Differences between ICD-11 MMS and DSM-5 definition of premature ejaculation: a continuation of historical inadequacies and a source of serious misinterpretation by some European Regulatory Agencies (PART 2)

Possible Pathophysiological Roles of Neurotransmitter Systems in Men With Lifelong Premature Ejaculation: Protocol for a Scoping Review

BACKGROUND

Lifelong premature ejaculation (LPE) is a rare sexual condition believed to be caused by genetic neurobiological disorders. In the field of LPE, 2 main types of research have been conducted: direct genetic research and pharmacotherapeutic interference of neurotransmitter systems that can relieve the symptoms of LPE in male patients.

OBJECTIVE

We aim to provide an overview of studies on neurotransmitter systems as the pathophysiological cause of LPE by investigating direct genetic research or pharmacotherapeutic interference that relieves the main symptom of LPE in male patients.

METHODS

This scoping review will use the PRISMA-ScR tool (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). In addition, this study will use a peer-reviewed search strategy. Systematic searches will be conducted using 5 scientific databases (Cochrane Database of Systematic Reviews, PubMed or MEDLINE, Cumulative Index to Nursing and Allied Health Literature [CINAHL], EMBASE, and Epistemonikos). Additionally, pragmatic searches for relevant information in gray literature databases will be performed. Two reviewers will independently include relevant studies in a 2-stage selection strategy. Finally, data will be extracted from the studies and charted to summarize relevant study characteristics and key findings.

RESULTS

As of July 2022, we completed the preliminary searches according to the PRESS 2015 guidelines and started to determine the final search terms that we will use in all selected 5 scientific databases.

CONCLUSIONS

This scoping review protocol is the first to focus on neurotransmitter pathways in LPE by combining the results from the genetic and pharmacotherapy studies. The results could help identify potential research gaps or target candidate proteins and neurotransmitter pathways in LPE for further genetic research.

TRIAL REGISTRATION

Open Science Framework 10.17605/OSF.IO/JUQSD; https://osf.io/juqsd.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41301.

Current and emerging treatment options for premature ejaculation

Premature ejaculation (PE) is a prevalent male sexual dysfunction. Current standard treatment regimens include behavioural therapies, topical anaesthetics, dapoxetine and other selective serotonin reuptake inhibitors (SSRIs). Most of the pharmacotherapeutic options target neurotransmitters (such as serotonin and oxytocin) that have a role in the ejaculation mechanism. However, these treatments are mildly effective and only provide a temporary delay in the ejaculation latency time, and PE recurs when the treatment is stopped. Thus, a treatment for PE is urgently needed and research is ongoing to find the ideal PE therapy. The efficacy and safety of topical anaesthetics and SSRIs in delaying ejaculation have been confirmed in many well-designed controlled trials. Both preclinical and clinical studies on new-generation SSRIs are ongoing. Moreover, promising results came from clinical trials in which the efficacy of on-demand PE therapies targeting neurotransmitters other than serotonin, such as α1-adrenoceptor antagonists and oxytocin antagonists, was assessed. Surgical intervention and neuromodulation have been proposed as potential treatment options for PE; however, current PE guidelines do not recommend these treatments owing to safety concerns.

The network meta-analysis of "on-demand" and "daily" use of paroxetine in treating men with premature ejaculation from randomized controlled trials

This network meta-analysis aimed to assess the efficacy and safety of "on-demand" and "daily" use of paroxetine for patients with premature ejaculation (PE). We searched PubMed, Embase and Cochrane Library from inception to October 2021 to collect randomized controlled trials, and 24 articles including 2, 308 patients were finally involved. The results indicated that paroxetine (daily or on-demand) was superior to placebo at increasing intravaginal ejaculatory latency time (IELT), and 20 mg paroxetine daily was significantly better than fluoxetine and tramadol in improving IELT. Besides, 20 mg paroxetine on-demand was less effective than 20 mg paroxetine on-demand plus phosphodiesterase-5 inhibitors (PDEI5) and tramadol monotherapy in increasing IELT. Tramadol monotherapy was more effective than paroxetine monotherapy in improving sexual satisfaction score. Although patients treated with paroxetine had more coitus/week than patients treated with placebo, it was less than patients treated with PDEI5. These findings were robust to sensitivity analyses. The common adverse events related with paroxetine were fatigue, yawning and abnormal sleep (10.96%), gastrointestinal upset (10.80%). The "on-demand" and "daily" use of paroxetine can significantly improve the clinical symptoms of patients with PE and were well tolerated. Combination therapy and tramadol monotherapy can also be used as alternative treatments.

