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Recommendations
of Erectile Dysfunction:
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1. Obtain
a thorough medical and sexual history for all patients. (Strong)
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2. Use
a validated questionnaire especially Arabic version (if available) related
to ED to assess all sexual function domains and the effect of a specific
treatment modality. (Strong)
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3. Perform
physical examination in the initial assessment of men with ED to identify
underlying medical conditions and comorbid genital disorders that may be
associated with ED (Strong).
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4. Assess
routine laboratory tests, including glucose-lipid profile and total
testosterone, to identify and treat any reversible risk factors and
lifestyle factors that can be modified. (Strong).
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5. Consider
specific diagnostic tests in the initial evaluation only in the presence of
“Indications for specific diagnostic tests” (Strong).
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6. Ensure Including changes in diet, increased
physical activity, stop smoking, improve overall health at or before
treatment of erectile dysfunction. (Strong)
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7. Inform patients regarding approved PDE5Is,
including discussion of benefits and risks/burdens. (Strong).
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8. Use PDE5Is as first-line therapy. The dose
should be titrated to provide optimal efficacy. (Strong)
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9. Consider early rehabilitation programs (use
of PDE5I and VED) post-RP may improve erectile function (Strong).
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10. Inform patients that PDE5Is may be more
effective if combined with testosterone therapy when indicated. (Strong).
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11. Assess patients for, inadequate/incorrect
prescriptions, poor sexual stimulation, and fat meals when not advised (Conditional).
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12. Discuss benefits and risks/burdens
regarding the use of
VED, especially in well-informed older patients with infrequent sexual
intercourse and comorbidity requiring non-invasive, drug-free management of
ED (Conditional)
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13. Perform an in-office injection test. Home
therapy after positive office ICI test (Conditional).
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14. Alprostadil (PGE1) is the best agent
however its cost is a limitation. (Conditional)
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15. Use low intensity shockwave
treatment (LI-SWT) in patients not candidate for oral vasoactive treatment
or non-responders to PDE5Is (Conditional)
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16. Intracavernosal stem cell therapy should be
considered investigational for treatment of ED (Conditional)
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17. Intracavernosal Platelet Rich Plasma should
be considered investigational for ED
treatment (Conditional)
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18. Botulinum Neurotoxin A (BoNT-A): Should
be considered investigational for treatment of ED (Conditional).
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19. Surgery should be
reserved for men in whom less invasive reversible treatment has not
succeeded or is contraindicated or undesirable. Strong
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20. Arterial
revascularization surgery is offered only to select patients with ED who
meet strict clinical and radiographic criteria for surgical success. (Strong)
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21. Vascular surgery
for veno-occlusive dysfunction is no longer recommended. Strong
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22. Use implantation of a penile prosthesis as
third-line therapy if
other treatments fail or based upon patient preference Strong.
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Recommendations of Premature Ejaculation
(PE)
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23. Obtain medical and sexual history to
diagnose and classify PE, which should include assessment of intravaginal
ejaculatory latency time (IELT) (self-estimated), perceived control,
distress, and interpersonal difficulty due to the ejaculatory dysfunction. Strong
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24. Perform physical examination in the initial
assessment of PE to identify anatomical abnormalities that may be
associated with PE or other sexual dysfunctions, particularly erectile
dysfunction (ED). Strong.
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25. Use the patient-reported outcomes tools:
Premature Ejaculation Diagnostic Tool (PEDT) and Arabic Index of Premature
Ejaculation (AIPE) in daily clinical practice. (Conditional)
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26. Laboratory or neuro-physiological tests are
not routine. They should only be directed by specific findings from history
or physical examination. Strong.
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27. Define the subtype of PE and discuss
patient’s expectations thoroughly before starting any treatment. Strong.
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28. Treat the underlying cause (e.g., ED,
prostatitis, LUTS, anxiety, hyperthyroidism) as the initial goal for
patients with acquired PE. Strong.
