Category
Characteristic clinical features
Bacteriuria
Inflammation
I. Acute Bacterial
Acute UTI
+
+
II. Chronic Bacterial
Recurrent UTI caused by the same organism
NR
+
III. CP/CPPS
Primarily pain complains: also voiding complaints and sexual dysfunction
–
NR
Type A: Inflammatory subtype (formerly: non-bacterial prostatitis)
−
+
Type B: Non inflammatory subtype (formerly: prostatodynia)
−
−
IV. Asymptomatic
Diagnosed during evaluation of other genitourinary complaints
−
+
Several studies have also shown that antibiotic treatment of patients with CP may help to delay ejaculation. Treatment for CP is usually targeted towards gram-negative rods, but other common species may arise, such as Enterococci, Ureaplasma urealyticum, and Pseudomonas species [17, 34]. The initial account that showed improvement in ejaculatory function through treatment of CP was a study by Boneff [35]. Patients were treated with a topical hydrocortisone antibiotic mixture introduced into the posterior urethra via catheterization after prostate massage. The men who underwent this treatment (n = 42) experienced a 52 % improvement in ejaculation status, defined by prolongation of copulation for up to 5 min. There was a greater benefit from this treatment in patients with co-existing CP (15/22, 68.2 %) than just PE alone (7/20, 35 %).In a follow-up to their previous prevalence study, El-Nashaar and Shamloul studied a cohort of 145 men who complained of PE for at least 6 months prior to the study [21]. EPS-positive prostatitis was found in 94 (64.8 %) of these men, all of whom were asymptomatic. Antibiotic treatment was given for 1 month and 62 (83.9 % of those treated) showed a significant increase in their IELT and no recurrence of PE or CP after 4 months. Zohdy et al. performed a similar study of 210 men with CP symptoms and concomitant PE [22]. The goal was to determine clinical parameters that may predict successful outcomes in treatment of CP. They found that 59.0 % of the men treated with antimicrobial therapy had a significantly greater increase in IELT, in comparison to an untreated cohort. In addition, there was a difference in outcome between men with acquired PE and lifelong PE, where men with acquired PE responded more effectively to the antibiotic treatment. They also found that men with higher levels of inflammation experienced greater benefits (70.0 %) to antibiotic treatment in their IELTs compared to individuals with lower levels (31.4 %).
In summary, the urologic literature has shown a higher prevalence of CP or CPPS among PE patients and vice versa. There is also an association between the qualities of the patient’s CP, i.e., duration of symptoms and levels of inflammation, and the possibility of having PE. Lastly, the beneficial effect of treatment with antibiotics on the improvement of ejaculatory function has been strongly supported.
Together, this evidence strongly supports the idea that CP may be a common cause of acquired PE, thus it should be ruled out, especially in men with associated pelvic pain and/or urinary symptoms. EPS analysis, such as the Meares–Stamey test, is a cheap and easy tool that can delineate such an etiology of the patients with PE [36]. Culture of the EPS with speciation of the organism may be beneficial in cases refractory to empiric antibiotic use. Although the connection between prostatic inflammation and pathology of the ejaculatory reflex has been proposed to occur through modulation of the neurophysiologic pathway [37], further studies are required to elucidate the exact mechanism.
13.4 Varicocele and PE
Varicocele, the abnormal dilatation of veins in the pampiniform plexus due to retrograde venous flow, has been shown to impact sexual function. Varicoceles are a common urological condition, with the estimated incidence ranging from 15 % of the general population to 35 % of men with primary fertility issues depending on the screening method [23].
The impact of varicocele on ejaculation has recently been hypothesized as a possible etiology of acquired PE. In an Italian cross-sectional study, Lotti et al. evaluated 2,448 sexual dysfunction patients for the presence of varicocele [24]. Their comparison of groups, varicocele versus no varicocele, showed a significant difference in PE status (29.2 vs. 24.9 % in subjects with or without varicocele, respectively) when adjusted for factors such as age, anxiety levels, and prolactin levels. The researchers showed an association between severity of varicocele on Doppler ultrasound analysis and seminal levels of interleukin-8, a surrogate marker for non-bacterial prostatitis. These findings were extrapolated to hypothesize that PE may be a clinical symptom of an underlying inflammatory state caused by varicocele and/or prostatitis. The authors also note that venous congestion through a connection between the testicular and prostatic venous systems may predispose a varicocele patient to prostatitis.
