Premature Ejaculation: Definition and Prevalence

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 concomitant 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. Past criticism of outcome-based studies results of numerous epidemiological stu- include an overall lack of standardization with dies.1,2,13,22,27 Overall, the prevalence rate of PE regard to defining PE, distinguishing between falls somewhere between 25 and 40% in the global normal versus abnormal ejaculatory latency time, population of men across all age groups.20,24,27–29 investigator defined entry criteria and the physio- However, past data on the overall prevalence of PE logical and psychological evaluation of patients are varied, once again, in great part owing to the lack with PE.1,26 The lack of a consistent and accurate of prior standardization of the definition of PE and measure of ejaculatory latency and the paucity of criteria for patient enrollment in epidemiologic of standardized measures of ancillary outcomes, studies. Some authors have reported prevalence such as patient/partner satisfaction, significantly rates as low as 4%30,31 and as high as 66%.32 limits the impact and comparison of previous Results from the National Health and Social Life studies. Finally, the lack of a validated self-report Survey (NHSLS), a large study of sexual behavior in outcomes instrument for the study of PE, such as a demographically representative sample of adults the International Index of Erectile Function (IIEF) in the United States, indicate a prevalence rate of for ED, further complicates enrollment in clinical 29%.28 The NHSLS surveyed 1410 men in the trials. United States between the ages of 18 and 59. Similar Recently, the 2nd International Consultation on findings are reported in the more recent Global Sexual Dysfunction proposed a set of recommended Study of Sexual Attitudes and Behaviors (GSSAB), a inclusion and exclusion criteria for study enroll- large, survey-based study where the prevalence of ment in clinical trials.26 The recommended inclu- common sexual dysfunctions was studied in 29 sion criteria are as follows: countries, which were stratified into seven geographic regions.29 The majority of the prevalence 1. PE should be consistent, occurring in the majority rates reported in these seven regions were very of attempts over the last 6 months and of similar to the prevalence rate reported by the evaluable events in a baseline run-in period. NHSLS, with four of the seven regions reporting 2. Patients should be involved in a stable, mono- prevalence rates from 27.4 to 30.5%. One notable gamous, heterosexual relationship. exception was the Middle East region, in which the 3. Patients and partners must be willing to attempt authors report a prevalence rate of 12.4%. It should sex a certain number of times during baseline and be noted that sampling techniques in the GSSAB treatment periods. were not standardized from country to country, which could have affected the reported prevalence Criteria for exclusion from enrollment are recom- rates. mended as follows: Data on the prevalence of PE across ethnic groups in the US are mixed. Studies have shown a 1. Patients with potentially reversible etiologies of differential prevalence across ethnicity. However, PE. there is a lack of total agreement between the 2. Recommendation that patients with concomitant reported trends. The NHSLS found that the pre- sexual dysfunctions, anatomical penile abnorm- valence of PE in black, white and Hispanic male 27 alities and neurological disorders with known subjects to be 34, 29 and 27%, respectively. association with PE should ‘probably’ be However, neither group was found to be statistically excluded. different. In a more recent study, on an older 33 3. Patients with partners with diagnosed sexual population, Carson et al. reported a somewhat dysfunction. different trend. In a survey of 1320 men in the 4. If the study medication is a selective serotonin United States between ages 40 and 80, these reuptake inhibitor (SSRI), the appropriate contra- investigators reported prevalence rates of 29, 21 indications for use of this drug should be 16% for Hispanic, black and white male subjects, observed. respectively (Figure 1). Regarding how often men 5. Concurrent use of other treatment for PE. reported ejaculating before penetration, these investigators also reported a similar trend, with prevalence rates of 38, 16 and 4% for Hispanic, white and The committee does not insist that ED should black male subjects, respectively (Figure 2). Thus, automatically be an exclusion criterion, but should while several studies have reported differential be accounted for using stratification or a pre-defined prevalence of PE across specific ethnic groups, the sub-group analysis. only consistently reported trend is the higher

International Journal of Impotence Research Premature ejaculation C Carson and K Gunn S8

Figure 1 Prevalence of PE in ethnic groups. Prevalence of PE in the ethnic groups assessed by a positive response (‘always’, ‘almost always’ or ‘usually’) to the question: ‘How often do you come too quickly?’ The study population includes men who have been sexually active in the last 3 months.