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29. Consider pharmacotherapy as the first-line
treatment for patients with lifelong PE i.e. dapoxetine Strong.
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30. The use of off-label topical anaesthetic
agents i.e. the lidocaine/prilocaine spray is suggested as a viable
alternative to oral treatment with SSRIs. (Conditional)
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31. Use psychological/behavioural therapies in
combination with pharmacological treatment in the management of acquired
PE. (Conditional).
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32. Use various behavioural techniques in
treating variable and subjective PE (Strong).
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33. The on-demand Tramadol is a weak
alternative to SSRIs. (Conditional).
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34. PDE5Is alone or in combination with other
therapies in patients with PE (without ED) may be used. (Conditional).
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Recommendations for Delayed
Ejaculation (DE)
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35. Perform a thorough analysis of the
complaint to exclude misdiagnosed other sexual dysfunctions stressing
on anorgasmia Strong.
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36. Obtain a detailed medical and sexual
history to exclude risk factors (medications especially SSRIs,
antipsychotics, drug abuse, DM, depression, LUTS, etc) Strong.
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37. Define if DE is lifelong or acquired,
global or situational. Strong.
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38. Assess intravaginal ejaculatory latency
time (IELT) (self-estimated) (Conditional).
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39. Include physical examination in the initial
assessment of DE to identify hypogonadism or anatomical abnormalities that
may be associated with DE or other sexual dysfunctions, particularly
erectile dysfunction Strong.
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40. Request post-coital first voided urine
sample to exclude retrograde ejaculation Strong.
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41. Use specific questionnaires, specialized
laboratory tests and radiologic investigation when indicated only. (Conditional).
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42. If acquired DE, consider stopping or
modifying underlying incriminated drug regimen. Strong.
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43. Improving erectile function and maximizing
stimulation may trigger ejaculation. (Conditional).
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44. Psychosexual therapy can be particularly
helpful in primary DE. (Conditional)
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45. Testosterone replacement in hypogonadal
patients may improve DE. (Conditional)
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46. Cabergoline and bupropion could be
beneficial for some cases of delayed ejaculation. (Conditional).
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47. Use PDE5I treatment significantly improved
ejaculation and orgasm Strong.
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48. Sympathetic α1 receptor agonists may help
ejaculation with variable success rates in non-SCI patients. (Conditional)
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49. Use penile vibratory stimulation or
electro-ejaculation for sperm retrieval in patients with fertility issues
and SCI. Strong.
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Recommendations for Peyronie’s
Disease (PD)
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50. Obtain a detailed history with specific
emphasis on various characteristics of PD, such as onset, duration, course,
pain, deformity, and ED. (Strong)
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51. Perform
physical examination, include assessment of palpable plaques, penile
length, extent of curvature (self-photograph, or pharmacological-induced
erection). Strong.
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52. Do
not use specific PD questionnaire, ultrasound measurement of plaque size in
everyday clinical practice. (Conditional).
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53. erform proper pre-operative counselling
including the available treatment options and the known benefits and risks
of each treatment, and the patient expectation will reduce post treatment
patient dissatisfaction. (Strong)
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54. Use conservative treatment in patients not
fit for surgery or when surgery is not acceptable to the patient. (Conditional).
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55. Consider that intralesional collagenase
injection has shown some outcome benefits in PD management. (Strong).
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56. Offer extracorporeal shockwave treatment in
the active stage of the disease may alleviate penile pain. Do not use
extracorporeal shockwave treatment to improve penile curvature and reduce
plaque size. (Conditional).
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57. Offer penile traction devices and vacuum
devices may reduce penile deformity and increase penile length. (Conditional).
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58. Do not use oral treatment with vitamin E
and tamoxifen for signifiant reduction in penile curvature or plaque size.
(Strong).
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59. Do not offer other oral treatments in
chronic phase of PD (acetyl esters of carnitine, pentoxifylline,
colchicine). (Conditional).
