Delayed Ejaculation and Associated Complaints: Relationship to Ejaculation Times and Serum Testosterone Levels

BackgroundAlthough delayed ejaculation (DE) is typically characterized as a persistently longer than anticipated or desired time to ejaculation (or orgasm) during sexual activity, a timing-based definition of DE and its association with serum testosterone has not been established in a large cohort.AimTo examine in an observational study estimated intravaginal ejaculatory latency time (IELT) and masturbatory ejaculation latency time (MELT) in men self-reporting DE, assess the association of IELT and MELT with serum testosterone levels, and determine whether correlation with demographic and sexual parameters exist.MethodsMen who resided in the United States, Canada, and Mexico were enrolled from 2011 to 2013. Self-estimated IELT and MELT were captured using an Ejaculatory Function Screening Questionnaire in a sample of 988 men screened for possible inclusion in a randomized clinical trial assessing testosterone replacement therapy for ejaculatory dysfunction (EjD) and who self-reported the presence or absence of DE and symptoms of hypogonadism. Additional comorbid EjDs (ie, anejaculation, perceived decrease in ejaculate volume, and decreased force of ejaculation) were recorded. Men with premature ejaculation were excluded from this analysis. IELT and MELT were compared between men self-reporting DE and men without DE. The associations of IELT and MELT with serum testosterone were measured.OutcomesIELT, MELT, and total testosterone levels.ResultsSixty-two percent of screened men self-reported DE with or without comorbid EjDs; 38% did not report DE but did report at least one of the other EjDs. Estimated median IELTs were 20.0 minutes for DE vs 15 minutes for no DE (P < .001). Estimated median MELTs were 15.0 minutes for DE vs 8.0 minutes for no DE (P < .001). Ejaculation time was not associated with serum testosterone levels. Younger men and those with less severe erectile dysfunction had longer IELTs and MELTs.Clinical ImplicationsEstimated ejaculation times during vaginal intercourse and/or masturbation were not associated with serum testosterone levels in this study; thus, routine androgen evaluation is not indicated in these men.Strengths and LimitationsThis large systematic analysis attempted to objectively assess the ejaculation latency in men with self-reported DE. Limitations were that ejaculation time estimates were self-reported and were queried only once; the questionnaire did not distinguish between failure to achieve orgasm and ejaculation; and assessment of DE was limited to heterosexual vaginal intercourse and masturbation.ConclusionIELT and MELT were longer in men with DE, and there was no association of ejaculation times with serum testosterone levels in this study population.Morgentaler A, Polzer P, Althof S, et al. Delayed Ejaculation and Associated Complaints: Relationship to Ejaculation Times and Serum Testosterone Levels. J Sex Med 2017;14:1116–1124.     

Estimations of Typical,Ideal, Premature Ejaculation,and Actual Latencies by Men and Female Sexual Partners of Men During Partnered Sex

BackgroundThe ejaculation latency (ELT) criterion for men with premature ejaculation (PE), including its 2 major subtypes of lifelong and acquired, relies heavily on expert opinion, yet such information represents only one source of data for this determination; furthermore, information regarding ELTs for PE within specific subgroups of men (eg, gay, bisexual) has been lacking.AimTo obtain data regarding men's lived experiences and expectations regarding typical ejaculation, ideal ejaculation, and PE and (for men) self-reported ejaculatory latencies during partnered sex across a variety a groups, including men vs women (ie, sexual partners of men), men with and without PE, and straight vs gay/bisexual men.MethodsWe recruited 1,065 men and sexual partners of men, asking them to estimate typical ejaculation, ideal ejaculation, and PE and (for men) self-latencies through an online survey posted on social media. Demographics, sexual identity, and sexual response data were also collected.ResultsTypical and self-reported ELTs were closely aligned with those reported in the literature, with ideal ELTs generally longer than typical ELTs. Median PE ELTs were consistently estimated around 1.5 min, with nearly all subgroups—men vs women; straight vs gay; PE and non-PE men—showing alignment on this criterion. Men with lifelong PE did not differ from men with acquired PE in either their PE ELT estimation or their self-reported ELT.Clinical ImplicationsThe data support the idea of extending the latency cutoff for establishing a PE diagnosis beyond the current 1-minute threshold.Strengths & LimitationsA large sample size drawn from a multinational population powered the study, whereas the use of social media for recruitment and lack of inclusion of lesbian and asexual individuals may have missed relevant data from some who have had sexual experience with men.ConclusionStraight and nonstraight men do not differ in their ELT estimations. In addition, the use of different ELT criteria for lifelong vs acquired PE may be unnecessary.Côté-Léger P, Rowland DL. Estimations of Typical, Ideal, Premature Ejaculation, and Actual Latencies by Men and Female Sexual Partners of Men During Partnered Sex. J Sex Med 2020;17:1448–1456.     