Figure 2 Percent of men reporting ejaculation before penetration by ethnic group. Percent of men responding with a positive response (‘always’, ‘almost always’ or ‘usually’) to the question: ‘How often do you ejaculate before penetration’. The study population includes men who have been sexually active in the last 3 months.

prevalence of PE in black subjects when compared in the Northern Europe (20.7%) and Southern to white subjects. Europe (21.5%) regions was slightly less. In 1999, Results from the GSSAB found PE to be the most Fugl-Meyer et al.31 reported a prevalence of 4% (51 common sexual dysfunction in six of seven world- of 1281) in a large representative population study wide geographic regions studied.29 Only in the of Swedes ages 18–74. Remarkably low prevalences Middle East region was the prevalence of PE of other common forms of sexual dysfunction were (12.4%) eclipsed by other sexual dysfunctions, also reported, with erectile difficulties reported only including ED (14.1%) and lack of sexual interest by 3% of men surveyed. These results suggest that (21.6%). The prevalence rates for the Non-European Swedes have an unexplainably lower prevalence of West (27.4%), Central/South American (28.3%), PE and other sexual dysfunctions than can be found East Asia (29.1%) and Southeast Asia (30.5%) in the US or other regions. Of course, this assumes regions were roughly equivalent and in agreement that the study design allowed for an accurate with the data from the NHSLS.27,28 Prevalence of PE representation of the entire Swedish population.

International Journal of Impotence Research Premature ejaculation C Carson and K Gunn S9 Although results from the GSSAB clearly indicate middle- or high-income status.28 All three groups that PE is the most prevalent sexual dysfunction in reported roughly a 30% prevalence of PE. Also, no men worldwide, the GSSAB also provides evidence significant difference in prevalence is recognizable for a differential prevalence of PE based on geogra- in men in households experiencing a recent increase phy, a trend that has no proven foundation. Clearly, or decrease in household income.27 Results from the more extensive examination across socio-cultural GSSAB indicate that only one of seven regions and geographical boundaries is necessary. There are studied showed a statistically significant positive many undocumented or untested factors that may association between PE and ‘financial problems’.29 influence the geographic and ethnic distribution of The prevalence of PE also does not change across the prevalence of PE. Socio-cultural and religious occupation status, specifically those who are either differences likely play a significant role. Views on retired or unemployed.34 the appropriate engagement of sexual activity, male The prevalence of PE does not appear to vary with virility and the relationship dynamics between male regard to marital status. Results from the NHSLS do and female subjects vary greatly across religious and not demonstrate a differential prevalence of PE cultural boundaries. Thus, it is reasonable to assume among currently married, never married or di- that the influence of religion and culture on the male vorced, separated or widowed men.27,28 This may psyche would consequently influence a male’s seem surprising, as PE has long been linked with propensity for sexual dysfunction, as most sexual sexual anxiety and the novelty of sexual experi- dysfunctions carry a strong psychological compo- ence.3 Thus, married men would seem to be less nent. likely to report PE if one assumes that they are more Evidence exists to suggest a negative association comfortable and less anxious about a sexual en- between education and PE. From the NHSLS, men counter with their long-term spouse