Sexual Dysfunction and Infertility

The Relation of Enuresis and Irritable Bowel Syndrome with

Premature Ejaculation: A Preliminary Report

Mohammadreza Barghi*

Department of Urology, Shohada-e-Tajrish Hospital, Shaheed Beheshti University of 

Medical Sciences, Tehran, Iran

ABSTRACT

Introduction: In this retrospective study, we reviewed the outpatient data of patients

with premature ejaculation to investigate the association of that disorder with irritable

bowel syndrome and a positive history of enuresis.

Materials and Methods: All patients with premature ejaculation who had presented

to the author's office from March 2002 to June 2003 were selected. Their medical

records were reviewed, and data including symptoms of irritable bowel syndrome,

history of enuresis, and psychologic disorders were collected. The results of our

analysis were compared with the worldwide reported prevalence of enuresis and

irritable bowel syndrome in the male general population.

Results: Forty-one consecutive patients were asked whether they had ever

experienced irritable bowel syndrome, enuresis, psychologic problems, and/or the

feeling of tickling or sexual pleasure at ejaculation. Of those 41 patients, 18 reported

the symptoms of irritable bowel syndrome (43.9% versus 10% in the general

population; P < .001). A reliable answer about the history of enuresis was obtained

from 35 patients, 14 of which had experienced that disorder (40% versus 10% in the

general population; P < .001). Of those 35 patients, 6 (17.4%) had experienced both

irritable bowel syndrome and enuresis. Twenty-two of 37 patients (59.5%) reported

psychologic problems including stress, agitation, and obsession-compulsive disorder.

Conclusion: The results of this study suggest the association of premature

ejaculation with irritable bowel syndrome and enuresis, which in turn may indicate

that those disorders share a common neurologic pathophysiology. A special attention

of the physicians to the symptoms of these diseases together may be of great help for

the patients.

KEY WORDS: premature ejaculation, irritable bowel syndrome, enuresis

201

Urology Journal

UNRC/IUA

Vol. 2, No. 4, 175-6 Autumn 2005

Printed in IRAN

Introduction

Premature ejaculation (PE) is a common

problem with a prevalence reported to be as high

as 35% in men.(1-3) Although PE has in the past

been attributed only to psychologic problems, the

complete pathophysiologic mechanism of that

disorder remains undefined.(1,4) However, the

oversensitivity of the penis to stimulation 

(the effect of which can be controlled by using

local anesthetic sprays or a condom) or the

effectiveness of antidepressants in the treatment

of PE suggests a central disorder as the 

cause.(1,4-8)

Received October 2004

Accepted June 2005

*Corresponding author: Shohada-e-Tajrish Hospital,

Tajrish Sq, Tehran, Iran. Tel: ++98 21 2718001

E-mail: mbarghi@yahoo.com



Premature Ejaculation, Irritable Bowel Syndrome, and Enuresis

Patients with irritable bowel syndrome (IBS)

and enuresis also benefit from treatment with

antidepressants,(9) and the oversensitivity of the

organs targeted in those disorders suggests the

pathophysiologic mechanism of the disease.(8)

Electrophysiologic studies have shown that an

abnormal reaction of the penile skin to sensory

stimulation and the resultant response of the

central nervous system are characteristic of

patients with PE.(4,8)

The association of IBS with urinary disorders

and PE, if based on a common mechanism for all

3 disorders, is reasonable,(8,10) although further

research to confirm that theory is required. This

review of outpatient data was performed to

investigate the frequency of IBS and a positive

history of enuresis in patients with PE.

Materials and Methods

In this retrospective study, all patients with PE

who had presented to the author's office in

Tehran, from March 2002 to June 2003, were

selected. Their records were reviewed, and the

following data were collected: symptoms of IBS,

history of enuresis, mood and other psychologic

disorders, a feeling of tickling or sexual pleasure

in the frenulum at ejaculation, and the results of

sensory examination of genitalia in which very

gentle touches of the examiner's finger and a

wisp of cotton were used to assess the patient's

subjective perception of the sensitivity of the

frenulum and glans as opposed to the abdominal

skin. In this study, IBS was defined according to

Rome II criteria,(11) which specifies that the

patient must have experienced at least 3 months

of continuous or recurrent abdominal pain or

discomfort that is relieved by defecation and/or is

associated with a change in the frequency or

consistency of stool, plus 2 or more of the

following symptoms that occur at least one-fourth

of the time: altered stool frequency, form, or

passage; the passage of mucus; and bloating or

abdominal distention. Enuresis was defined as

bedwetting after the age of 3 years.(12) Patients in

whom a history of enuresis and IBS were not

confirmed because of vague or unreliable answers

were excluded from the data analysis. The

prevalence of enuresis and IBS in general

population are 10% and 10%, respectively.(8,13) The

results of this study were compared with those

statistics by means of z approximation. Data

analyses were performed with SPSS software

(Statistical Package for the Social Sciences,

version 11.5, SPSS Inc, Chicago, Ill, USA). A P

value of less than 0.05 was considered significant.