Compliance With Fluoxetine Use in Men With Primary Premature Ejaculation

BackgroundPremature ejaculation (PE) is a common sexual dysfunction for which selective serotonin reuptake inhibitors (SSRIs) have been used effectively for treatment. However, compliance with therapy and predictors of long-term SSRI use in the treatment of PE are not well known.AimTo analyze our experience with drop-out rates with fluoxetine in the primary PE population and to identify predictors of continued use of this agent.MethodsMen with primary PE constituted who used fluoxetine and had at least 12 months follow-up constituted the study population. Subjects underwent a comprehensive interview to ascertain self-reported (non-stopwatch) intravaginal ejaculatory latency time (IELT), self-rated control over ejaculation, and personal and patient-reported partner distress due to PE. Patients were treated with fluoxetine 20 mg daily, with the possibility of dose titration up or down based on efficacy and side effects.OutcomesThe PE parameters of interest included self-reported IELT, self-rated control over ejaculation, personal and partner distress due to PE, and medication adherence.Results130 men were included in the study. Dropout rates at 6 and 12 months were 56% and 72%. Self-rated “poor” ejaculatory control decreased from 98%–41% (P < .01), high personal distress from 47%–11% (P < .01), and high partner distress rates from 72%–27% (P < .01). Predictors of continued use at 12 months included high partner distress, being unpartnered, and having a post-treatment IELT ≥5 minutes (P < .01). Overall side effects included headache (5%), dizziness (4%), nausea (5%), nervousness (5%), and sleepiness (8%); however, moderate to severe side effects reported included nausea (2%), sleepiness (2%), headache (2%), and dizziness (2%).Clinical ImplicationsCompliance with SSRIs is a well-described problem in the depression literature, but data are sparse regarding continued use of SSRIs in the treatment of PE.Strengths and LimitationsWe report on 12-month compliance with SSRIs for the treatment of PE. Our early compliance rates were more encouraging than what has been reported in the past. However, IELT was self-reported and not measured objectively, and we did not use validated patient-reported outcomes but rather self-reported ejaculatory control and distress levels, which have limitations.ConclusionsFluoxetine is an effective agent for the treatment of PE with significant improvement realized in IELT, ejaculatory control, and distress levels for both men and their partners. Despite its efficacy, continued use of fluoxetine beyond 6 months is poor.Jenkins LC, Gonzalez J, Tal R, et al. Compliance with Fluoxetine Use in Men with Primary Premature Ejaculation. J Sex Med 2020;16:1895–1899.     

Oral agents for the treatment of premature ejaculation: review of efficacy and safety in the context of the recent International Society for Sexual Medicine criteria for lifelong premature ejaculation

IntroductionNew diagnostic criteria for lifelong premature ejaculation (PE) have been proposed by the International Society of Sexual Medicine (ISSM), including an intravaginal ejaculatory latency time (IELT) of less than about 1 minute, lack of control over ejaculation, and PE‐related distress or bother.AimThe aim of this study was to review evidence supporting the efficacy and safety of oral agents for the treatment of PE in the context of the new ISSM criteria.MethodsThe PubMed database was searched for randomized, double‐blind, placebo‐controlled studies of oral agents in PE that included stopwatch measurements of IELT.Main Outcome MeasuresThe main outcome measure used for this study was a review of the efficacy and safety data of oral agents for PE aligned with ISSM criteria.ResultsSince the latest meta‐analyses using similar criteria (conducted in 2004 and 2005 for selective serotonin reuptake inhibitors [SSRIs] and phosphodiesterase type 5 [PDE‐5] inhibitors, respectively), eight studies evaluated SSRIs vs. placebo, one compared SSRIs, two evaluated PDE‐5 inhibitors, and one evaluated an SSRI/PDE‐5 inhibitor combination. New agents included dapoxetine (five studies) and tramadol (one study). Six studies enrolled men who met an approximation of the ISSM criteria. Although evidence suggests that most SSRIs, tramadol, and dapoxetine increase IELT to varying degrees, few studies included control over ejaculation and PE‐related distress or bother as enrollment criteria or used validated patient‐reported outcome instruments to evaluate these parameters. Among studies that provided comprehensive adverse event data, safety and tolerability observations in men with PE were generally similar to those observed in other populations; however, with the exception of dapoxetine, known SSRI‐class effects (e.g., withdrawal syndrome) were not evaluated in men with PE.ConclusionsThis systematic review of well‐controlled clinical trials in PE has demonstrated that while many oral agents, particularly SSRIs, tramadol, and dapoxetine, have proven effective and safe for the treatment of men with PE, few have been evaluated for their effects on the specific elements of the ISSM criteria. McMahon CG and Porst H. Oral agents for the treatment of premature ejaculation: Review of efficacy and safety in the context of the recent international society for sexual medicine criteria for lifelong premature ejaculation. J Sex Med 2011;8:2707–2725.     

Premature and delayed ejaculation: genetic and environmental effects in a population-based sample of Finnish twins

IntroductionA number of different theoretical approaches to understanding the etiology of ejaculatory dysfunction have been proposed, but no behavior genetic study has yet, to our knowledge, been conducted to explore the genetic and environmental influences on ejaculatory dysfunction.AimThe aim of the present study was to explore the genetic and environmental effects on premature (PE) and delayed (DE) ejaculation in a population-based sample.MethodsThe genetic and environmental influences on PE and DE were investigated in a population-based sample of 1,196 Finnish male twins, age 33–43 years, with 91 identical and 110 complete twin pairs. Several different aspects of ejaculatory function were measured by a self-report questionnaire (e.g., latency time, subjective experience of ejaculatory control). Factor analyses distinguished two subcomponents of ejaculatory function, and subsequently, composite variables measuring PE and DE were created. Structural equation modeling was performed on the composite variables.Main Outcome MeasuresMeasurement of genetic and environmental effects on PE and DE.ResultsThe results suggested moderate genetic influence (28%) on PE, but not on DE (0%). There was a moderate familial effect on DE with shared environmental effects accounting for 24% of the variance. However, omission of the shared environmental component did not directly result in a significantly decreased model fit for DE, and omission of the additive genetic component did not directly result in a significantly decreased fit for the PE model.ConclusionsThe findings from the present study provide useful information regarding the etiology and understanding of ejaculatory dysfunction. Jern P, Santtila P, Witting K, Alanko K, Harlaar N, Johansson A, von der Pahlen B, Varjonen M, Vikström N, Ålgars M, and Sandnabba K. Premature and delayed ejaculation: Genetic and environmental effects in a population-based sample of Finnish twins.     

