbal questionnaire, which included questions about the following topics: (i) demographic information (e.g., age, body mass index [BMI], employment status, lifestyle, and educational level); (ii) duration of PE and medical and sexual history; (iii) self-estimated IELT; (iv) Zung Self-Rating Anxiety Scale; (v) Zung Self-Rating Depression Scale; and (vi) International Index of Erectile Function (IIEF)-5. The reliability of the instruments (Zung selfrating anxiety/depression scales and IIEF-5) was assessed with Cronbach’s alpha coefficient. The internal consistencies of the Zung Self-Rating Anxiety and Depression Scales and IIEF-5 were 0.79, 0.78, and 0.80, respectively. Premature Ejaculation Based on their responses to the survey questions, each patient was placed into one of the following
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 to 25 minutes). 4. The ability to delay imminent ejaculation is diminished or absent. 5. The preoccupation is not better explained by another mental disorder.
categories: LPE, APE, NVPE, or PLED [9]. Symptoms for the four PE syndromes are summarized in Table 1.
Anxiety and Depression As two indices reflecting the degree of negative psychological impacts, anxiety and depression were assessed by the Chinese versions [16] of the Zung Self-Rating Anxiety [17] and Depression Scales [18], respectively. These questionnaires, which have been used in various studies in China, each contain 20 questions (Appendices 1 and 2). After the patient had completed the questionnaire, the scores for the Zung Self-Rating Anxiety/ Depression Scales were combined. The total score was divided by 80 and compared with a standard cut-off score for anxiety or depression, where <0.5 indicated no anxiety/depression and ⱖ0.5 indicated anxiety/depression. Erectile Function The erectile function of patients was measured with the IIEF-5 instrument [19], in its Chinese version [20]. This instrument contained five questions, each of which was graded on a scale from 0 to 5 points. An IIEF-5 score ⱖ22 indicated normal erectile function, and <22 indicated erectile dysfunction (ED). Statistical Analysis Data analyses were carried out with SPSS version 13.0 software (SPSS Inc., Chicago, IL, USA). J Sex Med 2013;10:1603–1611
1606 Table 2
Zhang et al. Demographic characteristics of the subjects according to the four PE syndromes
Characteristics
All
LPE*
APE*
NVPE*
PLED*
P†
Age, years BMI, kg/m2 Age of first sexual intercourse, years Duration of the relationship, years Frequency of sexual intercourse in the past 4 weeks, times Self-estimated IELT, minutes Smoking Exercise Educational status Illiterate Literate Primary education High school Higher education Occupational status Student Unemployed Employed Retired Monthly income <1,000 RMB 1,000–2,000 RMB >2,000 RMB Total
35.52 ⫾ 10.38 25.34 ⫾ 4.51 24.41 ⫾ 4.15 6.15 ⫾ 4.57 4.37 ⫾ 3.52
31.82 ⫾ 11.34§ 24.53 ⫾ 4.26§ 25.34 ⫾ 4.03 6.02 ⫾ 5.45 4.52 ⫾ 2.21¶**
42.51 ⫾ 10.13‡¶** 27.32 ⫾ 2.15‡¶** 25.62 ⫾ 4.98 6.34 ⫾ 5.92 4.14 ⫾ 3.32¶**
31.60 ⫾ 8.15§ 23.71 ⫾ 4.41§ 24.83 ⫾ 5.12 6.03 ⫾ 5.21 6.11 ⫾ 3.76‡§**
34.74 ⫾ 9.24§ 24.82 ⫾ 3.14§ 25.72 ⫾ 4.11 6.21 ⫾ 4.76 3.15 ⫾ 2.17‡§¶
<0.01 0.01 0.73 0.70 <0.01
2.06 ⫾ 1.13 1,224 (61.57%) 1,449 (72.89%)
1.42 ⫾ 0.78¶** 441 (62.20) 502 (70.80)§¶
1.84 ⫾ 1.02¶** 338 (60.57) 455 (81.54)‡¶**
2.46 ⫾ 1.12‡§** 150 (59.29) 161 (63.64)‡§**
3.06 ⫾ 1.15‡§¶ 295 (63.03) 331 (70.73)§¶
<0.01 0.72 <0.01 0.98
197 299 373 603 516
(9.91%) (15.04%) (18.76%) (30.33%) (25.96%)
75 108 129 218 179
(10.58) (15.23) (18.19) (30.75) (25.25)
56 82 115 162 143
(10.04) (14.70) (20.61) (29.03) (25.63)
24 38 49 79 63
(9.49) (15.02) (19.37) (31.23) (24.90)
42 71 80 144 131
(8.97) (15.17) (17.09) (30.77) (27.99)
416 493 779 300
(20.93%) (24.80%) (39.19%) (15.09%)
147 177 282 103
(20.73) (24.96) (39.77) (14.53)
118 133 213 94
(21.15) (23.84) (38.17) (16.85)
58 64 97 34
(22.92) (25.30) (38.34) (13.44)
93 119 187 69
(19.87) (25.43) (39.96) (14.74)
(36.17%) (42.96%) (20.88%) (100.00%)
257 307 145 709
(36.25) (43.30) (20.45) (35.66)
203 233 122 558
(38.38) (41.76) (21.86) (28.07)
100 103 50 253
(39.53) (40.71) (19.76) (12.73)
159 211 98 468
(33.97) (45.09) (20.94) (23.54)
0.96
0.82 719 854 415 1,988
Data are expressed as the mean ⫾ standard deviation or number (percentage), as appropriate. *Difference between two subgroups assessed by one-way ANOVA or chi-square test, as appropriate †Difference among four PE syndromes assessed by one-way ANOVA or chi-square test, as appropriate ‡Significant difference compared with LPE §Significant difference compared with APE ¶Significant difference compared with NVPE **Significant difference compared witho 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; BMI = body mass index
Descriptive statistics were used to summarize the characteristics of the subjects. Data were expressed as the mean ⫾ standard deviation or number (percentage) when appropriate. Chi-square test and one-way anova were used for intergroup comparisons. For all tests, P < 0.05 was considered statistically significant.
