|
Recommendations for the diagnosis of Erectile Dysfunction:
Recommendations (20-24, 28-41)
|
GRADE Level of certainty
|
Strength Rating
|
1- Obtain a thorough medical and
sexual history for all patients.
|
High
(28-32)
|
(Strong)
|
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.
|
High
(28- 30)
|
(Strong)
|
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.
|
High
(33 – 34)
|
(Strong)
|
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.
|
High
(35-39)
|
Strong)
|
5- Consider specific diagnostic
tests in the initial evaluation only in the presence of “Indications
for specific diagnostic tests”.
|
High
(20-24, 35-41)
|
(Strong)
|
Recommendations for treatment of
ED
|
GRADE Level of certainty
|
Strength Rating
|
6- Ensure Including changes
in diet, increased physical activity, stop smoking, improve overall health
at or before treatment of erectile dysfunction.
|
High
(5, 42,43)
|
Strong
|
7- Inform
patients regarding approved PDE5Is, including discussion of benefits and
risks/burdens.
|
High
(20-24, 42, 44-48)
|
Strong
|
8- Use
PDE5Is as first-line therapy. The dose should be titrated to provide
optimal efficacy.
|
High (20-24, 42, 44-48)
|
Strong
|
9- Consider
early rehabilitation programs (use of PDE5I and VED) post-RP may improve
erectile function.
|
Moderate
(20-24, 49-56)
|
Strong
|
10-
Erectile
Dysfunction and hypogonadism: Inform patients that
PDE5Is may be more effective if combined with testosterone therapy when
indicated.
|
Moderate
(20-24, 57,58)
|
Strong
|
11-
PDE5Is
failure in patients with ED: Assess patients for,
inadequate/incorrect prescriptions, poor sexual stimulation, and fat meals
when not advised.
|
Low
(20-24, 44-48, 59-61)
|
Conditional
|
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.
|
Low
(20-24, 62, 63)
|
Conditional
|
13-
Perform
an in-office injection test. Home therapy after positive office ICI test
|
Low
(20-24, 57, 64)
|
Conditional
|
14-
Alprostadil
(PGE1) is the best agent however its cost is a limitation.
|
Low (57)
|
Conditional
|
15- Use low
intensity shockwave treatment (LI-SWT) in patients not candidate for oral
vasoactive treatment or non-responders to PDE5Is.
|
Low
(20-24, 65-75)
|
Conditional
|
16- Intracavernosal stem cell
therapy should be considered investigational for treatment of ED
|
Low
(20-24)
|
Conditional
|
17-
Intracavernosal Platelet
Rich Plasma should be considered investigational for ED treatment
|
Low
(20, 76-83)
|
Conditional
|
18- Botulinum
Neurotoxin A (BoNT-A): Should be considered investigational for
treatment of ED
|
Low
(20, 84-87)
|
Conditional
|
Recommendations
for Surgical treatment
|
|
|
19- Surgery should be reserved for men in whom less
invasive reversible treatment has not succeeded or is contraindicated or
undesirable.
|
High
(20-24)
|
Strong
|
20-
Arterial
revascularization surgery is offered only to select patients with ED who
meet strict clinical and radiographic criteria for surgical success.
|
Moderate (88-90)
|
Strong
|
21-
Vascular
surgery for veno-occlusive dysfunction is no longer recommended.
|
High
(20-24, 91)
|
Strong
|
22-
Use implantation of a
penile prosthesis as third-line therapy if other treatments
fail or based upon patient preference.
|
High
(92-100)
|
Strong
|
Clinical
Indicators for monitoring:
1. Thorough
medical and sexual history using a validated questionnaire especially Arabic
version.
2. Focused physical examination.
3. Testosterone
and lipid profile.
4. Consider
specific diagnostic tests when indicated.
Recommendation
for assessment and management of Premature Ejaculation
Recommendation
|
GRADE Level of certainty
|
Strength Rating
|
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.
|
High
(101-103)
|
Strong
|
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).
|
High
(101-103)
|
Strong
|
25- Use
the patient-reported outcomes tools: Premature Ejaculation Diagnostic Tool
(PEDT) and Arabic Index of Premature Ejaculation (AIPE) in daily clinical
practice.
|
Low
(104)
|
Conditional
|
26- Laboratory
or neuro-physiological tests are not routine. They should only be directed
by specific findings from history or physical examination.
|
High
(101-103)
|
Strong
|
27- Define
the subtype of PE and discuss patient’s expectations thoroughly before
starting any treatment.
|
High
(101-103)
|
Strong
|
28- Treat
the underlying cause (e.g., ED, prostatitis, LUTS, anxiety,
hyperthyroidism) as the initial goal for patients with acquired PE
|
High
(104)
|
Strong
|
29- Consider
pharmacotherapy as the first-line treatment for patients with lifelong PE
i.e. dapoxetine
|
High
(104-106)
|
Strong
|
30- The
use of off-label topical anesthetic agents i.e. the lidocaine/prilocaine
spray is suggested as a viable alternative to oral treatment with SSRIs.