Effect of Dapoxetine on Ejaculatory Performance and Related Brain Neuronal Activity in Rapid Ejaculator Rats

IntroductionA brain network specifically activated when ejaculation occurs has been described in rats. Increasing serotonin (5‐hydroxytryptamine [5‐HT]) tone impairs ejaculation and chronic 5‐HT selective serotonin reuptake inhibitors (SSRIs) are known to inhibit ejaculation. However, efficacy of acute treatment with SSRI varies from one compound to another. The SSRI dapoxetine has been reported to delay ejaculation when given on demand to men with premature ejaculation (PE), although the mechanism of action is unclear. Effects of acute SSRIs on activity of the brain ejaculation circuit in relation with ejaculation have never been examined.AimTo test the effects of acute administration of the short half‐life SSRI dapoxetine on ejaculatory performance and activity in brain ejaculation circuit in rapid ejaculator rats taken as PE model.MethodsStandard copulatory test was used to attribute one sexual category (sluggish, middle, or rapid) to male rats on the basis of their ejaculatory performance. Parameters of sexual, including ejaculatory, behavior, and Fos level of expression in discrete brain areas were assessed in the three sexual categories and in rapid category following acute oral treatment with dapoxetine.Main Outcome MeasuresEjaculation frequency (EF) and latency (EL) were measured as primary end points of ejaculatory behavior. Density of Fos‐immunopositive cells in specific brain areas of brain stem, hypothalamus, and thalamus was determined as marker of neuronal activity.ResultsEL and Fos level of expression in hypothalamic and thalamic structures were found related. Dapoxetine acute oral administration (300 mg/kg) to rapid ejaculator rats resulted in (i) diminution of ejaculatory performance (lengthened EL and decreased EF); and (ii) modulation of Fos level of expression in hypothalamic and thalamic nuclei of the brain ejaculatory circuit.ConclusionAcute treatment with dapoxetine, which reduced ejaculatory performance in rapid ejaculator rats, was also accompanied with changes in neuronal activity in components of the brain ejaculatory network. Clément P, Laurin M, Compagnie S, Facchinetti P, Bernabé J, Alexandre L, and Giuliano F. Effect of dapoxetine on ejaculatory performance and related brain neuronal activity in rapid ejaculator rats. J Sex Med **;**:**–**.     

Interrelationships among measures of premature ejaculation: the central role of perceived control

IntroductionDomains of premature ejaculation (PE) include short intravaginal ejaculatory latency time (IELT), poor perceived control over ejaculation, decreased satisfaction with sexual intercourse, and personal distress and interpersonal difficulty related to ejaculation. How these measures interrelate is unknown.AimHere, we evaluated the interrelationships between these PE-specific variables, applying cross-sectional data from a large U.S. observational study of men with PE.MethodsWe analyzed data from men with PE identified in a previously reported observational study. PE was diagnosed by experienced clinicians using the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision.Main Outcome MeasuresSubjects reported their stopwatch-measured IELT, perceived control over ejaculation, satisfaction with sexual intercourse, personal distress related to ejaculation, and interpersonal difficulty related to ejaculation. Relationships between variables were assessed using bivariate correlations, and the strength and significance of direct or indirect effects between variables were evaluated using a form of regression analysis known as path analysis.ResultsBivariate Pearson correlation coefficients for all relationships were significant at the P ≤ 0.05 level, with the exception of IELT and interpersonal difficulty related to ejaculation. When all variables were included in the model, IELT showed a significant direct effect on perceived control over ejaculation but did not show a significant direct effect on ejaculation-related personal distress or satisfaction with sexual intercourse. Perceived control over ejaculation showed a significant direct effect on both ejaculation-related personal distress and satisfaction with sexual intercourse, which each showed direct effects on interpersonal difficulty related to ejaculation.ConclusionsThe patient's perception of control over ejaculation is central to understanding how PE is associated with satisfaction with sexual intercourse and ejaculation-related distress. In contrast, the association of IELT with satisfaction with sexual intercourse and distress related to ejaculation is mediated by perceived control over ejaculation. Patrick DL, Rowland D, and Rothman M. Interrelationships among measures of premature ejaculation: The central role of perceived control.     