Advances and Missteps in Diagnosing Premature Ejaculation: Analysis and Future Directions

BACKGROUND

There are several problems with diagnostic criteria for premature ejaculation (PE) that lack objectivity, clarity and precision. They hamper accurate determination of PE prevalence estimates, investigations into the etiology of the dysfunction, impact on partners, development of validated Patient Reported Outcomes, regulatory authority oversight, and which men might benefit from specific treatment interventions.

AIM

We sought to review, analyze and comment on the evolution of the definitions of PE and offer suggestions for future directions for PE definitions. Our goal is to propose strategies whereby the criterion sets are useful to researchers, clinicians and governmental oversight agencies alike and bring harmony and scientific rigor among the conflicting and confusing definitions.

METHODS

There are several premature ejaculation definitions published in the peer reviewed medical literature. The PUBMED electronic database from 1970 to 2021 was searched for published definitions. Search terms included the medical subject headings of premature ejaculation, definition and diagnosis. In chronological order, Table 1 lists the various diagnosis and criteria sets for PE. We discuss the process by which constructs, which make up diagnostic criteria sets, are operationalized and validated.

RESULTS

We review definitions of PE beginning with Masters and Johnson's focus on partner orgasmic attainment and move through the nebulous and subjective criterion sets found in the early Diagnostic and Statistical Manuals and International Classification of Disease series, to the more evidenced-based definitions found in International Society of Sexual Medicine, Diagnostic and Statistical Manuals-5 and the American Urological Association (AUA) definitions. Additionally, we discuss how constructs and criteria sets have been adopted to minimize errors of inclusion and exclusion in defining disease/dysfunction.

STRENGTHS AND LIMITATIONS

This manuscript offers a careful chronological analysis of the published definitions of PE. This historical lens allows the reader to perceive the shifting science underlying the development of PE definitions. The manuscript is limited regarding our comments on acquired PE as evidenced-based research is incomplete.

CONCLUSION

Over the past 50 years there has been considerable forward momentum in defining PE based on well conducted scientific studies. We support the American Urological Association's modification in Intravaginal ejaculatory latency time to 2-minutes for lifelong PE, concur with the 11th revision of the International Classification of Diseases recommendation for changing the terminology from premature ejaculation to early ejaculation. We also recommend ongoing validation of definitions, moving away from the current heterosexist definition of PE based on penile-vaginal sex and urge further population based research into acquired PE to develop stronger evidenced-based criterion sets for this subtype.

Hyperthyroidism as an Underlying Cause of Premature Ejaculation

INTRODUCTION

Hormonal imbalances have been associated with various sexual dysfunction disorders. In particular, the connection of hyperthyroidism has been discovered to correlate to premature ejaculation (PE) but has yet to been thoroughly elucidated. As one of the most frequently self-reported sexual dysfunctions, it is imperative for health care professionals to evaluate possible underlying conditions in regard to treatment options for individuals with PE.

OBJECTIVES

To review the literature regarding hyperthyroidism effects on sexual dysfunction, with a focus on hyperthyroidism and PE.

METHODS

A literature review of articles and clinical studies was performed to define the classification, pathophysiology, diagnostic considerations, and management of hyperthyroidism on PE. Search terms included "hyperthyroidism" and/or "premature ejaculation," "treatment of premature ejaculation," "defining premature ejaculation," and "management of premature ejaculation."