than a non- with some college experience or who were college married man might be in a less-secure relationship. graduates were less likely to report ‘climax[ing] too Interestingly, aside from PE, non-married men early’ than participants who were either high school reported higher rates of all other sexual dysfunc- graduates with no college experience or had not tions than married men in the NHSLS. Perhaps there completed high school.27 Results from the GSSAB is no difference in anxiety to perform between also demonstrate that education is negatively asso- married and non-married men. On the contrary, ciated with the incidence of PE.29 Laumann et al.27 anxiety and novelty may not be sufficient predictors suggest that the elevated prevalence of PE in men of PE in these populations of men or the general with less education might really be explainable by population as well. Interestingly, some evidence the reasonable assumption that health status is in exists from smaller studies to suggest that preva- part a function of one’s educational status. In lence of PE is elevated in married men.34–36 essence, individuals with more education are likely However, the impact of such evidence is subject to to have a greater quality of life, including improved scrutiny because of study populations, which are emotional and physical health, and thus, less likely not representative of the general population. to experience PE. Essentially, educational status Homosexual men have been an underrepresented might serve as an indirect forecaster of sexual group in studies of PE. In 1997, Rosser et al.37 dysfunction, including PE. Interestingly, in a smal- administered a questionnaire to 197 homosexual ler study investigating men with known poor men attending a health seminar for homosexual physical health status (type II diabetes mellitus), men. The authors reported that the condition of no link was found between the level of education ‘ejaculating too soon/too quickly’ was a ‘lifetime’ and the likelihood of reporting PE.34 However, problem for 44%, a rate much greater than what is regardless of educational status, the overall preva- accepted for the general population. Contrary to lence of PE in the type II diabetic subjects (40%) was these findings, in an earlier study (1976), Bell and greater than the prevalence of PE reported by the Weinberg38 report a PE prevalence of 27% in gay GSSAB and NHSLS. These results, although contra- men surveyed, which is in agreement with estimates dicting the report of increased prevalence of PE in of the general population. This study, although less-educated men, corroborate the conclusion that conducted in a larger sample size (686), is limited perhaps health status is a more direct predictor of by the fact that all men were residents of San the prevalence of PE than educational status. Francisco. The overall lack of studies focusing on Assuming higher income, like educational status, sexual dysfunction in homosexuals makes any clear is associated with greater overall quality of life, one estimation or statement regarding the prevalence of might expect a differential prevalence between high- PE in this population nearly impossible at the and low-income status with regard to the prevalence moment. Nathan24 suggests that a difference in of PE. However, little evidence exists to support a heterosexual versus homosexual rates of reported disparate prevalence of PE between populations PE could be attributed to a difference in what is with different income or occupation status. The defined as ‘premature’ between the two groups. NHSLS reports no recognizable difference in pre- Clearly, more epidemiologic and outcome-based valence in men living in households with low-, studies targeted at homosexual men are necessary

