Review

International Journal of Impotence Research (2006) 18, S5–S13. doi:10.1038/sj.ijir.3901507

Premature ejaculation: definition and prevalence

C Carson1 and K Gunn2

  1. 1Department of Urology, University of North Carolina, Chapel Hill, NC, USA
  2. 2Clinical Research Center, University of North Carolina Doris Duke Clinical Research Foundation, Chapel Hill, NC, USA

Correspondence: Professor C Carson, Department of Urology, University of North Carolina, 2140 Bioinformatics Building, Campus Box 7235, Chapel Hill, NC 27599-7235, USA. E-mail: culley_carson@med.unc.edu

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Abstract

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.

Keywords:

premature ejaculation, orgasm, sexual dysfunction, epidemiology

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Introduction

Premature ejaculation (PE), or rapid ejaculation, is reported to be the most common sexual dysfunction in men.1, 2 The clinical perceptions and management of PE have evolved in recent years. PE was once considered to be a singular disorder of psychological etiology that was treated by behavioral therapy or crude attempts to distract or dull sexual stimulation. PE has more recently been viewed as a more finely nuanced disease with multiple subtypes. A major paradigm shift has occurred, as the role of a physiological basis for the condition has gained momentum. To date, the lack of a universally acknowledged definition of PE and criteria for diagnosis has complicated the examination and analysis of PE in clinical and research-related settings.

Recently, PE has become a topic of increasing interest in sexual medicine. As our understanding of the etiology and clinical characterization of PE advances, so do new managements and treatments for the disorder. The increased attention in PE has elevated the need for better understanding and recognition of epidemiology of this disorder. Particularly, it is important to have a clear and universal perspective of the demographic characteristics and risk factors associated with PE. Also, the impact of PE on men and their partner's sexual relationship and life satisfaction needs to be defined. The cornerstone of improved understanding lies in defining PE and its criteria for diagnosis in a universally accepted and cohesive manner. Improved standard of care for PE can be achieved by focusing the clinician's awareness of the epidemiology, etiology and clinical presentation of this disorder.

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Defining and categorizing PE

Despite the predominance of PE, the creation of a 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 orgasm on 50% of intercourse attempts. The obvious criticism of this definition is its dependence on the partner's ability or likelihood to orgasm. Currently, the most accepted definitions of PE come from the DSM-IV-R and ICD-10, which both refer to PE as a condition of short ejaculatory latency that causes personal distress and is beyond the patients ability to control.4, 5 Both definitions are echoed by the American Urological Association (AUA), which states 'premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners.'1

The recommended ejaculatory latency time for diagnosing PE has varied in the literature from 1 to 2 min or less.6, 7 Importantly, no widely accepted standard for 'normal' ejaculatory latency exists. However, a recently published study by Patrick et al.8 on a large community-based population of men and their partners might give the best estimate of 'normal' ejaculatory latency to date. The investigators found that the median intravaginal ejaculatory latency time (IELT), recorded using a partner-held stopwatch, was 7.3 min for men without PE, whereas men with PE had a median IELT of 1.8 min.

Grenier and Byers9 recently explored the way men with PE identify with and define their condition. The authors report that men who self-report PE are likely to report a high percentage of intercourse experiences in which ejaculation occurred sooner than desired, a low degree of perceived control over the occurrence of ejaculation and a high level of concern about ejaculating too soon. Thus, men suffering from PE appeared to define their disorder using criteria nearly identical the DSM-IV, ICD-10 and AUA definitions. The minor exception being that ejaculatory latency is replaced by the percentage of time one feels they ejaculated too soon, a less objective measure than the actual amount of time until ejaculation.

Although once considered a condition primarily psychological in nature, many have recognized and suggested various diagnostic subgroups of PE. A clinical distinction has been made between those with life-long PE, or primary PE (PPE), and those with more recently acquired PE, or secondary PE (SPE).6, 10, 11, 12 PPE is believed to have a sequential natural history from the beginning of sexual life and occurs in the absence of demonstrable organic 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 reason, ruling out ED in a patient with PE is important. The management of PE will likely be ineffective until ED is identified and subsequently treated first.