Results

From among 1150 patients who presented for

the treatment of urologic problems, 72 (6%) had

experienced PE. The last 41 consecutive patients

had been asked whether they had experienced

symptoms of IBS, enuresis, a psychologic

disorder, and/or the feeling of tickling or sexual

pleasure at ejaculation. Of those 41, 18 reported

IBS (43.9% versus 10% in general population; 

P < .001). A reliable answer about the history of

enuresis was obtained in 35 patients, and 14 of

those responses were positive for the disorder

(40% versus 10% in general population; P < .001).

Of the 35 patients who reported enuresis, 6

(17.4%) also reported IBS. Twenty-two (59.5%) of

37 patients reported psychologic problems

including stress, agitation, and/or obsession-

compulsion.

Thirty-three patients had properly answered the

question about experiencing a state of sexual

pleasure or a tickling sensation in the frenulum

at ejaculation, and 17 (51.5%) of those responses

were "yes." The response to touching the

frenulum was stronger than that to touching the

glans, penile shaft, or abdomen in 20 (54.1%) of

37 subjects, and 9 (24.3%) subjects reported that

their response to touching the glans was

stronger.

Discussion

Premature ejaculation is a prevalent

problem(1,2) that elicits concern about impotence

in men and can cause dissatisfaction in their

sexual partner and conflict in that

relationship.(1,3) The prevalence of PE is reported

to be as high as 35% in some studies.(1,3,4) Men

without PE can usually voluntarily postpone

ejaculation after penetration for a time sufficient

to enable the orgasm of the sexual partner, but

that control is absent or too weak in men with

PE.(1,4) Some individuals with PE ejaculate before

sexual contact occurs, and as a result, an erection

firm enough to enable intercourse cannot be

sustained. Achieving pregnancy may be difficult

for some couples as a result.(1-3)

Various authors have defined PE as the

inability to postpone ejaculation until the sexual

partner's orgasm has occurred in at least 50% of

202



Barghi

sexual contacts involving penetration.(1,3)

Premature ejaculation is considered a primary

disease if the patient has experienced episodes of

the disorder during his first sexual encounters.

Premature ejaculation that begins after years of

sexual activity may be caused by a urinary tract

infection, conflict between partners, or neurologic

disorders.(1,14) The presenting complaint of some

patients with PE may be irrelevant; instead of

addressing their sexual dysfunction, they may

refer to the small size of their penis or a concern

about prostate disease, infertility, or low-back

problems.(1,14)

The cause of PE was thought in the past to be

psychologic in origin, and treatment protocols

usually consisted of psychotherapy and

antidepressant drugs.(1,4) The effectiveness of

such therapy and the correlation of PE with

psychologic stress have supported that

approach.(1,5-7,9) However, recent studies and

neurophysiologic investigations suggest that this

disorder may have an organic cause. (4,9) The

oversensitivity of the penis to touch and vibrating

stimulation or the overactivity of ejaculation

center in the brain as a result of stimulation of

the patient's genitalia may contribute to PE.

Investigations with positron emission

tomography have shown that the right prefrontal

cortex (in contrast to other cortical areas)

exhibits increased activity during orgasm. That

phenomenon can be the cause of the activation of

subcortical portions of the brain that potentiate

ejaculation. Thus dysfunction in the right

prefrontal cortex and its impact on the

subcortical area may be a cause of PE.(4,9,15)

Surprisingly, positron emission tomography has

revealed that in patients with IBS, blood

circulation increases in the prefrontal cortex in

association with rectal distention, but in healthy

individuals, blood circulation increases in the

anterior cingulate gyrus when the rectum is

distended. Such hyperemia in the frontal lobe can

cause increased alertness as a result of the

activation of a vigilance network. It seems that

the anterior cingulate gyrus and frontal lobe are

mutually inhibitory, and the dysfunction of this

system may cause increased afferent sense input

from autonomic nervous system.(8,10)

