International Journal of Psychiatry in Clinical Practice, 2010; 14: 3–7

ORIGINAL ARTICLE

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Enuresis in childhood and premature ejaculation in adult life: An enigmatic similarity

HALIL CIFTCI1, ABDURRAHMAN ALTINDAG2, MURAT SAVAS1, ERCAN YENI1 & AYHAN VERIT1 1Harran

Universitesi, Sanliurfa, Turkey and 2Gaziantep Universitesi, Gaziantep, Turkey

Abstract Objective. To investigate a possible association between enuresis in childhood and premature ejaculation in adult life. Methods. The authors conducted a retrospective study, with two cohorts, consisting of 60 men with premature ejaculation, and 60 comparison subjects who were asked to assess their enuresis in childhood, a history of psychological problems. Results. While 20 (33.3%) subjects with premature ejaculation reported a history of enuresis in childhood, only seven (11.6%) subjects without premature ejaculation had this problem in childhood. Enuresis in childhood was significantly more common in men with a premature ejaculation than controls. While 35 (58.3%) patients with premature ejaculation reported a history of psychological problems, only four (6.6%) controls reported this kind of problems. There was a significant difference between these groups regarding psychological problems. Conclusion. The results of this study suggest that the history of enuresis in childhood seems to increase the risk of having premature ejaculation and psychological problems in adult life. These results lead to a premise that these disorders may share a common etiology and/or neurological pathophysiology. Key Words: Enuresis, premature ejaculation, erectile dysfunction, psychological problems

Introduction According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV) [1], nocturnal enuresis (NE) is defined as an involuntary voiding of urine during sleep, with a severity of “at least twice a week”, in children aged  5 years in the absence of congenital or acquired defects of the central nervous system (CNS). It is a common problem, which may lead to important psychosocial sequel. This disorder can affect 5–18 % of children in different age groups [2–4]. Bladder overactivity and/or a lack of nocturnal arginine vasopressin release, leading to polyuria; and an inability to wake from sleep to bladder sensations [5], genetic, ethnic and physical factors, family antecedent, are the proposed causative factors for NE [6,7]. Currently the nature of the disorder has not been clarified.

Premature ejaculation (PE) the most common male sexual disorder [8], also referred to as early ejaculation or rapid ejaculation, affects 30–40% of sexually active men [8,9], perhaps as many as 75% of men at some periods in their lives [10]. Recently, a new proposal for the pending DSM-V and ICD-11 definition of PE has been put forward [11,12]. According to this proposal, PE should be classified according to a “syndromal” approach, incorporating well-controlled clinical and epidemiologic stopwatch studies [11]. In the new proposal, the four PE syndromes are defined lifelong premature ejaculation, acquired premature ejaculation, natural variable premature ejaculation, and premature-like ejaculatory dysfunction. In lifelong premature ejaculation, ejaculation occurs too early at nearly every intercourse, with every woman, from about the first sexual

Correspondence: Abdurrahman Altindag, Gaziantep Universitesi, Gaziantep, Turkey. E-mail: [email protected] (Received 12 September 2008; accepted 13 July 2009) ISSN 1365-1501 print/ISSN 1471-1788 online © 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: 10.3109/13651500903198012

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encounter onward, in the majority of cases, in other words, lifelong PE is a chronic ejaculatory dysfunction. Acquired premature ejaculation differs in relation to the underlying somatic or psychological problems such as anxiety disorders and multiple sclerosis. Early ejaculations in men with natural variable PE occur accidentally and are situation related. Men with premature-like ejaculatory dysfunction experience or complain of PE while the ejaculation time is in the normal range. This type of PE should not be regarded as a symptom or manifestation of true medical pathology. Psychological and/or relationship problems may underlie the complaints [13]. PE can impact on a man’s life in many aspects, such as reducing self-esteem, affecting relationship, causing anxiety, embarrassment and depressed feelings. Moreover, PE places a significant burden on the patient’s partner, evidenced as a higher prevalence of female sexual dysfunction associated with PE [14]. Premature ejaculation syndromes require different forms of treatment. Lifelong PE should be treated with medication, and acquired PE needs medication and/or psychotherapy. Normal variable PE requires psychoeducation and premature like ejaculatory dysfunction requires either psychotherapy, psychoeducation or counselling [13]. Recently there have been reports about the treatment of enuresis (pediatric cases) with SSRIs [15]. It should also be considered that history of enuresis were common in PE (40 versus 10% in the general population) [16]. In this study we investigate whether there is any association between enuresis in childhood and PE in adult life, and speculate about possible common etiologies. Methods The study consisted of 60 men with PE who applied to the urology outpatient clinics in Sanliurfa, Turkey in the period between June 2007 and February 2008. The controls were 60 healthy and sexually active men without PE. The study has been approved by the institutional review board and has therefore been performed in accordance with the ethical standards laid down in an appropriate version of the 1964 Declaration of Helsinki. The questionnaire for participants related to NE in childhood, PE in adult life, psychiatric and medical history. The subjects have been asked about psychological problems such as any stress, irritability, anxiety, embarrassment, depressed feeling, and previous psychiatric consultations for any problem and were accepted as a psychiatric problematic group. In this study NE was defined as involuntary voiding of urine during sleep, with a severity of “at least twice a week”, in children aged  5 years, in the absence of congenital or acquired defects

