1
Relationship between Premature Ejaculation and Chronic Prostatitis/Chronic Pelvic Pain Syndrome Jun Ho Lee, MD, PhD* and Sung Won Lee, MD, PhD† *Department of Urology, National Police Hospital, Seoul, Korea; †Department of Urology, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea DOI: 10.1111/jsm.12796
ABSTRACT
Introduction. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common etiology of premature ejaculation (PE). However, the current data are insufficient to explain this relationship and to support routine screening of men with PE. Aims. This study aims to evaluate the relationship between PE and CP/CPPS. Methods. A cross-sectional study was conducted that included 8,261 men who had participated in a health examination. The Premature Ejaculation Diagnostic Tool (PEDT), the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), and the International Index of Erectile Function-5 (IIEF) were used for assessment of symptoms. A full metabolic work-up and serum testosterone level checks were also performed. We then investigated the relationship using the Spearman correlation test, multiple linear regression, and logistic regression analyses. Main Outcome Measures. Associations of PEDT with NIH-CPSI. Results. The mean age was 50.4 ± 5.5 years. In total, 2,205 (24.9%) men had prostatitis-like symptoms (NIH-CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIHCPSI pain score of ≥8). Additionally, 2,144 men (24.2%) were classified as demonstrating PE (PEDT > 10). The PEDT score was found to have a significant positive correlation with the NIH-CPSI pain domain score (correlation coefficient = 0.206; P < 0.001). After adjusting for age, metabolic syndrome status, testosterone level, and IIEF score, there was no change in the positive correlation between the NIH-CPSI pain domain score and PEDT score (Beta = 0.175; P < 0.001). After adjusting for age, testosterone level, metabolic syndrome, and IIEF score, the odds ratio (OR) for PE significantly increased with the severity of pelvic pain (mild prostatitis-like symptoms, OR for PE: 1.269, 95% confidence interval: 1.113–1.447; moderate to severe symptoms, OR for PE: 2.134: 95% confidence interval: 1.782–2.557). Conclusions. Our data showed a significant correlation between the PEDT score and the NIH-CPSI score. We suggest routine screening for CP/CPPS in men with PE and PE in men with CP/CPPS. Lee JH and Lee SW. Relationship between premature ejaculation and chronic prostatitis/chronic pelvic pain syndrome. J Sex Med **;**:**–**. Key Words. Premature Ejaculation; Chronic Prostatitis; Erectile Dysfunction; Testosterone; Metabolic Syndrome
Introduction
P
remature ejaculation (PE) is defined as male sexual dysfunction characterized by ejaculation that always or nearly always occurs prior to or within 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome
© 2014 International Society for Sexual Medicine
reduction in latency time, often to about 3 minutes or less (acquired PE), according to the International Society for Sexual Medicine [1]. This definition also includes the inability to delay ejaculation on all or nearly all vaginal penetrations, with negative personal consequences, such as distress, bother, frustration, and/or the avoidance of J Sex Med **;**:**–**
2 sexual intimacy. PE is a common male sexual dysfunction affecting 30–40% of sexually active men in an age-dependent manner [2–4]. PE is associated with comorbid conditions, such as diabetes [5], thyroid disease [6], and lower urinary tract symptoms [7]. PE also has commonly been reported in men with chronic prostatitis/chronic pelvic pain syndrome (CP/ CPPS) [8]. However, previous studies on PE and CP/CPPS had relatively small populations [9–11]. In addition, over 50% of the studied populations were under 40 years of age [9–12], but being over 40 years of age is associated with an increased risk of CP/CPPS [13]. Moreover, there was no consideration of erectile dysfunction (ED) or testosterone levels, which would be potential confounding factors when evaluating the relationship between PE and CP/CPPS [14– 16]. Understanding the relationship between PE and CP/CPPS is clinically important because the correction of comorbid disease could cure the PE condition. Because of methodological limitations of the existing studies and insufficient evidence, we performed the present study to establish the relationship between PE and CP/CPPS. Aims
The aim of our study was to evaluate the relationship between PE and CP/CPPS. Methods
Subjects From August 2011 to November 2013, 8,727 male police officers over 40 years of age participated in a urological health checkup. The participants were applicants. Only applicants over 40 years of age were allowed to participate in medical examinations. This health screening included anthropometric measurements (blood pressure measurements, waist circumference, height, and weight), prostate specific antigen levels, testosterone levels, a complete blood cell count, basic blood chemistry analyses, a urine analysis, transrectal ultrasonography, and uroflowmetry. Medical histories were collected using a standardized structured questionnaire. The participants were also asked to complete questionnaires concerning urological health status, including the International Prostate Symptom Score, the Overactive Bladder Symptom Score, the Premature Ejaculation Diagnostic Tool (PEDT), the InterJ Sex Med **;**:**–**
Lee and Lee national Index of Erectile Function-5 (IIEF), and the National Institutes of Health-Chronic Prostatitis Symptoms Index (NIH-CPSI). Additionally, a questionnaire on androgen deficiency in aging males (from August 2011 to August 2012) and an aging male’s symptoms rating scale (from September 2012 to November 2013) were administered. Because the government of South Korea provides all medical services carried out in the National Police Hospital to police officers for free, all clinical, laboratory, functional, and radiological exams during the urological health checkup were available. All of the participants provided written informed consent, and data concerning the participants were collected prospectively. To evaluate the relationship between PE and pelvic pain, data from the NIH-CPSI, PEDT, anthropometric measurements, testosterone levels, basic blood chemistry, and metabolic syndrome (MetS) assessment, as well as other diverse clinical parameters were used in this analysis. The Institutional Review Board of the National Police Hospital approved this study (IRB number: 16222–201408-HR-002).