An alternative scheme for categorizing PE has been to classify PE as either biogenic or psychogenic in nature, with multiple sub-categories of each.13, 14 This classification system arises from the realization that psychologically or behaviorally based sex therapies have poor long-term success rates over time.15, 16 Thus, perhaps a biogenic cause of PE exists that is refractory to psychological sex therapy. However, the limitation of the biogenic/psychogenic model of PE lies in the scarcity of reported etiologic data to support such a categorization.

Two observations should be noted from the discussion of the definition and classification of PE. First, for many years, PE was researched under a variety of criteria for diagnosis. This has made comparison of outcomes data from different studies difficult and speculative at best. Second, because new evidence suggests that PE is likely an etiologically complex disorder, clinicians must update their attitude and the attitude of their patients with regard to the way PE is viewed. In the future, a simple diagnosis of PE, without further sub-categorization, will do little to direct the clinician along an appropriate line of management. Categorization of a PE diagnosis (i.e., acquired versus life-long) must be sought in order to achieve effective clinical and research-related outcomes.

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Clinical characteristics of men with PE

PE is usually a self-reported diagnosis. The diagnosis is made solely by the sexual history of the patient. Thus, clinicians must be willing to solicit sensitive information from the patient's past sexual history. Men with PE, as with other forms of sexual dysfunction, desire treatment and resolution of their condition. However, most are reluctant and unlikely to request treatment out of embarrassment or shame.2, 9, 17, 18, 19, 20 Of those that do seek medical attention, many have waited years before doing so.11 Another roadblock to diagnosis is that clinicians may not be able to rely on the accuracy or completeness of a man's testimony of his ejaculatory behavior, as demonstrated by Rowland et al.21 Discrepancies also exist between the man and his partner's reports of the man's ejaculatory behavior. For instance, women have been found to report shorter ejaculatory latency times than their male partner reported.22 Thus, the partner's report of the man's ejaculatory behavior might serve as an informative tool for clinicians.

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Interpretation and standards for clinical trials

The amount of literature with epidemiologic and outcomes data regarding PE continues to increase. However, the comparison and evaluation of these data from different studies has been limited. Each of the four major reviews of epidemiologic reports published to date highlight the prior lack of consistency with regard to defining PE, diagnostic criteria and study design.18, 23, 24, 25 This heterogeneity has limited the comparison of epidemiologic data across studies, a point that is highlighted by the fact that, to date, no meta-analysis of PE studies has been published.

The criticisms and suggestions for improving outcome-based studies are highly relevant to further epidemiologic studies, and thus worth noting. Past criticism of outcome-based studies include an overall lack of standardization with regard to defining PE, distinguishing between normal versus abnormal ejaculatory latency time, investigator defined entry criteria and the physiological and psychological evaluation of patients with PE.1, 26 The lack of a consistent and accurate measure of ejaculatory latency and the paucity of standardized measures of ancillary outcomes, such as patient/partner satisfaction, significantly limits the impact and comparison of previous studies. Finally, the lack of a validated self-report outcomes instrument for the study of PE, such as the International Index of Erectile Function (IIEF) for ED, further complicates enrollment in clinical trials.

Recently, the 2nd International Consultation on Sexual Dysfunction proposed a set of recommended inclusion and exclusion criteria for study enrollment in clinical trials.26 The recommended inclusion criteria are as follows:

  1. PE should be consistent, occurring in the majority of attempts over the last 6 months and of evaluable events in a baseline run-in period.
  2. Patients should be involved in a stable, monogamous, heterosexual relationship.
  3. Patients and partners must be willing to attempt sex a certain number of times during baseline and treatment periods.

Criteria for exclusion from enrollment are recommended as follows:

  1. Patients with potentially reversible etiologies of PE.
  2. Recommendation that patients with concomitant sexual dysfunctions, anatomical penile abnormalities and neurological disorders with known association with PE should 'probably' be excluded.
  3. Patients with partners with diagnosed sexual dysfunction.
  4. If the study medication is a selective serotonin reuptake inhibitor (SSRI), the appropriate contraindications for use of this drug should be observed.
  5. Concurrent use of other treatment for PE.

The committee does not insist that ED should automatically be an exclusion criterion, but should be accounted for using stratification or a pre-defined sub-group analysis.

