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Keywords:

  • PE;
  • ED;
  • Type 2 Diabetes;
  • Hypertension;
  • HADS;
  • IIEF-5

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

Introduction.  Sexual problems are common in the general population. Studies have shown that most of these sexual problems are related to their social lives, medical illnesses, and psychological status. Among the sexual problems in men, premature ejaculation (PE) is one of the most frequent, yet it is the least well-understood of the sexual dysfunctions of men.

Aim.  To determine the prevalence of sexual problem particularly PE and erectile dysfunction (ED) among people living in urban areas and to investigate the characteristics associated with these sexual problems in a Malaysian population.

Main Outcome Measure.  The PE which is defined as an intravaginal ejaculation latency time less than 2 minutes was assessed in the ED and non-ED group.

Methods.  The Hospital Anxiety and Depression scale is used as a measure of the psychological status [30]. The ED status was assessed using the International Index of Erectile Function questionnaire.

Results.  The prevalence of self-reported sexual problems for ED and PE were 41.6% and 22.3%, respectively. In those subjects with ED, 33.5% reported to have PE. Of the total of 430 subjects, anxiety was present in 8.1%, while depression was 5.3%. The prevalence of PE accounted for 25% anxiety and 14.6% for depression respectively in the population. EDs were associated with diabetes and hypertension (OR [95% CI]: 5.33 [2.33, 10.16], 3.40 [1.76, 6.57], P < 0.05), respectively, while factors associated with PE were anxiety and depression (OR [95% CI]: 1.29 [0.68, 2.45], 1.39 [0.69, 2.78]), respectively.

Conclusion.  Prevalence of ED is associated with medical symptoms such as diabetes and hypertension and a rise in the prevalence of age while psychological distress such as anxiety and depression also contribute to a higher PE rate. Quek KF, Sallam AA, Ng CH, and Chua CB. Prevalence of sexual problems and its association with social, psychological and physical factors among men in a Malaysian Population: A cross-sectional study. J Sex Med 2008;5:70–76.


Introduction

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

Sexual problem is a common medical disorder among the general population [1–15]. Studies have shown that most of these sexual problems are related to their social lives, medical illnesses, and psychological status. The areas of social life which relates to sexual problem are marriage status and its relationships [16], while medical illnesses are due to diabetes [17] and hypertension [18]. Anxiety [19,20] and depression [21] are among the psychological problems implicated to sexual problem, although the cause and effect natures of this link remains unknown.

Among the sexual problems in men, premature ejaculation (PE) is one of the most frequently encountered sexual dysfunctions [22] with possible familial genetic vulnerability [23]. Unlike erectile dysfunction (ED), in which vaginal penetration is impossible without an erection [24], men with PE are in fact functional and able to have an orgasm. PE is defined as a persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration, and before the person wishes it, due to little or no voluntary control, which causes distress to the sufferer and/or partner [25].

Premature ejaculation is a prevalent condition that can cause distress for a man, his partner, and their relationship. This may also be the early symptom of ED because of the rising anxiety and frustration due to soft erection [26]. In the clinical setting, PE is defined as ejaculation after a fixed time (range from 0.5 minute to 7 minutes, depending on clinical setting) after penetration or is referred to as intravaginal ejaculation latency time (IELT) [27,28,29]. It is postulated that PE may be part of the normal biological variation of the IELT in men, but its paradoxical or fixed course throughout life (chronic PE) is considered as being pathological [26].

The lack of information as to what constitutes sexual problem has made it impossible to establish the etiology, diagnostic methods, and management of this condition. Thus, the aim of the present study is to determine the prevalence of sexual problem particularly PE and ED among people living in urban areas and to investigate the characteristics associated with these sexual problems in a Malaysian population.

Materials and Methods

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

A total of 430 subjects were recruited in the study, after giving them a detailed information sheet on the study procedures. Subjects who consented to take part in the study were given and asked to complete a multiple-choice questionnaire. The questionnaire consisted of five parts, namely (i) demographic data, e.g., age, marital status, education, occupation, etc.; (ii) medical history; (iii) sexual function status that enquire about sexual behavior, sexual difficulties, and satisfaction. The PE is defined as an IELT ≤2 minutes; and (iv) operationalization of PE using the length of time between penetration and ejaculation.