PE, CP/CPPS, and ED Assessment The PEDT, NIH-CPSI, and IIEF were used for the assessment of PE, CP/CPPS, and ED, respectively. Males with PEDT scores >10 and 9–10 were classified as having PE and possible PE, respectively [17]. Symptoms were classified as a “mild prostatitis-like symptom” if respondents reported perineal or ejaculatory pain and had a NIH-CPSI pain score of ≥4 and 21), mild ED (IIEF > 16 to ≤21), mild to moderate ED (IIEF > 11 to ≤16), moderate ED (IIEF > 7 to ≤11), and severe ED (IIEF ≤7). MetS Assessment Two blood pressure (mm Hg) measurements, obtained 5 minutes apart, were averaged using a mercury sphygmomanometer on the right arm. Waist circumference (cm), to the nearest 0.1 cm, was measured midway between the lowest rib and the iliac. Body weight (kg) and body height (cm) were also recorded. Serum was collected in the morning (between 7:00 and 9:00 am) after an overnight fast. The biochemical analyses included the fasting serum glucose level, the triglyceride level, and the high-density lipoprotein cholesterol level. A diagnosis of MetS was made if three
3
Premature Ejaculation and Chronic Prostatitis or more of the National Cholesterol Education Program-Adult Treatment Panel III criteria [19] were satisfied.
Testosterone Assay Serum testosterone was measured via radioimmunoassay using a kit from Cisbio Bioassays, Inc. (Parc Marcel Boiteux, Codolet, France). The intra-assay coefficients of variation for all of the assays were less than 9%, and the inter-assay coefficients of variation were less than 12%. For each assay, all samples from each subject were measured in the same assay run. Statistical Analysis We excluded 19 men for whom NIH-CPSI, IIEF-5, and/or PEDT data were missing. Three hundred men who had not engaged in sexual intercourse within the previous 6 months were also excluded. Additionally, 147 patients who had pyuria or had been administered related drugs, including alpha blockers, phosphodiesterase type 5 inhibitors, antipsychotics, or selective serotonin reuptake inhibitors, were excluded. Finally, the remaining 8,261 subjects were analyzed for pelvic pain and PE. First, we evaluated simple relationships between age and the PDET, IIEF, and NIH-CPSI scores using the Pearson correlation test. Second, we evaluated the relationship between the NIHCPSI pain domain score and the PEDT score using the Pearson correlation test after stratification for age and severity of ED. Third, the association between the NIH-CPSI pain domain score and the PEDT score was calculated after adjusting for age, MetS status, IIEF score, and testosterone level using a multiple linear regression test. Fourth, the ratio of PE was calculated according to the severity of pelvic pain, and the trend was analyzed using the Mantel–Haenszel Extension test. Finally, odds ratios (ORs) for PE, with relation to severity of pelvic pain, were calculated using logistic regression after adjusting for age, testosterone level, MetS status, and IIEF score. Statistical analyses were performed using the Statistical Package for Social Sciences, version 11.0 (SPSS Inc., Chicago, IL, USA). A P < 0.05 was considered to be statistically significant.