of the CNS [1]. Results were depended on the memory of the patient. Patients in whom a history of enuresis was not confirmed because of vague or unreliable answers were excluded from the study. PE was defined as intravaginal ejaculatory latency time less than one minute and the patients had been suffering from PE at least 6 months [17], thus corresponding to the PE syndromes of lifelong and acquired PE. We also investigated marriage period, education and family income in PE and control groups. Statistical analysis Student’s t-test, chi-square test and correlation analyses were performed using SPSS for Windows Release 11.5 (SPSS Inc.) and P  0.05 were considered statistically significant. The results are given as mean  standard deviation of mean. Results Mean ages of the study group and control group were 35.1  7.9 years (range 24–53) and 39.6  4.1 years (range 22–48), respectively. Demographic characteristics of study and control groups are given in Table I. Demographic characteristics of study and control groups. There were no significant differences between patients and controls with respect to mean age, the duration of marriage, education status and family income. NE was documented in 20 (33.3%) patients with PE and seven (11.6%) controls, there was a significant difference between these groups (P  0.001). NE was resolved at 11.1  2 (8–16) years for subjects with PE and at 11.8  2 (9–15) for controls. There was no significant difference between PE and control groups (P  0.05). While 35 (58.3%) patients with PE reported a history of psychiatric disorders, only four (6.6%) controls reported this kind of problems. There was a significant difference between the two groups (P  0.001). Results are summarized in Table II. Clinical characteristics of study and control groups.

Discussion The diagnosis of PE is based upon brief medical and sexual history of a shortened latency time, poor control over ejaculation, low satisfaction with intercourse, and distress regarding the condition [18]. The pathophysiology of both lifelong and acquired PE appears to be both medical and psychogenic. While psychogenic factors appear to be contributory to PE, pharmacological intervention of PE can modify intravaginal ejaculatory latency time, which suggests

Enuresis and premature ejaculation

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Table I. Demographic characteristics of study and control groups.

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Patients (PE  ) (n  60) Mean age Marriage period (years)  10 10–20 Education Uneducated Primary school High school Family income (per month) Low (  $200) Middle ($200–500) High (  $500)

Controls (PE–) (n  60)

35.1  7.9 (range 24–53)

39.6  4.1 (range 22–48)

36 (60%) 24 (40%)

38 (70.7%) 22 (29.3%)

30 (50%) 17 (32.5%) 13 (17.5%)

22 (35.3%) 24 (48%) 14 (16.7%)

22 (37.5%) 27 (45%) 11 (17.5%)

22 (36.7%) 26 (43.3%) 12 (20%)

P value P  0.05 P  0.05

P  0.05

P  0.05

PE, premature ejaculation.

that there is a biological variable, and it is likely biologically dependent upon neurotransmitters and hormones [19]. However, recent studies and neurophysiological investigations suggest that this disorder may have an organic cause [20]. According to Waldinger et al., the distinction of the four PE syndromes illustrates that there is not one particular pathophysiology of PE, but that there are different pathophysiologies dependent on the type of PE. For example, the pathophysiologies of lifelong and acquired PE are more closely related to disturbances of peripheral neuronal functioning, whereas the pathophysiologies of normal variable PE and premature-like ejaculatory dysfunction are speculated to be related to cognitive and unconscious mental processes [13]. Different treatment approaches have been used for the treatment of PE including local anesthetic sprays, vascular surgery, propranolol, and serotonin reuptake inhibitors. SSRIs are reported to be effective for treating premature ejaculation [21,22]. Treatments of PE and enuresis have similar features that suggest the common pathophysiological characteristics of these disorders. Evidence about the pathophysiology of enuresis and its association with PE is that some CNS abnormalities such as changes in the pontine reticular formation may cause a lack of awareness of bladder distension. Thus this pathophysiology may contribute to the dysfunction of all pelvic floor sphincters due to a delay in the maturation of sensory-motor neurons [23,24]. To our knowledge the relationship between childhood NE and PE has been investigated in one study by

