Clinical correlation between erectile function and ejaculatory function in the Czech male population
Clinical correlation between erectile function and ejaculatory function in the Czech male population
Watcharaphol Alexandre Kamnerdsiri 1 2
JesuÂ s Eugenio RodrÂõguez Martinez 0 2
Christopher Fox 2
Petr Weiss 2
0 Murcian Institute of Sexology , Murcia , Spain , 3 Westmead Clinical School, Faculty of Medicine and Health, University of Sydney , Sydney , Australia , 4 Institute of Sexology, First Faculty of Medicine, Charles University , Prague , Czech Republic
1 Department of Psychiatry, First Faculty of Medicine, Charles University , Prague , Czech Republic
2 Editor: Praveen Thumbikat, Northwestern University , UNITED STATES
This study explores the relationship between erectile function and ejaculatory function, to inform the clinical psychosexological and sexual medicine practice treatment protocols. A total of 1,004 Czech males aged between 15 and 84 years (m = 42.8 yrs; sd = 17.6 years) completed a sexual behavior questionnaire. A cross-sectional design was adopted. Erectile function was measured with the International Index of Erectile Function (IIEF-5) and ejaculatory function measured using self-report intravaginal ejaculation latency time and the Index of Premature Ejaculation (IPE). Linear regression analyses were used to explore the relationships between premature ejaculation and erectile dysfunction.
Competing interests: The authors have declared
that no competing interests exist.
Materials and methods
The sample mean self-reported intravaginal ejaculatory latency time was 9.34 minutes. The
overall mean on the IPE was 19.44 (sd = 2.368). The Control domain mean was 81.13 (sd =
17.22); Sexual Satisfaction domain mean 78.60 (sd = 20.59); and the Distress domain
mean was 86.86 (sd = 18.32). The mean score on the IIEF-5 was 19.28 (sd = 2.53). The
results indicate a relationship between premature ejaculation and erectile dysfunction. With
age significantly associated with all measures.
Higher levels of erectile function are associated with a better control and sexual satisfaction,
and less distress about ejaculation. This association supports the consideration of this
relationship in the development of new clinical practice guidelines for erectile dysfunction and
Sexual dysfunction is characterized by distress with changes during any stage of the sexual
response cycle. Sexual dysfunctions can affect men and women at any time of their lives and
impact on perception of sexual satisfaction [
]. In men, erectile dysfunction (ED) and
premature ejaculation (PE) are the two main complaints [
Erectile dysfunction is defined as the persistent inability to attain and/or maintain an
erection to permit satisfactory sexual performance [
]. It is estimated that it affects up to 52% of
men, from which 5% to 20% experience moderate to severe symptoms [
]. Furthermore, it is
believed that erectile function can be influenced by psychological disorders , including
], anxiety [
] and panic attacks .
Premature ejaculation (PE) is defined as a persistent or recurrent ejaculation with minimal
sexual stimulation before, on, or shortly after penetration and before the person desires
]. It is considered the most common sexual dysfunction in men, with prevalence
reported from 3% to 30% [10±12] Men with PE also report reduced or absent perceived
ejaculatory control, and the presence of negative personal consequences [
]. Premature ejaculation
is strongly associated with performance anxiety [
One in three men with ED, also experience PE [
]. Jannini, Lombardo and Lenzi explain
the ED-PE interaction as a result of the man's attempt to control his ejaculation results in a
reduction in his excitement level (which can result in ED). The resultant ED leads to a greater
focus on arousal (and excitement) to encourage the erection to return with this increased
excitation leading to PE[
Although erection and ejaculation occur at different phases of a man's sexual response
there are commonalities. Both processes are associated with pelvic floor muscles and good
function contributes to better erections and ejaculatory control [
]. Psychological distress,
anxiety (including performance anxiety) and depression are associated with erectile
dysfunction and premature ejaculation [
]. The comorbidity of EF and PE is connected through
a number of physiological and psychological processes and variables.