Results
Patient Characteristics The characteristics of the study population are shown in Table 1. The mean age was 50.4 ± 5.5 years. The mean testosterone level was 613 ng/dL (21.3 nmol/L), and 3,258 (36.8%) men had MetS. In total, 2,205 (24.9%) men had prostatitis-like symptoms (NIH-CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIH-CPSI pain score of ≥8). Additionally, 1,155 (13.0%) men were classified as possibly demonstrating PE, and 2,144 men were classified as demonstrating PE (24.2%). Relationships between Age and IIEF, PEDT, and NIH-CPSI Scores Table 2 shows a significant positive correlation between the PEDT score and age and a significant negative correlation between the PEDT and IIEF scores. The PEDT score was weakly but significantly correlated with the NIH-CPSI total score (correlation coefficient = 0.288; P < 0.001), the NIH-CPSI pain domain score (correlation coefficient = 0.206; P < 0.001), and the NIH-CPSI voiding domain score (correlation coefficient = 0.248; P < 0.001). Age and the IIEF score were significantly correlated with the NIH-CPSI total score, the NIH-CPSI pain domain score, and the NIH-CPSI voiding domain score. Additionally, the NIH-CPSI total score, the NIH-CPSI
Table 1
Patients’ characteristics
Variable
Mean (standard deviation)
Main Outcome Measures
Age Height (cm) Body weight (kg) PSA Testosterone (ng/dL) Triglyceride (mg/dL) HDL-cholesterol (mg/dL) Glucose, fasting (mg/dL) Waist circumference (cm) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) NIH-CPSI Total score Quality of life domain score Pain domain score Voiding domain score IIEF PEDT
50.4 (5.5) 172.4 (4.1) 74.4 (8.0) 0.94 (0.41) 613 (210) 162.8 (61.1) 44.8 (10.6) 105.3 (21.1) 88.3 (6.4) 126.9 (15.2) 82.4 (10.3)
Association of the PEDT score with NIH-CPSI score.
NIH-CPSI = National Institutes of Health Chronic Prostatitis Symptom Index; IIEF = International Index of Erectile Function-5 questionnaire; PEDT = Premature Ejaculation Diagnostic Tool
8.7 (6.5) 3.7 (2.5) 2.0 (3.1) 2.9 (2.4) 17.7 (5.3) 7.3 (4.8)
J Sex Med **;**:**–**
4 Table 2
Lee and Lee Pearson correlations of PEDT score with age, IIEF score, and NIH-CPSI scores
PEDT score Age
Age
IIEF
0.027 (0.011)
−0.409 (
Relationship between Premature Ejaculation and Chronic Prostatitis/Chronic Pelvic Pain Syndrome Jun Ho Lee, MD, PhD* and Sung Won Lee, MD, PhD† *Department of Urology, National Police Hospital, Seoul, Korea; †Department of Urology, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea DOI: 10.1111/jsm.12796
ABSTRACT
Introduction. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common etiology of premature ejaculation (PE). However, the current data are insufficient to explain this relationship and to support routine screening of men with PE. Aims. This study aims to evaluate the relationship between PE and CP/CPPS. Methods. A cross-sectional study was conducted that included 8,261 men who had participated in a health examination. The Premature Ejaculation Diagnostic Tool (PEDT), the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), and the International Index of Erectile Function-5 (IIEF) were used for assessment of symptoms. A full metabolic work-up and serum testosterone level checks were also performed. We then investigated the relationship using the Spearman correlation test, multiple linear regression, and logistic regression analyses. Main Outcome Measures. Associations of PEDT with NIH-CPSI. Results. The mean age was 50.4 ± 5.5 years. In total, 2,205 (24.9%) men had prostatitis-like symptoms (NIH-CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIHCPSI pain score of ≥8). Additionally, 2,144 men (24.2%) were classified as demonstrating PE (PEDT > 10). The PEDT score was found to have a significant positive correlation with the NIH-CPSI pain domain score (correlation coefficient = 0.206; P < 0.001). After adjusting for age, metabolic syndrome status, testosterone level, and IIEF score, there was no change in the positive correlation between the NIH-CPSI pain domain score and PEDT score (Beta = 0.175; P < 0.001). After adjusting for age, testosterone level, metabolic syndrome, and IIEF score, the odds ratio (OR) for PE significantly increased with the severity of pelvic pain (mild prostatitis-like symptoms, OR for PE: 1.269, 95% confidence interval: 1.113–1.447; moderate to severe symptoms, OR for PE: 2.134: 95% confidence interval: 1.782–2.557). Conclusions. Our data showed a significant correlation between the PEDT score and the NIH-CPSI score. We suggest routine screening for CP/CPPS in men with PE and PE in men with CP/CPPS. Lee JH and Lee SW. Relationship between premature ejaculation and chronic prostatitis/chronic pelvic pain syndrome. J Sex Med **;**:**–**. Key Words. Premature Ejaculation; Chronic Prostatitis; Erectile Dysfunction; Testosterone; Metabolic Syndrome
Introduction
P
remature ejaculation (PE) is defined as male sexual dysfunction characterized by ejaculation that always or nearly always occurs prior to or within 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome
© 2014 International Society for Sexual Medicine
reduction in latency time, often to about 3 minutes or less (acquired PE), according to the International Society for Sexual Medicine [1]. This definition also includes the inability to delay ejaculation on all or nearly all vaginal penetrations, with negative personal consequences, such as distress, bother, frustration, and/or the avoidance of J Sex Med **;**:**–**
2 sexual intimacy. PE is a common male sexual dysfunction affecting 30–40% of sexually active men in an age-dependent manner [2–4]. PE is associated with comorbid conditions, such as diabetes [5], thyroid disease [6], and lower urinary tract symptoms [7]. PE also has commonly been reported in men with chronic prostatitis/chronic pelvic pain syndrome (CP/ CPPS) [8]. However, previous studies on PE and CP/CPPS had relatively small populations [9–11]. In addition, over 50% of the studied populations were under 40 years of age [9–12], but being over 40 years of age is associated with an increased risk of CP/CPPS [13]. Moreover, there was no consideration of erectile dysfunction (ED) or testosterone levels, which would be potential confounding factors when evaluating the relationship between PE and CP/CPPS [14– 16]. Understanding the relationship between PE and CP/CPPS is clinically important because the correction of comorbid disease could cure the PE condition. Because of methodological limitations of the existing studies and insufficient evidence, we performed the present study to establish the relationship between PE and CP/CPPS. Aims
The aim of our study was to evaluate the relationship between PE and CP/CPPS. Methods
Subjects From August 2011 to November 2013, 8,727 male police officers over 40 years of age participated in a urological health checkup. The participants were applicants. Only applicants over 40 years of age were allowed to participate in medical examinations. This health screening included anthropometric measurements (blood pressure measurements, waist circumference, height, and weight), prostate specific antigen levels, testosterone levels, a complete blood cell count, basic blood chemistry analyses, a urine analysis, transrectal ultrasonography, and uroflowmetry. Medical histories were collected using a standardized structured questionnaire. The participants were also asked to complete questionnaires concerning urological health status, including the International Prostate Symptom Score, the Overactive Bladder Symptom Score, the Premature Ejaculation Diagnostic Tool (PEDT), the InterJ Sex Med **;**:**–**
Lee and Lee national Index of Erectile Function-5 (IIEF), and the National Institutes of Health-Chronic Prostatitis Symptoms Index (NIH-CPSI). Additionally, a questionnaire on androgen deficiency in aging males (from August 2011 to August 2012) and an aging male’s symptoms rating scale (from September 2012 to November 2013) were administered. Because the government of South Korea provides all medical services carried out in the National Police Hospital to police officers for free, all clinical, laboratory, functional, and radiological exams during the urological health checkup were available. All of the participants provided written informed consent, and data concerning the participants were collected prospectively. To evaluate the relationship between PE and pelvic pain, data from the NIH-CPSI, PEDT, anthropometric measurements, testosterone levels, basic blood chemistry, and metabolic syndrome (MetS) assessment, as well as other diverse clinical parameters were used in this analysis. The Institutional Review Board of the National Police Hospital approved this study (IRB number: 16222–201408-HR-002).
PE, CP/CPPS, and ED Assessment The PEDT, NIH-CPSI, and IIEF were used for the assessment of PE, CP/CPPS, and ED, respectively. Males with PEDT scores >10 and 9–10 were classified as having PE and possible PE, respectively [17]. Symptoms were classified as a “mild prostatitis-like symptom” if respondents reported perineal or ejaculatory pain and had a NIH-CPSI pain score of ≥4 and 21), mild ED (IIEF > 16 to ≤21), mild to moderate ED (IIEF > 11 to ≤16), moderate ED (IIEF > 7 to ≤11), and severe ED (IIEF ≤7). MetS Assessment Two blood pressure (mm Hg) measurements, obtained 5 minutes apart, were averaged using a mercury sphygmomanometer on the right arm. Waist circumference (cm), to the nearest 0.1 cm, was measured midway between the lowest rib and the iliac. Body weight (kg) and body height (cm) were also recorded. Serum was collected in the morning (between 7:00 and 9:00 am) after an overnight fast. The biochemical analyses included the fasting serum glucose level, the triglyceride level, and the high-density lipoprotein cholesterol level. A diagnosis of MetS was made if three
3
Premature Ejaculation and Chronic Prostatitis or more of the National Cholesterol Education Program-Adult Treatment Panel III criteria [19] were satisfied.
