Variable
Lifelong premature ejaculation
Acquired premature ejaculation
Natural variable premature ejaculation
Premature-like ejaculatory dysfunction
IELT
Very short IELT (<1–1.5 min)
(Very) short IELT (<1.5–2 min)
Normal IELT (3–8 min)
Normal or long IELT (3–30 min)
Frequency
Consistent
(In)consistent
Inconsistent
(In)consistent
Etiology
Neurobiological and genetic
Medical and/or psychological
Normal variation of ejaculatory performance
Psychological
Treatment
Medication with or without counselling
Medication and/or psychotherapy
Psycho-education, reassurance
Psychotherapy
Prevalence
Low (?)
Low (?)
High (?)
High (?)
5.1.1 Lifelong Premature Ejaculation
With lifelong PE, ejaculation occurs too early at nearly every intercourse, with (nearly) every woman, and from about the first sexual encounters onwards. Based on self-selected samples, the majority of these men (80–90 %) ejaculate intravaginally within 30–60 s, and most of the remainder (10 %) between 1 and 2 min (Fig. 5.1). As the prevalence of an intravaginal ejaculatory latency time (IELT) of less than 1 min in unselected male cohorts in mainly Western countries is about 1–3 %, the prevalence of lifelong PE may be rather low [7]. The ejaculation remains rapid during life in the majority (70 %) of these men or may be aggravated during the course of aging (30 %). Some men ejaculate during foreplay, before penetration (ejaculatio ante portas), or as soon as their penis touches the vagina (ejaculatio intra portas). No accepted cure for lifelong PE is known, but various drugs (including SSRIs) and psychotherapy treatments may be effective in postponing the ejaculatory response [6].
Fig. 5.1
Intravaginal ejaculation latency time (IELT) measured with stopwatch in 110 men with lifelong premature ejaculation, of whom 90 % ejaculated within 1 min after vaginal penetration, including 80 % within 30 s
5.1.2 Acquired Premature Ejaculation
Complaints of men with acquired PE differ in relation to the underlying somatic or psychological problem. In these men, PE occurs at some point in a man’s life after experiencing normal ejaculatory latencies; the onset may be either sudden or gradual. Acquired PE differs in that sufferers develop early ejaculation at some point in their life having previously had normal ejaculation experiences. Acquired PE may be due to sexual performance anxiety [8], psychological or relationship problems [8, 9], ED [10], prostatitis [11], hyperthyroidism [12], or during withdrawal/detoxification from prescribed [13] or recreational drugs [14, 15]. In a study of 1,326 consecutive men with PE, lifelong PE was present in 736 men (74.4 %), and acquired PE was present in 253 men (25.6 %) [16]. The acquired form of PE may be cured by medical and/or psychological treatment of the underlying cause [6].
5.1.3 Natural Variable Premature Ejaculation
Men exhibiting this pattern experience short ejaculatory latencies only in certain situations. This type of response should not be regarded as a symptom or manifestation of underlying psychopathology but of normal variation in sexual performance. The syndrome is characterized by the following symptoms. (i) short ejaculatory latencies are inconsistent and occur irregularly, (ii) the ability to delay ejaculation, that is, to withhold ejaculation at the moment of imminent ejaculation, may be diminished or lacking, and (iii) the experience of diminished control of ejaculation is associated with either a short or normal ejaculation time, that is, an ejaculation of less or more than 1.5 min. Treatment of these men should consist of reassurance and education that this pattern of ejaculatory response is normal and does not require drug treatment or psychotherapy [6].
5.1.4 Premature-Like Ejaculatory Dysfunction
Men under this classification experience or complain of PE while the ejaculation time is in the normal range, i.e., around 2–6 min, and in some instances the ejaculatory latency may even be of very long duration, i.e., between 5 and 25 min [6]. This response should not be regarded as a symptom of an underlying medical or neurobiological pathology although psychological and/or relationship problems may underlie the complaint. The syndrome is characterized by the following symptoms: (i) subjective perception of consistent or inconsistent short ejaculatory latency during intercourse, (ii) preoccupation with an imagined early ejaculation or lack of control of ejaculation, and (iii) the IELT is in the normal or even long range (i.e., an ejaculation that occurs between 3 and 25 min), and (iv) the ability to delay ejaculation may be diminished or lacking.