In conclusion, the presence of varicocele has been shown to be associated with high levels of inflammation in the pelvic area. In the large study conducted by Lotti et al., biological support was given to show the association between the PE and varicocele, yet it is uncertain which of these states may predispose a man to the other pathology. More research should be conducted to understand the underlying mechanism that connects these two pathologies.
13.5 Monosymptomatic Enuresis and PE
Gokce et al. recently hypothesized an underlying neurological mechanism between lifelong PE and monosymptomatic enuresis (ME). In a randomized prospective study, the researchers found that 37.2 % of a cohort of men with lifelong PE had a history of primary ME compared with 15.1 % of the control population (p < 0.005) [25]. Although the authors proposed a mechanism of a deficiency in the central nervous system inhibition of both ejaculation and micturition, further studies are required to confirm this association and clarify the underlying mechanism.
13.6 Circumcision and PE
Circumcision, removal of the penile foreskin, is a routine practice among Islamic and Jewish communities. Considering the loss of high amounts of specialized sensory mucosa during this surgery, some authors claimed that circumcision has a negative impact on the overall sensory mechanism of the human penis [38]. Some international epidemiological studies demonstrated lower prevalence for PE in the Middle East, confirming this presumption [13]. However, clinical studies regarding the penile sensitivity, PE status, and sexual satisfaction are not conclusive [26, 27, 39]. Adult circumcision was found to be associated with worsened erectile function, decreased penile sensitivity, and improved satisfaction without causing any changes in sexual activity [26]. Senkul et al. also evaluated the sexual performance of 42 adults before and 12 weeks after circumcision by using brief male sexual function inventory (BMSFI) questionnaire and they could not demonstrate any difference in sexual function [39]. It is of note that these authors also observed significantly longer mean IELTs after circumcision and considered this as an advantage of this procedure.
On the other hand, Waldinger et al. measured the IELTs of 500 men in the Netherlands, United Kingdom, Spain, the United States, and Turkey. They observed that Turkish men, all but two being circumcised (122/124), had significantly lower median IELT (3.7 min) compared to the median IELT value of each of the other countries [7]. Interestingly, the authors also compared circumcised men with non-circumcised men in countries excluding Turkey and observed that IELT values were independent of circumcision status, which also has been confirmed with a later study [40]. Similarly, a recent study investigated the role of postcircumcision mucosal cuff length in PE by measuring it in men with and without PE [31]. These authors concluded that neither postcircumcision mucosal cuff length nor circumcision timing is a risk factor for PE. Considering the above mentioned, circumcision does not seem to be a risk factor for development of PE, however further studies focusing on the genetic background of the societies performing this surgery or the psychological burden of this procedure may be necessary.
13.7 Conclusion
PE is a common problem among men of all ages. The clinical relevance of PE cannot be ignored and may signify underlying perturbations to a man’s normal physiologic state. An underlying urologic inflammatory process may predispose individuals to sexual dysfunction, especially acquired PE. Evidence is available in the literature that shows that diagnosis and treatment of prostatitis with antibiotics may be useful in patients with PE and prostatitis-like symptoms. Other associations, such as varicocele, enuresis, and circumcision may predispose individuals to PE, but the clinical evidence is lacking.
It is important for all clinicians to recognize that urologic risk factors may predispose individuals to acquired PE. An organic etiology needs to be ruled out when evaluating any patient with complaints of PE.
References
1.
Montorsi F (2005) Prevalence of premature ejaculation: a global and regional perspective. J Sex Med 2(Suppl 2):96–102PubMedCrossRef
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