The Hospital Anxiety and Depression Scale (HADS) is used as a measure of psychological status [30]. The scores for anxiety and depression were calculated out of a maximum score of 21 for each of the scales. A score of 11 or more on either of the scales was considered indicative of the presence of anxiety or depression [30]. The ED status was assessed using the International Index of Erectile Function (IIEF-5) questionnaire, of which a threshold scores of <21 to diagnosis ED.

Data Analysis

The data collected were processed and analyzed by using routine statistical methods, and a P < 0.05 level was taken to indicate the significant difference. Measures of association were summarized by the prevalence odds ratio with 95% confidence intervals. All the statistics was performed by using the spss version 11.0 (SPSS Inc., Chicago, IL, USA).

Results

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

A total of 430 subjects consented to participate in the study. Demographic characteristics of the subjects are shown in Table 1. The prevalence of self-reported sexual problem for ED and PE were 41.6% and 22.3%, respectively. In those subjects with ED, there was 33.5% reported concurrently to have PE. The prevalence rates in different age groups are shown in Table 2. The present results show the overall prevalence rate of sexual problems increasing with age particularly in ED. In contrast, PE rate decreased with age. Data on the IIEF-5 score of ED among subjects with ED are presented in Figure 1. The result shows that the majority of subjects reported to have ED have mild to moderate severity of ED.

Table 1.  Demographic of subjects with and without premature ejaculation (PE) by the presence of erectile dysfunction (ED)
Demographic characteristicsEDNo ED
PE (n = 60)No PE (n = 119)PE (n = 36)No PE (n = 215)
  1. Values are numbers (percentages); t-test result: *P < 0.05.

Mean (SD) age (years)50.4 ± 12.7 53.0 ± 10.0*34.5 ± 8.3 39.1 ± 9.0
Ethnic origin
 Malay25 (41.7) 38 (31.9)20 (55.6) 97 (45.1)
 Chinese12 (20.0) 54 (45.4) 8 (22.2) 88 (40.9)
 Indian23 (38.3) 27 (22.7) 8 (22.2) 30 (14.0)
Educational status
 No formal education. 4 (6.7) 10 (8.4)  1 (0.5)
 Primary education 4 (6.7) 15 (12.6)  6 (2.8)
 Secondary education 6 (10.0) 39 (32.8) 6 (16.7) 21 (9.8)
 High education36 (60.0) 55 (46.2)30 (83.3)187 (87.0)
Occupational status
 Employed36 (60.0) 59 (49.6)36 (100)204 (94.9)
 Unemployed 4 (6.7)  7 (5.9)  3 (1.4)
 Retired20 (33.3) 53 (44.5)  8 (3.7)
Civil status
 Married 4 (6.7)  3 (2.5) 6 (16.7) 28 (13.0)
 Single53 (88.3)116 (97.5)29 (80.5)186 (86.5)
 Divorced 3 (5.0) 1 (2.8)  1 (0.5)
No. of children
 Nil 6 (10.0)  6 (5.0))13 (36.1) 40 (18.6)
 1–218 (30.0) 39 (32.8)10 (27.8) 69 (32.1)
 3–427 (45.0) 49 (41.2) 9 (25.0) 82 (38.1)
 >5 9 (15.0) 25 (21.0) 4 (11.1) 24 (11.2)
Length of relationship (years)
 0–5 9 (15.0)  7 (5.9)18 (50.0) 74 (34.4)
 5–10 2 (3.3)  7 (5.9) 6 (16.7) 62 (28.8)
 10–2017 (28.3) 29 (24.4)10 (27.8) 50 (23.3)
 >2032 (53.3) 76 (63.9) 2 (5.5) 29 (13.5)
Cigarettes (yes/no)20/40 33/8216/20 75/92
Alcoholic (yes/no)12/48 21/98 3/33 14/171
Table 2.  The prevalence of sexual dysfunction according to age group
Age groupSexual problem (n)Normal (n)PE n (%)ED n (%)PE and ED n (%)Overall sexual problem (%)
  1. ED = erectile dysfunction; PE = premature ejaculation.

