Towards a Universal Definition of Premature Ejaculation

Abstract

Although the scientific production regarding premature ejaculation (PE) has sharply increased in relatively recent years,1 there is still a vibrant debate gravitating around its current definitions.2 Overall, definitions have widely changed across the years, having been continuously depleted of, or enriched with, various criteria. for example, the number of coital thrusts was not considered in the most recent definitions, while the partner's distress, although not always mentioned explicitly, was somewhat included.3 Such “unfinished business”, using the words stolen from a seminal paper recently published in the Journal of Sexual Medicine,4 of defining PE reveals that there is still a high demand for truly standardized, unanimously accepted, and operationalized criteria. Nowadays, PE is usually defined according to the International Society of Sexual Medicine (ISSM)5 and American Psychiatric Association (APA),6 which both require the 3 criteria of (i) short ejaculatory latency (called “intravaginal ejaculatory latency time”, or IELT), (ii) perceived lack of control over ejaculation and (iii) presence of distress due to the condition. Hence, the definition of PE has been considered “tridimensional”.7 These criteria have been considered “set in stone” and have not been reconsidered in the previous 15 years. Only some relevant changes have been recently included, such as the “2 minutes” time criterion considered by the American Urology Association (AUA)8 and the differentiation of lifelong and acquired PE made by the ISSM.5 Another important novelty is the absence of strict time criteria in the 11th Revision of the International classification of diseases for mortality and morbidity statistics (ICD-11) definition.9 This absence, which could be criticized when the definition is used in research and experimental protocols,2 could be considered, from a clinical perspective, an interesting alternative to the other mainstream taxonomies. However, it should be considered that the same strict temporal criteria which are necessary to adequately recognize individuals with PE (and therefore guide towards treatment) do not seem universally adequate.4 The use of patient-reported outcomes (PROs), such as the Premature Ejaculation Diagnostic Tool (PEDT),10 can provide additional information. Still, these questionnaires are somewhat limited in their reliability, also because each of them considers the 3 criteria differently. This is further complicated by the notion that, while time is – apparently - easy to measure (although some flaws should also be considered in this case, such as the invasiveness of stopwatch measurements and distraction from intercourse), the definitions of distress and lack of control are more difficult to quantify adequately. Moreover, Rowland et al. correctly argued that the indisputability of the equation time = stimulation, with a longer time of penetration corresponding to higher stimulation, is still questionable. Indeed, considering the significant subjectivity in arousal, and the variability of coital thrusts (frequency, strength, depth), whether it is possible to establish if a longer time of stimulation means “better” stimulation is still a challenging question. Penile stimulation can be significantly affected by several factors, resulting in unreliable measurements. Examples include the recently defined lost penis syndrome (LPS)11 but also, bona fide, sexual positions, penile rigidity, and so on. Moreover, and interestingly, arousal is not included yet among criteria (indeed, a patient might have PE when extremely aroused but perhaps not in other conditions), nor the experienced levels of orgasm, typically blunted in PE.12 This testifies that the debate should continue, and empirical evidence should be provided.

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