Clinical and Demographic Correlates of Ejaculatory Dysfunctions Other Than Premature Ejaculation: A Prospective,Observational Study

IntroductionEjaculatory dysfunctions other than premature ejaculation are commonly encountered in specialized clinics; however, their characterization in community‐dwelling men is lacking.AimThe aim of this study was to evaluate the prevalence, severity, and associated distress of four ejaculatory dysfunctions: delayed ejaculation (DE), anejaculation (AE), perceived ejaculate volume reduction (PEVR) and/or decreased force of ejaculation (DFE) as a function of demographic and clinical characteristics in men.MethodsObservational analysis of 988 subjects presenting with one or more types of ejaculatory dysfunctions other than premature ejaculation who screened for a randomized clinical trial assessing the efficacy of testosterone replacement on ejaculatory dysfunction. Demographic and clinical characteristics were assessed as potential risk factors using regression analysis.Main Outcome MeasuresThe main outcome measures used were ejaculatory dysfunction prevalence and scores (3‐item Men's Sexual Health Questionnaire Ejaculatory Dysfunction‐Short Form [MSHQ‐EjD‐SF]), and bother (MSHQ‐EjD‐SF Bother item) and sexual satisfaction/enjoyment (International Index of Erectile Function Questionnaire Q7, Q8) as a function of subject's age, race, body mass index (BMI) and serum testosterone levels (measured by liquid chromatography tandem mass spectrometry).ResultsMean (standard deviation [SD]) age of the participants was 52 years (11). Eighty‐eight percent of the men experienced more than one type of ejaculatory dysfunction and 68% considered their symptoms to be bothersome. Prevalence of the ejaculatory dysfunctions was substantial across a range of age, race, BMI, and serum testosterone categories. Prevalence of PEVR and DFE were positively associated with age (<40 years vs. 60–70 years: PEVR: odds ratio [OR], 3.05; 95% confidence interval [CI], 1.32–7.06; DFE: OR, 2.78; 95% CI, 1.46–5.28) while DFE was associated with BMI (≥30 kg/m² vs. < 25 kg/m²: OR, 1.80; 95% CI, 1.062–3.05). All ejaculatory dysfunctions were more prevalent in black men.ConclusionThe majority of the participants experienced multiple ejaculatory dysfunctions and found them to be highly bothersome. Ejaculatory dysfunctions were prevalent across a wide range of demographic and clinical characteristics. Paduch DA, Polzer P, Morgentaler A, Althof S, Donatucci C, Ni X, Patel AB, and Basaria S. Clinical and Demographic Correlates of Ejaculatory Dysfunctions Other Than Premature Ejaculation: a Prospective, Observational Study. J Sex Med 2015;12:2276–2286.     

Premature Ejaculation: Bother and Intravaginal Ejaculatory Latency Time in Iran

IntroductionComplaints of premature ejaculation (PE) and its repercussions are culture‐dependent.AimTo report the measured intravaginal ejaculatory latency time (IELT) and the impact of PE in Kermanshah, Iran.MethodsFrom November 1996 through October 2008, 3,458 patients presented to us with self‐diagnosed PE. In the first visit, after obtaining a psychosocial and sexual history, PE‐specific bother was self‐rated by the patients and the patients were advised to measure their IELTs over the next 2–3 weeks. In the second visit, the measured IELTs were reported by the patients.Main Outcome MeasuresPatients' measured IELT and bother score.ResultsAge range was 17–80 years (mean 34.1, standard deviation [SD] 9.1, median 32). Sixty‐five percent were married. Primary and secondary PE was reported by 2,105 (60.8%) and 1,353 (39.1%) patients, respectively. Occasional PE was reported by 36 (0.01%). Of those with multiple partners, 6% had partner‐specific PE. IELT distribution was positively skewed. Anteportal ejaculation was reported by 97 (2.8%). In 3,458 self‐reported PE patients, IELT was 1–15 seconds in 542 (15.7%), 16–30 seconds in 442 (12.8%), 31–60 seconds in 978 (28.3%), > 1 ≤ 2 minutes in 551 (15.9%), > 2 ≤ 5 minutes in 712 (20.6%), and >5 minutes in 136 (3.9%). IELTs of ≤1 minutes and ≤2 minutes were reported by 59.5% and 75.5%, respectively. Median bother score was 3 of 4. Pearson's correlation between IELT and bother (r = ?0.607) was highly negative, with shorter IELTs being correlated with more bother. Six hundred forty‐three patients (18.6%) always consumed opium to lengthen their IELTs. All 21 patients who started to use Tramadol as a PE treatment became addicted to it. Of 168 divorced couples due to PE, 23 divorced because the sexually dissatisfied wives became involved in extramarital affairs. Applying the Diagnostic and Statistical Manual of Mental Disorders criteria for PE and a cutoff IELT point of ≤2 minutes, and thus excluding the patients with IELTs of longer than 2 minutes, the patients with occasional PE, and the patients who reported no personal bother, of 3,458 self‐reported PE patients, 2,571 (74.3%) had PE. Including the 97 patients with anteportal ejaculation, arithmetic mean IELT in 2,571 patients was 45.87 seconds, SD 36.1, median 40, and range 0–120. Excluding the anteportal ejaculation, arithmetic mean IELT in the remaining 2,474 patients was 47.67 seconds, SD 35.71, median 42, range 1–120, and geometric mean 31.06.ConclusionPE has a devastating impact. In clinical practice, primary lifelong PE is by far the most common variety of PE. Occasional PE is a very rare cause of presentation. A significant proportion of the patients who consider themselves as premature ejaculators have IELTs of more than 2 minutes; the sexual medicine community should reach a consensus on the clinical diagnostic and therapeutic approach to these patients who consider themselves as premature ejaculators. The most important cause of bother in PE is the briefness of the ejaculatory latency, rather than the lack of control. Second‐round ED (pseudoED) was reported for the first time. The worst type of PE, i.e., anteportal ejaculation, is not very rare; thus, geometric mean that excludes anteportal ejaculation is not suitable statistics to report the ejaculatory latency time; instead, median is the best measure of IELT reporting. Cutoffs of 0.5–2.5 percentiles are not suitable means to diagnose PE. Zargooshi J. Premature ejaculation: Bother and intravaginal ejaculatory latency time in Iran.     