Main Outcome Measures Based on the new classification, the complaint of PE was classified as one of four PE subtypes. The Zung Self-Rating Anxiety/Depression Scales and IIEF-5 instruments were used to assess the anxiety, depression, and erectile function of patients. Results
Demographic Characteristics Of the 2,382 male patients sampled, 1,988 agreed to participate in the study (response rate of 83.46%). The mean age and BMI for all subjects were 35.52 ⫾ 10.38 years and 25.34 ⫾ 4.51 kg/m2, respectively. After completing the questionnaires, J Sex Med 2013;10:1603–1611
the patients were classified as follows: LPE, 709 patients (35.66%); APE, 558 patients (28.07%); NVPE, 253 patients (12.73%); and PLED, 468 patients (23.54%). The demographic characteristics for patients in the four PE syndrome groups are presented in Table 2 and Figure 1.
Associated Factors for Patients in the Four PE Syndrome Groups As shown in Tables 2 and 3, there were differences among the four PE syndrome groups with respect to mean age (P < 0.01), BMI score (P = 0.01), frequency of sexual intercourse in the past 4 weeks (P < 0.01), and self-estimated IELT (P < 0.01). A significant difference was also found with regard to exercise status (P < 0.01). No significant differences among the subgroups were found with respect to the age of first intercourse (P = 0.73), duration of the relationship (P = 0.70), smoking (P = 0.72), education level (P = 0.98), occupational status (P = 0.96), or monthly income (P = 0.82). Patients in the APE group showed higher mean age and BMI than other groups. Patients in the
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Distribution for Premature Ejaculation Syndromes
Figure 1 Distribution of the four premature ejaculation (PE) syndromes based on age group. LPE = lifelong PE; APE = acquired PE; NVPE = natural variable PE; PLED = premature-like ejaculatory dysfunction
PLED group showed lower mean frequency of sexual intercourse than patients in the other groups. Significant differences in the frequency of each of the examined comorbidities, except varicocele, were found among the four PE syndrome
Table 3
groups. Hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED were more prevalent in the APE group, whereas anxiety and depression were more prevalent in the PLED group.
The distribution of comorbidities in the subjects according to the four PE syndromes
Comorbidities
LPE*
Anxiety Depression Sexual desire disorder Hypertension Diabetes mellitus Varicocele CP ED
242 164 145 65 26 94 213 194
(34.13)¶** (23.13)** (20.45)§¶** (9.17)§ (3.67)§ (13.26) (30.04)§ (27.36)§¶**
APE* 214 141 262 98 64 82 339 219
(38.35)¶** (25.27)** (46.95)‡¶** (17.56)‡¶** (11.47)‡¶** (14.70) (60.75)‡¶** (39.25)‡¶**
NVPE* 69 50 33 19 9 31 73 29
(27.27)‡§ (19.76)** (13.04)‡§ (7.51)§ (3.56)§ (12.25) (28.85)§** (11.46)‡§**
PLED* 221 147 54 42 23 60 181 87
(47.22)‡§ (31.41)‡§¶ (11.54)‡** (8.97)§ (4.91)b (12.82) (38.68)‡§¶ (18.59)‡§¶
P† <0.01 <0.01 <0.01 <0.01 <0.01 0.74 <0.01 <0.01
Data are expressed as number (percentage). *Difference between two subgroups assessed by one-way ANOVA or chi-square test, as appropriate † Difference among four PE syndromes assessed by one-way ANOVA or chi-square test, as appropriate ‡Significant difference compared with LPE §Significant difference compared with APE ¶ Significant difference compared with NVPE **Significant difference compared with PLPE PE = premature ejaculation; LPE = lifelong PE; APE = acquired PE; NVPE = natural variable PE; PLED = premature-like ejaculatory dysfunction; CP = chronic prostatitis; ED = erectile dysfunction
J Sex Med 2013;10:1603–1611
1608 Discussion
Traditionally, PE has been described as a complaint, disorder, or dysfunction [11]. The classification of PE proposed by Waldinger [21] emphasizes the relevance of distinguishing among PE-related syndromes. A syndrome is a cluster of consistent symptoms. An individual might feel that his ejaculation time is too short without having symptoms consistent with the syndrome of PE [12]. Among the 1,988 patients sampled in the present study, the prevalences of the PE syndromes were in this order: LPE (35.66%), APE (28.07%), PLED (23.54%), and NVPE (12.73%). These findings confirm the assertions of Waldinger [13] that patients suffering from LPE and APE are more likely to seek treatment than those in other subgroups. In a similar study conducted by Serefoglu et al. [15], the majority of men were diagnosed with LPE (62.45%), followed by APE (16.09%), NVPE (14.56%), and PLED (6.90%). Although LPE was also the most common PE subtype among the patients that they studied, its prevalence rate was considerably higher than the prevalence observed in the present study. This difference in prevalence rates might be explained by the cultural and religious differences between the Chinese and Western patient populations used in the respective studies. Previous studies have reported the relationship between PE and its associated factors, such as psychological factors, chronic prostatitis, and ED [22–27]. A community-based observational study [28] showed that, compared with men without PE, men with PE (stopwatch-assessed IELT ⱕ 2 minutes) had lower levels of sexual functioning and satisfaction, and higher levels of personal distress and interpersonal difficulty. Another study performed in Chinese men [24] reported a significant correlation of PE with the National Institutes of Health Chronic Prostatitis Symptom Index (NIHCPSI) and IIEF-5 scores. Compared with patients without PE, patients with PE had higher NIHCPSI scores (37.2 ⫾ 4.6 vs. 18.2 ⫾ 5.6) and lower IIEF-5 scores (16.7 ⫾ 3.2 vs. 22.6 ⫾ 2.9). For the four PE syndromes, Serefoglu et al. [14] found that several comorbidities (e.g., diabetes mellitus, chronic prostatitis, and hypertension) were more prevalent in patients with APE, whereas cardiovascular diseases were more prevalent in patients with PLED. Furthermore, results from their other study [29] showed that patients with APE had more severe complaints than patients with LPE, NVPE, and PLED. Patients with APE reported J Sex Med 2013;10:1603–1611
