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Keywords:

  • male sexual disorders;
  • premature ejaculation;
  • spondylitis

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

We aimed to evaluate the premature ejaculation (PE) among ankylosing spondylitis (AS) patients. Fifty male patients with AS who were diagnosed according to the modified New York criteria and fifty normal healthy controls (NHC) were included in this study. The details of patient age, disease duration, morning stiffness, laboratory activity, disease severity and medication use were obtained by reviewing the medical record. The Bath AS Functional Index (BASFI) was used to measure the functional status of the patients with AS. By taking a careful medical and sexual history, patients were classified as lifelong, natural variable, acquired PE or premature ejaculatory dysfunction. In addition to medical and sexual history, self-estimated intravaginal ejaculatory latency times (IELT) of patients were used in the classification of patients. To our knowledge, this is the first study of frequency of PE in men with AS. The prevalence rates of PE in patient and healthy controls were 32 and 30%, respectively (p = 0.331). The prevalence of PE was not significantly different between AS patients and NHC groups as regards the four PE syndromes. Average estimated IELT was 10 009 ± 51.9 sec in the PE group and 145.26 ± 43.01 sec in the non-PE group (p = 0.000). Patients with lifelong PE had a significantly lower mean estimated IELT than the other group (p = 0.000). Patients with premature-like ejaculatory dysfunction had the highest estimated IELT (p = 0.000). There was a significant association between self-estimated IELT and distribution of the patients according to the four PE syndromes (p = 0.01). Both AS patients and NHC groups have the same results. The present study demonstrates that PE in men with AS is as prevalent as it is in the general population. Although this study is restricted in terms of the number of patients, it is the first study ever conducted. For more meaningful results, multi centred studies with more patients are required.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Ankylosing spondylitis (AS) is a chronic inflammatory disease of axial skeleton with an unknown aetiology. It usually starts with sacroiliac involvement and affects the whole axial skeleton in later stages (Inman, 1997; Van, 2005). Sacroiliitis is the hallmark of the disease and low back pain is usually the first symptom (Inman, 1997). Axial ankylosis may be observed as the disease progresses. Due to limitation of spinal mobility, especially in progressive and severe cases, postural deformities such as decrease in lumbar lordosis and thoracic kyphosis can be seen (Van, 2005). All these pathologies could lead to serious functional impairments resulting in deprivation of daily living activities which eventually result in an impaired quality of life (Ward, 1998). Premature ejaculation (PE) is believed to be the most common male sexual complaint, and it affects approximately 20–30% of the male population across all age groups (Laumann et al., 2005). Conflicting prevalence rates are likely because of the absence of a universally accepted definition of PE. There are two widely used definitions of PE: the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) (World Health Organisation, 1994; American Psychiatric Association, 2000; Serefoglu et al., 2010). The Second International Consultation defines PE according to three essential criteria: brief ejaculatory latency, loss of control, and psychological distress in the patient and/or partner (Lue et al., 2004). The assessment of PE in clinical trials has relied heavily upon intravaginal ejaculatory latency time (IELT), defined as the time between vaginal intromission and intravaginal ejaculation (Waldinger, 1998). Waldinger and Schweitzer recently emphasized the relevance of distinguishing between PE as a ‘compliant’ vs. PE as a ‘syndrome,’ and published a new proposal for pending DSM-V and ICD-11 definitions of PE (Waldinger, 2006; Waldinger, 2006). In addition to distinguishing between ‘lifelong’ and ‘acquired’ PE, Waldinger and Schweitzer proposed the existence of two more PE syndromes: ‘natural variable PE’ and ‘premature-like ejaculatory dysfunction PE’ (Godpodinoff, 1989; Waldinger, 2006).

In this study, we aimed to evaluate the PE among AS patients and compare the rate of PE with normal healthy controls (NHC). We believe that if larger evidence-based studies are conducted, natural variable PE and premature-like ejaculatory dysfunction will be the most common PE types both in the general population and in AS patients.

Materials and methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Fifty male patients with AS who were diagnosed according to the modified New York criteria and fifty NHC were included in this study. NHC were randomly chosen among persons accompanying the patients admitted to urology clinic. Informed consents of the patients were obtained at the beginning of the study.

In both groups, the participants were married, younger than 65 years and had active sexual life during the past 4 weeks. Participants were questioned about their medical history including systemic diseases, chronic use of drugs or cigarette smoking. Patients with specific clinical conditions that obviously interfere with erectile function were excluded from the study. The exclusion criteria were as follows: severe genital anatomic deformities that disturb erection; psychological and social problems that make it impossible for the patient to participate in the study; history of major pelvic surgery; patients under medications such as phosphodiesterase type 5 inhibitors, statins, antidepressants and immunosuppressives; patients with the diagnosis of hypertension, diabetes mellitus, congestive heart failure, bronchial asthma, coronary heart disease, malignancy, cirrhosis of liver and chronic renal failure.

The details of patient age, disease duration, morning stiffness, laboratory activity, disease severity and medication use were obtained by reviewing the medical record. The Bath AS Functional Index (BASFI) was used to measure the functional status of the patients with AS.