|
Moderate
(104-106)
|
Conditional
|
31- Use
psychological/behavioural therapies in combination with pharmacological
treatment in the management of acquired PE
|
Low (104-106)
|
Conditional
|
32- Use
various behavioural techniques in treating variable and subjective PE
|
Moderate
(104-106)
|
Strong
|
33- The
on-demand Tramadol is a weak alternative to SSRIs.
|
Low
(104-106)
|
Conditional
|
34- PDE5Is
alone or in combination with other therapies in patients with PE (without
ED) may be used.
|
Low
(104-106)
|
Conditional
|
Clinical
Indicators for monitoring:
1. Medical and sexual history to diagnose and classify
PE, use the patient-reported outcomes tools.
2. Focused physical examination.
3. Routine laboratory with seminal fluid culture and
sensitivity to exclude underlying cause in patients with acquired PE
Recommendations
for assessment of Delayed Ejaculation (107-109)
Recommendation
|
GRADE
Level of certainty
|
Strength
Rating
|
35-
Perform
a thorough analysis of the complaint to exclude misdiagnosed other
sexual dysfunctions stressing on anorgasmia
|
High
107
|
Strong
|
36-
Obtain
a detailed medical and sexual history to exclude risk factors (medications
especially SSRIs, antipsychotics, drug abuse, DM, depression, LUTS, etc)
|
High 107
|
Strong
|
37-
Define
if DE is lifelong or acquired, global or situational.
|
High
107
|
Strong
|
38-
Assess
intravaginal ejaculatory latency time (IELT) (self-estimated)
|
Low
(108-109)
|
Conditional
|
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
|
High
(108-109)
|
Strong
|
40-
Request
post-coital first voided urine sample to exclude retrograde ejaculation.
|
High
(108-109)
|
Strong
|
41-
Use
specific questionnaires, specialized laboratory tests and radiologic
investigation when indicated only.
|
Low
(108-109)
|
Conditional
|
42-
If
acquired DE, consider stopping or modifying underlying incriminated drug
regimen.
|
High
(108-109)
|
Strong
|
43-
Improving
erectile function and maximizing stimulation may trigger ejaculation.
|
Low (108-109)
|
Conditional
|
44-
Psychosexual
therapy can be particularly helpful in primary DE.
|
Low (108-109)
|
Conditional
|
45-
Testosterone
replacement in hypogonadal patients may improve DE.
|
Low (108-109)
|
Conditional
|
46-
Cabergoline
and bupropion could be beneficial for some cases of delayed ejaculation.
|
Low (108-109)
|
Conditional
|
47-
Use
PDE5I treatment significantly improved ejaculation and orgasm.
|
High
(107-109)
|
Strong
|
48-
Sympathetic
α1 receptor agonists may help ejaculation with variable success rates in
non-SCI patients.
|
Low (108-109)
|
Conditional
|
49-
Use
penile vibratory stimulation or electro-ejaculation for sperm retrieval in
patients with fertility issues and SCI.
|
High (108-109)
|
Strong
|
Clinical
Indicators for monitoring:
1. Medical and
sexual history with intravaginal ejaculatory latency time (IELT).
2. Focused physical examination.
3. Define if DE is
lifelong or acquired, global or situational.
4. Specialized
laboratory tests and radiologic investigation when indicated only.
Recommendations for
evaluation and management of Peyronie’s Disease (PD):
Recommendations
|
GRADE
Level of certainty
|
Strength
Rating
|
50. There
is currently no international standard evaluation and treatment for PD and
a detailed history should be obtained with specific emphasis on various
characteristics of PD, such as onset, duration, course, pain, deformity,
ED.
|
Moderate
(20-24, 110-113)
|
Strong
|
51. Physical examination, include assessment of
palpable plaques, penile length, extent of curvature (self-photograph, or
pharmacological-induced erection).
|
High
(20-24, 110-113)
|
Strong
|
52. Do not use specific PD questionnaire,
ultrasound measurement of plaque size in everyday clinical practice.
|
Low
114
|
Conditional
|
53. 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.
|
Moderate
(86,114,115,116)
|
Strong
|
54.
Use conservative
treatment in patients not fit for surgery or when surgery is not acceptable
to the patient.
|
Low (114,115,116)
|
Conditional
|
55.
Intralesional collagenase
injection has shown some outcome benefits in PD management.
|
Moderate
(116)
|
Strong
|
56.
Extracorporeal shockwave
treatment may only be offered in the active stage of the disease to
alleviate penile pain. Do not use extracorporeal shockwave treatment to
improve penile curvature and reduce plaque size.
|
Low
(115)
|
Conditional
|
57.
Use penile traction
devices and vacuum devices to reduce penile deformity and increase penile
length.
|
Low
(114)
|
Conditional
|
58.