Zhang et al. higher levels of distress and interpersonal difficulty along with lower levels of sexual satisfaction. Similar findings were also observed in our study. We found that there was a significant difference among the subtypes of PE with respect to several demographic characteristics, including age, BMI score, frequency of sexual intercourse in the past 4 weeks, self-estimated IELT, and exercise status. We also observed an association between PE subtypes and various comorbidities, except varicocele. Although the patients in the APE group were the ones who exercised the most, they scored higher for mean age and BMI than patients in the other groups, with more comorbidities, such as hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED. These seemingly conflicting findings might result from the incidence of comorbidities, which were also associated with the age of the patients, because the incidence rates of several comorbidities (e.g., hypertension, diabetes mellitus, and ED) are known to increase with increasing age. In addition, patients in the PLED group scored significantly lower for mean frequency of sexual intercourse than patients in the other groups, and more suffered from anxiety and depression. These findings were in contrast to those obtained by Serefoglu et al. [29]. They found that patients in the APE group reported higher levels of distress and interpersonal difficulty as well as lower levels of sexual satisfaction. However, our findings confirm the presumptions proposed by Waldinger [13] that complaints of PLED might be caused by underlying psychological or relationship problems. In addition, although the relationships between PE and its associated factors have been considered in several studies, few studies have addressed these relationships among the NVPE and PLED subgroups. Therefore, further studies on the prevalence and associated factors of the four PE syndromes are needed to confirm and extend these results. Several limitations of the current study should be considered. Patients were only included in our survey if they volunteered the complaint of PE and sought treatment. The prevalence of the four PE syndromes in this survey was different from that in the general male population. Therefore, further community-based studies should be performed. We collected our data through personal interviews rather than written questionnaires. Patients may have felt embarrassed when discussing this sensitive personal problem, which could have affected the accuracy of our findings. Others methods of
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Distribution for Premature Ejaculation Syndromes obtaining data from these patients, such as Internet-based surveys, should be considered for future studies. Conclusions
This report represents the first study to examine the relative distribution of four PE syndromes in China. We found that LPE was the most common subtype of PE among the surveyed patients. Patients with PLED had the lowest frequency of sexual intercourse. Hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED were most prevalent in APE, whereas anxiety and depression were most prevalent in PLED. The findings of our study confirm the view of Waldinger [13] and the data found by Serefoglu [15] that the prevalence rates of LPE and APE in a clinical setting are higher than those of NVPE and PLED, and that there are clinically relevant differences among the four PE subtypes. Further studies, perhaps using a more anonymous means to gather data on this sensitive personal condition, may yield more accurate information on the distribution of PE subtypes in Chinese and other populations. Acknowledgment
The authors thank Dr. Puyu Su for his expertise in statistical analysis. Corresponding Author: Chaozhao Liang, MD, PhD, Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, Anhui, China. Tel: 86-551-2922046; Fax: 86-551-2922046; E-mail: [email protected] Conflicts of Interest: The authors have no conflicts of interest to report.
Statement of Authorship
Category 1 (a) Conception and Design Chaozhao Liang; Xiansheng Zhang (b) Acquisition of Data Jingjing Gao; Jishuang Liu; Lei Xia; Jiajia Yang; Zongyao Hao; Jun Zhou (c) Analysis and Interpretation of Data Xiansheng Zhang; Jingjing Gao
Category 2 (a) Drafting the Article Xiansheng Zhang; Jingjing Gao; Jishuang Liu
(b) Revising It for Intellectual Content Chaozhao Liang; Xiansheng Zhang; Jingjing Gao
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Zhang et al. 24 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. 25 Tang WS, Khoo EM. Prevalence and correlates of premature ejaculation in a primary care setting: A preliminary crosssectional study. J Sex Med 2011;8:2071–8. 26 Son H, Song SH, Kim SW, Paick JS. Self-reported premature ejaculation prevalence and characteristics in Korean young males: Community-based data from an Internet survey. J Androl 2010;31:540–6. 27 Park HJ, Park JK, Park K, Lee SW, Kim SW, Yang DY, Moon du 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. 28 Rowland DL, Patrick DL, Rothman M, Gagnon DD. The psychological burden of premature ejaculation. J Urol 2007;177:1065–70. 29 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.
Appendix 1. Self-Rating Anxiety Scale
Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
None or a little of the time
Some of the time
Good part of the time
Most or all of the time
I feel more nervous and anxious than usual. I feel afraid for no reason at all. I get upset easily or feel panicky. I feel like I’m falling apart and going to pieces. I feel that everything is all right and nothing bad will happen. My arms and legs shake and tremble. I am bothered by headaches and neck and back pains. I feel weak and get tired easily. I feel calm and can sit still easily. I can feel my heart beating fast. I am bothered by dizzy spells. I have fainting spells or feel like it. I can breathe in and out easily. I get feeling of numbness and tingling in my fingers or toes. I am bothered by stomach aches or indigestion. I have to empty my bladder often. My hands are usually dry and warm. My face gets hot and blushes. I fall asleep easily and get a good night’s rest. I have nightmares.
