Description of and Relationships among Potential Variables Supported for the Diagnosis of Delayed Ejaculation

Round 1

Reviewer 1 Report

The manuscript is well written, and referenced to the international literature on delayed ejaculation. The results are dense and intelligently commented and discussed, if I may say so. The discussion is in my opinion adequate and allows one to grasp the importance of the results highlighted as well as their limitations. Globally this paper meets the standards expected of a scientific article. If there are shortcomings to be found - or if ideas should be suggested - they are minor and concern more precisely the practical contribution of the research which, through a more precise contextualization of the questions addressed in the article, could be further emphasized.  It is therefore these points that I will adress.

The introduction is logical but - and this is only a minor suggestion - could be extended (i) by recalling the impact of ejaculation disorders on individual and inter-individual psychological functions (ii) by briefly developing the particular status of delayed ejaculation which is a sexual dysfunction but yet valued in the collective imagination (e.g. via pornography): delayed ejaculation is therefore a sexual dysfunction rooted in a particular social context and this context makes it complicated for people who suffer from it to recognize it. If these points are addressed in the discussion (420 et seq.), it would seem appropriate to me to mention them in the introduction and perhaps to develop them further. These points of development would further improve the quality of the article in that they would further emphasize the need for a tool to help patients become aware of their suffering and would open up perspectives for neophyte readers to the full complexity of the problems of male sexual dysfunction. But these points are only suggestions that can (not should) be developed, in my opinion, but they would also allow for further development and opening of the discussion (e.g., l 386 and following). In line with this idea, a paragraph on the difficulty of approaching sexual dysfunctions from the patient's point of view would reinforce the need for a standardized tool: beyond the most relevant measure, the question of a tool with added value in the clinical interactional context of a sexological consultation would thus be highlighted.

In the end - in the very conclusion of the article - the interest of the article is, according to the authors, to have been able to propose, from a limited number of items, a tool for the investigation of delayed ejaculation. If the article aims at developing a measure via the question of useful diagnostic criteria, the literature review quickly overlooks the question of the need for standardized tools for the assessment of sexual dysfunctions and, more specifically, delayed ejaculation. In my opinion, this point could be further developed in order to position the study both with regard to the phenomenon investigated and from the point of view of methodology, always in the logic that I suggested in the first paragraph of my reading. Surprisingly, the reference to the Male Sexual Health Questionnaire (Rosen, 2004) is not mentioned at any point, even though some of the items in this questionnaire address the questions addressed in this research. The point here is not to question the submitted article, but rather to further legitimize the construction of the specific tool that the authors have proposed: it includes items found in the MSHQ and allows us to go further.

Author Response

Reviewer 1

1. The manuscript is well written, and referenced to the international literature on delayed ejaculation. The results are dense and intelligently commented and discussed, if I may say so. The discussion is in my opinion adequate and allows one to grasp the importance of the results highlighted as well as their limitations. Globally this paper meets the standards expected of a scientific article. If there are shortcomings to be found - or if ideas should be suggested - they are minor and concern more precisely the practical contribution of the research which, through a more precise contextualization of the questions addressed in the article, could be further emphasized.  It is therefore these points that I will address.

>>>>>Response: We appreciate the Reviewer’s careful reading of the manuscript and the positive comments above, as well as the thoughtful remarks that follow.

2. The introduction is logical but - and this is only a minor suggestion - could be extended (i) by recalling the impact of ejaculation disorders on individual and inter-individual psychological functions (ii) by briefly developing the particular status of delayed ejaculation which is a sexual dysfunction but yet valued in the collective imagination (e.g. via pornography): delayed ejaculation is therefore a sexual dysfunction rooted in a particular social context and this context makes it complicated for people who suffer from it to recognize it. If these points are addressed in the discussion (420 et seq.), it would seem appropriate to me to mention them in the introduction and perhaps to develop them further. These points of development would further improve the quality of the article in that they would further emphasize the need for a tool to help patients become aware of their suffering and would open up perspectives for neophyte readers to the full complexity of the problems of male sexual dysfunction. But these points are only suggestions that can (not should) be developed, in my opinion, but they would also allow for further development and opening of the discussion (e.g., l 386 and following). In line with this idea, a paragraph on the difficulty of approaching sexual dysfunctions from the patient's point of view would reinforce the need for a standardized tool: beyond the most relevant measure, the question of a tool with added value in the clinical interactional context of a sexological consultation would thus be highlighted.

>>>>>Response: We thank the Reviewer for these insights and have, in response, attempted to provide greater context/description of this particular male sexual dysfunction by adding a paragraph to the end of the first section of the Introduction, lines 53-61.

3. In the end - in the very conclusion of the article - the interest of the article is, according to the authors, to have been able to propose, from a limited number of items, a tool for the investigation of delayed ejaculation. If the article aims at developing a measure via the question of useful diagnostic criteria, the literature review quickly overlooks the question of the need for standardized tools for the assessment of sexual dysfunctions and, more specifically, delayed ejaculation. In my opinion, this point could be further developed in order to position the study both with regard to the phenomenon investigated and from the point of view of methodology, always in the logic that I suggested in the first paragraph of my reading.

>>>>>Response: This point had been made in the first sentence under “Section 1.2 Rationale and Goals, lines 78-79.” We make further reference to this general goal on lines 456-458 of the Discussion. To ensure that the audience understands the value of our study relative to the construction of a validated PRO, we have now added a phrase identifying the lack of such an instrument in the first line of the Abstract, line 11 and have also noted how our findings will help inform the development of an appropriate PRO for DE in the Conclusion section (lines 488-489).