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The prevalence of PE

PE, ED and hypoactive sexual desire disorder (HSDD) are the major disorders of sexual function in men. Of these three, PE is likely the most prevalent sexual dysfunction according to the results of numerous epidemiological studies.1, 2, 13, 22, 27 Overall, the prevalence rate of PE falls somewhere between 25 and 40% in the global population of men across all age groups.20, 24, 27, 28, 29 However, past data on the overall prevalence of PE are varied, once again, in great part owing to the lack of prior standardization of the definition of PE and of criteria for patient enrollment in epidemiologic studies. Some authors have reported prevalence rates as low as 4%30, 31 and as high as 66%.32

Results from the National Health and Social Life Survey (NHSLS), a large study of sexual behavior in a demographically representative sample of adults in the United States, indicate a prevalence rate of 29%.28 The NHSLS surveyed 1410 men in the United States between the ages of 18 and 59. Similar findings are reported in the more recent Global Study of Sexual Attitudes and Behaviors (GSSAB), a large, survey-based study where the prevalence of common sexual dysfunctions was studied in 29 countries, which were stratified into seven geographic regions.29 The majority of the prevalence rates reported in these seven regions were very similar to the prevalence rate reported by the NHSLS, with four of the seven regions reporting prevalence rates from 27.4 to 30.5%. One notable exception was the Middle East region, in which the authors report a prevalence rate of 12.4%. It should be noted that sampling techniques in the GSSAB were not standardized from country to country, which could have affected the reported prevalence rates.

Data on the prevalence of PE across ethnic groups in the US are mixed. Studies have shown a differential prevalence across ethnicity. However, there is a lack of total agreement between the reported trends. The NHSLS found that the prevalence of PE in black, white and Hispanic male subjects to be 34, 29 and 27%, respectively.27 However, neither group was found to be statistically different. In a more recent study, on an older population, Carson et al.33 reported a somewhat different trend. In a survey of 1320 men in the United States between ages 40 and 80, these investigators reported prevalence rates of 29, 21 16% for Hispanic, black and white male subjects, respectively (Figure 1). Regarding how often men reported ejaculating before penetration, these investigators also reported a similar trend, with prevalence rates of 38, 16 and 4% for Hispanic, white and black male subjects, respectively (Figure 2). Thus, while several studies have reported differential prevalence of PE across specific ethnic groups, the only consistently reported trend is the higher prevalence of PE in black subjects when compared to white subjects.

Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

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.

Full figure and legend (96K)

Figure 2.
Figure 2 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

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.

Full figure and legend (79K)

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

Although results from the GSSAB clearly indicate that PE is the most prevalent sexual dysfunction in men worldwide, the GSSAB also provides evidence for a differential prevalence of PE based on geography, a trend that has no proven foundation. Clearly, more extensive examination across socio-cultural and geographical boundaries is necessary. There are many undocumented or untested factors that may influence the geographic and ethnic distribution of the prevalence of PE. Socio-cultural and religious differences likely play a significant role. Views on the appropriate engagement of sexual activity, male virility and the relationship dynamics between male and female subjects vary greatly across religious and cultural boundaries. Thus, it is reasonable to assume that the influence of religion and culture on the male psyche would consequently influence a male's propensity for sexual dysfunction, as most sexual dysfunctions carry a strong psychological component.

Evidence exists to suggest a negative association between education and PE. From the NHSLS, men with some college experience or who were college graduates were less likely to report 'climax[ing] too early' than participants who were either high school graduates with no college experience or had not completed high school.27 Results from the GSSAB also demonstrate that education is negatively associated with the incidence of PE.29 Laumann et al.27 suggest that the elevated prevalence of PE in men with less education might really be explainable by the reasonable assumption that health status is in part a function of one's educational status. In essence, individuals with more education are likely to have a greater quality of life, including improved emotional and physical health, and thus, less likely to experience PE. Essentially, educational status might serve as an indirect forecaster of sexual dysfunction, including PE. Interestingly, in a smaller study investigating men with known poor physical health status (type II diabetes mellitus), no link was found between the level of education and the likelihood of reporting PE.34 However, regardless of educational status, the overall prevalence of PE in the type II diabetic subjects (40%) was greater than the prevalence of PE reported by the GSSAB and NHSLS. These results, although contradicting the report of increased prevalence of PE in less-educated men, corroborate the conclusion that perhaps health status is a more direct predictor of the prevalence of PE than educational status.