Scores and response options for questions (except nos. 5, 9, 13, 17, and 19) are as follows: 1 = none or a little of the time; 2 = some of the time; 3 = good part of the time; and 4 = most or all of the time. Scores and response options for questions 5, 9, 13, 17, and 19 are as follows: 4 = none or a little of the time; 3 = some of the time; 2 = good part of the time; and 1 = most or all of the time.
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Distribution for Premature Ejaculation Syndromes Appendix 2. Self-Rating Depression Scale
Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
A little of the time
Some of the time
Good part of the time
Most or all of the time
I feel downhearted and blue. Morning is when I feel the best. I have crying spells or feel like it. I have trouble sleeping at night. I eat as much as I used to. I still enjoy sex. I notice that I am losing weight. I have trouble with constipation. My heart beats faster than usual. I get tired for no reason. My mind is as clear as it used to be. I find it easy to do the things I used to. I am restless and can’t keep still. I feel hopeful about the future. I am more irritable than usual. I find it easy to make decisions. I feel that I am useful and needed. My life is pretty full. I feel that others would be better off if I were dead. I still enjoy the things that I used to do.
Scores and response options for questions 1, 3, 4, 7–10, 13, 15, and 19 are as follows: 1 = none or a little of the time; 2 = some of the time; 3 = good part of the time; 4 = most or all of the time. Scores and response options for the questions 2, 5, 6, 11, 12, 14, 16–18, and 20 are as follows: 4 = none or a little of the time; 3 = some of the time; 2 = good part of the time; 1 = most or all of the time.
J Sex Med 2013;10:1603–1611
ORIGINAL RESEARCH—EJACULATORY DISORDERS Distribution and Factors Associated with Four Premature Ejaculation Syndromes in Outpatients Complaining of Ejaculating Prematurely Xiansheng Zhang, MD, PhD, Jingjing Gao, MB, Jishuang Liu, MM, Lei Xia, MM, Jiajia Yang, 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 DOI: 10.1111/jsm.12123
ABSTRACT
Introduction. Because available definitions of premature ejaculation (PE) were unable to encompass the various forms of PE, Waldinger et al. proposed a new classification that distinguished four PE syndromes. However, few studies have examined the prevalence rates of these four PE syndromes. Aims. The study aims to analyze the prevalence of and factors associated with four PE syndromes in outpatients who complained of ejaculating prematurely. Methods. Between December 2009 and December 2011, outpatients who complained of PE completed a detailed verbal questionnaire regarding their demographic data and medical and sexual history. Each patient was classified as having one of four PE subtypes: lifelong PE (LPE), acquired PE (APE), natural variable PE (NVPE), or prematurelike ejaculatory dysfunction (PLED). Main Outcome Measures. Based on the new classification scheme, PE was classified into four subtypes. The anxiety/depression status of patients was assessed by the Zung self-rating anxiety/depression scales, and erectile function was assessed by the International Index of Erectile Function-5 instrument. Results. This study included 1,988 male outpatients who complained of PE, with mean ages and body mass index (BMI) scores of 35.52 ⫾ 10.38 years and 25.34 ⫾ 4.51 kg/m2, respectively. Prevalence rates of PE syndromes were 35.66% for LPE, 28.07% for APE, 12.73% for NVPE, and 23.54% for PLED. Patients with APE had the highest mean ages and BMI scores, and they more frequently reported several comorbidities, including sexual desire disorder, hypertension, diabetes mellitus, chronic prostatitis, and erectile dysfunction. The PLED group had a lower mean frequency of sexual intercourse than other groups and higher rates of anxiety and depression. Conclusion. The prevalence of LPE was higher than that of other PE subtypes in an outpatient setting. Several comorbidities were more common in patients with APE and PLED. In particular, a lower frequency of intercourse and higher frequencies of anxiety and depression were found in patients with PLED. Zhang X, Gao J, Liu J, Xia L, Yang J, Hao Z, Zhou J, and Liang C. Distribution and factors associated with four premature ejaculation syndromes in outpatients complaining of ejaculating prematurely. J Sex Med 2013;10:1603–1611. Key Words. Premature Ejaculation; Syndromes; DSM-V; Distribution; Associated Factors
Introduction
P
remature ejaculation (PE) is one of the most common sexual complaints in men, affecting approximately 20% to 30% of the male population at one time [1–3]. Over the past decade, many studies have attempted to provide clearer guide-
© 2013 International Society for Sexual Medicine
lines for its definition and diagnosis and to explore new biomedical treatments for PE [4]. Although PE is generally understood, and associated diagnostic criteria have been proposed [5,6], the real prevalence of PE has been poorly understood until recently, due to the lack of a universally accepted definition of the disorder [7–9]. For instance, the J Sex Med 2013;10:1603–1611
