Erectio praecox or premature erection is a clinically important and specific clinical feature of lifelong PE [4]. Men with erectio praecox get an erection “too early”. This subtle symptom of lifelong PE has never been quoted in sexological literature until 2002, when Waldinger [2] reintroduced the term, thereby noting that many men with lifelong PE report this phenomenon either spontaneously or when asked for it. The phenomenon is so subtle, that men with lifelong PE may not be aware of it. It is not strange that it is noted by their female partner when she has had previous sexual experiences with men who did not have lifelong PE. However, until now there has not been any evidence based research into this remarkable and completely underreported clinical phenomenon, although we are currently investigating its occurrence in men with lifelong PE.

In 2014, Waldinger [8] noted that the new triad of “ejaculatio praecox”, “erectio praecox” and “detumescentia praecox” as part of the acute “hypertonic or hypererotic” state of lifelong PE necessitates an adaptation of his neurobiological hypothesis of 1998 [26]. The hypertonic state indicates that lifelong PE is not only characterized by a diminished serotonergic neurotransmission and a disturbance of 5-HT_1A and 5-HT_2C receptor functioning causing a disturbed serotonergic modulation of the IELT [8]. Based on currently available neurobiological knowledge on ejaculation, erectile functioning, and sexual arousal, Waldinger speculated that lifelong PE—when characterized by an acute hypertonic phenotype—is mediated by a more complex interaction of the central nervous system, the peripheral nervous system and the endocrinological system [8, 28]. Therefore, it would have to include serotonergic and other neurotransmitter and endocrinological processes—e.g., increased oxytocinergic, and/or increased dopaminergic neurotransmission, decreased prolactinergic functioning and increased activity of gonadotrophic factors [8, 28]. Also involved is the peripheral nervous system , e.g., the sympathetic and parasympathetic nervous system [8, 28]. What needs to be investigated is any interaction between all these factors which may give rise to a very rapidly occurring “overactivated” or “hypertonic” state of the genital area in relation to the sense organs [8]. New neurobiological and pharmacological research is required to unravel the factors mediating this hypertonic state of lifelong PE. The remarkable phenomenon that SSRIs induce much less erectile dysfunction and decreased libido in men with lifelong PE compared to depressed patients without lifelong PE, may well be related to the fact that these drugs diminish the hypertonus state of erection, ejaculation and arousal toward a more “normal” state represented by “normal” sexual functioning [8].

In recent years, research into oxytocinergic, dopaminergic, and endocrinological factors related to PE has been conducted by a number of research groups [25, 54–58]. However, their attention has not been directed to the hypertonic state of lifelong PE. But hopefully, the integration of neurobiological and endocrinological knowledge to elucidate the acute co-occurrence of premature ejaculation, premature erection, premature detumescence, and the acute hypererotic state, will become a new focus of research in the current decade [8].

The diagnosis of PE and the diagnosis of the four PE subtypes are not difficult as long as one is interested in diagnosing PE and spend time (at least 30 min) to talk with the patient. Questionnaires on PE should never replace the face to face contact of the physician and his PE patient.

So far, five validated questionnaires have been developed and published to date [66]. Currently, there are two questionnaires that have extensive databases meeting most of the criteria for test development and validation: The Premature Ejaculation Profile (PEP) [67] and the Index of Premature Ejaculation (IPE) [68]. A third brief diagnostic measure (PEDT) has also been developed, has a modest database and is available for clinical use [69, 70]. Two other measures, The Arabic Index of Premature Ejaculation and Chinese Index of Premature Ejaculation [71, 72] have minimal validation or clinical trial data available [66]. Importantly, the aforementioned questionnaires are sensitive for complaints of PE, but are inadequate to diagnose any of the four PE subtypes. Therefore, new research for the development of PE Subtype specific questionnaires is warranted.

Ignoring the PE classification of Bernard Schapiro in lifelong and acquired PE is not solely a tragic phenomenon of the past. Even today the danger exists that long standing hard characteristics of lifelong PE and its accurate research are ignored or become distorted. For example, a cohort of men with lifelong PE usually includes about 90% of males who ejaculate within 1 min and about 10% of males who ejaculate within 1–2 min [13]. A distortion of these percentages will be formed by studies of lifelong PE in which substantially more than 10% of men ejaculate within 1–2 min and less than 90% ejaculate within 1 min. Therefore it is better for scientific research to only include men who ejaculate within about 1 min, on the condition that IELT is measured by a stopwatch. Another danger for scientific research of lifelong PE is formed when one only uses validated or non-validated questionnaires to measure the IELT. For example, recently Ventus et al. [73] argued on the basis of a retrospective questionnaire study among a very small sample of Finnish twins and patients that the term lifelong PE is probably inappropriate as very few participants subjectively reported a bit longer IELT duration on a questionnaire than at baseline questionnaire measurement ignoring the subjective and inaccurate way of their IELT assessment. The consequences of such attempts to ignore or distort the existence of lifelong PE extremely threatens the scientific research of PE in general and will enormously harm the patient with lifelong PE [74].

In an editorial, Waldinger [74] has recently expressed his concern on current research of Lifelong PE, noting that PE research seems more and more to become performed by clinically inexperienced individuals who do not talk to or see patients with PE, do not have clinical experience with PE patients, but who sit behind their PCs, play with statistical programs, try to intimidate clinicians and reviewers with validated questionnaires, selectively choose references, and omit or ignore important information that does not support their view. Particularly, ignoring the necessity of using a stopwatch for accurate IELT research, ignoring the IELT cutoff point of 1 min for inclusion of men with lifelong PE in a study, and with regard to genetic research ignoring the importance of Hardy Weinberg equilibrium endangers the evidence based clinical, pharmacological and genetic research of lifelong PE.

But not only that. Research of lifelong PE that is solely performed by validated questionnairs without face to face contact with a patient with lifelong PE ought to be discouraged [74]. Particularly, studies in which anonymous men are recruited by Internet and are solely investigated by validated questionnaires and become diagnosed as lifelong PE endanger objective research of lifelong PE.

The study of Ventus et al. [73] and the study of Zhu et al. [75] are good examples to which erroneous but catastrophic conclusions such studies can lead. For example, according to the study of Ventus et al. [73] the authors suggest that lifelong PE is an inappropriate diagnosis. And according to Zhu et al. [75] 5-HTTLPR is associated with lifelong PE and L alleles might protect the male against lifelong PE.

Fortunately, the serious limitations and erroneous conclusions of these studies have been reported by other authors [49, 74]. But nevertheless, research of lifelong PE remains endangered by studies that only use validated questionnaires, include anonymous patients, ignore the stopwatch and objective real-time measurement of the IELT.