Prevalence and impact of premature ejaculation in outpatients complaining of ejaculating prematurely: using the instruments of intravaginal ejaculatory latency time and patient-reported outcome measures

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Abstract

This study was designed to assess the impact of premature ejaculation (PE) on a large population of men and their female partners using the instruments of intravaginal ejaculatory latency time (IELT) and patient-reported outcome (PRO) measures. A non-interventional, observational and cross-sectional field survey enrolled 2704 men with self-reported PE and their female partners from January 2010 to January 2012. PE was diagnosed by the International Society for Sexual Medicine (ISSM) criterion. IELT and sexual dysfunction were measured using a stopwatch and PRO measures, respectively. The incidence of PE in this study was 19.27%. PE negatively impacted on subjects and their partners, including reduced ejaculatory control and sexual satisfaction, and increased personal distress and interpersonal difficulty (P<0.001 for all). The severity of PE was considered worse by subjects than by their female partners (P<0.001). Reduced ejaculatory control and sexual satisfaction were considered the central themes of PE. Furthermore, a correlation was observed among the outcomes of IELT and PRO measures for subjects and their partners (absolute correlation coefficient ranged from 0.33 to 0.67). This in-depth qualitative study provides valuable insight into the PE status in Chinese men. Further research is needed to confirm and extend these results.

Introduction

Premature ejaculation (PE) is a common male sexual dysfunction, with prevalence rates ranging from 3% to 30%.1, 2, 3, 4 Over the past decade, most studies have shown that PE has a significant negative impact on both men and their partners, for example, affecting their sexual enjoyment, quality of life and relationship.5, 6, 7 Although we have witnessed substantial progress in understanding the effects of PE on men and their partners, the discrepancies among different studies are likely to remain due to the lack of a universally accepted definition and a validated measure for evaluating PE, and limited numbers of population-based studies.8, 9, 10

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Test Revision (DSM-IV-TR) defines PE as ‘a persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it and it causes marked distress or interpersonal difficulty and is not due to the direct effects of a substance.’11 PE diagnosis is based on the main dimensions of ejaculatory latency, control and sexual satisfaction. However, without a quantified diagnostic intravaginal ejaculation latency time (IELT) cutoff point, it seems vague, imprecise, subject to multiple interpretations, and the construct of authority-based opinions rather than well-controlled clinical and epidemiologic studies. For instance, men with an IELT of 10–20 min were diagnosed with PE if they perceived themselves as suffering from PE.12

Due to discontent with the existing definition of PE, as well as pressure from the regulatory agencies concerning the inadequacy of the PE definition, the ISSM has proposed an evidence-based definition for lifelong PE: ‘a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about 1 min of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.’13 On the basis of these criteria, a patient is diagnosed with PE if they experience vaginal penetration for less than 1 min, a loss of control and/or negative sexual consequences.

Quantitative measures of intercourse (for example, IELT and patient-reported outcome (PRO) measures) have been described and used as patient-related outcomes in clinical trials of PE.14 IELT is defined as the time between the start of vaginal intromission and the start of intravaginal ejaculation, and is frequently used in studies on the treatment of PE.9 However, latency time alone might not be sufficient for evaluating PE or its treatment, because the perception of latency time was not consistent across all men,15 and the impact of PE was multidimensional.16 In addition, PRO measures were used to assess PE and measure different aspects of the disorder,12, 17, 18 including perception of ejaculatory control, satisfaction with ejaculatory control and satisfaction with sexual intercourse. Although PRO measures are brief, capture relevant concepts of a condition, have known validity and reliability, are responsive to treatment, and are easy to administer and interpret,19 they are too subjective to weight the impact of PE equally. Hence, a combination of IELT and PRO measures is most appropriate for an in-depth analysis of PE status.18

In addition, although IELT and PRO measures have been used as diagnostic tools and investigational end points in both epidemiologic and drug treatment clinical trials,20, 21 no studies have evaluated objective parameters of PE utilizing the two available measures among a population of Chinese men with the complaint of PE. Therefore, the present study was designed to assess the prevalence and impact of PE on men and their female partners using the instrument of IELT and PRO measures.

Materials and methods

Subjects

A non-interventional, observational and cross-sectional field survey was conducted in the first affiliated hospital of Anhui Medical University located in Anhui, China. Subjects were men who complained of rapid ejaculation and who were referred to the andrology outpatient clinic between January 2010 and January 2012. This survey was reviewed and approved by Anhui Medical University research subject review board.