Good sexual function has a positive impact on people's sexual and psychological wellbeing
[19±21]. A healthy sex life has been reported to contribute to better physiological and
psychological function for men and women including better sex-life satisfaction, higher levels of
relationship satisfaction, increased mental health and greater satisfaction with general life [
Healthy erections (erectile quality and duration) has been reported to be associated with better
outcomes for female partners and include improved body image , a higher levels of
relationship satisfaction [
] along with higher probability of orgasm and sexual satisfaction.
Pleasure is considered one of the main objectives of human sexual expression. Men's
perception of increased duration of sexual play leads to increased enjoyment for him and his
]. With the desire for increased pleasure, ejaculation time has become central to a
couple's perception of sexual and relationship satisfaction. Althof and colleagues, along with
Giulano and colleagues reported better control over ejaculation has a significant positive effect
on perceived satisfaction with sexual intercourse and an inverse effect on the level of personal
distress associated with rapid ejaculation [
This research explores the relationship between premature ejaculation and erectile
dysfunction . The specific determinants and underlying factors linking ED and PE have yet to be
clearly identified . Therefore, the aim of this study is to analyze the relationship between
erectile function and three dimensions of ejaculatory function: control over ejaculation,
satisfaction with ejaculation, and distress levels caused by early or rapid ejaculation in a sample of
Czech men. The research outcomes will contribute to the development of a psychosexological
treatment protocol for the PE-ED as co-morbid conditions.
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Materials and methods
The sample of 1,004 Czech men aged between 15 and 84 years had a mean age of 42.8 years
(sd = 17.6). Age categories are reported in Table 1. Approximately two-thirds reported not
being in a relationship (single = 38.1%; divorced = 13.1%; widowed = 6.2%), and 42.6% of the
sample were married or in a relationship. Participants were more likely to have completed
secondary studies (39.1%) or vocational training studies 30%), than university education (19.1%)
or completing primary studies 11.8%). Eighty-eight per cent of the participants identified as
heterosexual with 10.7% unedifying as bisexual and 1.4% as same-sex attracted. The study
participation rate was 82%.
Participants completed an anonymous survey pack. The survey instrument contained
demographic questions, a sexual history, the International Index of Erectile Function Five item
version (IIEF-5) and the Index of Premature Ejaculation (IPE). The completed survey pack was
returned to the researchers. Ethical approval was granted by the First Faculty of Medicine of
Charles University in Prague, Czech Republic.
The shorter, five-item version of the International Index of Erectile Function (IIEF-5) was
used to measure erectile function. The full IIEF consists of 15 items and investigates five
domains. The IIEF is a valid and reliable instrument developed in conjunction with the clinical
trial program for sildenafil [29,30], with a high reliability in the detection of the effects of
erectile dysfunction treatment . The IIEF has a very high internal consistency (α = 0.82±0.96
. The IIEF-5 is a tool that is widely used in screening erectile dysfunction due to its fast
implementation. The IIEF-5 was validated with reported internal consistency with Cronbach's
alpha scores of 0.98 and 0.88 [31,32]. Lower scores indicate greater severity of ED with men
who report scores under 21 are considered to be experiencing erection issues.
Ejaculatory control was assessed using the Index of Premature Ejaculation (IPE), a valid
and reliable instrument with three domains: (1) evaluation of control over ejaculation, (2)
satisfaction with ejaculation, and (3) distress associated with PE . The IPE consists of 10 items
with a very good internal reliability and very high test/retest reliability with results ranging
between 0.70 and 0.90 . Convergent validity was reported as excellent for all three domains
(control = 0.75; satisfaction = 0.60; and distress = 0.68). Convergent validity was assessed
against intravaginal ejaculatory latency time. Scores in each domain can range from 0 to 100,
Number of Participants
(n = 1,004)
with higher scores indicating greater control over ejaculation, satisfaction with ejaculation,
and lower distress due to ejaculation. The IPE does not have a cut-off points on each domain
and is not a diagnostic tool.