RESULTS

To improve the accuracy of diagnosing PE, there needs to be a set definition amongst the different guidelines, as using these guidelines can help determine possible underlying etiologies of PE. The correlation of hyperthyroidism and PE has been described in a limited number of studies. It has been reported that individuals with hyperthyroidism are much more likely to have PE than individuals with euthryoidism. Management of hyperthyroidism has been shown to alleviate the symptoms of PE.

CONCLUSION

Further understanding of hyperthyroidism as an underlying cause of PE could lead to increased efficacy of treatment and management of PE. Tannenbaum J, Youssef M, Attia AS, et al. Hyperthyroidism as an Underlying Cause of Premature Ejaculation. Sex Med Rev 2021;XX:XXX-XXX.

Traumatic masturbation syndrome may be an important cause of erectile dysfunction in pre-mature ejaculation patients

We aimed to investigate of whether atypical masturbation behaviour is a pre-disposing factor in ED aetiology in pre-mature ejaculation (PE) patients. In addition to demographic data, self-estimated intravaginal ejaculatory latency time (IELT) was prospectively questioned in 2,572 patients between the ages of 18 and 60 who applied with the complaint of pre-mature ejaculation between March 2018 and May 2020. The masturbation habits of the patients were questioned with open-ended questions. After the exclusion criteria, 1,819 patients were evaluated. One thousand one hundred-fifty (63.2%) of patients were classified as lifelong PE, 369 (20.3%) were acquired PE, while 300 (16.5%) were natural-variable PE. According to the IIEF score, 714 patients (39.3%) had ED associated with PE. Eighty-eight per cent of men declared that they had masturbated in the last 4 weeks. Atypical masturbatory behaviours such as 'through clothes' and 'rubbing in prone position' were significantly higher in patients with ED (13% vs. 9%, p = .04 and 11% vs. 7%, p = .02 respectively). Atypical masturbatory behaviours are also seen in a significant part of the pre-mature ejaculation population and increase the rate of erectile dysfunction accompanying PE. This situation draws attention to the necessity of questioning masturbation habits, especially in the combination of PE and ED.

Premature Ejaculation, True or False? Clinical evaluation of PE patients with multiple intercourse in one day

Clinical characteristics of 216 adult males previously diagnosed with premature ejaculation (PE) were studied. Using a survey questionnaire, characteristics included intravaginal ejaculation latency time (IELT), penile hardness scores and the refractory period (RP). Ninety-four PE patients reported they had experienced vaginal intercourse more than once (2 to 4 times) in one day (~44%). IELT was significantly increased at the second and subsequent intercourses, and IIEF-15 (International Index of Erectile Function-15) and relevant subclass scores were markedly improved compared to their first intercourse and also compared to the single intercourse group in this cohort study. Overall sexual satisfaction was achieved in the PE patients with multiple intercourse experiences. The same trend was observed in both the patients diagnosed with lifelong and acquired PE. Based on the evidence, the argument is that the PE patients who were diagnosed using their performance at the first intercourse but who have the ability to participate in multiple vaginal intercourses in one day are unlikely to be true PE. The false PE may account for over 40% of PE patients diagnosed by current guidelines and definitions.

Management of premature ejaculation: a clinical guideline from the Italian Society of Andrology and Sexual Medicine (SIAMS)

Premature ejaculation (PE) is the most prevalent male sexual dysfunction, and the most recently defined. PE is often mistakenly considered a purely psychosexological symptom by patients: the lacking awareness in regards to the pathophysiology and treatments often lead to resignation from the patients' side, making PE the most underdiagnosed sexual complaint. However, an ever-growing body of evidence supporting several organic factors has been developed in the last decades and several definitions have been suggested to encompass all defining features of PE. In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), we propose 33 recommendations concerning the definition, pathophysiology, treatment and management of PE aimed to improve patient care. These evidence-based clinical guidelines provide the necessary up-to-date guidance in the context of PE secondary to organic and psychosexological conditions, such as prostate inflammation, endocrine disorders, and other sexual dysfunctions, and suggest how to associate pharmacotherapies and cognitive-behavioral therapy in a couple-centered approach. New therapeutic options, as well as combination and off-label treatments, are also described.

