Premature Ejaculation: Definition and Prevalence
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International Journal of Impotence Research (2006) 18, S5–S13 & 2006 Nature Publishing Group All rights reserved 0955-9930/06 $30.00 www.nature.com/ijir REVIEW Premature ejaculation: definition and prevalence C Carson1 and K Gunn2 1Department of Urology, University of North Carolina, Chapel Hill, NC, USA and 2Clinical Research Center, University of North Carolina Doris Duke Clinical Research Foundation, Chapel Hill, NC, USA Premature ejaculation (PE) is likely the most common sexual dysfunction in men, with a worldwide prevalence of approximately 30%. To date, the lack of a universally acknowledged definition of PE has complicated the examination and analysis of PE in clinical and research-related settings. The impact of PE on men and their partners also needs to be clearly defined. Clearly, a better understanding of the epidemiology of this disorder, especially with regard to prevalence and risk factors, is necessary. The prevalence of PE appears to vary across socio-cultural and geographic populations. The elucidation of the etiology of PE and risk factors associated with PE has been difficult. However, several risk factors for PE exist that have strong support in the literature. Clearly, an improved and universal definition and understanding of PE and its epidemiology will improve the clinical management of PE and the success of future epidemiologic studies and clinical trials. International Journal of Impotence Research (2006) 18, S5–S13. doi:10.1038/sj.ijir.3901507 Keywords: premature ejaculation; orgasm; sexual dysfunction; epidemiology Introduction for the disorder. The increased attention in PE has elevated the need for better understanding and Premature ejaculation (PE), or rapid ejaculation, is recognition of epidemiology of this disorder. Parti- reported to be the most common sexual dysfunction cularly, it is important to have a clear and universal in men.1,2 The clinical perceptions and management perspective of the demographic characteristics and of PE have evolved in recent years. PE was once risk factors associated with PE. Also, the impact of considered to be a singular disorder of psychological PE on men and their partner’s sexual relationship etiology that was treated by behavioral therapy or and life satisfaction needs to be defined. The crude attempts to distract or dull sexual stimulation. cornerstone of improved understanding lies in PE has more recently been viewed as a more finely defining PE and its criteria for diagnosis in a nuanced disease with multiple subtypes. A major universally accepted and cohesive manner. Im- paradigm shift has occurred, as the role of a proved standard of care for PE can be achieved by physiological basis for the condition has gained focusing the clinician’s awareness of the epidemiol- momentum. To date, the lack of a universally ogy, etiology and clinical presentation of this acknowledged definition of PE and criteria for disorder. diagnosis has complicated the examination and analysis of PE in clinical and research-related settings. Recently, PE has become a topic of increasing Defining and categorizing PE interest in sexual medicine. As our understanding of the etiology and clinical characterization of PE Despite the predominance of PE, the creation of a advances, so do new managements and treatments standardized definition and diagnostic criteria has been elusive. In 1970, Masters and Johnson3 defined the condition as the inability of a man to delay ejaculation long enough for his partner to reach Correspondence: Professor C Carson, Department of orgasm on 50% of intercourse attempts. The obvious Urology, University of North Carolina, 2140 Bioinfor- criticism of this definition is its dependence on the matics Building, Campus Box 7235, Chapel Hill, NC partner’s ability or likelihood to orgasm. Currently, 27599-7235, USA. the most accepted definitions of PE come from the E-mail: [email protected] DSM-IV-R and ICD-10, which both refer to PE as a Premature ejaculation C Carson and K Gunn S6 condition of short ejaculatory latency that causes exists that is refractory to psychological sex therapy. personal distress and is beyond the patients ability However, the limitation of the biogenic/psychogenic to control.4,5 Both definitions are echoed by the model of PE lies in the scarcity of reported etiologic American Urological Association (AUA), which data to support such a categorization. states ‘premature ejaculation is ejaculation that Two observations should be noted from the occurs sooner than desired, either before or shortly discussion of the definition and classification of after penetration, causing distress to either one or PE. First, for many years, PE was researched under a both partners.’1 variety of criteria for diagnosis. This has made The recommended ejaculatory latency time for comparison of outcomes data from different studies diagnosing PE has varied in the literature from 1 to difficult and