Participants self-reported ever experiencing a sexual problem (n = 126; 12.5%) and currently
experiencing a sexual problem (n = 133; 13.2%). Of those men who had experienced a sexual
problem, 43 men reported PE (4.3%). The mean age of the experience was 20.43 years (sd =
6.79) with onset as young as 11 years and as old as 45 years. Forty-six men reported a past
history of ED (4.6%). The mean age for this sub-sample was 41.13 years (sd = 18.509) with ages
ranging from 15 to 72 years. Of those currently experiencing a sexual problem, 12 men
reported PE (1.2%) and 75 men reported current ED issues (7.5%)
The mean self-reported intravaginal ejaculatory latency time (IELT) was 9.34 minutes
(sd = 10.37), with 89 men reporting ILTS of less than 1 minute (8.9%), and a further 51 men
reporting between one and two minutes ILTS (5.1%). The IELT estimates are reported in
Table 2. Twelve men (1.2%) reported they currently experienced premature ejaculation (No =
50; missing = 942). There was no significant correlation between self-reported premature
ejaculation and researcher-diagnosis (based on IELT). An independent sample t-test resulted in
no significant differences on self-reported IELT and perception of premature ejaculation. A
significant negative correlation exists between age and self-reported IELT (r = -.234; p < .001).
A one-way analysis of variance was conducted to explore the impact of age on self-reported
IELT. There was a statistically significant difference between age-groups: F (7,790) = 6.193,
p < .001.
Index of premature ejaculation
The mean scores of participants on the three domains of the IPE are reported in Table 3. A
statistically significant negative association was recorded between age and the control domain
(r = -.251; p < .001); sexual satisfaction domain (r = -.259; p < .001); and the distress domain
(r = -.176; p < .001). Analyses of variance were undertaken to explore the impact of age on
each of the domains with significant differences recorded between age-groups on each
domain: control domain (F (6,631) = 9.729, p < .001); sexual satisfaction domain (F (6,629) =
10.812, p < .001); and distress domain (F (6,633) = 4.444, p < .001).
A diagnosis of IELT of one minute or less was used to classify the presence of PE .
Eighty-nine men were identified and a dichotomous variable (yes/no) applied. Significant
Pearson's correlation was indicated on all three domains: control (r = .156; p < .001); sexual
satisfaction (r = .214; p < .001); and distress (r = .109; p < .001).
Number of Participants
(n = 1,004)
The mean score on the IIEF-5 was 19.28 (sd = 2.53). Scores ranged from nine (moderate ED)
to 24 (No ED). No participants reported severe ED and 10.5% (n = 105) indicated no ED.
Approximately, two-thirds of the sample recorded some level of ED. Table 4 presents the
EEF5 data. Seventy-five men (7.5%) self-reported current ED. There were no association between
self-reports of ED and the IIEF-5 scores. There was a statistically significant negative
correlation between age and ED (as measured by the IIEF-5; r = .260; p < .001). Significant mean
differences exist between age groups on the IIEF-5 mean scores (F (6,727) = 10.950, p < .001).
The relationship between the presence of ED and the three domains of IPE was significant
and positive for IIEF-5 scores and also using a dichotomous variable: presence of ED/no
presence of ED. As perceived control and sexual satisfaction increased so did the IIEF-5 scores
(less ED). The increase in distress marked lower distress as the IIEF-5 scores increased. Table 5
reports the correlations for these data.
The PE-ED relationship
A significant association exists between the presence of PE and ED (r = 0.162; p < .001). Age
has an influence on the presence of PE and ED, as well as on the three domains of the IPE.
Partial correlations were conducted between IIEF-5 scores and the three domains of the IPE
(Control, Satisfaction and Distress) while controlling for age. An inspection of the zero-order
correlations suggested controlling for age had little effect on the relationship. These data are
presented in Table 5.
