Due to the lack of a standardized definition, diagnostic tools, and the social hypersensitivity of the disease, the results of studies on the risk factors of PE are still controversial. A multicenter cross-sectional study by Zhang et al. [12] investigated the risk factors of PE and reported that ED, weak sexual desire, lower frequency of sexual intercourse, diabetes, chronic prostatitis, primary married status, lower body mass index, higher age, education level, monthly income, office work, drinking habits, and decreased force of ejaculation were significantly associated with PE. There are no previous studies in the literature that have evaluated the impact of polygamy in PE. Our study indicated that there is a statistically significant difference between the number of sexual partners and PE. Polygamous men have a lower incidence of premature ejaculation and higher sexual satisfaction than monogamous men. Potential reasons include increased sexual experience, relationship maturation, increased sexual intercourse frequency, and psychosexual comfort.
Existing studies regarding the association between age and premature ejaculation are limited. Our study reported no statistically significant association between age groups and PE which was compatible with a multicenter internet-based survey from the Korean Andrological Society in young and middle-aged men that noted no significant differences among PE according to age categories [13]. In contrast to our findings, Kempeneers et al. [8] reported that PE decreased with age due to sexual experience and relationship maturation with a partner.
Sexual frequency is a risk factor of PE and has a clear impact. According to the existing literature, there is no approved frequency of sexual intercourse that lowers or prevents PE. In our study, we acknowledged that a lower frequency of sexual intercourse was significantly related to a higher incidence of PE, which was consistent with a 10-year interval web-based survey on the prevalence and risk factors of PE (The Korean Internet Sexuality Survey (KISS) 2016) by Song, W. H. et al. similarly reported that a low frequency of sexual intercourse per month was related to PE [14]. The study results indicate that a sexual intercourse frequency of two or more times per week significantly lowers the risk of PE.
In our study, the prevalence of PE was 37.1%, which was higher than that reported in previous studies [4, 15, 16]. A study by Karabakan et al. [17], in young Turkish men, revealed a low prevalence of approximately 9.2% PE. The Global Online Sexuality Survey among Arabic Males (GOSS‐AR‐M) published a much higher prevalence of approximately 83.7% PE [18]. A higher PE rate (40.6%) as compared with our study was also reported in a cross‐sectional study conducted at a primary care clinic [19]. The prevalence of PE varies among studies due to the lack of a universally accepted definition and diagnostic tools, as well as the social hypersensitivity of the disease, and the various methods of data collection and analysis.
Several studies have evaluated the association between PE and ED and their co-occurrence, and they have shown a complex relationship between the two diseases. A large, randomized study of 4997 heterosexual men with regular sexual intercourse, aged 18–65 years from nine Asia–Pacific countries, presented that more than 30% of PE patients have concomitant ED, which was in agreement with our findings [20]. Tsai et al. [6] reported that erectile dysfunction is the leading risk factor for about 36% to 50% of PE. A new taxonomic entity called loss of control of erection and ejaculation (LCEE) was introduced by Colonnello et al. [7] that sights the two sexual symptoms as deeply interrelated, and helps the assessment of concomitant presence of PE and ED, and to improve both PE diagnosis and management. A systemic review and meta-analysis of 18 articles, for a total of 57,229 patients, of which 12,144 (21.2%) patients had PE, reported a bidirectional relationship between PE and ED; the presence of PE was associated with a significant increase in ED risk (odds ratio 3.68 (2.61, 5.18), p < 0.0001) [21]. Consistent with these studies, in this study, we reported that men with PE have a two-fold risk of developing ED due to anxiety, interpersonal distress, and partner dissatisfaction. In our study, the prevalence of ED was higher in PE patients (64%). Premature ejaculation places a significant burden on an individual and their partner associated with psychological distress and dissatisfaction. Xi et al. reported that when diagnosing erectile dysfunction in patients with PE, SHIM has a sensitivity of about 100% while has a specificity only about 36%; meanwhile, the IIEF-EF is has a higher sensitivity and specificity of about 100% and 77.2% respectively. The authors of this study suggested that the cutoff of SHIM and IIEF-EF should be lowered when assessing erectile function among PE population (SHIM at 17.5 and IIEF-EF at 24.5, respectively). Larger trials are needed to further validate and to expose about the relationship between PE and ED and its association in monogamous and polygamous families. This study mainly focuses the relationship between PE and polygamy compared to monogamous men, and to the best of our knowledge, this is the first study aimed at evaluating the relationship of PE among polygamous men [22].
Neurophysiological, psychosocial, and cognitive factors are some of the mechanisms that involve the pathophysiology of the disease [23]. The coexistence of PE and ED should be carefully evaluated and should not be considered to be separate entities that would increase treatment failure rates [24].