As the duration of the ejaculation latency in these men is normal, the experience of the response is not related to a medical or neuro-biological disturbance [6]. Rather, there is either a misperception of the actual ejaculation time, for various reasons, or the ejaculation latency is too short for the female partner to attain an orgasm. Complaints of these men may be alleviated by the various sorts of psychotherapy and treatment should not a priori assume the use of pharmaceuticals. However, evidence-based controlled trials are required to investigate the optimal treatment for couples affected by this pattern of responding.
In 261 potent men with self-reported PE, Serefoglu et al. found that the majority of the men were diagnosed with lifelong PE (62.5 %); the remaining men were diagnosed as having acquired (16.1 %), natural variable PE (14.5 %), or premature-like ejaculatory disorder (6.9 %) [17]. Men with lifelong PE had significantly lower mean self-reported IELT (20.47 ± 28.90 s), whereas men with premature-like ejaculatory dysfunction had the highest mean IELT (286.67 ± 69.96 s, p = 0.001).
5.2 Definitions of Premature Ejaculation
Research into the treatment and epidemiology of PE is heavily dependent on how PE is defined. The medical literature contains several univariate and multivariate operational definitions of PE. [18–26], (Table 5.2). Each of these definitions characterize men with PE using all or most of the accepted dimensions of this condition: ejaculatory latency, perceived ability to control ejaculation, and negative psychological consequences of PE including reduced sexual satisfaction, personal distress, partner distress, and interpersonal or relationship distress. The major criticisms of the extant definitions included their failure to be evidenced-based, lack of specific operational criteria, excessive vagueness, and reliance on the subjective judgment of the diagnostician.
Table 5.2
Definitions of premature ejaculation
Definition | Source |
|---|---|
A male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within 1 min 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 | International Society of Sexual Medicine [45] |
Persistent or recurrent ejaculation with minimal sexual stimulation, before, on or shortly after penetration and before the person wishes it. The condition must also cause marked distress or interpersonal difficulty and cannot be due exclusively to the direct effects of a substance | DSM-IV-TR [29] |
For individuals who meet the general criteria for sexual dysfunction, the inability to control ejaculation sufficiently for both partners to enjoy sexual interaction, manifest as either the occurrence of ejaculation before or very soon after the beginning of intercourse (if a time limit is required, before or within 15 s) or the occurrence of ejaculation in the absence of sufficient erection to make intercourse possible. The problem is not the result of prolonged absence from sexual activity | International Statistical Classification of Disease, 10th edn. [20] |
The inability to control ejaculation for a “sufficient” length of time before vaginal penetration. It does not involve any impairment of fertility, when intravaginal ejaculation occurs | European Association of Urology. Guidelines on Disorders of Ejaculation [23] |
Persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration, and before the person wishes it, over which the sufferer has little or no voluntary control, which causes the sufferer and/or his partner bother or distress | International Consultation on Urological Diseases [24] |
Ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners | American Urological Association Guideline on the Pharmacologic Management of Premature Ejaculation [22] |
The man does not have voluntary, conscious control, or the ability to choose in most encounters when to ejaculate | Metz and McCarthy [21] |
The Foundation considers a man a premature ejaculator if he cannot control his ejaculatory process for a sufficient length of time during intravaginal containment to satisfy his partner in at least 50 percent of their coital connections | Masters and Johnson [18] |