International Journal of Impotence Research Premature ejaculation C Carson and K Gunn S10 in order to better describe and compare the condi- effect, a reduction in sexual performance anxiety or tion of PE in this population. an improved ability to maintain an erection. In a separate study investigating clomipramine as a treatment of PE, clomipramine was found to be an Risk factors for PE effective treatment of PE alone, but not effective in Advancing age does not appear to be a risk factor for treating patients with PE and ED.43 Thus, not only is PE. Numerous authors have documented no in- ED a significant risk factor for PE, but a significant creased risk of PE as men age.2,9,25,27,28 Thus, PE is barrier to overcome in order to treat PE in patients unlike ED, which has a well-documented associa- with concomitant ED. tion with increasing age.39 Interestingly, ED also Poor overall health and/or a simultaneous urolo- exists as a significant risk factor and comorbidity for gical condition increase the risk for sexual dysfunc- PE (see below). Although these findings seem tion, including PE. The NHSLS found that men who contradictory, it must be remembered that ED is self-report ‘poor to fair health status’ have a not the sole risk factor for PE and that PE is a significantly elevated risk of PE, as well as ED and condition with significant heterogeneity with re- low sexual desire.27 The presence of urinary tract gards to classification and etiology. Thus, although symptoms also demonstrate an increased risk for PE, advancing age is expected to increase the risk for ED, ED and low sexual desire; however, this elevated one cannot draw the same conclusion with regard to risk is only statistically significant for ED. Screponi PE simply because ED is a risk factor for PE. et al.44 have shown prostate inflammation and Youth has long been postulated as a significant chronic bacterial prostatitis to be more common in risk factor for PE. PE is believed to be more common men with PE than in controls. These results are not in men with limited sexual experience.3,4,40 Surpris- supported by an earlier study by Dunn et al.45 which ingly, results of the NHSLS show that younger showed no significant association between a pa- individuals (18–29 years old) do not appear to be tient’s self-report of ‘prostate trouble’ and PE. at any greater risk for PE than older individuals, up However, the study by Dunn et al.,45 asks for the to age 59.27 The prevalence of PE appears constant participant’s self-perception of health problems, over all age groups from 18 to 59 years old. Although such as ‘prostate trouble’, and does not specify what youth is not identified as a significant risk factor for clinical symptoms or conditions are implicit in the PE in the NHSLS, it should be recognized that, term ‘prostate trouble’. Thus, as with ED, to unlike ED, PE occurs as often in younger male effectively treat PE the clinician must view and subjects as it does in older male subjects. Therefore, manage the condition in the broader context of PE is likely the only major sexual dysfunction to overall health, rather than seeing PE as an isolated manifest in young adult male subjects and is thus, urological condition. worthy of increased efforts for diagnosis and treat- Patients with type II diabetes mellitus, especially ment to avoid spending the greater majority of one’s those with poor metabolic control, are also at a adulthood with the condition. significantly greater risk of developing PE.34 For ED and PE frequently coexist. ED is increasingly example, El-Sakka found that patients with diabetes being recognized as the single greatest risk factor for for 10 years or longer were nearly three times as PE.10 The cooccurrence of PE and ED has been likely to report PE as those with diabetes for less reported to be high, as Grenier and Byers9 found that than 5 years. Those with poor metabolic control nearly 36% of men with ED also reported a PE (Glycohemoglobin HbA1c 47%) were nearly 10 condition. Although another study reports their times as likely to report PE as patients with good cooccurrence at 50% in older men from the Nether- (HbA1c 4.7–6.2%) or fair (HbA1c 6.3–7%) metabolic lands.41 In 1989, Godpodinoff11 reported that 60% control. Of the more notable diabetes-related com- of men with SPE studied had prior difficulties with plications (i.e. neuropathy, nephropathy and retino- ‘erectile rigidity’. In a separate study, men with SPE pathy), El-Sakka found that only diabetes-related were also more likely to have compromised penile cardiovascular disease was a significant risk factor vascular integrity than patients with PPE on penile for PE. Doppler ultrasonography.12 A study of PE in A patient’s mental health is intimately linked to patients with type II diabetes found that participants their likelihood of reporting sexual dysfunction. without PE were four times as likely to have normal Emotional problems and stress may be both a risk erectile function as patients with PE.34 Clearly, the factor for and result of sexual dysfunction, particu- risk ED imparts on the likelihood of developing PE larly PE.27,28 PE has been suggested to be caused by is undeniable. or associated with anxiety over sexual encoun- In 2001, sildenafil was found to be an effective ters.3,20,40 Generalized clinical anxiety also appears treatment for PE, outperforming three anti-depres- to be a significant risk factor for PE. In a large British sants (clomipramine, sertraline, paroxetine) as well study (N ¼ 789) using the Hospital Anxiety and as the ‘pause-and-squeeze’ technique.42 The inves- Depression (HAD) Scale, Dunn et al. identified a tigators suggest that the effectiveness of sildenafil in strong association between anxiety and PE.45–47 treating PE might be owing to a possible central Dunn et al. estimated that 12% of all cases of PE