Self-Reported Shorter Than Desired Ejaculation Latency and Related Distress-Prevalence and Clinical Correlates: Results From the European Male Ageing Study

BACKGROUND

Few data have looked at the occurrence and clinical correlates of self-reported shorter than desired ejaculation latency (rapid ejaculation, RE) and its related distress in the general population.

AIM

To determine the prevalence and clinical correlates of self-reported RE and RE- related distress in middle age and older European men.

METHODS

Subjects were recruited from population samples of men aged 40-79 years across 8 European centers.

OUTCOMES

Self-reported RE and its related distress were derived from the European male Aging Study (EMAS) sexual function questionnaire (EMAS-SFQ). Beck's depression Inventory (BDI) was used for the quantification of depressive symptoms, the Short Form 36 health survey (SF-36) for the assessment of the quality of life, the International Prostate Symptom Score (IPSS) for the evaluation of lower urinary tract symptoms.

RESULTS

About 2,888 community dwelling men aged 40-79 years old (mean 58.9 ± 10.8 years) were included in the analysis. Among the subjects included, 889 (30.8%) self-reported RE. Among them, 211 (7.3%) claimed to be distressed (5.9% and 1.4% reported mild or moderate-severe distress, respectively). Increasing levels of RE-related distress were associated with a progressive worse sexual functioning, higher risk of ED and with couple impairment, along with a higher prevalence of depressive symptoms (all P < 0.05). Furthermore, a worse quality of life and higher IPSS score were associated with RE-related distress (all P < 0.05). The aforementioned results were confirmed even when patients using drugs possibly interfering with ejaculation or those without a stable relationship were excluded from the analysis.

CLINICAL IMPLICATIONS

RE is a frequent condition in men from the general population; however, its related distress is relatively modest. Nonetheless, men with any degree of self-reported RE show increasing levels of depression, worse quality of life and worse couple satisfaction.

STRENGTHS & LIMITATIONS

This is the first study estimating the prevalence of self-reported RE and its related distress, along with their biological and psychological correlates, in a population sample of European middle age and older men. However, is should be recognized that the diagnosis of RE was derived from patient reports and not supported by Intra-ejaculatory-Latency-Time (IELT) measurements.

CONCLUSION

Self-reported RE is relatively common in European men aged more than 40 years. The reported limited RE-related distress may explain the relatively low number of medical consultations for RE. RE-related distress is associated with worse sexual function, couple impairment, and more LUTS resulting in a worse quality of life and mood disturbances. Corona G, Rastrelli G, Bartfai G, et al. Self-Reported Shorter Than Desired Ejaculation Latency and Related Distress-Prevalence and Clinical Correlates: Results From the European Male Ageing Study. J Sex Med Rev 2021;18:908-919.

Clinical features of and couple's attitudes towards premature ejaculation: a multicenter cross-sectional study

INTRODUCTION

The current study aimed to investigate the clinical features of and couple's attitudes towards premature ejaculation (PE).

METHODS

Qualified patients were continuously enrolled from 15 medical centers in different regions of China. Patient data were collected from March 1 2017 to July 31 2017. All men were assessed by the Premature Ejaculation Diagnostic Tool (PEDT) and Intravaginal Ejaculation Latency Time (IELT). Besides, sexual desire, force of ejaculation, and the five-item International Index of Erectile Function (IIEF-5) score were recorded. The couple's attitudes towards PE were evaluated by a self-designed questionnaire.

RESULTS

In total, 1033 males diagnosed with PE and their sexual partners and 3176 males without PE were enrolled. The mean PEDT and IELT scores of the patients with PE were 14.38 ± 3.68 and 1.59 ± 0.85, respectively. IIEF-5, sexual desire, and force of ejaculation significantly decreased in patients with PE. Among the 1033 couples, 44.3%, 21.39%, and 33.98% of the couples were seeking PE because of the dissatisfaction of the males, the females or both partners, respectively. In terms of the males who were dissatisfied with PE, 49.51% and 17.86% complained of short IELT and inability to control ejaculation. In terms of the females dissatisfied with PE, 41.61%, 19.93%, 21.68%, and 14.51% complained of arousal difficulty, weak sexual desire, failing to have organism and poor relationship, respectively.