Do not use oral treatment
with vitamin E and tamoxifen for significant reduction in penile curvature
or plaque size.
|
High
(20-24,
114)
|
Strong
|
59.
Do not offer other oral
treatments in chronic phase of PD (acetyl esters of carnitine,
pentoxifylline, colchicine).
|
Low
(114)
|
Conditional
|
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.
|
High (20-24,
117,118)
|
Strong
|
61.
Prior to surgery, assess
penile length, curvature severity, erectile function (including response to
pharmacotherapy in case of ED) and patient expectations.
|
High
(20-24,
117,118)
|
Strong
|
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.
|
High
(20-24,
117,118)
|
Strong
|
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.
|
Moderate
(20-24,
117,118)
|
Strong
|
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.
|
High
(20-24,
117,118)
|
Strong
|
Clinical
Indicators for monitoring:
1. Medical and sexual history.
2. Focused physical examination (self-photograph, or pharmacological-induced erection).
3. Penile length, curvature severity, and
erectile function.
Recommendations
for diagnosis of ischemic priapism
Recommendation
|
GRADE
Level of certainty
|
Strength
Rating
|
65.
Obtain
thorough history, is important in making diagnosis, etiology and type of
priapism.
|
High
(119-122)
|
Strong
|
66.
Perform physical
examination of the genitalia, the perineum and the abdomen.
|
High (119-122)
|
Strong
|
67.
Include
laboratory investigations, complete blood count, coagulation profile and
arterial blood gases.
|
High
(119-122)
|
Strong
|
68.
Perform
color duplex ultrasound of the penis and perineum for the differentiation
between ischemic and non-ischemic priapism.
|
High
(119-122)
|
Strong
|
69.
Use
magnetic resonance imaging of the penis to predict smooth muscle
viability in prolonged ischemic priapism.
|
Moderate
(119-122)
|
Strong
|
70.
Perform selected pudendal
arteriogram when embolization is planned for the management of non-ischemic
priapism.
|
High
(119-122)
|
Strong
|
Recommendations
for the treatment of ischemic priapism:
Recommendations
|
GRADE Level of certainty
|
Strength Rating
|
71.
Start management of
ischaemic priapism as early as possible (within four to six hours)
and follow a stepwise approach.
|
High (119-122)
|
Strong
|
72.
First, decompress the
corpora cavernosa by penile aspiration until fresh red blood is obtained.
|
Low
(119)
|
Conditional
|
73.
Proceed to the next step,
which is ICI of a sympathomimetic drug, in priapism that persists despite
aspiration.
|
High (119-122)
|
Strong
|
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.
|
High (119-122)
|
Strong
|
75.
Consider more immediate
surgical intervention in ischemic priapism of extended durations (typically
greater than 72h), is unlikely to resolve with ICI therapy alone.
|
High
(119-122)
|
Strong
|
76.
Perform distal shunt
surgical procedures. Result of proximal procedures in case of
failure is questionable.
|
High (119-122)
|
Strong
|
77.
Consider insertion of a
penile prosthesis only if priapism episode is > 36 hours, or in
cases for which all other interventions have failed.
|
High
(119-122)
|
Strong
|
Recommendations for the treatment of non-ischemic
priapism
Recommendations
|
GRADE Level of certainty
|
Strength Rating
|
78. Perform
definitive management at the discretion of the treating physician,
because non-ischaemic priapism is not an emergency.
|
Low (123-126)
|
Conditional
|
79.
Perform superselective
arterial embolization, using temporary material.
|
High
(20-24)
|
Strong
|
80.
Repeat the procedure with
temporary or permanent material for recurrent nonischaemic priapism
following selective arterial embolization.
|
Low (123-126)
|
Conditional
|
81. Reserve
selective surgical ligation of a fistula as a final treatment option when
embolization has failed.
|
Low (123-126)
|
Conditional
|
Recommendations for the treatment of Stuttering
priapism
Recommendations
|
GRADE Level of certainty
|
Strength Rating
|
82.
Treatment of Stuttering
priapism, manage each acute episode similar to that for ischaemic priapism.
|
Low (119-121)
|
Conditional
|
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.
|
Low (119-121)
|
Conditional
|
84.
Initiate treatment with
phosphodiesterase type 5 inhibitors in stuttering priapism only when the
penis is in its flaccid state.
|
High
(119)
|
Conditional
|
85.
Use digoxin, α-adrenergic
agonists, baclofen, gabapentin, or terbutaline only in patients with
very frequent and uncontrolled relapses stuttering priapism.
|
Low (119-121)
|
Conditional
|
86. Use intracavernous
self-injections at home of sympathomimetic drugs until ischaemic priapism
has been alleviated.
|
Low (119-121)
|
Conditional
|
Clinical
Indicators for monitoring:
1. Medical and sexual history.
2. Focused physical examination.
3. laboratory investigations, complete blood
count, coagulation profile and arterial blood gases.
4. Color duplex ultrasound of the penis and
perineum
|