IBS, however, seems to be associated with

sexual dysfunction caused by disease-related

stress and depression, which in turn can

potentiate erectile dysfunction and PE.(10)

However, the association of IBS with sexual

dysfunction remains unsupported by sufficient

evidence, although mood disorders have been

reported in about 80% of patients with IBS.(8) It

has been also demonstrated that a low threshold

of sensory neurons correlates with increased

motility of the intestine and colon in patients

with IBS.(8)

There are also clues about the pathophysiology

of enuresis and its association with PE. Disorders

in central nervous system, particularly that of

pontine reticular formation, may cause a lack of

awareness of bladder distention and may

contribute to the dysfunction of pelvic floor

sphincters,(6,16-19) which may cause, for example,

the relaxation of bladder sphincters during sleep.

Furthermore, a delay in the maturation of

sensory-motor neurons as well as cognitive

dysfunction are prevalent in children with

enuresis.(18,20,21) Attention deficit and

hyperactivity disorder and encopresis (10% to

25%) are also not uncommon in that pediatric

population.(22)

Treatments of PE, IBS, and enuresis have

similar features that address the common

pathophysiologic characteristics of those

disorders. Opioids are effective in the treatment

of PE as well as IBS and enuresis.(23,24) The

effectiveness of using local anesthetics and

condoms to suppress the sensory impulses from

the penis to the central nervous system indicates

an oversensitivity of the  penile skin, a

mechanism characteristic of enuresis and

IBS.(1,25) Drugs such as antidepressants(5-7) or

behavioral conditioning methods such as frequent

intercourse, step-by-step sexual contact, and/or

compression of the penis(1,26) may be successful in

treating PE.

The methods described above affect the central

nervous system. Antidepressants and conditional

methods are also useful in the treatment of

enuresis,(9,10,27) and antidepressants may help to

control IBS by suppressing neural waves from the

intestine to the brain.(7-10) The elimination of

some special foods from the daily diet of patients

with IBS(28) and considering allergens and

hypercalciuria as potential causes of

enuresis(20,29,30) indicate that local sensory

stimulation can influence IBS and enuresis. 

The results of this study are limited by a lack

of retrospective design; the small, nonrandomized

sample size; and the lack of confirmed diagnoses

(especially in patients with concomitant

psychologic problems), and as a result, the

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Premature Ejaculation, Irritable Bowel Syndrome, and Enuresis

association of IBS and/or enuresis with PE

cannot be definitively established. Nevertheless,

the frequency of IBS, enuresis, and psychologic

problems in subjects with PE was significant in

our study, which suggests that those disorders

share common pathophysiologic features.

Conclusion 

Weak control of target organs by the cerebral

cortex and the abnormally low threshold of

sensory neurons in the intestine and genitalia

may be responsible for the severe reaction of the

central nervous system in patients with PE, IBS,

or enuresis. It thus seems reasonable that

patients with those characteristics would be

susceptible to all 3 disorders. However, the

association of PE with IBS and enuresis

suggested in this study requires additional

research. Physicians who remain alert for the

symptoms of those disorders and consider the

possibility of a common pathophysiologic

mechanism of action will provide great help for

their patients so afflicted.

References

1. Wiese AC, McGoal S. Abakong for premature

ejaculation. Abakong Institute for Men's Health.

Available from: http://www.abakong-for-premature-

ejaculation.com/

2. Laumann EO, Gagnon JH, Michael RT, Michaels S. The

social organization of sexuality: sexual practices in the

United States.  Chicago: University Of Chicago Press;

1994. p. 351-76.

3. Masters WH, Johnson VE. Human sexual inadequacy.

Boston: Little, Brown; 1970. p. 16-9.

4. Ozcan C, Ozbek E, Soylu A, Yilmaz U, Guzelipek M,

Balbay MD. Auditory event-related potentials in patients

with premature ejaculation. Urology. 2001;58:1025-9.

5. Chia S. Management of premature ejaculation -- a

comparison of treatment outcome in patients with and

without erectile dysfunction. Int J Androl. 2002;25:301-5.

6. Yilmaz U, Tatlisen A, Turan H, Arman F, Ekmekcioglu

O. The effects of fluoxetine on several neurophysiological

variables in patients with premature ejaculation. J Urol.

1999;161:107-11.

7. Kim SC, Seo KK. Efficacy and safety of fluoxetine,

sertraline and clomipramine in patients with premature

ejaculation: a double-blind, placebo controlled study. J

Urol. 1998;159:425-7.

