The Prevalence of Atherosclerosis and Related Factors in Both Types of Premature Ejaculation (Acquired and Lifelong) in Men

Background: investigate the prevalence and The related factors between the two types of premature ejaculation (lifelong PE[LPE], acquired PE [APE] in men and atherosclerosis. Methods: One hundred patients complaining of PE and 100 control subjects were enrolled in this prospective study.All cases underwent a full medical history and Clinical examination.Blood pressure,serum lipid prole, testosterone,and Body mass index (BMI) were measured.The Arabic index of premature ejaculation (AIPE) and self-estimated (IELT) Intravaginal latency time was used for PE evaluation. Atherosclerosis was diagnosed by measuring the Carotid artery intima-media thickness (CIMT). Patients were divided into two major groups, (Group 1) [PE group] and (Group 2) [Control group]. Results: The mean age of cases in (group1) and (group 2) were 44.5 ± 11.7 versus 42.3 ± 10.8 yrs. The Systolic BP, diastolic (BP), Serum Triglycerides, serum LDL (BMI), the prevalence of atherosclerosis and smoking rate showed higher results in (group1) compared to group2, with signicant difference (p<0.001). The IELT was signicantly lower in group1 (2.67± 1.25) compared to group2 (3.77±1.52), (p<0.001). The prevalence of APE (74%) was signicantly higher than LPE (26%) in group1(p<0.001). regression analysis revealed that patients with APE showed more comorbidities than LPE patients concerning the prevalence of atherosclerosis, hypertension, and hyperlipidemia (p<0.001 for all items).Both of APE and LPE were signicantly related to age>35y, BMI ≥ 25 kg/m2, smoking, Bl pressure and hyperlipidemia (p<0.001 for all factors). Conclusions: APE prevalence LPE.


Background
Premature ejaculation (PE) is considered the most frequent sexual dysfunction affecting about 15-30% of males above the age of 18 years¹.
In 1994, Waldingeriet al. 2 Gao et al.showed that patients with PE complaints, always suffer from comorbidities, such as chronic prostatitis. Hypertension, diabetes mellitus, cardiovascular diseases, varicocele, etc. 4 Moreover, Lewis et al. established that CV risk factors such as smoking, Body mass index (BMI), hypertension, heavy dietary intake of cholesterol, and unsaturated fat have been reported as predictors of sexual dysfunction 5 .
Hypertension damages the endothelium through increasing the hemodynamic pressure on endothelium and enhance the permeability of arterial walls for lipoproteins and sequentially accelerate atherosclerosis 6 .
All organs in the body, including the genital organs, require an adequate blood supply to obtain oxygen and nutrition to function probably.Many shreds of evidence have con rmed that hypoxia, ischemia,and oxidative stress produced by that arterial occlusive disease such as atherosclerosis are important etiologic factors in male sexual dysfunction 7 Currently, non-invasive technique for measurements of arterial intima-media thickness (IMT) was generally used for evaluation of subclinical arterial changes and well known that this was a good predictor of signi cant cardiovascular disease CVD 8 .Carotid intima-media thickness (CIMT),which is detected and estimated by ultrasound using the B-mode,is a subclinical indicator of atherosclerosis.Furthermore, measurementsof atherosclerotic plaque extents in the carotid artery are important to follow up and in assessments alterations of atherosclerosis 9 There are no studies that have systematically evaluated the correlation between atherosclerotic changes and PE complaints. Therefore, the current study performed to investigate the prevalence and The related comorbidities between the two types of premature ejaculation (lifelong PE[LPE], acquired PE [APE] in men and atherosclerosis Methods A total of 100 patients aged (25-65) years,who visited the outpatient clinic with the complaint of premature ejaculation and 100 normal control cases were enrolled in this prospective study.
The present study protocol was reviewed and approved by the National. Institution's Research Ethics Committee, faculty of medicine. Informed consent was taken from all patients.
Atherosclerosis was diagnosed by measuring the carotid artery intima-media thickness (CIMT) (Fig-1). A well-de ned lesion with a focal thickening ≥ 1.2 mm within of carotid artery was considered as carotid plaque (Fig-2), and documented atherosclerosis 11 . It was detected by an expert radiologist using (ultrasound machine GE Logiq 5, USA) with a linear array transducer working with frequency range 7-10 MHz. the measurements were taken at the common carotid artery bilaterally, three measurements were taken on both sides (anterior,lateral, and posterior projections) of the far and near the wall. Then, the average of all the reported reading was recorded 11 . Patients were divided into two main groups, (Group 1) [PE group] and (Group2, control group). The two groups were evaluated and analyzed using the parameters obtained.