20–291236 8 (17.0) 3 (6.0) 1 (2.0)25.0
30–39419718 (13.0) 9 (7.0)14 (10.0)30.0
40–494452 9 (9.0)22 (23.0)13 (14.0)46.0
50–597324 1 (1.0)53 (55.0)19 (20.0)75.0
≥6045 6 0 (0.0)32 (63.0)13 (25.0)88.0
image

Figure 1. Percentage of men with the various degree of ED (n = 179). ED = erectile dysfunction; IIEF-5 = International Index of Erectile Function.

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From the HAD scale, the median anxiety score and depression score were 6 and 4, respectively. Of the total 430 subjects, anxiety was present in 8.1%, while depression was 5.3%. The prevalence of PE accounted for 25% and 14.6% respectively for anxiety and depression in this population. This was related to the severity of both anxiety and depression by HAD scale, with statistically significant trend across categories of HADS score (Figures 2 and 3).

image

Figure 2. Percentage of men with premature ejaculation in each anxiety level (n = 96).

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image

Figure 3. Percentage of men with premature ejaculation in each depression level.

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Erectile dysfunctions were associated with a variety of predominant medical illnesses. The main association was with self-reported type 2 diabetes (Table 3). When adjusted for age, the odds ratio for this association was 5.33 (95% CI 2.33, 10.16). EDs were also associated with self-reported hypertension with an adjusted odds ratio of 3.40 (95% CI 1.76, 6.57). Diabetes and hypertension were also associated with other erectile problems such as problem of getting erection and the ability to maintain an erection. In addition, the main association with PE was anxiety and after adjusted for age, the odds ratio (95% CI) was 1.29 (0.68, 2.45) (Table 3). An association was also observed between PE and depression, with an odds ratio of 1.39 (0.69, 2.78). There is a significant association between nocturia and ED (Table 4) (P = 0.001). Those who have more frequency of sexual intercourse were found to significantly have high PE (Table 5) (P = 0.005).

Table 3.  Adjusted odds ratio (95% CI) for association between various self-reported social, medical, and psychological factors and various sexual problems
Sexual problemAge (years)Marital difficultiesDiabetesHypertensionAnxietyDepression
Erectile problem
 Problem getting an erection1.13 (1.10, 1.16)1.45 (0.58, 3.61)8.01 (6.59, 9.14)3.88 (1.97, 7.63)1.38 (0.72, 2.64)1.62 (0.79, 3.30)
 Problem maintaining an erection1.08 (1.06, 1.11)2.24 (0.81, 6.17)3.89 (1.85, 8.18)2.36 (1.17, 4.74)1.29 (0.62, 2.70)1.27 (0.56, 2.79)
 Erectile dysfunction1.13 (1.11, 1.16)1.49 (0.57, 3.86)5.33 (2.33, 10.16)3.40 (1.76, 6.57)1.29 (0.68, 2.45)1.39 (0.69, 2.78)
Premature ejaculation1.06 (0.98, 1.02)0.86 (0.36, 2.03)0.33 (0.16, 0.67)1.42 (0.71, 2.86)2.83 (1.45, 5.54)2.08 (0.97, 4.44)
Table 4.  Association between nocturia and ED
Nocturia urinationNon-ED n (%)ED n (%)Total n (%)
  1. χ2, P = 0.0001.

  2. ED = erectile dysfunction.

Not frequent249 (60.29)164 (39.71)413 (100.00)
Frequent  2 (11.76) 15 (88.24) 17 (100.00)
251 (58.37)179 (41.63)430 (100.00)
Table 5.  Relationship between frequency of sexual intercourse in a month and PE
CasesnMeanSDSEM
  1. t-test, P = 0.005.

  2. PE = premature ejaculation.

Non-PE611.741.170.15
PE212.331.200.26

None of the cases are prostatitis and there are only few cases of hyperlipidemia/hypercholesterolemia. Those who had regular sexual and intercourse (2–3 times a week) are relatively low and in this study, all single subjects have partner. No significant difference between time of ejaculation and the marriage status was noted in this study (P = 0.112).