1604 Diagnostic and Statistical Manual of Mental Disorders (DSM)-III definition of PE includes the criterion of control but not that of ejaculation time, whereas the converse is true in the DSM-IV-TR [10]. Most definitions of PE contain three parts, including: (i) short ejaculatory time; (ii) lack of perceived self-efficacy or control over the timing of ejaculation; and (3) personal distress and interpersonal difficulty related to ejaculatory dysfunction [11]. The International Society for Sexual Medicine ad hoc committee has defined lifelong PE as “a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy [6].” Based on these diagnostic criteria, a man would be diagnosed with this disorder if he experiences PE after vaginal penetration of ⱕ1 minute (intravaginal ejaculation latency time [IELT] of 0.5–1 minute), loss of control, and/or negative sexual consequences. In spite of these definitions, clinicians reported that men who did not meet the diagnostic criteria for lifelong PE (i.e., men with IELT of 5–10 minutes) were seeking treatment for the complaint of PE. This circumstance suggested that the available definitions of PE did not encompass all of the forms of PE. To address this issue, Waldinger and Schweitzer [12,13] proposed a new classification scheme of PE that was based on the duration of ejaculation time, frequency of complaints, and course of the disorder over the lifetime of the patient. In addition to the subtypes of lifelong PE (LPE) and acquired PE (APE), they added the natural variable PE (NVPE) and premature-like ejaculatory dysfunction (PLED) subtypes [9,12]. The NVPE subtype is characterized by inconsistent and irregular early ejaculation. At other times, most patients in the NVPE group have normal or extended ejaculation times. Therefore, this type of PE is considered to be a manifestation of the normal variation of ejaculatory performance. In contrast, PLED is characterized by normal or extended IELT, but with a diminished or absent ability to delay imminent ejaculation. The PLED subtype should not be regarded as a symptom or manifestation of a true medical pathology. Psychological or relationship problems may underlie complaints of PLED [9]. Waldinger posited that men with the NVPE and PLED subtypes were often captured as having PE in epidemiological studies, because of the J Sex Med 2013;10:1603–1611
Zhang et al. broad definition used. However, these patients would not likely seek medical treatment, because their PE syndromes were irregular, and the IELT was usually within the normal range [13]. Serefoglu et al. [14] performed a populationbased study to investigate the prevalence of the four PE syndromes according to the new classification. They found that the prevalences of LPE, APE, NVPE, and PLED were 2.3%, 3.9%, 8.5%, and 5.1%, respectively. Moreover, 10.0% of men with PE complaints had seen a doctor, most of whom described acquired PE. In another study, Serefoglu et al. [15] evaluated the distribution of patients who were admitted to an outpatient clinic with the complaint of ejaculating prematurely. They reported that the majority of the men were diagnosed as having LPE (62.5%); the remaining men were diagnosed as having APE (16.1%), NVPE (14.5%), or PLED (6.9%). These studies confirmed the assertions of Waldinger [13] that patients suffering from LPE and APE were those who were most likely to seek treatment. Although this new classification scheme provides a better perspective of the epidemiology, pathophysiology, etiology, and treatment of PE, few studies have investigated the four PE syndromes, particularly in China. Therefore, the present study was designed to analyze the prevalence of and factors associated with the four PE syndromes in outpatients who sought treatment for the complaint of ejaculating prematurely.
Aim Based on the classification of PE proposed by Waldinger [13], we evaluated the prevalence of and factors associated with four PE syndromes in outpatients who sought treatment for the complaint of ejaculating prematurely. Methods
Subjects A noninterventional, observational, cross-sectional field survey was carried out between December 2009 and December 2011. Subjects were selected from male patients who complained of PE and were referred to the Andrology Clinic of the First Affiliated Hospital of Anhui Medical University in Hefei, Anhui, China. To be included in the study, subjects had to meet the following criteria: (i) male patient aged ⱖ18 years who comprehended and spoke Chinese; (ii) in a heterosexual, stable, and monogamous sexual relationship with the same female partner for >6 months.
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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 minutes (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 a 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.
Before study enrollment, patients were informed about the research. Those who participated were asked to complete a consent document. Prior to the survey, a presurvey was completed by a small number of subjects and their partners to refine the survey questions and improve their clarity. This study was reviewed and approved by the Anhui Medical University Research Subject Review Board.
Study Design The survey was conducted by face-to-face interview. A careful medical and sexual history was taken by an experienced clinician. Eligible subjects participated in the survey by completing a verbal questionnaire, which included questions about the following topics: (i) demographic information (e.g., age, body mass index [BMI], employment status, lifestyle, and educational level); (ii) duration of PE and medical and sexual history; (iii) self-estimated IELT; (iv) Zung Self-Rating Anxiety Scale; (v) Zung Self-Rating Depression Scale; and (vi) International Index of Erectile Function (IIEF)-5. The reliability of the instruments (Zung selfrating anxiety/depression scales and IIEF-5) was assessed with Cronbach’s alpha coefficient. The internal consistencies of the Zung Self-Rating Anxiety and Depression Scales and IIEF-5 were 0.79, 0.78, and 0.80, respectively. Premature Ejaculation Based on their responses to the survey questions, each patient was placed into one of the following
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 to 25 minutes). 4. The ability to delay imminent ejaculation is diminished or absent. 5. The preoccupation is not better explained by another mental disorder.
categories: LPE, APE, NVPE, or PLED [9]. Symptoms for the four PE syndromes are summarized in Table 1.