Serum C-reactive protein (CRP), as measured by rate nephelometry (normal less than 6 mg/dl), was used to assess laboratory activity with the Westergren erythrocyte sedimentation rate (ESR).

A careful medical and sexual history was taken, with special attention to the duration of the ejaculation time; the onset, course, and circumstances of the complaint such as distress and interpersonal difficulty related to the ejaculatory dysfunction; degree of sexual stimulus; impact on sexual activity and quality of life; drug use or abuse; and existence of another sexual dysfunction. Following this detailed history, the patients were classified as ‘lifelong’ and ‘acquired’, ‘natural variable PE’, and ‘premature-like ejaculatory dysfunction,’ as defined by Waldinger (Waldinger, 2008) (Table 1). Self-estimated IELT of patients were also recorded. A physical examination was performed to identify any underlying medical conditions associated with PE or other sexual dysfunctions.

Table 1.   Demographic data on 50 patients with AS and 50 controls, and characteristics of patients with ankylosing spondylitis (AS)
VariableASControlsp-value
  1. BASFI, Bath AS Functional Index; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate.

Mean age38.5 ± 10.338.7 ± 7.070.892
Disease duration (years)10.1 ± 4.4
Duration of morning stiffness (mins)210 ± 110
ESR (mm/h)50 ± 1920 ± 18p < 0.05
CRP (mg/dL)20 ± 148 ± 5p < 0.05
Haemoglobin (g/dL)12.5 ± 112.7 ± 060.74
BASFI score (range 0–100)52.8 ± 24.7

Data were analysed on a personal computer using Statistical Package for Social Sciences software (spss; Chicago, IL, USA). The Chi-square and Mann–Whitney U-tests were used for intergroup comparisons with 2-tailed p < 0.05 considered statistically significant.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Mean ages of patient and control group were 38.5 ± 10.3 (21–64) and 38.7 ± 7.07 (24–56), respectively (p = 0.892). Table 1 lists the clinical and demographic characteristics of patients and healthy controls. Patients were receiving non-steroidal anti-inflammatory drugs (20%) and sulfasalazine (20%) or both (20%), methotrexate (40%). None of the patients was receiving tumour necrosis factor alpha blocker.

To our knowledge, this is the first study of frequency of PE in men with AS. The prevalence rates of PE in patient and healthy controls were 32 and 30%, respectively (p = 0.331). The mean self-estimated IELT were 120 ± 49.5 sec (20–1200 sec) in the AS, and 133.72 ± 51.3 sec (24–890 sec) in the NHC (p = 0.627).

Data of NHC and AS patients are shown in Table 2, according to the four PE syndromes. The prevalence of PE was not significantly different between AS patients and NHC groups, as regards the four PE syndromes (p = 0.709).

Table 2.   Ankylosing spondylitis (AS) patients and normal healthy controls (NHC) group distribution according to the four premature ejaculation (PE) syndromes
PE syndromesASNHC
N (%)N (%)
Lifelong PE5 (10)5 (10)
Acquired PE2 (4)2 (4)
Natural variable PE4 (8)5 (10)
Premature-like ejaculatory disfunction5 (10)3 (6)
Non-PE34 (68)35 (70)

Average estimated IELT were 100.09 ± 51.9 sec in the PE group, 145.26 ± 43.01 sec in the non-PE group (p = 0.000). Patients with lifelong PE had a significantly lower mean estimated IELT than the other group (p = 0.000). Patients with premature-like ejaculatory dysfunction had the highest estimated IELT (p = 0.000). There was a significant association between self-estimated IELT and distribution of the patients according to the four PE syndromes (p = 0.01). Both AS patients and NHC groups obtained the same results. We were not able to relate any clinical features or laboratory findings to PE.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

AS is the major subtype of a group of chronic inflammatory diseases known as spondyloarthropathies. It affects young adults with the peak age of 20 and 30 years. Men are more often affected than women, with a ratio of approximately 3 : 1. PE is suspected to be the most prevalent male sexual complaint and the prevalence of PE is considerably high also in the younger generation. Both diseases are common in the same age groups.

PE is the most common male sexual dysfunction. Although there is no commonly accepted definition of PE, it is now considered the persistent or recurrent inability to voluntarily delay ejaculation upon or shortly after penetration or with minimal sexual stimulation (Vandereycken, 1986). The population of men with PE is not homogenous. In 1943, Schapiro classified PE as either lifelong PE or acquired PE. Waldinger expanded this classification to include lifelong PE, acquired PE, natural variable PE and premature-like ejaculatory dysfunction. Lifelong PE is a syndrome characterized by a cluster of core symptoms including early ejaculation at nearly every intercourse within 1930–1960s in the most cases (80%) or at 1–2 min (20%), with every or nearly every sexual partner and from the first sexual encounter onwards. In acquired PE, early ejaculation occurs at some point in a man’s life. The man has had normal ejaculation experiences before. The onset is either sudden or gradual. The dysfunction may be a result of urological or thyroid dysfunctions. In natural variable PE, early ejaculations are inconsistent and occur irregularly. The ability to delay ejaculation may be diminished or lacking. Ejaculation time may be short or normal. Men with premature-like ejaculatory dysfunction complain of PE, but have a normal ejaculatory latency of 3–6 min. It is characterized by a preoccupation with a subjective but false perception of PE, with IELT within the normal range, but often with reduced ejaculatory control (McMahon et al., 2008).