Men with an IELT of less than 1 min (belonging to the 0.5 %) have “definite” premature ejaculation, while men with IELTs between 1 and 1.5 min (between 0.5 and 2.5 %) have “probable” premature ejaculation (Fig. 5.2). In addition, an additional grading of severity of premature ejaculation should be defined in terms of associated psychological problems. Thus, both definite and probable premature ejaculation need further psychological subclassification in nonsymptomatic, mild, moderate, and severe premature ejaculation | Waldinger et al. [44] |
5.2.1 Traditional Definitions
The first official definition of PE was proposed in 1980 by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) [27]. This definition was progressively revised as the DSM-III-R, DSM-IV, and finally DSM-IV-TR definitions to include the “shortly after penetration” as an ejaculatory latency criterion, “before the person wishes it” as a control criterion and “causes marked distress or interpersonal difficulty” as a criterion for the negative psychological consequences of PE [19, 28, 29]. Although DSM-IV-TR, the most commonly quoted definition, and other definitions of PE differ substantially, they are all authority-based, i.e., expert opinion without explicit critical appraisal, rather than evidence-based, and have no support from controlled clinical and/or epidemiological studies [30]. The DSM definitions are primarily conceptual in nature, vague in terms of operational specificity, multi-interpretable, fail to provide any diagnostic IELT cut-off points and rely on the subjective interpretation of these concepts by the clinician [31, 32]. The absence of a clear IELT cut-off point in the DSM definitions has resulted in the use of a broad range of subjective latencies for the diagnosis of PE in clinical trials ranging from 1 to 7 min [33–41]. The failure of DSM definitions to specify an IELT cut-off point means that a patient in the control group of one study may very well be in the PE group of a second study, making comparison of studies difficult and generalization of their data to the general PE population impossible.
This potential for errors in the diagnosis of PE was demonstrated in two recent observational studies in which PE was diagnosed solely by the application of the DSM-IV-TR definition [42, 43]. Giuliano et al. diagnosed PE using DSM-IV-TR criteria in 201 of 1,115 subjects (18 %) and predictably reported that the mean and median IELT was lower in subjects diagnosed with PE compared to non-PE subjects. There was, however, substantial overlap in stopwatch IELT values between the two groups. In subjects diagnosed with PE, the IELT range extended from 0 s (ante-portal ejaculation) to almost 28 min with 48 % of subjects having an IELT in excess of 2 min and 25 % of subjects exceeding 4 min. This study demonstrates that a subject diagnosed as having PE on the basis of DSM-IV-TR criteria has a 48 % risk of not having PE if a PE diagnostic threshold IELT of 2 min, as suggested by community-based normative IELT trial, is used [44].
5.2.2 Lifelong Premature Ejaculation
The first contemporary multivariate evidence-based definition of lifelong PE was developed in 2008 by a panel of international experts, convened by the International Society for Sexual Medicine (ISSM), who agreed that the diagnostic criteria necessary to define PE are: time from penetration to ejaculation, inability to delay ejaculation and negative personal consequences from PE. This panel defined lifelong PE as a male sexual dysfunction characterized by…“…ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, the inability to delay ejaculation on all or nearly all vaginal penetrations, and the presence of negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy” [45].
This definition is supported by evidence from several controlled clinical trials.
Evidence to support inclusion of the criterion of “…ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration …” (Table 5.3).