Relationship between premature ejaculation and depression in Korean males

IntroductionThe psychological impacts of premature ejaculation (PE), which include guilt, anxiety, and distress, have been well established in Western countries. However, in Asia, although a substantial number of epidemiological studies have surveyed the prevalence of PE, researchers have not thoroughly investigated the relationship between PE and depression, or have defined PE properly.AimWe studied the association between PE and depression and other psychological disturbances, in a Korean cohort by applying an appropriate definition for PE and validated outcome measures of depression.MethodsA total of 956 males (≥20 years) were initially approached via an Internet survey company. Participants were asked to complete a questionnaire requesting detailed medical and sexual histories, which included questions from the Erectile Function Domain score in the International Index of Erectile Function (IIEF‐EF) and the Beck Depression Inventory (BDI). The prevalence of PE was evaluated using two different definitions—self‐assessed PE and presumed PE. Presumed PE was defined as a short ejaculation time (an estimated intravaginal ejaculatory latency time ≤5 minutes), an inability to control ejaculation, and the presence of distress resulting from PE.Main Outcome MeasuresEjaculation‐related questionnaire, the IIEF‐EF, and BDI.ResultsA total of 334 men were evaluated. The prevalence of PE was 10.5% according to the Presumed PE definition, whereas by self‐assessment, it was 25.4%. Self‐assessed PE patients suffered from various psychological problems, such as depression, low self‐esteem, bother, and low sexual satisfaction. Even after excluding erectile dysfunction (ED) subjects, a significant relationship was found between self‐assessed PE and depression. Moreover, after further classification of the Self‐assessed PE group, we found that subjects included in this group, but not in the Presumed PE group, suffered more from psychological burden than any other members of the cohort.ConclusionKorean men with subjective perceptions of PE are prone to various psychological problems, which include depression. Son H, Song SH, Lee J‐Y, and Paick J‐S. Relationship between premature ejaculation and depression in Korean males. J Sex Med 2011;8:2062–2070.     

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision as an appropriate diagnostic for premature ejaculation

IntroductionThe Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria for premature ejaculation (PE) are multifactorial, and include concepts of latency, perceived control over ejaculation, and personal distress and interpersonal difficulty related to the condition. Recent publications have suggested that these criteria are not supported by empirical evidence, leading to the proposal that a PE diagnosis should be based solely on intravaginal ejaculatory latency time (IELT), while the presence of other factors (such as perceived lack of control over ejaculation) may be used to guide treatment decisions.AimTo examine the evidence supporting the elements of the DSM-IV-TR criteria for PE.Main Outcome MeasuresLiterature searches on IELT, perceived control over ejaculation, and personal distress and interpersonal difficulty related to ejaculation.ResultsFrom a historical perspective, there has been a lack of large observational studies that evaluated the contributions of the DSM-IV-TR components in men with PE. However, recently performed large observational studies have generated data supporting the inclusion of perceived control over ejaculation and personal distress related to ejaculation in the definition of PE. Furthermore, emerging evidence indicates that a perceived lack of control over ejaculation is directly associated with elevated personal distress related to ejaculation and decreased satisfaction with sexual intercourse, while the effects of IELT on these parameters are indirect, and mediated by perceived control over ejaculation. A key advantage of the DSM-IV-TR approach to the diagnosis of PE is that it firmly links PE to a negative outcome for the patient, which is an element common to diagnostic criteria for other conditions, including depression, hypertension, and osteoporosis.ConclusionsThis new evidence strongly suggests that the DSM-IV-TR criteria for PE encompass aspects of the condition that patients describe as important. Shabsigh R, and Rowland D. The DSM-IV-TR as an appropriate diagnostic for premature ejaculation.     

An Evidence‐Based Unified Definition of Lifelong and Acquired Premature Ejaculation: Report of the Second International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation

IntroductionThe International Society for Sexual Medicine (ISSM) Ad Hoc Committee for the Definition of Premature Ejaculation developed the first evidence‐based definition for lifelong premature ejaculation (PE) in 2007 and concluded that there were insufficient published objective data at that time to develop a definition for acquired PE.AimThe aim of this article is to review and critique the current literature and develop a contemporary, evidence‐based definition for acquired PE and/or a unified definition for both lifelong and acquired PE.MethodsIn April 2013, the ISSM convened a second Ad Hoc Committee for the Definition of Premature Ejaculation in Bangalore, India. The same evidence‐based systematic approach to literature search, retrieval, and evaluation used by the original committee was adopted.ResultsThe committee unanimously agreed that men with lifelong and acquired PE appear to share the dimensions of short ejaculatory latency, reduced or absent perceived ejaculatory control, and the presence of negative personal consequences. Men with acquired PE are older, have higher incidences of erectile dysfunction, comorbid disease, and cardiovascular risk factors, and have a longer intravaginal ejaculation latency time (IELT) as compared with men with lifelong PE. A self‐estimated or stopwatch IELT of 3 minutes was identified as a valid IELT cut‐off for diagnosing acquired PE. On this basis, the committee agreed on a unified definition of both acquired and lifelong PE as a male sexual dysfunction characterized by (i) ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE); (ii) the inability to delay ejaculation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.ConclusionThe ISSM unified definition of lifelong and acquired PE represents the first evidence‐based definition for these conditions. This definition will enable researchers to design methodologically rigorous studies to improve our understanding of acquired PE. Serefoglu EC, McMahon CG, Waldinger MD, Althof SE, Shindel A, Adaikan G, Becher EF, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An evidence‐based unified definition of lifelong and acquired premature ejaculation: Report of the second International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation. J Sex Med 2014;11:1423–1441.     