Discussion

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

The prevalence of ED in this study is almost similar to other study [32]. Similarly, the findings of PE in this study shared some similarity with other study as well [31]. This study looks at the prevalence of sexual problem especially PE and its relation with a wide range of medical, social, and psychological factors in a general population sample. It is generally believed that male sexual interest and activity persist throughout their entire life. However, age was found to be an important association with sexual problems particularly ED. This may reflect its association with medical symptoms, which rises in prevalence of age such as diabetes and hypertension. In addition, marital dissatisfaction such as a lack or loss of sexual desire also accounted for the increased prevalence of ED. In contrast, the age of the men and their marital dissatisfaction were not correlated with the PE rate. Nonetheless, psychological distress such as anxiety and depression contributes mostly to a higher PE rate, which is in accord with previous findings [33].

Most of the comorbities are associated with ED and PE and the results are similar to other study [34,35]. The ED is found to be highly prevalent among the higher age group, whereas the PE is found higher in lower age group. Hyperlipidemia/hypercholesterolemia were not found to be significantly associated with ED in this study because of low number of cases of hyperlipidemia/hypercholesterolemia noted in this study.

Lower urinary tract symptoms usually have been noted to be associated with ED and in this study nocturia was statistically found associated with ED. Those who have more nocturia will be more likely to develop ED.

All the single men (n = 40) has regular partner. Therefore, the reported ejaculation is for sexual intercourse. All ejaculation times were assessed on sexual intercourse and not masturbation and there is no attempt in the study to compare the difference for ejaculation time during sexual intercourse and masturbation.

Various psychological treatments have been proposed to treat or cope with PE. As far as psychologists are concerned, PE is a psychological disorder caused by the learned behavior, hyperexcitability in the genital part or unconscious psychological conflicts. The use of psychotherapy is to help to delay ejaculation or to assist couples to learn to accept PE [36]. However, animal and human studies have shown that ejaculation is regulated by various areas in the central nervous system, and the rapidity of ejaculation is controlled by neurotransmitter such as serotonin [37]. Presently, a number of clinical studies on serotonin reuptake inhibitors (e.g., paroxetine, clomipramine, and sertaline) have repeatedly shown the efficacy of serotonergic antidepressants in delaying ejaculations [37–39].

This study has a few limitations such as a self-reporting methodology and, a survey confined to a particular urban area as part of a cross-sectional survey. However, we do not recommend face-to-face interviews because this may give rise to embarrassment when talking about very private and sensitive issues, or may induce subjects to give socially desirable answers about their sexual behavior. In the present study, we have explained the objective of the study and participants have to give their consent before commencement of these self-reported surveys. Even though the prevalence of sexual problems may be higher in those who have consented to participate in such a survey that it in turn may lead to an overestimation of their occurrence in the general population, this should not affect the integrity of the observed association. In addition, we used an in-house developed questionnaire which essentially has good sensitivity and specificity, and thus is a suitable, reliable, valid, and sensitive instrument to measure the sexual dysfunction in the general population.

Although IELT has been occasionally used as the determination of PE, nevertheless, it is made known that IELT alone may not sufficient or reliable to be used as PE determination. The findings would be more comprehensive if other instruments such as Index of Premature Ejaculation could be utilized [40]. This study is unable to show whether there are any cultural or social differences that can arise between this study compared with other studies.

From the findings of this study, we have shown that sexual dysfunction is prevalent in the male population, and several physiological and physical factors appear to be associated with these problems. Further work clarifying the direction of the association is needed to address the impact of both physical and psychological factors which play a part in the etiology of sexual problems. A similar approach should also be extended to their counterpart (female) as previous studies have shown arousal problem, orgasmic dysfunction, inhibited enjoyment, vaginal dryness, and dyspareunia were among the major sexual problems encountered by females [33]. The pattern of these sexual problems in females in association with other characteristics should be addressed promptly so that they can complement both genders to cope with their sexual problem effectively. Currently, there is a wide range of physical and physiological approaches for the treatment of sexual problems described in literature [41]. Our study raises the possibility that if such approaches are effective, they may have a wide range of social and psychological benefits in the general population.

Acknowledgment

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References

We would like to express our gratitude and sincere thanks to the Research and Development Unit, University of Malaya for providing the research grant (FP010/2003C) for this study.

Conflict of Interest: None declared.

References

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. Acknowledgment
  8. References