Assuming higher income, like educational status, is associated with greater overall quality of life, one might expect a differential prevalence between high- and low-income status with regard to the prevalence of PE. However, little evidence exists to support a disparate prevalence of PE between populations with different income or occupation status. The NHSLS reports no recognizable difference in prevalence in men living in households with low-, middle- or high-income status.28 All three groups reported roughly a 30% prevalence of PE. Also, no significant difference in prevalence is recognizable in men in households experiencing a recent increase or decrease in household income.27 Results from the GSSAB indicate that only one of seven regions studied showed a statistically significant positive association between PE and 'financial problems'.29 The prevalence of PE also does not change across occupation status, specifically those who are either retired or unemployed.34

The prevalence of PE does not appear to vary with regard to marital status. Results from the NHSLS do not demonstrate a differential prevalence of PE among currently married, never married or divorced, separated or widowed men.27, 28 This may seem surprising, as PE has long been linked with sexual anxiety and the novelty of sexual experience.3 Thus, married men would seem to be less likely to report PE if one assumes that they are more comfortable and less anxious about a sexual encounter with their long-term spouse than a non-married man might be in a less-secure relationship. Interestingly, aside from PE, non-married men reported higher rates of all other sexual dysfunctions than married men in the NHSLS. Perhaps there is no difference in anxiety to perform between married and non-married men. On the contrary, anxiety and novelty may not be sufficient predictors of PE in these populations of men or the general population as well. Interestingly, some evidence exists from smaller studies to suggest that prevalence of PE is elevated in married men.34, 35, 36 However, the impact of such evidence is subject to scrutiny because of study populations, which are not representative of the general population.

Homosexual men have been an underrepresented group in studies of PE. In 1997, Rosser et al.37 administered a questionnaire to 197 homosexual men attending a health seminar for homosexual men. The authors reported that the condition of 'ejaculating too soon/too quickly' was a 'lifetime' problem for 44%, a rate much greater than what is accepted for the general population. Contrary to these findings, in an earlier study (1976), Bell and Weinberg38 report a PE prevalence of 27% in gay men surveyed, which is in agreement with estimates of the general population. This study, although conducted in a larger sample size (686), is limited by the fact that all men were residents of San Francisco. The overall lack of studies focusing on sexual dysfunction in homosexuals makes any clear estimation or statement regarding the prevalence of PE in this population nearly impossible at the moment. Nathan24 suggests that a difference in heterosexual versus homosexual rates of reported PE could be attributed to a difference in what is defined as 'premature' between the two groups. Clearly, more epidemiologic and outcome-based studies targeted at homosexual men are necessary in order to better describe and compare the condition of PE in this population.

Risk factors for PE

Advancing age does not appear to be a risk factor for PE. Numerous authors have documented no increased risk of PE as men age.2, 9, 25, 27, 28 Thus, PE is unlike ED, which has a well-documented association with increasing age.39 Interestingly, ED also exists as a significant risk factor and comorbidity for PE (see below). Although these findings seem contradictory, it must be remembered that ED is not the sole risk factor for PE and that PE is a condition with significant heterogeneity with regards to classification and etiology. Thus, although advancing age is expected to increase the risk for ED, one cannot draw the same conclusion with regard to PE simply because ED is a risk factor for PE.

Youth has long been postulated as a significant risk factor for PE. PE is believed to be more common in men with limited sexual experience.3, 4, 40 Surprisingly, results of the NHSLS show that younger individuals (18–29 years old) do not appear to be at any greater risk for PE than older individuals, up to age 59.27 The prevalence of PE appears constant over all age groups from 18 to 59 years old. Although youth is not identified as a significant risk factor for PE in the NHSLS, it should be recognized that, unlike ED, PE occurs as often in younger male subjects as it does in older male subjects. Therefore, PE is likely the only major sexual dysfunction to manifest in young adult male subjects and is thus, worthy of increased efforts for diagnosis and treatment to avoid spending the greater majority of one's adulthood with the condition.