CONCLUSIONS

PE has a negative impact on erectile function, sexual desire, and force of ejaculation. Sexual partners play important roles in the medical procedures for addressing PE.

Gene Variants in Premature Ejaculation: Systematic Review and Future Directions

INTRODUCTION

A growing number of genetic association studies have been performed to investigate the association between the genetic susceptibility alleles and the risk of premature ejaculation (PE); however, the results remain inconclusive.

OBJECTIVES

This systematic review aimed: (i) to determine whether an association exists between gene(s) or allelic variant(s) and PE; (ii) to assess whether the associations are consistent across studies in magnitude and direction, and (iii) to identify any limitation, gap, or shortcoming in the included studies.

METHODS

The literature search was conducted in PubMed, MEDLINE, Scopus, Cochrane Library, EMBASE, Academic Search Complete, Google Scholar, and CINAHL databases.

RESULTS

Different gene variants associated with PE were assessed. 25 genetic association studies met the inclusion criteria that investigated 11 genes, 2,624 men with PE compared with 9,346 men as controls, twins, and siblings. 19 studies demonstrated a significant association with PE, whereas 4 studies denied such a relationship. SLC6A4 gene polymorphism was investigated in 11 studies (7 studies demonstrated a significant relationship with PE, and 4 studies denied such a relationship). Dopamine transporter gene (DAT1) polymorphism was investigated in 4 studies exhibiting a significant relationship. Androgen receptor gene polymorphisms were investigated in 2 studies, 1 with a significant relationship and the other with a non-significant relationship. Oxytocin gene polymorphisms and tryptophan hydroxylase 2 gene polymorphisms were investigated in 2 studies with a significant relationship.

CONCLUSION

While this review has highlighted several genes that may be potentially associated with PE such as SLC6A4, limitations such as variance in study methods, lack of robust findings, small sample sizes, lack of reproducibility, quality of reporting, and quality of assessment remain a major concern. Further efforts such as standardizing reporting, exploring complementary designs, and the use of genome-wide association studies technology are warranted to test the reproducibility of these early findings. Mostafa T, Abdel-Hamid IA, Taymour M, et al. Gene Variants in Premature Ejaculation: Systematic Review and Future Directions. Sex Med Rev 2020;8:586-602.

Management Options for Premature Ejaculation and Delayed Ejaculation in Men

INTRODUCTION

Many men experience distressing issues regarding the timing of orgasm and ejaculation, such as premature ejaculation (PE) and delayed ejaculation (DE). Despite being highly prevalent, both PE and DE are poorly understood and present a management challenge for sexual medicine specialists.

AIM

To summarize existing data on the medical management of PE and DE.

METHODS

A comprehensive literature review pertaining to the management of PE and DE was conducted using PubMed and clinicaltrials.gov for data published up until May 2019. Our focus was on double-blind, placebo-controlled trials and meta-analyses of such studies.

MAIN OUTCOME MEASURE

Peer-reviewed studies on treatment options for PE and DE were critically analyzed for results and methodological rigor.

RESULTS

The peer-reviewed data on PE management continue to evolve. Psychotherapy, pharmacotherapy, and procedural interventions have all been associated with some degree of efficacy. A strong evidence base supports the off-label use of selective serotonin reuptake inhibitors and local anesthetics in PE given consistent increases in ejaculation latency time. Education and mental health assessments remain important components of PE management despite a dearth of peer-reviewed data on these interventions. Numerous treatment strategies have been evaluated for DE; limited data support psychotherapy, pharmacotherapy, and/or penile vibratory stimulation as management options.

CONCLUSION

A number of management options for PE or DE exist but none has been formally approved by the US Food and Drug Administration. New and novel treatments would be of great value in managing issues regarding the timing of ejaculation/orgasm. Martin-Tuite P, Shindel AW. Management Options for Premature Ejaculation and Delayed Ejaculation in Men. Sex Med Rev 2020; 8:473-485.