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Prostatitis and premature ejaculation: two enemies of masculinity

Prostatitis and premature ejaculation are urological problems that impact sexual and reproductive health in males frequently. The aim of this narrative review is to provide an overview of the relationship between premature ejaculation and prostatitis. A narrative review literature was performed in the PubMed and SCOPUS databases. The most relevant aspects of the etiology of premature ejaculation were detailed, and the causal relationship between prostatitis and premature ejaculation was explored. Treatment should consider the pathophysiology and diagnosis; this is a significant challenge for the urologist. A total of 45 original articles were compiled in a table within the main findings. Both alterations are associated with a decrease in the quality of life and have a negative impact on the couple's relationship. The timely treatment offers improvement or complete recovery for the patients.


INTRODUCTION
Prostatitis and premature ejaculation (PE) are highly frequent genitourinary problems that negatively affect the quality of life of men and their partners, causing anxiety, sexual dysfunction, and even fertility problems [1]. PE occurs between 30% to 40% of sexually active men and is an age dependent disorder [2], this can also be associated with higher prevalence diseases in older adults such as hypertension and diabetes [3], even with neurotransmitters levels such as serotonin, independent of age and comorbidities. PE patients report a short time between vaginal penetration and ejaculation -less than 2 minutes-being unable to sexually satisfy their partner [4] in more than half of sexual intercourse, according to one of the classifications used [5][6][7].
On the other hand, prostatitis is considered the most common urological disorder in men younger than 50 years; it has a variable prevalence, between 1.8 to 65% [8] that depends of methodology, with an general average of 14.2%. Prostatitis is positively associated with age, being 1.7 times higher in men from 40 to 49 years compared to individuals from 20 to 39 years, and 3.1 times higher in people from 50 to 59 years [9]. The National Institute of Health (NIH) classified prostatitis into four categories according to its origin: acute prostatitis (AP), chronic prostatitis (CP), chronic pelvic pain syndrome (CPPS) with and without signs of inflammation, and asymptomatic prostatitis [6,10]. The prevalence of prostatitis in PE patients and vice versa, suggests a causal relationship between these two genitourinary problems, since both acute and chronic prostatitis can alter ejaculatory latency leading to an acquired PE syndrome. Therefore, this narrative literature review aims to provide an overview of the relationship between PE and prostatitis.

MATERIALS AND METHODS
A narrative review literature on some topics related to PE and prostatitis was performed in PubMed and SCOPUS databases, without time limit, using "premature ejaculation" and "prostatitis" MeSH terms. The total of papers (original articles, subject reviews, and experimental investigations) were included. Also, we review bibliography reported in each paper. One hundred and sixty articles were examined and those with the most relevant information were chosen according to the authors' criteria.

Etiology of premature ejaculation
PE is a frequent sexual complaint, its appearance does not immediately suppose the existence of a male sexual disorder because some patients can have sexual satisfaction with variable ejaculatory latency times; their etiology can be diverse and different physiological and psychological causes have been proposed [11]. This alteration can appear throughout life or be acquired throughout sexual life [12], a subclassification has been proposed in four types: a) primary; b) acquired; c) variable, which is not constant and only occurs in specific situations; and d) subjective, in which the disorder is not real, but the patient believes that he suffers from it [13]. Both the pathophysiology and the treatment of PE remain an essential challenge for the urologist; even the diagnosis is difficult because it has been considered by some to be a predominantly psychological condition, for which reason its treatment was restricted sometimes to behavioral therapies [14]. PE causes include glans hypersensitivity, neurotransmission abnormalities, central serotonergic pathway, erectile difficulties, erectile dysfunction, varicocele, circumcision, consumption of some prescription drugs, recreational drugs, thyroid disorders, and prostatitis, among others [15][16][17]. Men with primary PE may have an underlying genetic predisposition to rapid ejaculation and various genetic polymorphisms related to serotonin and dopamine neurotransmission that predispose to developing the disease [18]. Additionally, men with acquired PE can have a variety of factors, including anxiety and depression, about sexual performance [19,20].

Prostatitis as a cause of premature ejaculation
Prostatitis has an acute or chronic presentation, the pathophysiology is not fully clarified, but under the concept of intraprostatic reflux, bacterial prostatitis can be explained. This reflux by dragging bacteria from the urethra causes acute inflammation of the gland (acute bacterial prostatitis); when the immune response is not as strong, a slower process known as chronic bacterial prostatitis originates [8,21]. Bacterial prostatitis has implications for fertility, and altered seminal parameters have been reported in the semen of patients, which could be associated with bacteriospermia, because bacteria can induce harmful effects on sperm [22].
CP has been associated with urethral catheterization and infections caused by bacteria [23], viruses [24], fungi [25], and even microorganisms that cause sexually transmitted diseases such as Chlamydia trachomatis and Trichomonas vaginalis [26]. Clinical symptoms are better known as chronic pelvic pain syndrome [27]. In 1995, the NIH proposed a new classification of CP refocusing it on the concept of chronic pelvic pain syndrome (CPPS), defined as pain associated with sexual dysfunctions such as PE and that affects the quality [28]; due to the pathophysiology, symptomatology and the negative psychological effect that this type of pain causes should be considered as a trigger for sexual dysfunction and can affect all components of the sexual cycle [29]. Men with CPPS have reported pain during ejaculation and during sexual intercourse, decreased sexual desire, and premature ejaculation [30]. Considering the role of the prostate in the ejaculatory mechanism, a direct influence of local inflammation on the pathogenesis of some cases of acquired PE seems possible [31,32], which has been pointed out in studies showing that up to 75% of men suffering from PC / CPPS also suffer from sexual problems and mainly from PE [33]. The symptoms of the lower urinary tract frequently appear in the CPPS associated with sexual dysfunction [34,35], these symptoms consist of storage disorders and urination such as urgency and urinary incontinence, nocturia, and overactive bladder, which constantly interfere with daily activities [36,37].