Temperament-Character Traits and Attitudes Toward Premature Ejaculation in 4 Types of Premature Ejaculation

BackgroundAlthough temperament-character traits and attitudes toward premature ejaculation (PE) are known to be associated with PE, it is of great significance to study them in PE. Moreover, few studies have evaluated these traits and attitudes in the new classification of 4 subtypes of PE.AimWe investigated the temperament-character traits and attitudes toward PE in 4 types of PE and their associations with PE.MethodsBetween December 2018 and December 2019, we conducted a survey in our hospital, and enrolled 350 men who complained of PE and 252 men without any complaint of PE. Temperament-character traits and attitudes toward PE were independently assessed by the Temperament and Character Inventory-Revised and several targeted questions, respectively. The Index of Premature Ejaculation (IPE) was used to evaluate ejaculation control, sexual life satisfaction, and distress caused by PE.OutcomesThe outcomes included differences of temperament-character traits and attitudes toward PE among 2 groups and their associations with PE.ResultsOf the 2 groups, men with PE complaints had lower novelty seeking/self-transcendence (NS/ST) scores and higher harm avoidance (HA) scores vs men without any complaints of PE. Among the 4 types of PE, men with variable PE had the highest score of HA and lowest score of NS; the lowest score of ST was recorded in men with lifelong PE. Additionally, the total and subdomain scores of IPE in men with subjective PE were higher than the other subtypes of PE. After adjusting for age, positive correlations were observed in HA score and total and subdomain scores of IPE, whereas the inverse was true corresponding to NS and ST.Clinical ImplicationsThe current study has provided a new perspective for understanding the impact of psychological factors on PE.Strengths & LimitationsThis is the first study to systematically assess the effects of personality traits and attitudes on PE, especially among the 4 types of PE. The main drawback is that the generalizability of this study may be limited by the fact that it was conducted in a single cultural/societal background.ConclusionMen who complained of PE tended to react with indifference or rejection to novelty, tended to feel unsatisfied, cannot effectively adapt to changes in the surrounding environment, and tended to avoid situations involving risk. These characteristics could lead to their becoming disheartened when faced with PE. Furthermore, the attitude of men with PE reflects the needs of the patient during treatment from one aspect.Gao P, Gao J Wang Y, et al. Temperament-Character Traits and Attitudes Toward Premature Ejaculation in 4 Types of Premature Ejaculation. J Sex Med 2021;18:72–82.     

Improved Ejaculatory Latency,Control and Sexual Satisfaction When PSD502 is Applied Topically in Men with Premature Ejaculation: Results of a Phase III,Double-Blind,Placebo-Controlled Study

IntroductionPSD502 is a novel aerosolized, lidocaine-prilocaine, spray being developed for the treatment of lifelong premature ejaculation. The clinical profile of PSD502 is described in one of two double-blind, placebo-controlled, phase III studies.AimTo determine the effect of PSD502 on the Index of Premature Ejaculation (IPE) and intravaginal ejaculatory latency (IELT) of men with lifelong PE.MethodsMen with lifelong PE who documented an IELT ≤ 1 minute with two or more of the first three sexual encounters during a 4-week baseline period were randomized to receive double-blind treatment with PSD502 or placebo for 3 months. Patients completed IPE and Premature Ejaculation Profile questionnaires at entry and monthly visits, and recorded stop-watch timed IELT during each encounter. Safety was assessed by collecting adverse event data and standard safety measures.Main Outcome MeasuresStopwatch timed IELT recordings and a patient-reported outcome questionnaire the IPE were used in this study to determine the effect of PSD502 applied topically 5 minutes before intercourse.ResultsTwo hundred fifty-six men with PE were randomized from 38 centers in the U.S., Canada, and Poland. The geometric mean IELT over the 3-month treatment period increased from a baseline of 0.56 minute and 0.53 minute in the PSD502 and placebo group respectively to 2.60 and 0.80 minute. There were significantly greater increases in the scores for the IPE domains of ejaculatory control, sexual satisfaction and distress in the PSD502 group than in the placebo group, with a mean 5.0 point difference between treatments in change from baseline in the IPE domain for ejaculatory control, 4.6 point difference in change from baseline in the IPE domain for sexual satisfaction, and a 2.5 point difference in change from baseline in the IPE domain for distress. This was supported by improvements in all secondary endpoints.ConclusionIn this study, PSD502 applied topically to the glans penis 5 minutes before intercourse showed significantly improved ejaculatory latency, ejaculatory control, sexual satisfaction and distress and was shown to be well tolerated by patients and partners. Carson C, and Wyllie M. Improved ejaculatory latency, control and sexual satisfaction when PSD502 is applied topically in men with premature ejaculation: Results of a phase III, double-blind, placebo-controlled study.     