ED and PE frequently coexist. ED is increasingly being recognized as the single greatest risk factor for PE.10 The cooccurrence of PE and ED has been reported to be high, as Grenier and Byers9 found that nearly 36% of men with ED also reported a PE condition. Although another study reports their cooccurrence at 50% in older men from the Netherlands.41 In 1989, Godpodinoff11 reported that 60% of men with SPE studied had prior difficulties with 'erectile rigidity'. In a separate study, men with SPE were also more likely to have compromised penile vascular integrity than patients with PPE on penile Doppler ultrasonography.12 A study of PE in patients with type II diabetes found that participants without PE were four times as likely to have normal erectile function as patients with PE.34 Clearly, the risk ED imparts on the likelihood of developing PE is undeniable.

In 2001, sildenafil was found to be an effective treatment for PE, outperforming three anti-depressants (clomipramine, sertraline, paroxetine) as well as the 'pause-and-squeeze' technique.42 The investigators suggest that the effectiveness of sildenafil in treating PE might be owing to a possible central effect, a reduction in sexual performance anxiety or an improved ability to maintain an erection. In a separate study investigating clomipramine as a treatment of PE, clomipramine was found to be an effective treatment of PE alone, but not effective in treating patients with PE and ED.43 Thus, not only is ED a significant risk factor for PE, but a significant barrier to overcome in order to treat PE in patients with concomitant ED.

Poor overall health and/or a simultaneous urological condition increase the risk for sexual dysfunction, including PE. The NHSLS found that men who self-report 'poor to fair health status' have a significantly elevated risk of PE, as well as ED and low sexual desire.27 The presence of urinary tract symptoms also demonstrate an increased risk for PE, ED and low sexual desire; however, this elevated risk is only statistically significant for ED. Screponi et al.44 have shown prostate inflammation and chronic bacterial prostatitis to be more common in men with PE than in controls. These results are not supported by an earlier study by Dunn et al.45 which showed no significant association between a patient's self-report of 'prostate trouble' and PE. However, the study by Dunn et al.,45 asks for the participant's self-perception of health problems, such as 'prostate trouble', and does not specify what clinical symptoms or conditions are implicit in the term 'prostate trouble'. Thus, as with ED, to effectively treat PE the clinician must view and manage the condition in the broader context of overall health, rather than seeing PE as an isolated urological condition.

Patients with type II diabetes mellitus, especially those with poor metabolic control, are also at a significantly greater risk of developing PE.34 For example, El-Sakka found that patients with diabetes for 10 years or longer were nearly three times as likely to report PE as those with diabetes for less than 5 years. Those with poor metabolic control (Glycohemoglobin HbA1c >7%) were nearly 10 times as likely to report PE as patients with good (HbA1c 4.7–6.2%) or fair (HbA1c 6.3–7%) metabolic control. Of the more notable diabetes-related complications (i.e. neuropathy, nephropathy and retinopathy), El-Sakka found that only diabetes-related cardiovascular disease was a significant risk factor for PE.

A patient's mental health is intimately linked to their likelihood of reporting sexual dysfunction. Emotional problems and stress may be both a risk factor for and result of sexual dysfunction, particularly PE.27, 28 PE has been suggested to be caused by or associated with anxiety over sexual encounters.3, 20, 40 Generalized clinical anxiety also appears to be a significant risk factor for PE. In a large British study (N=789) using the Hospital Anxiety and Depression (HAD) Scale, Dunn et al. identified a strong association between anxiety and PE.45, 46, 47 Dunn et al. estimated that 12% of all cases of PE might be associated with clinically significant anxiety. Other authors have shown anxiety to have less of an impact on PE.48 However, it seems improbable that patients with PE experience no anxiety, either as a cause or and an effect of their condition. Unlike anxiety, depression has not been shown to be a significant risk factor for PE, although it is a risk factor for ED.28, 45

Some evidence exists to support a familial or genetic link to the occurrence of PE. Recently, Waldinger49 reported a high prevalence of PPE in first-degree relatives of 14 men diagnosed with PPE who were willing to ask their first-degree relatives if they also suffered from PPE. Of 11 first-degree relatives personally interviewed, 10 (95%) were diagnosed with PPE. Although this prevalence rate is strikingly high, this report's impact is limited by the small sample size. The results of this study are supported, however, by a much earlier report of familial predisposition by Schapiro in 1943.50 The discovery of a true genetic predisposition for PE would further advance the notion of an organic etiology for PE.