Testosterone Assay Serum testosterone was measured via radioimmunoassay using a kit from Cisbio Bioassays, Inc. (Parc Marcel Boiteux, Codolet, France). The intra-assay coefficients of variation for all of the assays were less than 9%, and the inter-assay coefficients of variation were less than 12%. For each assay, all samples from each subject were measured in the same assay run. Statistical Analysis We excluded 19 men for whom NIH-CPSI, IIEF-5, and/or PEDT data were missing. Three hundred men who had not engaged in sexual intercourse within the previous 6 months were also excluded. Additionally, 147 patients who had pyuria or had been administered related drugs, including alpha blockers, phosphodiesterase type 5 inhibitors, antipsychotics, or selective serotonin reuptake inhibitors, were excluded. Finally, the remaining 8,261 subjects were analyzed for pelvic pain and PE. First, we evaluated simple relationships between age and the PDET, IIEF, and NIH-CPSI scores using the Pearson correlation test. Second, we evaluated the relationship between the NIHCPSI pain domain score and the PEDT score using the Pearson correlation test after stratification for age and severity of ED. Third, the association between the NIH-CPSI pain domain score and the PEDT score was calculated after adjusting for age, MetS status, IIEF score, and testosterone level using a multiple linear regression test. Fourth, the ratio of PE was calculated according to the severity of pelvic pain, and the trend was analyzed using the Mantel–Haenszel Extension test. Finally, odds ratios (ORs) for PE, with relation to severity of pelvic pain, were calculated using logistic regression after adjusting for age, testosterone level, MetS status, and IIEF score. Statistical analyses were performed using the Statistical Package for Social Sciences, version 11.0 (SPSS Inc., Chicago, IL, USA). A P < 0.05 was considered to be statistically significant.
Results
Patient Characteristics The characteristics of the study population are shown in Table 1. The mean age was 50.4 ± 5.5 years. The mean testosterone level was 613 ng/dL (21.3 nmol/L), and 3,258 (36.8%) men had MetS. In total, 2,205 (24.9%) men had prostatitis-like symptoms (NIH-CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIH-CPSI pain score of ≥8). Additionally, 1,155 (13.0%) men were classified as possibly demonstrating PE, and 2,144 men were classified as demonstrating PE (24.2%). Relationships between Age and IIEF, PEDT, and NIH-CPSI Scores Table 2 shows a significant positive correlation between the PEDT score and age and a significant negative correlation between the PEDT and IIEF scores. The PEDT score was weakly but significantly correlated with the NIH-CPSI total score (correlation coefficient = 0.288; P < 0.001), the NIH-CPSI pain domain score (correlation coefficient = 0.206; P < 0.001), and the NIH-CPSI voiding domain score (correlation coefficient = 0.248; P < 0.001). Age and the IIEF score were significantly correlated with the NIH-CPSI total score, the NIH-CPSI pain domain score, and the NIH-CPSI voiding domain score. Additionally, the NIH-CPSI total score, the NIH-CPSI
Table 1
Patients’ characteristics
Variable
Mean (standard deviation)
Main Outcome Measures
Age Height (cm) Body weight (kg) PSA Testosterone (ng/dL) Triglyceride (mg/dL) HDL-cholesterol (mg/dL) Glucose, fasting (mg/dL) Waist circumference (cm) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) NIH-CPSI Total score Quality of life domain score Pain domain score Voiding domain score IIEF PEDT
50.4 (5.5) 172.4 (4.1) 74.4 (8.0) 0.94 (0.41) 613 (210) 162.8 (61.1) 44.8 (10.6) 105.3 (21.1) 88.3 (6.4) 126.9 (15.2) 82.4 (10.3)
Association of the PEDT score with NIH-CPSI score.
NIH-CPSI = National Institutes of Health Chronic Prostatitis Symptom Index; IIEF = International Index of Erectile Function-5 questionnaire; PEDT = Premature Ejaculation Diagnostic Tool
8.7 (6.5) 3.7 (2.5) 2.0 (3.1) 2.9 (2.4) 17.7 (5.3) 7.3 (4.8)
J Sex Med **;**:**–**
4 Table 2
Lee and Lee Pearson correlations of PEDT score with age, IIEF score, and NIH-CPSI scores
PEDT score Age
Age
IIEF
0.027 (0.011)
−0.409 (