Anejaculation: Relevance to Sexual Enjoyment in Men and Women

IntroductionEjaculation and orgasm are important components of sexual response in men. Our understanding of both phenomena is limited. Anejaculation can be a source of substantial distress, even when procreation (ostensibly the only purpose of ejaculation itself) is not a priority.AimTo present an opinion on male perceptions of ejaculation disorders (specifically anejaculation) based on a variety of data sources, including peer-reviewed literature.MethodsA non-systematic review of literature on anejaculation and other impairments of ejaculatory and orgasmic response was conducted. Relevant articles were critically analyzed and reportedMain Outcome MeasureAn opinion is presented, based on existing data sources, on how and why ejaculation is deemed important to men and their sexual partners.ResultsThe peer-reviewed literature on disorders of ejaculation is scant; existing reports oftentimes do not adequately distinguish between orgasm and ejaculation in assessment. Men’s perceptions of ejaculation quality appear to be positively associated with satisfaction with sexual response, particularly regarding orgasm. Based on very limited data, female sexual partners of men appear to often (but not always) value the orgasmic experience of their partner; only a minority prioritize actual ejaculation. There is evidence that disorders of ejaculation may be particularly troublesome for men who have sex with men.Clinical ImplicationsThe influence of medical conditions and treatments on ejaculation should be considered in the clinical context. Psychological adaptations and interventions may be of value in some cases.Strengths & LimitationsData on the clinical relevance of anejaculation outside the context of concomitant orgasmic dysfunction are sparse. Men’s experience of orgasm is at least partially associated with ejaculation-specific variables; whether this association is mediated by psychological, physical, or a combination of factors remains unclear.ConclusionsEjaculation, orgasm, and sexual satisfaction are closely intertwined but distinct phenomena.Shindel AW. Anejaculation: Relevance to Sexual Enjoyment in Men and Women. J Sex Med 2019;16:1324–1327.     

Understanding the Effects of Establishing Various Cutoff Criteria in the Definition of Men with Premature Ejaculation

IntroductionOver the past decade, professional organizations and consensus groups have offered a variety of definitions for premature ejaculation (PE), all generally including a set of common concepts but all varying in specific language and operationalization. Clearly articulated definitions of such conditions are important because they not only affect prevalence rates but also diagnostic inclusion—who is deemed to have the condition and therefore who might be eligible for treatment.AimThe current study had two goals: (i) to examine the effects on prevalence rates of moving the cutoff points from more stringent to less stringent for each of three PE criteria—ejaculatory latency, distress, and ejaculating before desired; and (ii) to explore in detail the relationships among the three criteria.MethodsUsing an Internet-based sample of 1,183 men, we examined the responses of 374 with PE-type symptoms based on consensus definitions, and determined the effect of decreasing restrictions on the cutoff criteria. In addition, we calculated both correlations and concordance rates among criteria.ResultsNumeric and graphic depiction of the effects of moving the cutoff point for each of the three criteria is provided in the URL “PE Prevalence©,” a dynamic tool developed specifically for this study (https://sites.google.com/a/valpo.edu/PEprevalence/). In addition, statistical relationships among the PE criteria suggest sufficient independence to warrant inclusion of all three in a diagnostic procedure as well as to consider a 2-minute ejaculatory latency as the threshold for a PE diagnosis.ConclusionsBased on our data, clinicians should approach the 1-minute ejaculatory latency time (ELT) criterion with flexibility, considering ELTs up to 2 minutes for a PE diagnosis. At the same time, frequency of occurrence of either ejaculating before desired or of distress about the condition, as long as they reach at least 50% of the time, had only minor impact on PE diagnostic inclusion. Rowland DL and Kolba TN. Understanding the effects of establishing various cutoff criteria in the definition of men with premature ejaculation. J Sex Med 2015;12:1175–1183.     

Antibiotic treatment can delay ejaculation in patients with premature ejaculation and chronic bacterial prostatitis

IntroductionPremature ejaculation (PE) is regarded as the most common male sexual disorder. Previous studies reported that prostatic inflammation was highly prevalent in PE. However, the effect of antibiotic treatment of cases with PE and chronic prostatitis has not been extensively investigated.AimTo examine the effect of antibiotic treatment in delaying ejaculation in patients with PE and chronic prostatitis.MethodsA total of 145 consecutive men attending of secondary premature ejaculation (SPE) were included in this study. Sequential microbiologic specimens were obtained from urine and prostatic fluid. Antibiotics were given for 1 month according to the results of their culture and sensitivity test. All patients were instructed to follow up with our clinic monthly for at least 4 months. At the end of the 4-month follow-up, another prostatic secretion analysis was performed.ResultsBased on expressed prostatic secretion culture and white blood cell (WBC) count, 94 (64.8%) were having chronic bacterial prostatitis. The remaining 51 (35.2%) patients had negative WBC count. Of the 94 patients with SPE and chronic bacterial prostatitis, 20 patients were left untreated and considered as a control group. All 74 patients with PE and chronic prostatitis continued the 1-month treatment duration. Following 1-month antibiotic treatment, all 74 patients with initially positive cultures had sterile final cultures (P < 0.05). Sixty-two (83.9%) patients showed increases in their ejaculatory latency time and reported good control of their ejaculation and were considered treatment responsive. None of the control group patients experienced any improvement either in their prostatic infection condition or in their ejaculation time. The follow-up of treatment-responsive patients (N = 62) revealed no recurrence of PE with negative prostatic culture.ConclusionsSuccessful eradication of causative organisms in patients with PE and chronic prostatitis may lead to marked improvement in intravaginal ejaculatory latency time and ejaculatory control. El-Nashaar A, and Shamloul R. Antibiotic treatment can delay ejaculation in patients with premature ejaculation and chronic bacterial prostatitis.     