International Journal of Impotence Research Premature ejaculation C Carson and K Gunn S11 might be associated with clinically significant can be detrimental to the overall relationship with anxiety. Other authors have shown anxiety to have their partner. Recently, McCullough et al.52 reported less of an impact on PE.48 However, it seems the results of 1158 men responding to a sexual health improbable that patients with PE experience no survey. The authors found that men with PE were anxiety, either as a cause or and an effect of their significantly more likely to report low satisfaction with condition. Unlike anxiety, depression has not been their sexual relationship, low satisfaction with sexual shown to be a significant risk factor for PE, although intercourse and difficulty relaxing during intercourse. it is a risk factor for ED.28,45 The female partners of men with PE also reported that Some evidence exists to support a familial or satisfaction with the sexual relationship decreased genetic link to the occurrence of PE. Recently, with increasing severity of the man’s condition.22 Waldinger49 reported a high prevalence of PPE in Although research has demonstrated that sex first-degree relatives of 14 men diagnosed with PPE therapy can provide long-term improvement in sexual who were willing to ask their first-degree relatives if satisfaction for men with PE, it does not provide a they also suffered from PPE. Of 11 first-degree long-term period without recurrence of PE.15,54 These relatives personally interviewed, 10 (95%) were findings suggest that the negative impact PE has on diagnosed with PPE. Although this prevalence rate sexual satisfaction may be improved without an is strikingly high, this report’s impact is limited by improvement in the actual condition due to enhanced the small sample size. The results of this study are trust, understanding or coping mechanisms in the supported, however, by a much earlier report of broader context of the relationship. Finally, although familial predisposition by Schapiro in 1943.50 The sexual satisfaction is diminished by PE, sex drive and discovery of a true genetic predisposition for PE overall interest in sex does not appear to be affected would further advance the notion of an organic by the presence of PE.52,55 etiology for PE. Aside from the general dissatisfaction and anxiety A patient’s sexual history can impart significant stemming from poor control over the timing of risk for the development of PE. Data from the ejaculation, PE appears to have a significant impact NHSLS suggest that the following traumatic sexual on a man’s overall sexual function. Byers and experiences are risk factors for PE: ‘any same sex Grenier22 found that men who report lower satisfaction activity ever’, ‘partner had an abortion ever’, with their ability to delay ejaculation are more likely to ‘sexually touched before puberty’ and a moderately also report sexual concerns unrelated to a PE condi- increased risk associated with being ‘sexually tion. PE has also been associated with less enjoyment harassed ever’.27 By comparison, only one of these of orgasm and difficulties with sexual arousal.21,51,52 risk factors, ‘sexually touched before puberty’, is This is likely explainable by the cooccurring stress and shared with ED. It is not unexpected that a traumatic anxiety of ejaculating sooner than desired. sexual experience would be a risk factor for PE, as The negative psychological impact of PE is mainly the likelihood for subsequent anxiety with regard to limited to diminished sexual satisfaction, as men future sexual activity would be high. with PE have not reported diminished relationship The evidence to date regarding an association or personal satisfaction. Men with PE are generally between PE and low frequency of sexual intercourse as satisfied with their overall relationship with their is conflicting. In 1974, Kaplan40 suggested that PE partner as men without PE.9,22,27 Likewise, a PE was associated with low sexual frequency, and that condition does not appear to diminish the female low frequency of sex afforded the men fewer partner’s satisfaction with the relationship.22 For opportunities to learn to control ejaculation. Since comparison, ED has been shown to be associated then, several authors have supported the notion that with both low emotional and low physical satisfac- low sexual frequency is a risk factor for PE,9,51,52 tion with sexual partners.27 Although PE may whereas other reports have found no such link.21,53 negatively impact a man’s sexual satisfaction, it Low sexual frequency, defined as ‘no more than once appears to have little, if any, negative impact on self- monthly’, was not a risk factor for PE in the NHSLS.27 esteem, overall happiness or quality of life.9 Results Most recently, results from the GSSAB indicate that from the NHSLS show only slightly positive asso- infrequent sex tended to be associated with PE.29 ciation between PE and ‘low general happiness’, Despite what would seem to be a reasonable which was not found to be statistically signifi- assumption, one cannot link the frequency of sexual cant.27,28 By comparison, ED and low sexual desire intercourse with PE with any great certainty. have a significantly positive association with ‘low general happiness’. Impact of PE on sexual, relationship satisfaction and quality of life Conclusions As it might be expected, men with PE are generally dissatisfied with sex or their sexual relationship with Clearly, in defining the epidemiology of PE, there their partner.9,22,42,52 This lack of sexual satisfaction are many limitations presented by the lack of

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