Statistical analysis
Statistical analysis was achieved using SPSS computer program, version 21 (Statistical Package for the Social Science; Chicago, IL). Data were demonstrated in expressions of mean ± standard deviation (SD), Median or frequencies and percentages%.The Comparison between the two groups was completed by using Student's t-test. Mann-Whitney test used for numerical with the abnormal distribution.Pearson's Chi-squared (χ2) test used to compare the non-parametric data.Multiple logistic regression analysis performed to analyze affecting factors. P values < 0.05 were revealed statistically signi cant.

Discussion
The International Society of Sexual Medicine's (ISSM)recently proposed a combined de nitions 12 . they suggested a precise de nition of both LPE and APE; depend on the time starting from penetration to ejaculation, lose the ability to delay ejaculation and negative personal outcomes. Although, APE has a supplementary constituent, the presence of a clinically considerable and frustrating decrease in latency time (often to about 3 minutes or lesser) 4 . This syndrome occurs suddenly or gradually through a patient's life who has normal ejaculation and practices formerly. APE may occur due to the result of urological diseases, vascular dysfunctions and or psychological disorders 11 .
Regarding variable premature ejaculation (VPE), the ejaculation time might be a short period or normal. Premature ejaculations are varying and occurs occasionally. The competency to delay ejaculation might be reduced or missing. Premature-like ejaculatory dysfunctions have been de ned when the IELT (within the normal range or may be of longer duration). The ability to postpone ejaculation may be reduced or absent and the belief of early ejaculation or loss of control of ejaculation present. Variable subjective insight of consistent or inconsistent quick ejaculation 4,5 . These de nitions are useful in clinical practice since they remarked by different features and may need different methods to manage. 6,7 In the current study, the patients complaining of premature ejaculationswere classi ed according to the two types of PE and analyzed with different atherosclerosis parameters.
Serefoglu et al. 13  Multiple studies documented those comorbid diseases, like cardiovascular diseases atherosclerosis, hypertension and DM observed to be more likely common in men with the complaint of PE 14 . Nonetheless, it was displayed that among the types of PE, these comorbidities were more obvious in acquired PE, even though the exact etiology of PE is not known 15 .These ndings were in agreement with our results, we reported signi cant differences in blood pressure and lipid pro le between the two groups P < 0.001.
Hypertension and diabetic Insulin. resistance was found to be associated with sympathetic overactivity, as observed in many patients 16 . Zorba et al 17 evaluated the impact of the autonomic nervous system on [24-hour] heart rate changeability in PE and reported that sympathetic activity was intensi ed in men with PE, especially the lifelong type.The overactivity in the sympathetic nervous system may produce initial pressure elevation in the male prostatic urethra and subsequent PE.
Xia et al. assessed the potential effect of the sympathetic nervous system function in patients with primary PE by examining the reaction of the sympathetic skin positioned in the male penis and documented that men with primary PE exhibit hyperactive sympathetic nervous system function 18 .
Bolat et al. 19 reported that blood pressures were markedly increased in men complaining of PE. About 59% of the premature ejaculator's men showed blood pressure ⩾130/85 mmHg.Correlation analysis exposed that elevated blood pressures showed a negative correlation with IELT.These ndings were similar to our results. Where we declared that Bl.P was signi cantly higher in PE men with atherosclerosis than those without atherosclerosis. (P < 0.01) Recently, Gao et al. 4 established that patients, with acquired PE complaints, displayed elevated body mass index (BMI) scores. These ndings are comparable to our results, where BMI, TG, and LDL were statistically signi cantly greater in PE patients with atherosclerosis than PE patients without atherosclerosis.(P < 0.01) Bolat et al . 19 reported also that serum HDL levels were similar between the groups. However,our results showed signi cant HDL elevation in PE group without atherosclerosis more than PE men with atherosclerosis. (P < 0.001).

Conclusions
The current study revealed a de nitive correlation between the two types of premature ejaculation (lifelong PE[LPE],acquired PE[APE] in men and atherosclerosis. Oxidative stress, hypoxia, and Ischemia produced by arterial occlusive diseases like atherosclerosis are essential etiologic factors in male sexual dysfunction. Besides, Hypertension and hyperlipidemia reported signi cantly associated with PE patients with atherosclerosis. BMI revealed a signi cant elevation in atherosclerosis patients. LPE and APE showed a positive correlation with age, smoking, and BMI.However,men with APE were older and showed signi cant associations with (systolic Bl.P, Diastolic Bl.P, HDL, LDL, and Triglycerides) Further studies are necessary to understand speci cally the association between atherosclerosis and the development and progress of premature ejaculation.
We recommend that proper management of cardiovascular disease risk factors, like hypertension and hyperlipidemia, may take part in the prevention of atherosclerosis and the subsequent development of PE. Carotid atherosclerotic plaque