Anxiety and Depression As two indices reflecting the degree of negative psychological impacts, anxiety and depression were assessed by the Chinese versions [16] of the Zung Self-Rating Anxiety [17] and Depression Scales [18], respectively. These questionnaires, which have been used in various studies in China, each contain 20 questions (Appendices 1 and 2). After the patient had completed the questionnaire, the scores for the Zung Self-Rating Anxiety/ Depression Scales were combined. The total score was divided by 80 and compared with a standard cut-off score for anxiety or depression, where <0.5 indicated no anxiety/depression and ⱖ0.5 indicated anxiety/depression. Erectile Function The erectile function of patients was measured with the IIEF-5 instrument [19], in its Chinese version [20]. This instrument contained five questions, each of which was graded on a scale from 0 to 5 points. An IIEF-5 score ⱖ22 indicated normal erectile function, and <22 indicated erectile dysfunction (ED). Statistical Analysis Data analyses were carried out with SPSS version 13.0 software (SPSS Inc., Chicago, IL, USA). J Sex Med 2013;10:1603–1611
1606 Table 2
Zhang et al. Demographic characteristics of the subjects according to the four PE syndromes
Characteristics
All
LPE*
APE*
NVPE*
PLED*
P†
Age, years BMI, kg/m2 Age of first sexual intercourse, years Duration of the relationship, years Frequency of sexual intercourse in the past 4 weeks, times Self-estimated IELT, minutes Smoking Exercise Educational status Illiterate Literate Primary education High school Higher education Occupational status Student Unemployed Employed Retired Monthly income <1,000 RMB 1,000–2,000 RMB >2,000 RMB Total
35.52 ⫾ 10.38 25.34 ⫾ 4.51 24.41 ⫾ 4.15 6.15 ⫾ 4.57 4.37 ⫾ 3.52
31.82 ⫾ 11.34§ 24.53 ⫾ 4.26§ 25.34 ⫾ 4.03 6.02 ⫾ 5.45 4.52 ⫾ 2.21¶**
42.51 ⫾ 10.13‡¶** 27.32 ⫾ 2.15‡¶** 25.62 ⫾ 4.98 6.34 ⫾ 5.92 4.14 ⫾ 3.32¶**
31.60 ⫾ 8.15§ 23.71 ⫾ 4.41§ 24.83 ⫾ 5.12 6.03 ⫾ 5.21 6.11 ⫾ 3.76‡§**
34.74 ⫾ 9.24§ 24.82 ⫾ 3.14§ 25.72 ⫾ 4.11 6.21 ⫾ 4.76 3.15 ⫾ 2.17‡§¶
<0.01 0.01 0.73 0.70 <0.01
2.06 ⫾ 1.13 1,224 (61.57%) 1,449 (72.89%)
1.42 ⫾ 0.78¶** 441 (62.20) 502 (70.80)§¶
1.84 ⫾ 1.02¶** 338 (60.57) 455 (81.54)‡¶**
2.46 ⫾ 1.12‡§** 150 (59.29) 161 (63.64)‡§**
3.06 ⫾ 1.15‡§¶ 295 (63.03) 331 (70.73)§¶
<0.01 0.72 <0.01 0.98
197 299 373 603 516
(9.91%) (15.04%) (18.76%) (30.33%) (25.96%)
75 108 129 218 179
(10.58) (15.23) (18.19) (30.75) (25.25)
56 82 115 162 143
(10.04) (14.70) (20.61) (29.03) (25.63)
24 38 49 79 63
(9.49) (15.02) (19.37) (31.23) (24.90)
42 71 80 144 131
(8.97) (15.17) (17.09) (30.77) (27.99)
416 493 779 300
(20.93%) (24.80%) (39.19%) (15.09%)
147 177 282 103
(20.73) (24.96) (39.77) (14.53)
118 133 213 94
(21.15) (23.84) (38.17) (16.85)
58 64 97 34
(22.92) (25.30) (38.34) (13.44)
93 119 187 69
(19.87) (25.43) (39.96) (14.74)
(36.17%) (42.96%) (20.88%) (100.00%)
257 307 145 709
(36.25) (43.30) (20.45) (35.66)
203 233 122 558
(38.38) (41.76) (21.86) (28.07)
100 103 50 253
(39.53) (40.71) (19.76) (12.73)
159 211 98 468
(33.97) (45.09) (20.94) (23.54)
0.96
0.82 719 854 415 1,988
Data are expressed as the mean ⫾ standard deviation or number (percentage), as appropriate. *Difference between two subgroups assessed by one-way ANOVA or chi-square test, as appropriate †Difference among four PE syndromes assessed by one-way ANOVA or chi-square test, as appropriate ‡Significant difference compared with LPE §Significant difference compared with APE ¶Significant difference compared with NVPE **Significant difference compared witho 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; BMI = body mass index
Descriptive statistics were used to summarize the characteristics of the subjects. Data were expressed as the mean ⫾ standard deviation or number (percentage) when appropriate. Chi-square test and one-way anova were used for intergroup comparisons. For all tests, P < 0.05 was considered statistically significant.
Main Outcome Measures Based on the new classification, the complaint of PE was classified as one of four PE subtypes. The Zung Self-Rating Anxiety/Depression Scales and IIEF-5 instruments were used to assess the anxiety, depression, and erectile function of patients. Results
Demographic Characteristics Of the 2,382 male patients sampled, 1,988 agreed to participate in the study (response rate of 83.46%). The mean age and BMI for all subjects were 35.52 ⫾ 10.38 years and 25.34 ⫾ 4.51 kg/m2, respectively. After completing the questionnaires, J Sex Med 2013;10:1603–1611
the patients were classified as follows: LPE, 709 patients (35.66%); APE, 558 patients (28.07%); NVPE, 253 patients (12.73%); and PLED, 468 patients (23.54%). The demographic characteristics for patients in the four PE syndrome groups are presented in Table 2 and Figure 1.
Associated Factors for Patients in the Four PE Syndrome Groups As shown in Tables 2 and 3, there were differences among the four PE syndrome groups with respect to mean age (P < 0.01), BMI score (P = 0.01), frequency of sexual intercourse in the past 4 weeks (P < 0.01), and self-estimated IELT (P < 0.01). A significant difference was also found with regard to exercise status (P < 0.01). No significant differences among the subgroups were found with respect to the age of first intercourse (P = 0.73), duration of the relationship (P = 0.70), smoking (P = 0.72), education level (P = 0.98), occupational status (P = 0.96), or monthly income (P = 0.82). Patients in the APE group showed higher mean age and BMI than other groups. Patients in the
1607
Distribution for Premature Ejaculation Syndromes
Figure 1 Distribution of the four premature ejaculation (PE) syndromes based on age group. LPE = lifelong PE; APE = acquired PE; NVPE = natural variable PE; PLED = premature-like ejaculatory dysfunction
PLED group showed lower mean frequency of sexual intercourse than patients in the other groups. Significant differences in the frequency of each of the examined comorbidities, except varicocele, were found among the four PE syndrome
Table 3
groups. Hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED were more prevalent in the APE group, whereas anxiety and depression were more prevalent in the PLED group.