Table 5.3
Findings of key publications regarding the time-to-ejaculate in PE
Author/s | Summary of primary findings |
|---|---|
Waldinger et al. [51] | 110 men with lifelong PE whose IELT was measured by the use of a stopwatch 40 % of men ejaculated within 15 s, 70 % within 30 s, and 90 % within 1 min |
McMahon [16] | 1,346 consecutive men with PE whose IELT was measured by the use of a stopwatch/wristwatch 77 % of men ejaculated within 1 min |
Waldinger et al. [52] | 88 men with lifelong PE who self-estimated IELT 30 % of men ejaculated within 15 s, 67 % within 30 s, and 92 % within 1 min after penetration Only 5 % ejaculated between 1 and 2 min |
Waldinger et al. [44] | Stopwatch IELT study in a random unselected group of 491 men in five countries IELT had a positive skewed distribution Application of 0.5 and 2.5 % as disease standards 0.5 % equated to an IELT of 0.9 min and 2.5 % to an IELT of 1.3 min |
Althof [47] | IELT estimations for PE men correlate reasonably well with stopwatch-recorded IELT |
Pryor et al. [48] | IELT estimations for PE men correlate reasonably well with stopwatch-recorded IELT |
Rosen et al. [49] | Self estimated and stopwatch IELT as interchangeable Combining self-estimated IELT and PROs reliably predicts PE |
Operationalization of PE using the length of time between penetration and ejaculation, the IELT, forms the basis of most current clinical studies on PE [46]. Intravaginal ejaculatory latency time can be measured by a stopwatch or estimated. Several authors report that estimated and stopwatch IELT correlate reasonably well or are interchangeable in assigning PE status when estimated IELT is combined with PROs [47–49].
Normative multinational (Netherlands, United Kingdom, United States, Spain, and Turkey) reports of IELT been only recently been published [7]. The median IELT was 5.4 min (range, 0.55–44.1 min) and the distribution of the IELT in all five countries was positively skewed (Fig. 5.2). The median IELT decreased significantly with age, from 6.5 min in the 18–30 years group, to 4.3 min in the group older than 51 years. Median IELT varied between countries, with Turkey having the lowest IELT. The median IELT value was independent of condom use or circumcision status (except in Turkey). A similar study conducted a few years later reported congruent results with a median IELT of 6 (range 0.1–15.2 min) [50].
Fig. 5.2
Distribution of intravaginal ejaculatory latency times (IELT) values in a random cohort of 491 men with a median IELT of 5.4 min [37]
Several studies suggest that 80–90 % of men seeking treatment for lifelong PE ejaculate within 1 min (Fig. 5.1) [16, 51, 52]. Waldinger et al. [51] reported IELTs <30 s in 77 % and <60 s in 90 % of 110 men with lifelong PE with only 10 % ejaculating between 1 and 2 min. These data are consistent with normative community IELT data, support the notion that IELTs of <1 min are statistically abnormal and confirm that an IELT cut-off of 1 min will capture 80–90 % of treatment seeking men with lifelong PE [44]. Further qualification of this cut-off to “about one minute” affords the clinician sufficient flexibility to also diagnose PE in the 10–20 % of PE treatment seeking men who ejaculate within 1–2 min of penetration without unnecessarily stigmatising the remaining 80–90 % of men who ejaculate within 1–2 min of penetration but have no complaints of PE.
Evidence to support inclusion of the criterion of “…the inability to delay ejaculation on all or nearly all vaginal penetrations…” (Table 5.4).
Table 5.4
Findings of key publications regarding ejaculatory control in PE
Author/s | Summary of primary findings |
|---|---|
Grenier and Byers [53] | Relatively weak correlation between ejaculatory latency and ejaculatory control (R = 0.31) Ejaculatory control and latency are distinct concepts |
Grenier and Byers [60] | Relatively poor correlation between ejaculatory latency and ejaculatory control, sharing only 12 % of their variance suggesting that these PROs are relatively independent |
Waldinger et al. [51] | Little or no control over ejaculation was reported by 98 % of subjects during intercourse Weak correlation between ejaculatory control and stopwatch IELT (p = 0.06) |
Rowland et al. [63] | High correlation between measures of ejaculatory latency and control (R = 0.81, p < 0.001) |
Patrick et al. [42] | Men diagnosed with PE had significantly lower mean ratings of control over ejaculation (p < 0.0001) 72 % of men with PE reporting ratings of “very poor” or “poor” for control over ejaculation compared to 5 % in a group of normal controls Intravaginal ejaculatory latency time (IELT) was strongly positively correlated with control over ejaculation for subjects (R = 0.51) |
Giuliano et al. [64]
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