A patient's sexual history can impart significant risk for the development of PE. Data from the NHSLS suggest that the following traumatic sexual experiences are risk factors for PE: 'any same sex activity ever', 'partner had an abortion ever', 'sexually touched before puberty' and a moderately increased risk associated with being 'sexually harassed ever'.27 By comparison, only one of these risk factors, 'sexually touched before puberty', is shared with ED. It is not unexpected that a traumatic sexual experience would be a risk factor for PE, as the likelihood for subsequent anxiety with regard to future sexual activity would be high.

The evidence to date regarding an association between PE and low frequency of sexual intercourse is conflicting. In 1974, Kaplan40 suggested that PE was associated with low sexual frequency, and that low frequency of sex afforded the men fewer opportunities to learn to control ejaculation. Since then, several authors have supported the notion that low sexual frequency is a risk factor for PE,9, 51, 52 whereas other reports have found no such link.21, 53 Low sexual frequency, defined as 'no more than once monthly', was not a risk factor for PE in the NHSLS.27 Most recently, results from the GSSAB indicate that infrequent sex tended to be associated with PE.29 Despite what would seem to be a reasonable assumption, one cannot link the frequency of sexual intercourse with PE with any great certainty.

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Impact of PE on sexual, relationship satisfaction and quality of life

As it might be expected, men with PE are generally dissatisfied with sex or their sexual relationship with their partner.9, 22, 42, 52 This lack of sexual satisfaction can be detrimental to the overall relationship with their partner. Recently, McCullough et al.52 reported the results of 1158 men responding to a sexual health survey. The authors found that men with PE were significantly more likely to report low satisfaction with their sexual relationship, low satisfaction with sexual intercourse and difficulty relaxing during intercourse. The female partners of men with PE also reported that satisfaction with the sexual relationship decreased with increasing severity of the man's condition.22

Although research has demonstrated that sex therapy can provide long-term improvement in sexual satisfaction for men with PE, it does not provide a long-term period without recurrence of PE.15, 54 These findings suggest that the negative impact PE has on sexual satisfaction may be improved without an improvement in the actual condition due to enhanced trust, understanding or coping mechanisms in the broader context of the relationship. Finally, although sexual satisfaction is diminished by PE, sex drive and overall interest in sex does not appear to be affected by the presence of PE.52, 55

Aside from the general dissatisfaction and anxiety stemming from poor control over the timing of ejaculation, PE appears to have a significant impact on a man's overall sexual function. Byers and Grenier22 found that men who report lower satisfaction with their ability to delay ejaculation are more likely to also report sexual concerns unrelated to a PE condition. PE has also been associated with less enjoyment of orgasm and difficulties with sexual arousal.21, 51, 52 This is likely explainable by the cooccurring stress and anxiety of ejaculating sooner than desired.

The negative psychological impact of PE is mainly limited to diminished sexual satisfaction, as men with PE have not reported diminished relationship or personal satisfaction. Men with PE are generally as satisfied with their overall relationship with their partner as men without PE.9, 22, 27 Likewise, a PE condition does not appear to diminish the female partner's satisfaction with the relationship.22 For comparison, ED has been shown to be associated with both low emotional and low physical satisfaction with sexual partners.27 Although PE may negatively impact a man's sexual satisfaction, it appears to have little, if any, negative impact on self-esteem, overall happiness or quality of life.9 Results from the NHSLS show only slightly positive association between PE and 'low general happiness', which was not found to be statistically significant.27, 28 By comparison, ED and low sexual desire have a significantly positive association with 'low general happiness'.

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Conclusions

Clearly, in defining the epidemiology of PE, there are many limitations presented by the lack of standardization in defining the disorder and in study design. What can be determined, with much certainty, is that PE is the most common sexual dysfunction in men worldwide, with a prevalence rate of roughly 30%. Evidence exists to support the assertion that the prevalence of PE might vary across different demographics, including geography, ethnicity and social status. Several risk factors for PE exist that have strong support in the literature, including ED and poor physical and emotional health.

PE clearly has a negative impact on the sexual satisfaction of men and their partners. Men suffering from PE are not likely to seek help for their condition. Thus, improved awareness and acceptance of this disorder in both clinicians and patients is necessary. A universally accepted definition of PE and improved standardization of study design are of paramount importance for further collection of epidemiologic as well as outcome-based data. Better defining this disorder and its epidemiology should improve the clinical management PE and the success of future epidemiology studies and clinical trials.

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