The distribution of comorbidities in the subjects according to the four PE syndromes
Comorbidities
LPE*
Anxiety Depression Sexual desire disorder Hypertension Diabetes mellitus Varicocele CP ED
242 164 145 65 26 94 213 194
(34.13)¶** (23.13)** (20.45)§¶** (9.17)§ (3.67)§ (13.26) (30.04)§ (27.36)§¶**
APE* 214 141 262 98 64 82 339 219
(38.35)¶** (25.27)** (46.95)‡¶** (17.56)‡¶** (11.47)‡¶** (14.70) (60.75)‡¶** (39.25)‡¶**
NVPE* 69 50 33 19 9 31 73 29
(27.27)‡§ (19.76)** (13.04)‡§ (7.51)§ (3.56)§ (12.25) (28.85)§** (11.46)‡§**
PLED* 221 147 54 42 23 60 181 87
(47.22)‡§ (31.41)‡§¶ (11.54)‡** (8.97)§ (4.91)b (12.82) (38.68)‡§¶ (18.59)‡§¶
P† <0.01 <0.01 <0.01 <0.01 <0.01 0.74 <0.01 <0.01
Data are expressed as number (percentage). *Difference between two subgroups assessed by one-way ANOVA or chi-square test, as appropriate † Difference among four PE syndromes assessed by one-way ANOVA or chi-square test, as appropriate ‡Significant difference compared with LPE §Significant difference compared with APE ¶ Significant difference compared with NVPE **Significant difference compared with PLPE PE = premature ejaculation; LPE = lifelong PE; APE = acquired PE; NVPE = natural variable PE; PLED = premature-like ejaculatory dysfunction; CP = chronic prostatitis; ED = erectile dysfunction
J Sex Med 2013;10:1603–1611
1608 Discussion
Traditionally, PE has been described as a complaint, disorder, or dysfunction [11]. The classification of PE proposed by Waldinger [21] emphasizes the relevance of distinguishing among PE-related syndromes. A syndrome is a cluster of consistent symptoms. An individual might feel that his ejaculation time is too short without having symptoms consistent with the syndrome of PE [12]. Among the 1,988 patients sampled in the present study, the prevalences of the PE syndromes were in this order: LPE (35.66%), APE (28.07%), PLED (23.54%), and NVPE (12.73%). These findings confirm the assertions of Waldinger [13] that patients suffering from LPE and APE are more likely to seek treatment than those in other subgroups. In a similar study conducted by Serefoglu et al. [15], the majority of men were diagnosed with LPE (62.45%), followed by APE (16.09%), NVPE (14.56%), and PLED (6.90%). Although LPE was also the most common PE subtype among the patients that they studied, its prevalence rate was considerably higher than the prevalence observed in the present study. This difference in prevalence rates might be explained by the cultural and religious differences between the Chinese and Western patient populations used in the respective studies. Previous studies have reported the relationship between PE and its associated factors, such as psychological factors, chronic prostatitis, and ED [22–27]. A community-based observational study [28] showed that, compared with men without PE, men with PE (stopwatch-assessed IELT ⱕ 2 minutes) had lower levels of sexual functioning and satisfaction, and higher levels of personal distress and interpersonal difficulty. Another study performed in Chinese men [24] reported a significant correlation of PE with the National Institutes of Health Chronic Prostatitis Symptom Index (NIHCPSI) and IIEF-5 scores. Compared with patients without PE, patients with PE had higher NIHCPSI scores (37.2 ⫾ 4.6 vs. 18.2 ⫾ 5.6) and lower IIEF-5 scores (16.7 ⫾ 3.2 vs. 22.6 ⫾ 2.9). For the four PE syndromes, Serefoglu et al. [14] found that several comorbidities (e.g., diabetes mellitus, chronic prostatitis, and hypertension) were more prevalent in patients with APE, whereas cardiovascular diseases were more prevalent in patients with PLED. Furthermore, results from their other study [29] showed that patients with APE had more severe complaints than patients with LPE, NVPE, and PLED. Patients with APE reported J Sex Med 2013;10:1603–1611
Zhang et al. higher levels of distress and interpersonal difficulty along with lower levels of sexual satisfaction. Similar findings were also observed in our study. We found that there was a significant difference among the subtypes of PE with respect to several demographic characteristics, including age, BMI score, frequency of sexual intercourse in the past 4 weeks, self-estimated IELT, and exercise status. We also observed an association between PE subtypes and various comorbidities, except varicocele. Although the patients in the APE group were the ones who exercised the most, they scored higher for mean age and BMI than patients in the other groups, with more comorbidities, such as hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED. These seemingly conflicting findings might result from the incidence of comorbidities, which were also associated with the age of the patients, because the incidence rates of several comorbidities (e.g., hypertension, diabetes mellitus, and ED) are known to increase with increasing age. In addition, patients in the PLED group scored significantly lower for mean frequency of sexual intercourse than patients in the other groups, and more suffered from anxiety and depression. These findings were in contrast to those obtained by Serefoglu et al. [29]. They found that patients in the APE group reported higher levels of distress and interpersonal difficulty as well as lower levels of sexual satisfaction. However, our findings confirm the presumptions proposed by Waldinger [13] that complaints of PLED might be caused by underlying psychological or relationship problems. In addition, although the relationships between PE and its associated factors have been considered in several studies, few studies have addressed these relationships among the NVPE and PLED subgroups. Therefore, further studies on the prevalence and associated factors of the four PE syndromes are needed to confirm and extend these results. Several limitations of the current study should be considered. Patients were only included in our survey if they volunteered the complaint of PE and sought treatment. The prevalence of the four PE syndromes in this survey was different from that in the general male population. Therefore, further community-based studies should be performed. We collected our data through personal interviews rather than written questionnaires. Patients may have felt embarrassed when discussing this sensitive personal problem, which could have affected the accuracy of our findings. Others methods of
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Distribution for Premature Ejaculation Syndromes obtaining data from these patients, such as Internet-based surveys, should be considered for future studies. Conclusions
This report represents the first study to examine the relative distribution of four PE syndromes in China. We found that LPE was the most common subtype of PE among the surveyed patients. Patients with PLED had the lowest frequency of sexual intercourse. Hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED were most prevalent in APE, whereas anxiety and depression were most prevalent in PLED. The findings of our study confirm the view of Waldinger [13] and the data found by Serefoglu [15] that the prevalence rates of LPE and APE in a clinical setting are higher than those of NVPE and PLED, and that there are clinically relevant differences among the four PE subtypes. Further studies, perhaps using a more anonymous means to gather data on this sensitive personal condition, may yield more accurate information on the distribution of PE subtypes in Chinese and other populations. Acknowledgment
The authors thank Dr. Puyu Su for his expertise in statistical analysis. Corresponding Author: Chaozhao Liang, MD, PhD, Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, Anhui, China. Tel: 86-551-2922046; Fax: 86-551-2922046; E-mail: [email protected] Conflicts of Interest: The authors have no conflicts of interest to report.
