Prevalence, Characteristics and Implications of Premature Ejaculation/Rapid Ejaculation Stanley E. Althof*,† From the Department of Urology, Case School of Medicine and Center for Marital and Sexual Health of South Florida, West Palm Beach, Florida Purpose: Premature ejaculation/rapid ejaculation is a common but incompletely understood male sexual dysfunction. The purposes of this review are to 1) raise awareness of the prevalence and characteristics of PE/RE, its impact on the male and his partner, and the lack of approved medications indicated for its treatment, 2) encourage dialogue about PE/RE between physicians and patients, and 3) stimulate the development of appropriate new therapies. Materials and Methods: A MEDLINE search was performed to retrieve articles relating to PE/RE pathophysiology, etiology, impact, diagnosis and treatment. Sexual medicine journals not indexed in MEDLINE, sexual medicine texts and congress abstracts were also reviewed. Results: No universally accepted definition, licensed treatment, validated screening instrument or diagnostic criteria have been established for PE/RE, and its pathophysiology and etiology are incompletely understood. Additional barriers are the reluctance of patients and physicians to talk about PE/RE and the lack of knowledge regarding available treatments. Current pharmacological treatments include off label uses of antidepressants, topical anesthetics or phosphodiesterase-5 inhibitors. All are associated with drawbacks that limit their efficacy. Psychological counseling and behavioral therapy have a valuable role, although resources for this modality are limited. Conclusions: Prevalence rates of 20% to 30% and negative effects on the quality of life of men and their partners illustrate the need for improved, standardized methods of PE/RE diagnosis, assessment and treatment. Medications indicated specif- ically for PE/RE and effective on an as needed basis are required. Behavioral therapies should emphasize pleasure, arousal, control, confidence and satisfaction, and they may have the best success when coupled with pharmacological approaches. Key Words: testis; ejaculation; sexual dysfunctions, psychological; behavioral medicine lthough PE/RE is the most common male sexual dys- The distress induced by PE/RE affects not only the male, function, much remains to be learned about this vex- but also his sexual partner, the relationship as a whole and A ing condition. There is no universally accepted other areas of his life.1,2,7 The stigma associated with having definition, there are no validated screening instruments spe- a sexual problem inhibits men from discussing it with their cific for this dysfunction, and the pathophysiology and etiol- physician and partner.2,7,8 Embarrassment, lack of knowl- ogy remain incompletely understood. The number of men edge and a tendency to dismiss sexual problems as unim- presenting for treatment of PE/RE does not align with re- portant or not within the purview of medicine inhibit ported prevalence rates. Derived from the responses of men physicians from asking their patients if they have PE/RE to survey questions regarding sexual symptoms or problems, symptoms.7,9 Further, men who desire treatment may not the prevalence rates for PE/RE in men across a broad age know which specialist to consult. Should they seek treat- range, eg 18 to 59, or 21 to 65 years or older, are approxi- ment from a urologist, primary care physician, psychiatrist 1–6 mately 20% to 30%. Because the definition of PE/RE is or sex therapist? Additional reasons for not seeking treat- not uniform across studies, a reported prevalence rate may ment are selfishness, the belief that there is no treatment be an overestimate if compared with various diagnostic cri- and a lack of motivation unless encouraged by their part- teria, or an underestimate if men are inhibited from re- ner.2 The lack of standardized, validated screening criteria sponding openly to survey questions. Unfortunately there is is a barrier to diagnosis. These issues create a gap between no large-scale, population based study using agreed upon symptoms and resolution. Men do not know to ask about diagnostic criteria that examines the influence of patient their condition and others do not know whom to ask about age, ethnicity and culture on ejaculatory disorders. their condition, while physicians and mental health clini- cians do not routinely assess patients for symptoms of Submitted for publication May 4, 2005. PE/RE despite its high prevalence. * Correspondence: Department of Psychology, Case School of Med- Historically PE/RE was thought to be primarily psycho- icine, Center for Marital and Sexual Health of South Florida, 1515 North Flagler Dr., Suite 540, West Palm Beach, Florida 33401 logical in etiology, although recent research has documented (telephone: 561-822-5454; FAX: 561-822-5456; e-mail: sxa6@ that the condition also has a physiological basis, involving po.cwru.edu). primarily serotonergic but also dopaminergic and adrenergic † Financial interest and/or other relationship with Auxilium, Eli 10,11 Lilly/ICOS, Johnson and Johnson, Pfizer, Sanofi-Synthelabo and neurotransmission. Psychological and cognitive aspects Solvay. contribute but are difficult to characterize.12,13 There is 0022-5347/06/1753-0842/0 842 Vol. 175, 842-848, March 2006 THE JOURNAL OF UROLOGY® Printed in U.S.A. Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/S0022-5347(05)00341-1 PREVALENCE OF PREMATURE EJACULATION/RAPID EJACULATION 843 likely a mixed etiology or spectrum of PE/RE etiologies, ulation sufficiently but in whom the dysfunction later devel- involving psychological and physiological influences (Appen- oped.17 dix 1).11,13–15 PE/RE should not be confused with ED. They are different Men with PE/RE may not be aware of these physiological disorders. ED is defined as the inability to achieve or main- and psychological factors or that anything can be done to tain erection sufficient for satisfactory sexual perfor- remedy them. In contrast to ED, no regulatory authority has mance.21 PE/RE and ED can coexist but different approved a medication for PE/RE. This may also contribute pathological mechanisms underlie each disorder.3,11 A sub- to under treatment because men may assume that no pre- set of men have PE/RE after the onset of ED. They recognize scription treatment is available and, therefore, they do not that erection is time limited and they adaptively learn to discuss it with their physician.7 In a survey of men 40 years ejaculate prior to erectile softening. Thus, a detailed sexual or older 1% stated that they had received treatment for history is necessary in men who present with ejaculatory PE/RE, although 18% responded that they “always/almost complaints. always” or “usually” ejaculated prematurely, highlighting The most frequently used primary end point for PE/RE in 16 the problem of under treatment. A 2004 multicountry sur- clinical research is IELT, defined as the time from vaginal vey of more than 11,500 men in the United States, Italy and penetration to the start of intravaginal ejaculation.8 How- Germany found an overall PE/RE prevalence of 25% and less ever, the use of IELT alone is not likely to be the best method than 12% of the men who self-reported PE/RE had sought of diagnosis or treatment evaluation since it does not con- 2 treatment. sider individual perceptions of control over ejaculation, sat- Pharmacological treatments in use but not approved by isfaction with sexual intercourse and associated distress. the United States FDA or EMEA for PE/RE include antide- Supporting this point, in a recent study in which 1,587 men pressants, topical anesthetics and PDE-5 inhibitors. Psycho- were divided into PE/RE and nonPE/RE groups based on logical counseling and behavioral therapy are also used but DSM-IV-TR criteria results showed considerable overlap in they require time, money, commitment and the availability IELT between the groups.22 Furthermore, there is currently of a well trained sex therapist. Each of these approaches is no uniform method of measuring IELT. Many studies have associated with drawbacks that limit its usefulness. The incorporated a stopwatch to measure IELT, while others AUA has published consensus guidelines for the pharmaco- relied on IELT estimated by the individual. Self-estimated logical management of PE,3 which recognize that a univer- IELT and IELT measured by a stopwatch may vary. Al- sally accepted definition and improved, standardized though further study in this area is needed, reports suggest methods of diagnosis, assessment and treatment are needed. that discrepancies may exist.8,11,23 In addition, there is lack Pharmacological treatments developed specifically for PE/ of consensus on the IELT cutoff defining PE/RE due to the RE, and better psychological and behavioral interventions paucity of normative data. Some investigators suggest that along with algorithms for combined psychotherapy and it should be 1 minute based on the distribution of IELTs in pharmacotherapy are research goals. The aims of this article PE/RE populations that they have studied,8 while others are to 1) raise awareness of the characteristics and preva- suggest 2 minutes based on a review and summary of pub- lence of PE/RE, its impact on the male and his partner, and lished IELT data in men with PE/RE.11 Despite these con- the lack of approved prescription medications indicated for flicting opinions it is acknowledged that IELT is less its treatment, 2) encourage dialogue about the condition meaningful than the perception of control and satisfaction between physicians and patients, and 3) stimulate the de- 3 velopment of new pharmacological, psychological and com- with sexual intercourse by a man. Finally, the frequency of bined forms of therapy. sexual interactions in which IELT is below a specified cutoff is also a consideration, eg greater than 90%, greater than 75% or greater than 50% of the time, as is the period in MATERIALS AND METHODS question, eg the previous month, 6 months or year.