The inclusion criteria: (1) men and their female partners aged 18 years; (2) in a heterosexual, stable and monogamous sexual relationship with the same partner for at least six months; (3) good general health and able to speak and read Chinese.

The exclusion criteria: (1) men and their female partners with a physical condition that may interfere with sexual functioning; (2) a current or past history of drug or alcohol abuse; (3) a history of major psychiatric disorder (for example, major depression and dysthymia); (4) have previously reported low sexual desire and other forms of sexual dysfunction (for example, erectile dysfunction); (5) men were on medication that might affect ejaculatory function, for example, selective serotonin reuptake inhibitor antidepressants, tricyclic antidepressants, and sildenafil and topical penile treatments to prolong latency time.

Methods

As several subjective and sensitive personal questions were included in this study, a pre-survey was given to a small sample of men and their partners (N=30) to modify the originally designed items to ensure the feasibility of the survey. In addition, subjects and their partners were informed about the survey, and those who participated were asked to provide written consent.

This study was designed as a three-stage protocol. Subjects and their partners were required to participate in the survey via separate face-to-face interviews. The first stage involved collecting information from the men and their female partners regarding basic demographic variables (for example, age, educational status and occupational status), and medical and sexual history (for example, general comments or concerns regarding PE, and development and experience of PE). The second stage measured the IELT using a stopwatch, for which subjects and their partners were educated on what was to be measured, and then required to have sexual intercourse at least twice weekly and to record all sexual events for the following 4 weeks. The IELT was measured from initiation of vaginal penetration to ejaculation for every attempt at sexual intercourse. Ejaculation before penetration was assigned an IELT value of 0 min. Subjects or their partners could operate the stopwatch, whichever was easier, but had to ensure that this remained consistent throughout the study. After the study, all recorded IELT were collected, and the mean value was used in analyses. In the third stage, subjects and their partners were required to answer a question independently that evaluated the major impact of PE, ‘According to the following negative consequences due to PE, which one do you think influences your sexual life the most?’. The responses provided were ‘reduced ejaculatory control’, ‘reduced sexual satisfaction’, ‘increased personal distress’, ‘increased interpersonal difficulty’ and ‘other’.

Then, subjects and their partners completed the Chinese version of the PRO questionnaires.22 According to the Chinese textbook’s description, the PRO questionnaires contain five measures: control over ejaculation, satisfaction with sexual intercourse, severity of PE, personal distress and interpersonal difficulty. The PRO measures of control over ejaculation and satisfaction with sexual intercourse used the same 5-point response scale (range, 0 ‘very poor’ to 4 ‘very good’), with lower scores indicating greater dysfunction. The PRO measure of severity of PE used a 4-point response scale (range, 0 ‘none’ to 3 ‘severe’), with higher scores indicating greater dysfunction. The PRO measures of personal distress and interpersonal difficulty used a 5-point response scale (range, 0 ‘not at all’ to 4 ‘extremely’), with higher scores indicating greater dysfunction.22 In this survey, the PRO questionnaires were based on an observational study conducted by Patrick et al.12 (Table 1). Cronbach’s alpha for the PRO questions in our survey was 0.81, which indicated acceptable internal reliability.

Table 1 Patient-reported outcome (PRO) questions

According to the ISSM criteria,3 the diagnosis of PE was based on male sexual dysfunction characterized by ejaculation that always or nearly always occurs within 1 min of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences such as distress, bother, frustration and/or the avoidance of sexual intimacy.

Statistical analysis

All statistical analyses were performed using SPSS software (SPSS Inc., Chicago, IL, USA) version 13.0. Descriptive statistics were used to summarize the demographic characteristics and the PRO outcomes for the subjects and their partners. χ2 test was used for the intergroup comparisons, when appropriate. Correlations were assessed using Spearman’s rank correlation coefficient. For all tests, P<0.05 was deemed statistically significant.

Results

Demographics

Of 3425 couples who met the inclusion criteria, 2704 completed all aspects of the survey, with a response rate of 78.95%. Couples discontinued the study for the following reasons: ‘withdrawal of consent’ (N=363), ‘loss of follow up’ (N=120), ‘incomplete information’ (N=59) and ‘other reasons’ (N=179). The mean ages of subjects (range, 22–54 years) and their female partners (range, 21–52 years) were 33.21±10.17 years and 32.75±9.72 years, respectively. On the basis of ISSM criteria, 521 (19.27%) men were diagnosed with PE. The mean IELT for the PE and non-PE groups was 45.76±22.29 s and 132.28±47.86 s, respectively. The demographic characteristics of the subjects and their partners are summarized in Table 2 and Figure 1.