Statement of Authorship
Category 1 (a) Conception and Design Chaozhao Liang; Xiansheng Zhang (b) Acquisition of Data Jingjing Gao; Jishuang Liu; Lei Xia; Jiajia Yang; Zongyao Hao; Jun Zhou (c) Analysis and Interpretation of Data Xiansheng Zhang; Jingjing Gao
Category 2 (a) Drafting the Article Xiansheng Zhang; Jingjing Gao; Jishuang Liu
(b) Revising It for Intellectual Content Chaozhao Liang; Xiansheng Zhang; Jingjing Gao
Category 3 (a) Final Approval of the Completed Article Chaozhao Liang; Xiansheng Zhang References 1 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999;281: 537–44. 2 Rowland D, Perelman M, Althof S, Barada J, McCullough A, Bull S, Jamieson C, Ho KF. Self-reported premature ejaculation and aspects of sexual functioning and satisfaction. J Sex Med 2004;1:225–32. 3 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. 4 Rowland D, Burek M. Trends in research on premature ejaculation over the past 25 years. J Sex Med 2007;4:1454–61. 5 Peeters M, Giuliano F. Central neurophysiology and dopaminergic control of ejaculation. Neurosci Biobehav Rev 2008;32:438–53. 6 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. 7 American Psychiatric Association. Diagnostic criteria from DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000. 8 World Health Organization. The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva: World Health Organization; 1993. 9 Waldinger MD. Recent advances in the classification, neurobiology and treatment of premature ejaculation. Adv Psychosom Med 2008;29:50–69. 10 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. 11 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. 12 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. 13 Waldinger MD. Premature ejaculation: Advantages of a new classification for understanding etiology and prevalence rates. Sexologies 2008;17:30–5. 14 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.
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Appendix 1. Self-Rating Anxiety Scale
Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
None or a little of the time
Some of the time
Good part of the time
Most or all of the time
I feel more nervous and anxious than usual. I feel afraid for no reason at all. I get upset easily or feel panicky. I feel like I’m falling apart and going to pieces. I feel that everything is all right and nothing bad will happen. My arms and legs shake and tremble. I am bothered by headaches and neck and back pains. I feel weak and get tired easily. I feel calm and can sit still easily. I can feel my heart beating fast. I am bothered by dizzy spells. I have fainting spells or feel like it. I can breathe in and out easily. I get feeling of numbness and tingling in my fingers or toes. I am bothered by stomach aches or indigestion. I have to empty my bladder often. My hands are usually dry and warm. My face gets hot and blushes. I fall asleep easily and get a good night’s rest. I have nightmares.
Scores and response options for questions (except nos. 5, 9, 13, 17, and 19) are as follows: 1 = none or a little of the time; 2 = some of the time; 3 = good part of the time; and 4 = most or all of the time. Scores and response options for questions 5, 9, 13, 17, and 19 are as follows: 4 = none or a little of the time; 3 = some of the time; 2 = good part of the time; and 1 = most or all of the time.
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Distribution for Premature Ejaculation Syndromes Appendix 2. Self-Rating Depression Scale
Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
A little of the time
Some of the time
Good part of the time
Most or all of the time
I feel downhearted and blue. Morning is when I feel the best. I have crying spells or feel like it. I have trouble sleeping at night. I eat as much as I used to. I still enjoy sex. I notice that I am losing weight. I have trouble with constipation. My heart beats faster than usual. I get tired for no reason. My mind is as clear as it used to be. I find it easy to do the things I used to. I am restless and can’t keep still. I feel hopeful about the future. I am more irritable than usual. I find it easy to make decisions. I feel that I am useful and needed. My life is pretty full. I feel that others would be better off if I were dead. I still enjoy the things that I used to do.
Scores and response options for questions 1, 3, 4, 7–10, 13, 15, and 19 are as follows: 1 = none or a little of the time; 2 = some of the time; 3 = good part of the time; 4 = most or all of the time. Scores and response options for the questions 2, 5, 6, 11, 12, 14, 16–18, and 20 are as follows: 4 = none or a little of the time; 3 = some of the time; 2 = good part of the time; 1 = most or all of the time.
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