Premature ejaculation treatment caused by prostatitis
For treatment, it is essential to keep in mind therapies should be selected understanding the association between prostate and PE [38]; In the literature, two treatment approaches are proposed, those that are aimed at the pathophysiology of the disease and those that focus on treating the patient's psychological field. This type of treatment is also known as sex therapy and has multiple objectives, the most important are techniques to control or delay ejaculation, decrease the anxiety that the disorder generates and improve communication with the partner; this type of treatment is used with greater success in cases of primary PE [39]. Sexologists obtain better results when they integrate multidisciplinary strategies to carry out therapy in conjunction with urologists, in which in addition to the psychological part, the evaluation and treatment of the symptoms that cause sexual dysfunction are covered, the identification of an etiological factor does not necessarily mean if the cause of PE has been fully explained, and the patient may require a combination of treatment approaches [40]. Pharmacological and psychological or behavioral treatments together may be especially useful in men with acquired premature ejaculation where there is a clear psychosocial precipitating or long-standing lifetime cases where individual or couple responses to PE are likely to interfere with medical treatment and the ultimate success of treatment [41]. A careful examination of the prostate should be carried out before beginning any pharmacological or psychosexual therapy for PE. In the case of acquired PE, if infection or inflammation of the prostate are the possible causes, treating the infection with antibiotics or anti-inflammatory drugs should reduce the symptoms; for this, antibiotic-only therapies such as ciprofloxacin and anti-inflammatory therapies with an antibiotic such as hydrocortisone with clarithromycin [42,43].
Treatment focused on the pathophysiology of the disease are also αblockers, alpha-1 receptors predominate in the prostate gland, prostatic urethra, and bladder, and relaxation of the smooth muscles of the prostate and bladder are associated with relief of lower urinary tract symptoms (LUTS) in patients with them. Thus, tamsulosin [44] and terazosin decrease the CPPS associated with sexual dysfunction and improve the quality of life of patients [45]. Another type of efficient treatment for PE consists of the administration of selective serotonin reuptake inhibitors such as dapoxetine, which significantly increases the intravaginal latency time in patients with PE [46]. Additionally, local anesthetics and phosphodiesterase 5 inhibitors have also shown some efficacy in the treatment of PE [47,48]. Given this, the question arises: Which treatment should be offered first? The truth is that the Urologist's intuition, experience, and evidence should guide the choice of treatment, which is decisive for obtaining an excellent therapeutic result, as well as the adherence of the patient and his partner to treatment [49]. Finally, considering the role of prostatic diseases in the pathogenesis of PE, the prevention procedure must be based on the sexual and andrological education of young men and adults about both conditions. Consultations for PE are less than those due to erectile dysfunction [96], therefore it is crucial to raise awareness about the importance of asking questions during the primary care consultation to start some treatment or to refer to the indicated medical team. These types of professionals can address the situation with questions such as: How long is the typical time between penetration and ejaculation? Do you feel able to delay ejaculation? When did you first experience PE? Have you had PE? Since the beginning of your sexual life and with almost all your sexual partners? Does your partner express dissatisfaction with your PE? Does your partner avoid sexual relations? Is your PE affecting your overall relationship with your partner? Are you having sex for fear of feeling bad? And do you feel anxious, depressed, or embarrassed about your EP? [97]. With this broad group of questions, the diagnosis, the type of PE, and the consequences in terms of the partner and the quality of life can be covered. Besides, other useful tools are standardized questionnaires such as the PEDT (Premature Ejaculation Diagnostic Tool), the PEP (Premature Ejaculation Profile), the Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQEjD) and the widely used Premature ejaculation questionnaire proposed by Gindin and Huguet, in which scores between 30-40 points indicate a critical premature ejaculation that requires treatment (98].

CONCLUSION
Prostatitis and PE decrease the quality of life of the patients and have a negative impact on the couple's relationship, probably related to this due to a proactive female role in sexual relations that allows a sufficient duration to reach orgasm. A couple suffering from premature ejaculation will have an anxious man and an unsatisfied woman, which would recommend that this problem not be approached unilaterally. Finally, multiple treatment options offer greater hope for improvement or recovery for patients; In the case of acquired PE associated with acute or chronic prostatitis, antibiotics and anti-inflammatories have a notorious efficacy, but when these are administered by psychological therapy individually or better still as a couple, encouraging results are obtained [99]. Analyzing and studying these two alterations is quite timely, since the frequency with which they occur in the male population is high, and the implications for sexual and reproductive health are often devastating. On the other hand, both conditions could be covered in a friendlier way by designing sexual and reproductive health programs focused on identifying and attending to these changes in men, which is very important for men to put aside the fear or modesty produced by consulting on these topics. The integration of pharmacological treatment with dynamic behavioral rehabilitation optimizes the results, recovering ejaculatory control. 75% of the patients showed remarkable improvement after three months. Morgia, G., et al. 2017. [93] 60 patients between 20 and 50 years of age The benefits of treatment with curcumin and calendula extract could be related to the reduction of inflammatory cytokines and inflammatory cells. Zhu, D., et al. 2017. [94] 498 men with EP and 322 without EP. Men with EP had higher symptoms scores similar to those of prostatitis compared to participants in the control group Jeh, S.U., et al. 2018. [95] 1029 men with PD.
Compared with the group without EP, patients with EP had a higher prevalence of metabolic syndrome. Therefore, it could be considered an independent predisposing factor for the development of acquired EP.