Table 2 Demographic characteristics of subjects and their partners
Figure 1
figure1

Distribution of subjects on the basis of intravaginal ejaculatory latency time (IELT) groups.

In terms of the major impacts of PE (Figure 2), reduced ejaculatory control (57.69%) and sexual satisfaction (51.18%) were reported by the majority of subjects and their partners, respectively. In addition, there were significant differences between the PE and non-PE groups, in terms of subjects’ or their partners’ responses to PRO questions regarding control over ejaculation, satisfaction with sexual intercourse, personal distress and interpersonal difficulty (P<0.001 for all) (Table 3). The majority of men with PE gave ratings of ‘poor’ or ‘very poor’ for measures of control over ejaculation (78.12 vs 18.69% for men without PE) and satisfaction with sexual intercourse (77.54 vs 12.14% for men without PE, respectively). A higher proportion of men in the PE group vs the non-PE group gave a worse rating (‘quite a bit’ or ‘extremely’) for personal distress (69.87% vs 11.77%, respectively) and interpersonal difficulty (52.78% vs 12.19%, respectively). The mean scores of control over ejaculation, satisfaction with sexual intercourse, personal distress and interpersonal difficulty in the PE group were 0.88±0.74, 0.89±0.76, 2.83±0.96 and 2.31±1.24, respectively, whereas those in the non-PE group were 2.74±1.12, 2.72±1.01, 1.34±0.98 and 1.27±1.00, respectively. These findings were similar to the PRO outcomes reported by female partners. Female partners in the PE group also reported significantly lower scores of control over ejaculation (0.94±0.77 vs 2.49±1.17 for the non-PE group, respectively) and satisfaction with sexual intercourse (0.84±0.77 vs 2.52±0.93 for the non-PE group, respectively), and higher scores of personal distress (2.84±0.96 vs 1.29±0.96, respectively) and interpersonal difficulty (2.28±1.24 vs 1.25±1.00, respectively).

Figure 2
figure2

Distribution of subjects and their female partners based on the major PE complaint.

Table 3 Distribution of subjects’ and their partners’ responses to PRO measures

A significant difference was also found between men with PE and their partners’ responses to the PRO questions for severity of PE (P<0.01). The severity of PE reported by men with PE was distributed as follows: ‘mild’ 12.09%, ‘moderate’ 49.90% and ‘severe’ 37.81%. However, the ratings for female partners were ‘mild’ 45.87%, ‘moderate’ 32.05% and ‘severe’ 13.05%.

Several correlations were observed among the IELT and PRO outcomes (absolute correlation coefficient ranged from 0.33 to 0.67) (Table 4). Of the correlation between IELT and the PRO outcomes, IELT was positively correlated with the PRO measures of control over ejaculation and satisfaction with sexual intercourse for men and their partners but was negatively correlated with personal distress and interpersonal difficulty. IELT was more highly correlated with control over ejaculation (r=0.60 for men, r=0.52 for partners) than other PRO measures. For the correlation between the outcomes of PRO measures for subjects and their partners, control over ejaculation for men was more strongly correlated with personal distress (r=−0.67) than other PRO measures. The strongest correlation was found between control over ejaculation for men and their partners (r=0.60). In addition, the severity of PE for men with PE was more highly correlated with personal distress for men (r=0.60) and control over ejaculation for partners (r=−0.49) than other PRO measures.

Table 4 Correlation between subjects’ and their partners’ responses to PRO measures

Discussion

This is the first, large observational study to assess the status of PE using IELT and PRO measures in Chinese men. In addition, because the patients surveyed were those who had sought treatment for the complaint of PE, measuring the incidence of PE and its impact on this particular population may help improve the diagnosis and treatment of PE in clinical practice.

Previous studies have shown that IELT or PRO measures alone were not sufficient to characterize the status of PE accurately.11, 17 Outcomes of PRO measures might vary in importance between subjects and have differing meanings in different cultures, where the attitude of the partner and culturally determined extent of emancipation might have an impact on the subjective diagnosis of PE. In addition, results from a large observational study13 have shown a significant overlap between the IELTs of men with and without PE. This means that IELT does not categorize the PE and non-PE groups accurately. Therefore, in this study, we tried to determine PE status using a combination of IELT and PRO measures.