Barghi [16] and he reported that the weak control of target organs by the cerebral cortex and the abnormally low threshold of sensory neurons in the intestine and genitalia may be responsible for the severe reaction of the CNS in patients with PE, irritable bowel syndrome, or enuresis. It thus seems reasonable that patients with those characteristics would be susceptible to all three disorders, and frequency of irritable bowel syndrome, enuresis, and psychological problems in subjects with PE was significant in his study [17]. In line with the study of Barghi, we found PE in adult life being associated with enuresis in childhood [16]. In our study, NE was documented in 20 (33.3%) of 60 patients with PE. This proportion is approximately twice as high as that reported in the general population. Another significant point is that approximately 60% of patients with PE reported psychological problems. Barghi [16] found 59.5% of patients with PE had psychological problems. History of enuresis in childhood seems to increase the risk of having PE and psychological problems in adult life. Thus we think that there may be a relation with those disorders as a common cause and neurological pathophysiology. Additionally, there was no significant difference in values of the marriage period, family income and education status between having PE and control groups. However, we established that the presence of enuresis in childhood is increasing the risk of having PE and psychological problems. Further experimental studies are needed to clarify this issue, because the limitation of this study was that results depended just on the memory

Table II. Clinical characteristics of study and control groups. Patients (PE  ) (n  60) Nocturnal enuresis Psychological problems PE, premature ejaculation.

20 (33.3%) 35 (58.3%)

Controls (PE) (n  60) 7 (11.6%) 4 (6.6%)

P value P  0.001 P  0.001

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H. Ciftci et al.

of the participants. Rosen and Althof [25] reported an association between PE and adverse psychosocial and quality of life consequences, including detrimental effects on the partner relationship. Premature ejaculation is associated with low self-esteem, anxiety, depression and feelings of shame and inferiority [26]. In the present study, we found PE is associated with a history of psychological problems. Another limitation of this study is that we could not define the beginning of the psychological problems of the patients with PE whether before or after PE. When approaching enuresis (or encopresis) as a clinical subject or as a clinical or basic science research subject, or even as a topic of discussion for laypeople, it is important to recognize and even to state in some sense the paucity of our understanding of the complex nature of the involved organs. This is true as well of premature ejaculation. These storage and voiding organs and sexual organs and the neurovascular supplies to them (with input and output) have multiple efferents and afferents projecting to and from multiple areas of the peripheral and central nervous systems. These systems utilize sensory, filling/capacity (bladder and colorectum), and motor interactions that must be exquisitely timed and coordinated for proper and appropriate function. Additionally, there are voluntary and autonomic motivations involved. The coordination of all of these multiple functions and interactions in any of these systems would seem an overwhelming task. This complexity, or these complexities, would likely be very difficult to tease out in a standard clinical association-style research study, or with such research data. Therefore, causality may well have to be explored in well-designed future studies. In conclusion, we should be aware of men with a history of enuresis in childhood have a higher risk of PE and psychological problems in adult life. We think that these disorders may share a common etiology and/or neurological pathophysiology and it will be better to investigate these enigmatic pathologies together.

Key points • Enuresis in childhood was significantly more common in men with a premature ejaculation than healthy controls • Enuresis nocturna and premature ejaculation may share a common etiology and/or neurological pathophysiology

Acknowledgement None.

Statement of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.