4. Surprisingly, the reference to the Male Sexual Health Questionnaire (Rosen, 2004) is not mentioned at any point, even though some of the items in this questionnaire address the questions addressed in this research. The point here is not to question the submitted article, but rather to further legitimize the construction of the specific tool that the authors have proposed: it includes items found in the MSHQ and allows us to go further.

>>>>>Response: We thank the reviewer for reminding us of the MSHQ. We have now included a brief description and comment on the MSHQ in Section 4.4. “Constructing a Diagnostic Procedure for Assessing DE” (lines 442-445), noting that 2 of the 16 items in this instrument query about delayed/inhibited ejaculation. We have also added the Rosen et al, 2004 reference, line 595-596.

Reviewer 2 Report

This paper is a very thorough and carefully thought out examination of the physical and emotional factors inherent in a delayed/absent ejaculation (DE) situation, and of their mutual correlation. It should be published, as there is a dearth of surveys about DE and its consequent morbidity and infertility implications. It is not intended as a clinical paper I realise, but none the less having the word Diagnosis in the title will attract urological clinicians  As such it is an excellent theoretical paper demonstrating the consequences of DE,. However the paper's title suggests that the authors findings could help in the diagnosis of DE. Can the authors expand on how is this the case? It would be a substantially better and more clinically useful paper for this purpose if the authors could discuss how their results could or should be used in diagnosis of DE.  It would help in this respect if there was an appendix showing the precise wording of the questions in questionniare (just those questions used to elicit the data utilised in their paper) such that others could employ such questions when assessing DE in their research or clinical work. Is it possible also for the authors to derive from their survey, some guidance for diagnostitions about normal ranges or limits relevant to these DE factors for others to use or apply?  

Also in assessing "bothersome and/or distressing" during partnered sex, was this asked about the male feelings only or was the participant asked to include his partner's feelings and distress? 

It is clearly too late to change the questionairre phraseology and content but it is worth noting the reference on line 149 to "male not achieving an orgasm" confuses ejaculation with orgasm. Even in total absence of seminal emission many men still experience a near normal orgasmic sensation - indeed this is a taught feature of Tantric and Taoist sex and of coitus saxonicus. 

Also in the questionnaire, when enquiring about health conditions, did this include asking about associated medication, as much of DE is iatrogenic as has been reported elsewhere? This would be reflected in the questionnaire's reporting of whether DE was of recent or of more long-term  nature. 

Author Response

Reviewer 2

>>>>>We thank the reviewer for taking the time to read our manuscript carefully and for offering thoughtful suggestions

1. This paper is a very thorough and carefully thought-out examination of the physical and emotional factors inherent in a delayed/absent ejaculation (DE) situation, and of their mutual correlation. It should be published, as there is a dearth of surveys about DE and its consequent morbidity and infertility implications. It is not intended as a clinical paper I realise, but none the less having the word Diagnosis in the title will attract urological clinicians.  As such it is an excellent theoretical paper demonstrating the consequences of DE. However, the paper's title suggests that the authors findings could help in the diagnosis of DE. Can the authors expand on how is this the case? It would be a substantially better and more clinically useful paper for this purpose if the authors could discuss how their results could or should be used in diagnosis of DE.  It would help in this respect if there was an appendix showing the precise wording of the questions in questionnaire (just those questions used to elicit the data utilized in their paper) such that others could employ such questions when assessing DE in their research or clinical work. Is it possible also for the authors to derive from their survey, some guidance for diagnostitions about normal ranges or limits relevant to these DE factors for others to use or apply?  

>>>>>Response: The section of the Discussion entitled “4.4. Constructing a Diagnostic Procedure for Assessing DE” (lines 438-462) discusses how the findings from our study represent an important step in developing a diagnostic procedure (and PRO) for assessing DE. We have followed the Reviewer’s suggestion by including the items evaluated in this study in an Appendix (referenced in lines 152-153).

2. Also in assessing "bothersome and/or distressing" during partnered sex, was this asked about the male feelings only or was the participant asked to include his partner's feelings and distress? 

>>>>>Response: Only the respondents were asked this question, since the study did not include responses of the partners. We have noted this as a limitation of our study, lines 476-477.

3. It is clearly too late to change the questionnaire phraseology and content but it is worth noting the reference on line 149 to "male not achieving an orgasm" confuses ejaculation with orgasm. Even in total absence of seminal emission many men still experience a near normal orgasmic sensation - indeed this is a taught feature of Tantric and Taoist sex and of coitus saxonicus. 

>>>>>Response: We acknowledge this potential problem raised by the Reviewer. The lexicon of the questionnaire in most (but not all) instances distinguished between ejaculation and orgasm, and as noted in the Method section (line 115-116), men who chose not to ejaculate for any reason were removed from the study sample. We believe that this exclusion criterion likely tagged most men who might experience orgasm in the absence of ejaculation. Because such men may differ substantially from those who want and/or can and do ejaculate, we felt that exclusion was the best way to handle them.

4. Also in the questionnaire, when enquiring about health conditions, did this include asking about associated medication, as much of DE is iatrogenic as has been reported elsewhere? This would be reflected in the questionnaire's reporting of whether DE was of recent or of more long-term nature. 

>>>>>Response: Yes, as part of the survey question asking about chronic/major health issues, conditions/diseases known to be related to sexual functioning were identified. This question was followed by another item asking about the use of various medications. However, we did not use the information from this second question, as our interest focused on assessing DE rather than exploring its etiology. A reference to this issue had been included in the Limitation section (line 474-475), where we noted the need to address possible differences between men with lifelong vs acquired DE etiologies in a follow-up analysis.