Premature ejaculation (PE) or early ejaculation is a common male sexual dysfunction.1 Various professional bodies have provided different definitions for PE.
The International Society of Sexual Medicine, 2014, defines PE as follows: “Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration from the first sexual experience (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE).” It is associated with the “inability to delay ejaculation on all or nearly all vaginal penetrations” resulting in “negative personal consequences,” such as distress, bother, frustration, and/or the avoidance of sexual intimacy.2
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V) defines PE as follows: “A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it ....” The symptoms must have been present for at least 6 months and must be experienced on almost all (approximately 75-100%) or on all occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts). The symptoms can cause “clinically significant distress in the individual” and the sexual dysfunction cannot be better explained by a “non-sexual mental disorder” or as a “consequence of severe relationship distress or other significant stressors,” and is not attributable to “the effects of a substance/medication or another medical condition.”3
The lack of a clear definition and diagnostic criteria is a major challenge for the diagnosis of PE. Based on the proposed criteria by Raveendran, we proposed a novel classification for PE diagnosis, which will be useful for healthcare professionals worldwide.4
Four PE types have already been described: lifelong, acquired, variable, and subjective.5 However, this classification did not include other types of PE, such as transient or situational PE, that we encounter in daily clinical practice. Hence, we proposed a new classification for PE that will be useful clinically (Table 1).
PE can be symptomatic or asymptomatic. Asymptomatic PE is usually incidentally detected when measuring the intravaginal ejaculation latency time (IELT). Depending on the symptom severity, PE can be divided into mild, moderate, or severe. However, the PE symptoms are not directly correlated with IELT reduction. It is influenced by multiple factors such as IELT duration, reduction in IELT (acquired PE), personal and psychological factors, and other social and relationship factors. Lifelong PE is present from the start of sexual life and acquired PE manifests after a period of normal sexual life. PE symptoms can be transient, such as in situational PE, or it can be permanent and persist for more than 6 months as per the current definitions. PE can be isolated (simple PE) or associated with another sexual dysfunction (complicated PE). Depending upon the IELT reduction, PE can occur before penetration (ante portas) or after penetration (intra moenia). Depending upon the severity of the IELT reduction, PE can be graded as Grades 1-4 (Table 1). Depending upon the etiology, PE can be primary or idiopathic, where there is no identifiable cause, or secondary, where it can occur due to various medical, surgical, or psychiatric causes. Based on the pathophysiological mechanism, it can be classified into the predominantly peripheral sensory hyperexcitability, predominantly central hyperexcitability, or mixed group. Based on the type of sexual activity, PE can be associated with peno-vaginal, -anal, and -oral intercourse or masturbation.
In any sexual relationship, both partners act as a single unit, and the sexual dysfunction evaluation of one partner is incomplete without examining the other partner. In PE, irrespective of the erotology or PE type (such as lifelong or acquired), the defining factor of dysfunction is real or perceived short ejaculation time. The IELT is a measure of the ejaculation time and defined as the time from the moment of vaginal penetration until the moment of intravaginal ejaculation.6 Hence, it is always better to define PE with the same IELT cutoff irrespective of the PE type. Existing literature defines lifelong PE as IELT less than one minute and acquired PE as IELT less than three minutes.2 We have proposed a uniform IELT cutoff of three minutes for defining both lifelong and acquired PE.4 Depending upon the severity of the IELT reduction, we propose grading the IELT duration from Grades 1 to 4 (Table 2). Sometimes female sexual dysfunction, such as vaginismus and delayed orgasm, can be misdiagnosed as PE in the male partner.
Based on the severity of the IELT reduction, most people with lifelong PE have severe IELT reduction, whereas those with acquired PE have mild to moderate IELT reduction. However, the sexual distress depends upon various factors, including previous ejaculation time (in case of acquired PE), relation with the partner, personality, and sociocultural factors. Even though most people with acquired PE have mild to moderate IELT reduction, they are more concerned about their problem than individuals with lifelong PE.
PE can induce various psychological issues such as anxiety, depression, lack of sexual confidence, poor self-esteem, impaired quality of life, sexual dissatisfaction, and interpersonal difficulties.7 The psychological impact of PE depends upon various factors such as social and cultural factors, personality, and the relation between the partners, and it is not a direct measure of the severity of the IELT shortness. Hence, the psychological issues can be better considered as the impact of PE.
IELT varies with age.8 However, none of the guidelines address this aspect and propose a uniform cutoff for the diagnosis of PE irrespective of age. More studies are needed to define the age-related IELT cut-off.
Current definitions of PE consider only peno-vaginal sexual intercourse. People engaged in other sexual activities, such as anal sex, oral sex, or masturbation, and suffering from PE have to be considered in the future definitions of PE.
Acknowledgment: Acknowledge the support from Prof. Dr. Ege Can Serefoglu, for reviewing the manuscript and giving valuable suggestions
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