A multiple regression was used to identify the role of age, control, satisfaction and distress in
predicting ED. These independent variables explained 2.9% of the total variance (F (4,616) =
4.547, p = .001). Control was the only statistically significant predictor (Beta = .148, p = .003).
The rates of self-report PE in this sample were lower than reported in epidemiologic studies
(4.3% vs. 20±30% [33±35]). The self-report rates for ED were at the lower-end of prevalence
estimates (5% vs. 5%±20% ). Based on IELT measures (1±2 mins) slightly higher rates of
PE were recorded for the sample and were in line with previous estimates of lifelong PE .
Number of Participants
(n = 1,004)
This was also the case in the application of the IIEF-5 scores to determine presence of ED±
more men (approx. two-thirds) were recorded as experiencing some level of ED compared to
their self-reported rates of ED. There is a discrepancy between the self-reported incidence
rates and measured rates of PE and ED. There was no statistical support for any relationship
between self-report and researcher-measured PE or ED. This discrepancy and lack of support
between self-report and objective measures suggests that reliance on self-report of sexual
dysfunctions may be problematic. This relationship warrants further investigation.
Premature ejaculation was found to be negatively correlated with age. Older men were
more likely to report a shorter IELT. This was further supported through analysis were
differences were found between age groups with PE more prevalent among older groups of men
than younger groups of men. The relationship between the domains of the Index of Premature
Ejaculation  and IELT were investigated. Men recorded as experiencing PE based on
selfreport IELT were more likely to perceive less lower levels of ejaculatory control, less sexual
satisfaction and greater sexual distress. The domains were also explored in relation to age with
older men perceiving less ejaculatory control; higher sexual satisfaction and lower levels of
sexual distress. Although older men may experience PE and perceive less control, they are more
likely to be satisfied and experience less distress about PE.
The rates of recorded ED based on diagnosis using the IIEF-5 scores were similar to other
studies [32,33,39]. The increase in ED rates with age is also in line with past research. As men
age, they are more likely to experience ED. The current findings were confirmed through an
analysis of variance where differences were found between age groups [39±41]. Erectile
dysfunction was associated with the domains of the IPE. Higher rates of perceived control and
satisfaction, and lower distress were correlated with lower levels of erectile dysfunctions.
A relationship exists between the presence of PE and ED as confirmed in this study. Age
was found to be associated with each of the variables. Further analysis through partial
correlations however found that, when controlled, age had little effect. In exploring the predictability
of ED as an outcome of PE, only control was found to be a significant predictor, as presented
in Table 6. This suggests that when working with men who experience PE, then lower level of
perceived control are more likely to indicate the presence of ED.
Using Jannini, Lombardo and Lenzi model of PE-ED, men who experience PE and ED are
also likely to perceive less control as their focus on controlling ejaculation is likely to result in
distraction and erection loss [
]. The loss of erection in turn is requires greater arousal
Change from zero-order
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resulting in a rapid ejaculation. This circular relationship is likely to result in perceptions of no
control. Further investigation is required to confirm the role of perceived control in predicting
PE induced ED.
The main limitation of this study is the focus on Czech nationals. The reliance on
selfreport measures also leads to possible limitation as identified in this study. These limit the
generalizability of the results to wider populations. A further limitation is the application of
correlational analysis which does not allow for confirmed causality. Future research can explore the
causal relationships between variables.
Subsequent research can also focus on the psychobiological factors common to erectile and
ejaculatory functions, given the key point they both have in maintaining a good sexual health,
and the high prevalence of ED and PE in society. This link should also be taken into account
when developing new lines of therapy to improve both functions.
As has been identified, further research is required in to the relationship between self-report
and objective measures of sexual wellbeing. In this study, no relationship was found to exist
with less men self-reporting the presence of PE and ED than identified through IELTs
(admittedly still self-reported) and application of the IIEF-5 for diagnosing ED. The role of control in
predicting ED for PE sufferers also, is recommend for further research. Given the limited
research on the role of ED as an outcome of PE, more research into this relationship is
warranted generally. Age was found to be associated with all variables yet was found to have
limited impact on further analysis. Future research could consider age as a mediator or moderator
of the relationship between PE and ED given the role age has in both of these conditions. The
mediation-moderation relationship could be explored with the three domains of the IPE and
its function between PE and ED.