8. Oivyang C. Irritable bowel syndrome. In: Kasper DL,

Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson

AL, editors. Harrison's principles of internal medicine.

16th ed. New York: McGrow-Hill; 2005. p. 1789-93.

9. Siomopoulos V, Seneczko LO. Heterocyclic

antidepressants in nonpsychiatric disorders. Am Fam

Physician. 1984;29:203-8.

10. Read N. More on Proctalgia Fugax. Prof N Archive. GR

36, January 2000. Gut reaction. The IBS network.

Available from: http://www.ibsnetwork.org.uk/

GutReaction/GutReactionArcRea00.htm

11. Hasler WL, Owyang C. Irritable bowel syndrome. In:

Yamada T, Alpers DH, Laine L, Owyang C, Powell DW,

editors. Textbook of gastroenterology. 3rd ed.

Philadelphia: Lippincott Williams and Wilkins; 1999. 

p. 1884.

12. Tanagho EA. Disorders of the bladder, prostate, and

seminal vesicles.  In: Tanagho EA, McAninch JW,

editors. Smith's general urology. 15th ed. New York:

Lange Medical Books/McGraw-Hill; 2000. p. 648.

13. Wille S.  Primary nocturnal enuresis in children.

Background and treatment. Scand J Urol Nephrol Suppl.

1994;156:1-48.

14. Screponi E, Carosa E, Di Stasi SM, Pepe M, Carruba G,

Jannini EA.  Prevalence of chronic prostatitis in men

with premature ejaculation. Urology. 2001;58:198-202.

15. Tiihonen J, Kuikka J, Kupila J, et al. Increase in cerebral

blood flow of right prefrontal cortex in man during

orgasm. Neurosci Lett. 1994;170:241-3.

16. Tomasi PA, Siracusano S, Monni AM, Mela G, Delitala

G.  Decreased nocturnal urinary antidiuretic hormone

excretion in enuresis is increased by imipramine. BJU

Int. 2001;88:932-7. 

17. Norgaard JP, Hansen JH, Wildschiotz G, Sorensen S,

Rittig S, Djurhuus JC.  Sleep cystometries in children

with nocturnal enuresis. J Urol. 1989;141:1156-9.

18. Hallioglu O, Ozge A, Comelekoglu U, et al.  Evaluation

of cerebral maturation by visual and quantitative

analysis of resting electroencephalography in children

with primary nocturnal enuresis. J Child Neurol.

2001;16:714-8.

19. Kohyama J, Kumada S, Shimohira M, Araki S, Itoh M,

Iwakawa Y.  Nocturnal enuresis and the pontine reticular

formation. Eur Urol. 2000;38:631-4.

20. Husmann DA.  Enuresis. Urology. 1996;48:184-93. 

21. Mimouni M, Shuper A, Mimouni F, Grunebaum M,

Varsano I.  Retarded skeletal maturation in children with

primary enuresis. Eur J Pediatr. 1985;144:234-5.

22. Hublin C, Kaprio J, Partinen M, Koskenvuo M.

Nocturnal enuresis in a nationwide twin cohort. Sleep.

1998;21:579-85.

23. Eledjam JJ, Viel E, Bassoul B, Bruelle P.  Non-analgesic

effects of opioids. Cah Anesthesiol. 1991;39:111-4.

24. Corazziari E.  Role of opioid ligands in the IBS. Can J

Gastroenterol. 1999;13:71-5.

25. Berkovitch M, Keresteci AG, Koren G.  Efficacy of

prilocaine-lidocaine cream in the treatment of premature

ejaculation. J Urol. 1995;154:1360-1.

26. Master WH, Johnson VE. Principles of the new sex

therapy. Am J Psychiatry. 1976;133:548-54.

204



Barghi

27. Steers WD, Lee KS.  Depression and incontinence.

World J Urol. 2001;19:351-7. 

28. Zar S, Kumar D, Kumar D.  Role of food hypersensitivity

in IBS. Minerva Med. 2002;93:403-12. 

29. Valenti G, Laera A, Gouraud S, et al.  Low-calcium diet

in hypercalciuric enuretic children restores AQP2

excretion and improves clinical symptoms. Am J Physiol

Renal Physiol. 2002 ;283:F895-903.

30. Neveus T, Hansell P, Stenberg A.  Vasopressin and

hypercalciuria in enuresis: a reappraisal. BJU Int.

2002;90:725-9.

205