Erectile dysfunction, anxiety, perceived stress, and insomnia are more common among acquired premature ejaculation patients in contrast to other premature ejaculation syndromes

Time (of the intravaginal ejaculatory latency, or IELT); control (of the ejaculation); distress (perceived by the patient and the partner): These are the dimensions well recognized as being intrinsically connected, and affected, in premature ejaculation (PE) patients.1 However, it is unanimously accepted that PE is a tri- or multidimensional disorder (considering the impairment of the orgasm2), meaning that other relevant psychosexological correlates characterize the condition and contribute to its pathophysiology and clinical presentation. This finding significantly emerges also from the recent and interesting paper "erectile dysfunction, anxiety, perceived stress and Insomnia are more common among acquired premature ejaculation patients compared to other premature ejaculation syndromes" by Demirci et al. In particular, erectile dysfunction (ED) severity was found to be high in patients with acquired PE (APE) (80.0%) and moderate in lifelong PE (LPE) (38.5%), while the greatest number of patients with no ED were found in the type subgroup previously (although not consistently) defined in the past as "subjective" PE (SPE in the article, a now misleading acronym, being used for the well-structured taxonomic category of subclinical premature ejaculation, having major and minor diagnostic criteria: SPE3) (75.0%). However, looking at the other side of the coin, 11 of 18 of such SPE patients (thus more than 50%) were found to have moderate or severe ED too. If, on the one hand, it is bizarre to notice that such patients who thought they have ejaculated early despite a normal time (hence labelled as subjective PE) and, for this reason, in contrast to "true" PE patients (i.e., LPE and APE) end up having ED too, on the other hand (and looking from a more realistic perspective) such data are not surprising at all. Indeed, in clinical practice, 50% of patients with PE also report ED, and the correlation between erectile and ejaculatory function is so well-known that recently a new taxonomic entity called "loss of control of erection and ejaculation" has been proposed,3 to identify the condition of impaired ability to control at the same time erectile and ejaculatory function which so frequently occurs among patients,4 and so frequently it is neither diagnosed nor treated. In fact, the decision not to treat a patient that complains about PE because he thinks to have ejaculated early despite a normal time, can forecast potential risks in clinical management. Indeed, often such patients, despite showing a subnormal IELT, may still face a relevant lack of control in the ejaculation process (and significant perceived distress). ED can often be superimposed on these patients, who instinctively reduce their level of excitement in an attempt to control their ejaculation. Thereby, considering them as having a subjective disorder, simply reassuring rather than treating them, may worsen the situation, harbouring, bona fide, the risk of converting a situation of subclinical PE into an overt PE. Among the patients analyzed by Demirci et al., only four of 18 of subjective PE reported good or very good ejaculatory control. Moreover, the median value of their premature ejaculation diagnostic tool (PEDT), is 11, which yet accounts for a PE diagnosis. Indeed, PEDT, the most important psychometric test aiding the diagnosis of PE, has precisely two items dealing with control, two for distress, and one only for time. Interestingly, the Patient Reported Outcomes of this diagnostic tool are now validated for the autoerotic setting, enlarging the diagnostic possibilities of PE diagnosis to single people.5 More emphasis is given to the lack of control and distress, rather than the IELT, for defining what PE is. This has been similarly stated by the latest guidelines of the Italian Society of Andrology and Sexual Medicine, which recommended considering the aspects of the tri-dimensional definition of PE in order of clinical importance.6 Hierarchically, loss of control over ejaculation is clinically more relevant than the distress provoked in the patient or the partner, and even more than short IELT.7 We found another interesting finding in the Demirci et al.'s article. The Colleagues nicely found, by well-validated psychometric tools, that PE symptoms are associated with worse sleep quality and erectile function. Future research should concentrate on the levels of testosterone, robustly related to nocturnal apneas and ED, also in PE, which presents significantly higher levels of T with respect to other sexual dysfunctions such as ED.8 Altogether, this article reminds us once more that time is only one of the main criteria for establishing a diagnosis of PE and that the clinical spectrum of PE is quite more complex. We thereby encourage, when dealing with PE patients both in the research and in the clinical practice, to consider the sexual and non-sexual comorbidities,9 as well all the lights and shades of the current definitions and to realistically appraise the whole clinical spectrum of PE patients, very far from being only a matter of (short) time.10