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60. Perform surgery only when PD has been
stable for at least three months (without pain or deformity deterioration),
which is usually the case after twelve months from the onset of symptoms. Strong.
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61. Assess penile length, curvature severity,
erectile function (including response to pharmacotherapy in case of ED) and
patients’ expectations prior to surgery. Strong.
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62. Use tunical shortening procedures,
especially plication techniques as the first treatment option for PD with
adequate penile length, curvature < 60°, absence of special deformities
(hourglass, hinge) and adequate erection. Strong.
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63. Use grafting techniques for patients with
PD with less than adequate penile length, curvature > 60º, presence of
special deformities (hourglass, hinge) and adequate erection. (Strong).
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64. Use penile prosthesis implantation, with or
without any additional procedure (modelling, plication, relaxing parallel
incisions, grafting), in PD patients with ED not responding to
pharmacotherapy. Strong.
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Recommendations for
Priapism
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65. Obtain thorough history, is important in
making diagnosis, etiology and type of priapism. Strong
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66. Perform physical examination of the
genitalia, the perineum and the abdomen. Strong.
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67. Include laboratory investigations, complete
blood count, coagulation profile and arterial blood gases. Strong.
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68. Perform color duplex ultrasound of the
penis and perineum for the differentiation between ischemic and
non-ischemic priapism. Strong.
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69. Use magnetic resonance imaging of the penis
to predict smooth muscle viability in prolonged ischemic priapism. (Strong).
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70. Perform selected pudendal arteriogram when
embolization is planned for the management of non-ischemic priapism. Strong.
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71. Start management of ischaemic priapism as
early as possible (within four to six hours) and follow a stepwise
approach. Strong.
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72. First, decompress the corpora cavernosa by
penile aspiration until fresh red blood is obtained. (Conditional).
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73. Proceed to the next step, which is ICI of a
sympathomimetic drug, in priapism that persists despite aspiration. Strong.
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74. Repeat injections and aspiration for at
least up to 1 hour prior to proceeding with surgical intervention in
patients presenting with a priapism of less than 24 hours. Strong.
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75. Consider more immediate surgical
intervention in ischemic priapism of extended durations (typically greater
than 72h), is unlikely to resolve with ICI therapy alone. Strong.
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76. Perform distal shunt surgical procedures.
Result of proximal procedures in case of failure is questionable. Strong.
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77. Consider insertion of a penile prosthesis
only if priapism episode is > 36 hours, or in cases for which all
other interventions have failed. Strong.
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Recommendations for the treatment of
non-ischemic priapism
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78. Non-ischaemic priapism is not an emergency,
perform definitive management at the discretion of the treating
physician. (Conditional)
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79. Perform superselective arterial
embolization, using temporary material for recurrent nonischaemic priapism Strong
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80. Repeat the procedure with temporary or
permanent material for recurrent nonischaemic priapism following selective
arterial embolization. (Conditional)
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81. Reserve selective surgical ligation of a
fistula as a final treatment option when embolization has failed. (Conditional).
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Recommendations for the treatment of
Stuttering priapism
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82. Treatment of Stuttering priapism, manage
each acute episode similar to that for ischaemic priapism. (Conditional).
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83. Use hormonal therapies (mainly
gonadotropin-receptor hormone agonists or antagonists) and/or
anti-androgens for the prevention of future episodes in patients with
frequent relapses of stuttering priapism. Do not use them before sexual
maturation is reached. (Conditional)
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84. Initiate treatment with phosphodiesterase
type 5 inhibitors in stuttering priapism only when the penis is in its
flaccid state. (Conditional).
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85. Use digoxin, α-adrenergic agonists,
baclofen, gabapentin, or terbutaline only in patients with very
frequent and uncontrolled relapses stuttering priapism. (Conditional).
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86. Use intracavernous self-injections at home
of sympathomimetic drugs until ischaemic priapism has been alleviated. (Conditional).
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