speculative at best. Second, because 2 min or less.6,7 Importantly, no widely accepted new evidence suggests that PE is likely an etiologi- standard for ‘normal’ ejaculatory latency exists. cally complex disorder, clinicians must update their However, a recently published study by Patrick attitude and the attitude of their patients with regard et al.8 on a large community-based population of to the way PE is viewed. In the future, a simple men and their partners might give the best estimate diagnosis of PE, without further sub-categorization, of ‘normal’ ejaculatory latency to date. The investi- will do little to direct the clinician along an gators found that the median intravaginal ejacula- appropriate line of management. Categorization of tory latency time (IELT), recorded using a partner- a PE diagnosis (i.e., acquired versus life-long) must held stopwatch, was 7.3 min for men without be sought in order to achieve effective clinical and PE, whereas men with PE had a median IELT of research-related outcomes. 1.8 min. Grenier and Byers9 recently explored the way men with PE identify with and define their condition. Clinical characteristics of men with PE The authors report that men who self-report PE are likely to report a high percentage of intercourse PE is usually a self-reported diagnosis. The diag- experiences in which ejaculation occurred sooner nosis is made solely by the sexual history of the than desired, a low degree of perceived control over patient. Thus, clinicians must be willing to solicit the occurrence of ejaculation and a high level of sensitive information from the patient’s past sexual concern about ejaculating too soon. Thus, men history. Men with PE, as with other forms of sexual suffering from PE appeared to define their disorder dysfunction, desire treatment and resolution of their using criteria nearly identical the DSM-IV, ICD-10 condition. However, most are reluctant and unlikely and AUA definitions. The minor exception being to request treatment out of embarrassment or that ejaculatory latency is replaced by the percen- 2,9,17–20 shame. Of those that do seek medical atten- tage of time one feels they ejaculated too soon, a less 11 tion, many have waited years before doing so. objective measure than the actual amount of time Another roadblock to diagnosis is that clinicians until ejaculation. may not be able to rely on the accuracy or Although once considered a condition primarily completeness of a man’s testimony of his ejaculatory psychological in nature, many have recognized and 21 behavior, as demonstrated by Rowland et al. suggested various diagnostic subgroups of PE. A Discrepancies also exist between the man and his clinical distinction has been made between those partner’s reports of the man’s ejaculatory behavior. with life-long PE, or primary PE (PPE), and those For instance, women have been found to report with more recently acquired PE, or secondary PE 6,10–12 shorter ejaculatory latency times than their male (SPE). PPE is believed to have a sequential 22 partner reported. Thus, the partner’s report of the natural history from the beginning of sexual life and man’s ejaculatory behavior might serve as an occurs in the absence of demonstrable organic informative tool for clinicians. illness, such as erectile dysfunction (ED). Men with SPE will often manifest PE much later in their adult sexual life and often complain of prior or concomi- tant ED or other sexual dysfunctions.11 For this Interpretation and standards for clinical reason, ruling out ED in a patient with PE is trials important. The management of PE will likely be ineffective until ED is identified and subsequently The amount of literature with epidemiologic and treated first. outcomes data regarding PE continues to increase. An alternative scheme for categorizing PE has However, the comparison and evaluation of these been to classify PE as either biogenic or psychogenic data from different studies has been limited. Each of in nature, with multiple sub-categories of each.13,14 the four major reviews of epidemiologic reports This classification system arises from the realization published to date highlight the prior lack of that psychologically or behaviorally based sex consistency with regard to defining PE, diagnostic therapies have poor long-term success rates over criteria and study design.18,23–25 This heterogeneity time.15,16 Thus, perhaps a biogenic cause of PE has limited the comparison of epidemiologic data International Journal of Impotence Research Premature ejaculation C Carson and K Gunn S7 across studies, a point that is highlighted by the fact The prevalence of PE that, to date, no meta-analysis of PE studies has been published. PE, ED and hypoactive sexual desire disorder The criticisms and suggestions for improving (HSDD) are the major disorders of sexual function outcome-based studies are highly relevant to in men. Of these three, PE is likely the most further epidemiologic studies, and thus worth prevalent sexual dysfunction according to the noting.