References [1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. DSM IV. 4th ed. Washington, DC: American Psychiatry Press; 1995. [2] Lee SD, Sohn DW, Lee JZ, Park NC, Chung MK. An epidemiological study of enuresis in Korean children. Br J Urol Int 2000;85:869–73. [3] Butler RJ, Golding J, Northstone K; ALSPAC Study Team. Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs. Br J Urol Int 2005;96:404–10. [4] Bourquia A, Chihabeddine K. Enuresis: epidemiological study in Moroccan children. Saudi J Kidney Dis Transpl 2002;13:151–4. [5] Butler RJ, Holland P. The three systems: a conceptual way of understanding nocturnal enuresis. Scan J Urol Nephrol 2000;34:270–7. [6] Bader G, Neveus T, Kruse S, Sillén U. Sleep of primary enuretic children and controls. Sleep 2002;25:579–83. [7] Akis N, Irgil E, Aytekin N. Enuresis and the effective factors a case–control study. Scand J Urol Nephrol 2002;36: 199–203. [8] Montorsi F. Prevalence of premature ejaculation: a global and regional perspective. J Sex Med 2005;2(Suppl 2): 96–102. [9] Screponi E, Carosa E, Di Stasi SM, Pepe M, Carruba G, Jannini EA. Prevalence of chronic prostatitis in men with premature ejaculation. Urology 2001;58:198–202. [10] McMahon CG. Treatment of premature ejaculation with sertraline hydrochloride: a single-blind placebo controlled crossover study. J Urol 1998;159:1935–8. [11] Waldinger MD, Schweitzer DH. Changing paradigms from an historical DSM-III and DSM-IV view towards an evidence based definition of premature ejaculation. Part II: proposals for DSM-V and ICD-11. J Sex Med 2006;3:693–705. [12] Waldinger MD. The need for a revival of psychoanalytic investigations into premature ejaculation. J Men’s Health Gender 2006;3:390–6. [13] Waldinger MD. Premature ejaculation: State of the art. Urol Clin N Am 2007;34:591–9. [14] Sotomayor M. The burden of premature ejaculation: the patient’s perspective. J Sex Med 2005;2(Suppl 2):110–14. [15] Herguner S, Kilincaslan A, Gorker I, Tuzun U. Serotoninselective reuptake inhibitor-induced enuresis in three pediatric cases. J Child Adolesc Psychopharmacol 2007;17:367–9. [16] Barghi M. The relation of enuresis and irritable bowel syndrome with premature ejaculation: a preliminary report. Urology J 2005;2:201–5. [17] Waldinger MD, Zwinderman AH, Olivier B, Schweitzer DH. Proposal for a definition of lifelong premature ejaculation based on epidemiological stopwatch data. J Sex Med 2005; 2:498–507. [18] Shabsigh R. Diagnosing premature ejaculation: a review. J Sex Med 2006;3(Suppl 4):318–23. [19] Donatucci CF. Etiology of ejaculation and pathophysiology of premature ejaculation. J Sex Med 2006;3(Suppl 4):303–8. [20] Ozcan C, Ozbek E, Soylu A, Yilmaz U, Guzelipek M, Balbay MD. Auditory event-related potentials in patients with premature ejaculation. Urology 2001;58:1025–9.

Enuresis and premature ejaculation

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[21] Kara H, Aydın S, Agargun MY, Agargün MY, Odabas¸ O, Yilmaz Y. The efficacy of fluoxetine in the treatment of premature ejaculation: a double-blind placebo controlled study. J Urol 1996;156:1631–2. [22] Lee HS, Song DH, Kim CH, Choi HK. An open clinical trial of fluoxetine in the treatment of premature ejaculation. J Clin Psychopharmacol 1996;16:379–82. [23] Tomasi PA, Siracusano S, Monni AM, Mela G, Delitala G. Decreased nocturnal urinary antidiuretic hormone excretion in enuresis is increased by imipramine. Br J Urol Int 2001; 88:932–7.

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[24] Hallioglu O, Ozge A, Comelekoglu U, Topaloglu AK, Kanik A, Duzovali O, et al. Evaluation of cerebral maturation by visual and quantitative analysis of resting electroencephalography in children with primary nocturnal enuresis. J Child Neurol 2001;16:714–18. [25] Rosen RC, Althof S. Impact of premature ejaculation: the psychological, quality of life, and sexual relationship consequences. J Sex Med 2008;5:1296–307. [26] Sotomayor M. The burden of premature ejaculation: the patient’s perspective. J Sex Med 2005;2(Suppl 2): 110–14.

Enuresis in childhood and premature ejaculation in adult life: An enigmatic similarity.

Abstract Objective. To investigate a possible association between enuresis in childhood and premature ejaculation in adult life. Methods. The authors ...
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