The obtained results support a positive link between ejaculatory and erection functions [
], Furthermore, when attention is focused on the variable of erectile function, it seems that
people with greater erection problems score less on the dimensions of control and satisfaction
with erectile ejaculation, and report greater distress. These results coincide with the
meta-analysis of Corona et al 2015 . The current results must be interpreted with caution as the
authors have not investigated diagnoses, but only the risk of experiencing PE-ED.
The results of this study also match what is frequently observed in clinical psychosexual and
sexual medicine practice, where men report erectile function issues preceded by difficulties
with the ejaculatory function [
]. Therefore, a set of factors do exist which would affect both
functions and explain the PE-ED link. Both functions share biological mechanisms in
], whose appropriate functioning would facilitate a proper development of both
processes, and would be a key for good sexual health. For example, the use of drugs like
sympatholytic, selective serotonin reuptake inhibitors, or methadone, would affect both
functions . Endocrine alterations such as hyperthyroidism, or neurologic diseases like diabetic
neuropathy, can also cause disturbances in erectile and ejaculatory functions at the same time.
Psychological variables such as distress and mood disorders also have a decisive role in both
]. In this context, distress affects both functions by generating an increase in
sympathetic tone , and this anxiety, in many cases, would be caused by thoughts and concerns
about sexual performance, therefore becoming a vicious circle.
Erectile and ejaculatory functions would be affected by sexual performance anxiety .
This would cause an increase in sympathetic tone, hindering erection due to the peripheral
vasoconstriction it generates, and in turn accelerating the ejaculatory reflex, which would
increase the initial distress levels upon confirmation of a poor performance.
The strength of this study is the representativeness of their sample, due to its size and
selection criteria, and because the measures used (notwithstanding the limitation on
generalizability noted above).
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It appears PE and ED functions are related and that there are biologic and psychological
factors common for appropriate maintenance of both. In this context, it is recommended that
given this relation, in the clinical management of PE and ED, an evaluation of both functions
should be made, regardless that only one of them is the reason for seeking psychosexual and/
or medical attention, which would facilitate the selection of a more appropriate treatment, and
a better understanding of the underlying mechanisms of these dysfunctions.
Conceptualization: Watcharaphol Alexandre Kamnerdsiri, Petr Weiss.
Data curation: Watcharaphol Alexandre Kamnerdsiri.
Formal analysis: Watcharaphol Alexandre Kamnerdsiri, JesuÂs Eugenio RodrÂõguez Martinez,
Investigation: Watcharaphol Alexandre Kamnerdsiri, Petr Weiss.
Methodology: Watcharaphol Alexandre Kamnerdsiri, Petr Weiss.
Project administration: Watcharaphol Alexandre Kamnerdsiri.
Resources: Watcharaphol Alexandre Kamnerdsiri, Petr Weiss.
Software: Christopher Fox.
Supervision: Christopher Fox, Petr Weiss.
topher Fox, Petr Weiss.
Martinez, Christopher Fox.
Validation: Watcharaphol Alexandre Kamnerdsiri, JesuÂs Eugenio RodrÂõguez Martinez,
ChrisVisualization: Watcharaphol Alexandre Kamnerdsiri, JesuÂs Eugenio RodrÂõguez Martinez,
Writing ± original draft: Watcharaphol Alexandre Kamnerdsiri.
Writing ± review & editing: Watcharaphol Alexandre Kamnerdsiri, JesuÂs Eugenio RodrÂõguez
8 / 10
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Giuliano F, Patrick DL, Porst H, La Pera G, Kokoszka A, Merchant S, et al. Premature Ejaculation:
Results from a Five-Country European Observational Study. Eur Urol 2008; 53:1048±57. https://doi.
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