Son H et al. found the PE prevalence to be 18,3%. Other studies have reported PE prevalence of from 11 to 33% (Son et al., 2010). In the study conducted with 500 male patients, Althof et al. have reported the PE prevalence to be 1–3% rather than 20–30% as found in the previous studies (Althof et al., 2010). Serefoglu et al. (2010) found the prevalence of the four PE syndromes among patients admitted to a urology outpatient clinic with complaints of PE to be 62.5% in lifelong PE, 16.1% in acquired PE, 14.5% in natural variable PE and 6.9% in premature-like PE. In this study, the prevalence rates of PE in AS patients and NHC were 32% and 30%, respectively. We found that the prevalence of PE was no different in AS patients when compared with healthy controls. Moreover, the rate of PE among AS patients and control group is close to the national findings. Natural variable PE and premature-like ejaculatory dysfunction account for the seemingly very high prevalence previously reported in general population surveys of 20–30%, whereas the prevalence of lifelong PE and acquired PE is estimated at 2–5% (Waldinger, 2008). In our study, the prevalence rate of patients as regards the four PE syndromes is lower than that of patients in other studies due to limited number of patients. Yet, the total rate of natural variables and premature-like PE in both AS and control groups is higher than the total of lifelong and acquired PE ratios (p = 0,709). To reach a statistical significance, several hundred of patients should be evaluated in a multicentre trial.

Natural variable PE and premature-like ejaculatory dysfunction should not be regarded as a symptom or a manifestation of a real biological pathology, but rather as a normal variation on sexual performance (Waldinger, 2006). Waldinger has posited that men with natural variable PE and premature-like ejaculatory dysfunction are captured as having PE in epidemiological studies because of the broad definition used, but would not likely seek medical treatment because their PE is irregular and IELT is usually within normal range (Waldinger, 2008).

Waldinger and Schwietzer propose that four PE syndromes can be classified only by taking the sexual history without any need for a questionnaire or IELT stopwatch associated IELT (Waldinger & Schweitzer, 2006; Waldinger, 2008). Furthermore, current guidelines underline that self-estimated IELT is sufficient in daily clinical practice, which was found to be interchangeable with stopwatch-measured IELT in correctly assigning PE status with 80% sensitivity and specificity (Rosen et al., 2007, Wespes et al., 2009). A recent industry-funded community-based age-ranging study of an unselected normal population of 500 heterosexual couples from five countries involving stop-watch timing of the IELT during sexual intercourse provided previously lacking normative IELT data. This study showed that the distribution of the IELT was positively skewed, with a median IELT of 324 sec. This study demonstrated that Turkish men had the lowest IELT (222 sec). The median IELT decreased with age and among other countries (Serefoglu et al., 2009). However, according to the National Health and Social Life Survey study in the United States, where the DSM-4 definition of PE had been used, the prevalence of PE was not affected by age (Laumann et al., 1999).

As a result of an international study in 2011, IELT of ≤2 min is ≥75% of the intercourse episodes during a 4-week baseline period. However, this definition has not been used in our study due to its publication date, which is later than ours. We had already designed our study according to the previous definition (McMahon et al. 2011).

On the basis of collective data which reported that 90% of men complaining of lifelong PE ejaculate within 60 sec, and only 10% ejaculate within 60–120 sec, Waldinger et al. proposed that men with an IELT of <1 min are definitely at risk of lifelong PE (Waldinger et al., 2005). In our study, we found that IELT is significantly lower in PE patients than in non-PE patients. The IELT score in patients with PE was found to be 100.9 sec, lower than 222 sec. Like in other studies, we found the lowest IELT score in lifelong PE. Similarly, the longest IELT score was found in premature-like ejaculatory dysfunction. The results of IELT scores were the same in both AS and NHC.

AS is a chronic inflammatory disorder of the axial skeleton. In recent years, several authors reported an increased prevalence of sexual dysfunction among AS patients. Bal et al. reported that the prevalence rates of erectile dysfunction (ED) in AS patients and NHC were 35.1% and 26.9%, respectively (p = 0.335). Furthermore, Pırıldar et al. (2004) found the prevalence of ED in AS patients to be 12%. To our knowledge, this is the first study of the frequency of PE in men with AS.

Conclusion

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

The present study demonstrates that PE in men with AS is as prevalent as it is in the general population. We believe that if larger evidence-based studies are conducted, natural variable PE and premature-like ejaculatory dysfunction will be the most common PE types both in the general population and in AS patients. Although this study is restricted in terms of the number of patients, it is the first study ever conducted. For more meaningful results, multi-centred studies with more patients are required.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References
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