There are numerous definitions of PE, for example, the DSM-IV-TR11 and ISSM.13 Most definitions contain three parts: (1) a short ejaculatory latency; (2) a lack of perceived self-efficacy or control over the timing of ejaculation; (3) distress and interpersonal difficulty. According to the ISSM criteria, a patient is diagnosed with PE if they experience vaginal penetration for less than 1 min, a loss of control and/or negative sexual consequences. When applying only the time parameter of the ISSM definition of PE to a population-based cohort of 500 men using stopwatch-measured IELTs, only 1–3% of men would be eligible for the diagnosis.1, 23 In contrast, Liang et al.24 have found that the prevalence of PE (IELT<1 min, a loss of control) among 7372 Chinese men was 15.29%. However, in the present study, we found that 19.27% of men with self-reported PE were diagnosed with PE, and that the incidence of PE was higher than that in the above studies. We speculate that these differences in prevalence rates might be explained by the particular samples who complained of PE and the different cultural and religious influences between the Chinese and western patient populations.

Previous studies have confirmed that PE has a profound impact on men and their partners regarding aspects of sexual function, psychological status and quality of life.25, 26, 27 Patrick et al.12 found that men and their partners in the PE group reported significantly lower levels of ejaculatory control and sexual satisfaction, and higher levels of personal distress and interpersonal difficulty than those in the non-PE group. Furthermore, IELT was more strongly correlated with control over ejaculation for men (r=0.51) and their partners (r=0.46) than with other PRO measures. Control over ejaculation for men was most strongly correlated with personal distress for men (r=−0.66) and control over ejaculation for female partners (r=0.57). Similar results were observed in our study, in which the majority of men with PE and their partners considered reduced ejaculatory control (57.79%) and sexual satisfaction (51.18%) as the major impact of PE, respectively. Men with PE and their female partners also reported worse outcomes on ejaculatory control, sexual satisfaction, personal distress and interpersonal difficulty.

In addition, a significant difference was also observed between men with PE and their partners’ responses to the severity of PE in our study. The majority of men with PE rated the severity of PE as moderate (49.90%) or severe (37.81%), whereas these ratings were given by only 45.10% of female partners (moderate: 32.05%; severe: 13.05%). However, this discrepancy was not observed in Patrick’s study.12 We speculate that the difference between men and their partners’ response to PE severity might result from discrepancies in behavioral aspects and cognitive factors. Thus, if men have lower self-esteem and confidence, they might overestimate the severity of PE.

Overall, the findings of our study provide a framework for understanding the PE status in clinical practice in China. However, 80% of the samples who did not meet the ISSM criteria have also complained of PE. To our knowledge, PE is a multi-factored sexual dysfunction and related to psychological factors. We speculated that the complaint of PE among patients without PE should not be regarded as a symptom of a true medical pathology. Psychological or relationship problems might underlie their complaint. Hence, positive psychological therapy would be an advantage to the management of PE complaint.28 In addition, several limitations should be considered. First, because the study enrolled subjects who sought treatment for PE complaint, and should meet the inclusion criterion (for example, aged 18 and in a heterosexual, stable and monogamous sexual relationship), generalization of these findings may be limited. Second, face-to-face interviews may cause embarrassment when sensitive personal issues are at issue. Respondents may feel obliged to give socially acceptable answers during face-to-face interviews. Hence, other methods, for example, internet-based survey, can be used in further survey. Third, these findings are just from one clinic in China, and further studies should be performed in several countries. Finally, as previous studies on this issue are scarce, further research is needed to confirm and extend these results.

Conclusion

This in-depth qualitative study provides a valuable insight into the PE status in Chinese men. The prevalence of PE in this study was 19.27%. PE negatively impacts men and their partners, including reduced ejaculatory control and sexual satisfaction, and increased interpersonal difficulty. Further research is needed to confirm and extend these results.

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Acknowledgements

We thank Dr Zheng Peng for his assistance in the statistical analysis.

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Correspondence to X Zhang.

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The authors declare no conflict of interest.

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Keywords

  • female partner
  • men
  • premature ejaculation
  • sexual dysfunction

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