A Double-Blind,Placebo-Controlled Parallel Group Study to Evaluate the Effect of a Single Oral Dose of 5-HT1A Antagonist GSK958108 on Ejaculation Latency Time in Male Patients Suffering From Premature Ejaculation

BackgroundPremature ejaculation (PE) is a common male neurobiological sexual disorder, related to a disturbance in central serotonin (5-hydroxytryptamine or 5-HT) neurotransmission.AimTo assess the efficacy of a single oral dose of 5HT_1A receptor antagonist GSK958108 on ejaculation latency time (ELT) in male subjects suffering from PE.MethodsA total of 35 male subjects were enrolled in a Phase 1 double-blind, placebo-controlled, parallel group masturbation-model study. All subjects completed the study. No subject was withdrawn from the study. There were no major protocol deviations reported during the study.OutcomesThe primary outcome of the study was to evaluate the effect of a single oral dose of 5HT_1A receptor antagonist GSK958108 on ELT as measured in the masturbation model; additionally, we investigated drug’s safety and tolerability.ResultsIn the 3 mg GSK958108 treatment group, the ELT was estimated to be 16% longer (1.542 vs 1.328, 95% CI: -16% to +61%) than if the subjects had taken placebo. In the 7 mg GSK958108 treatment group, the ELT was estimated to be 77% longer (2.346 vs 1.328, 95% CI: +28% to +144%) than in the placebo group. The systemic exposure to GSK958108 increased with dosage between 3 mg and 7 mg. A significant trend toward an increase of ELT was observed with increasing plasma concentrations of GSK958108. A total of 4 patients all treated with 7 mg dose experienced minor drug related adverse events (5 adverse events in 4 patients): somnolence (n = 3), headache (n = 1), tinnitus (n = 1).Clinical ImplicationsIn the current double-blind, placebo-controlled parallel group study the 5HT_1A receptor antagonist GSK958108 was tested in 3 mg and 7 mg doses for PE treatment in humans. It was shown that GSK958108 significantly delayed ejaculation showing a new and safe alternative in PE treatment.Strengths & LimitationsThe present study showed innovative results suggesting an important role of 5HT_1A receptor antagonist in the PE treatment. However, the use of masturbation model and the small population are the main limitations of this investigation.Conclusion5HT_1A receptor antagonist GSK958108 3 mg per day and 7 mg per day was found to be well-tolerated, safe and effective for the treatment of PE subjects and demonstrated a strong association between 5HT1A receptors and ejaculation control in humans (NCT00861484).Migliorini F, Tafuri A, Bettica P, et al. A Double-Blind, Placebo-Controlled Parallel Group Study to Evaluate the Effect of a Single Oral Dose of 5-HT1A Antagonist GSK958108 on Ejaculation Latency Time in Male Patients Suffering From Premature Ejaculation. J Sex Med 2021;18:63–71.     

The diagnostic value of the premature ejaculation diagnostic tool and its association with intravaginal ejaculatory latency time

IntroductionPremature ejaculation (PE) is the most prevalent male ejaculation disorder. The premature ejaculation diagnostic tool (PEDT) was developed to systematically apply the DSM‐IV‐TR criteria in diagnostic PE.AimsTo evaluate the diagnostic value of the PEDT and its association with intravaginal ejaculatory latency time (IELT).Methods(i) Korean validation of PEDT: data was collected from men interviewed by one of the two clinical experts, who made a diagnostic of present or absence of PE, using DSM‐IV‐TR criteria. A total of 103 patients with PE and 100 men without PE were enrolled into the study and requested to complete the PEDT; and (ii) The correlation between IELT and PEDT: 200 participants were enrolled and each participant was asked to make out PEDT. All participants were requested to measure IELT.Main Outcome MeasuresValidity and reliability of the PEDT and its association with IELT.ResultsThe geometric mean IELT of the PE group was 115.37 ± 78.14 seconds. The number of men reporting IELTs of <1, 1 to ≤2, and >2 minutes were 28 (28.6%), 29 (29.6%), and 41 (41.8%), respectively. The Cronbach's alpha score was calculated as 0.93, showing adequate internal consistency. The test–retest correlation coefficients of each item were higher than 0.72 and the correlation coefficients of the total score was 0.88. (P < 0.001) Sensitivity and specificity analyses suggested a score of ≤8 indicated no PE, 9 and 10 probable PE, and ≥11 PE. The PEDT total score and IELT showed an adequate negative correlation. (ρ = ?0.77, P < 0.0001) also, the PEDT total score of the PE subgroup (IELT ≤ 2 minutes) and IELT showed a negative correlation. (ρ = ?0.6, P < 0.0001)ConclusionsThe PEDT was highly effective in detecting the presence of PE. The result of our study supports its validity as a diagnostic tool in the clinical setting. Kam SC, Han DH, and Lee SW. The diagnostic value of the premature ejaculation diagnostic tool and its association with intravaginal ejaculatory latency time. J Sex Med 2011;8:865–871.