Male Sexual Dysfunction

Guidelines Development Group (GDG) of Male Sexual Dysfunction committee.

 Funding:

- No funding resources for the development of the guidelines.

Abbreviation

Description

AIPE

Arabic Index of Premature Ejaculation

ART

Assisted reproductive technology

AUA

American Urological Association

BSSM

British Society for Sexual Medicine

CCH

Collagenase Clostridium histolyticum

CDU

Color duplex ultrasonography

DE

Delayed Ejaculation

DM

Diabetes mellitus

EAU

European Association of Urology

ED

Erectile dysfunction

EDV

End diastolic velocity

EE

Electo-ejaculation

EMA

European Medicines Agency

eNOS

Endothelial nitric oxide synthase

ESWT

Extracorporeal Shockwave Therapy

FDA

Food and drug administration

FSH

Follicular Stimulating Hormone

ICI

Intracavernous injection

ICSI

Intracytoplasmic sperm injection

IELT

Intravaginal ejaculation latency time

IHD

Ischaemic heart disease

IIEF

Iinternational Index of Erectile Function

iNOS

Inducible nitric oxide synthase

ISSM

International Society of Sexual Medicine

IVF

In-vetro fertilization

LH

Luteinizing Hormone

LUTS

Lower urinary tract symptoms

nNOS

Neuronal nitric oxide synthase

NPT

Nocturnal penile tumescence

PD

Peyronie’s disease

PDE5Is

Phosphodiesterase type 5 inhibitors

PE

Premature ejaculation

PEDT

Premature Ejaculation Diagnostic Tool

PGE1

Prostaglandin E 1

PP

Penile prosthesis

PSA

Prostate-specific antigen

PSV

Peak systolic velocity

PVS

Penile vibratory stimulation

QoL

Quality of life

RI

Resistive index

RP

Radical prostatectomy

SCD

Sickle cell disease

SCI

Spinal cord injury

SCs

Stem cells

SSRIs

Selective serotonin reuptake inhibitors

TA

Tunica albuginea

TGF-β1

Transforming growth factor beta 1

VED

Vacuum erection device

VOD

Veno-occlusive dysfunction

1- Erectile Dysfunction (ED): The persistent or recurrent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.

2- Premature Ejaculation: Ejaculation that always or nearly always occurs prior to or within about one minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about three minutes or less (acquired PE).

3- Delayed Ejaculation: Marked delay in ejaculation or marked infrequency or absence of ejaculation on almost all or all occasions (75-100% of the times) of partnered sexual activity without the individual desiring delay persisting for at least 6 months and causing significant distress to the individual.

4- Peyronie’s Disease (PD) is a symptomatic disorder characterized by a constellation of penile symptoms and signs, such as penile pain, curvature, shortening, narrowing, hinge deformity, and palpable plaque with subsequent ED.

5- Priapism is a persistent penile erection for more than four hours and not related to sexual stimulation or relieved by ejaculation. Priapism carries high risk of structural damage to the cavernosal tissue which may lead to permanent ED.

4- Anejaculation: The complete absence of ejaculation either antegrade or retrograde. Caused by failed seminal emission from the seminal vesicles, prostate, and ejaculatory ducts into the urethra. In true anejaculation, there is normal orgasmic sensation and is always associated with central or peripheral nervous system dysfunction or with drugs.

5- Painful Ejaculation: is a condition in which the patient may feel variable degrees of pain during or after ejaculation involving the penis, scrotum, and perineum.

6- Haemospermia: is the presence of blood in the seminal fluid ejaculate. The condition causes anxiety and may indicate underlying pathology in many cases.

 Scope of the guidelines

Sexual health-related issues are wide-ranging and of importance to the overall health and sense of well-being for couples and families, and to the social and economic development of communities and countries. Erectile dysfunction (ED) and disorders of ejaculation are frequent encounters in male sexual medicine in the Middle East with the association of different risk factors and medical comorbidities in Arab region countries. Pharmacological therapies have completely changed the diagnostic and therapeutic approach to ED. This article integrates recent international guidelines with local experience and highlights the apparent lack of congruency between available treatment and communication, cultural, and gender norms of Middle East populations that may inhibit treatment seeking.

The Egyptian Urological Association (EUA) Male Sexual Dysfunction Guidelines aims to present the contemporary evidence for medical practice in Egypt for the diagnosis and treatment of patients suffering from sexual dysfunction.

Recommendations of the Male Sexual Dysfunction

➡️Introduction

Strategies for diagnosis and treatment of male sexual problems should consider the sociocultural factors that influence diagnosis and treatment seeking and engagement behaviours necessary for successful outcomes. Specifically, the detrimental effects of sexual problems on quality of life and the potential benefits of proper diagnosis and treatment should be more widely communicated to diminish the social disgrace associated with sexual problems and their management.

Erectile dysfunction (ED) and premature ejaculation (PE) are the two main complaints in male sexual medicine in the Middle East (1-2). Pharmacological therapies have completely changed the diagnostic and therapeutic approach to ED (3,4). The prevalence of ED is 20–90% among patients with different risk factors and medical comorbidities in Arab region countries and severe ED in patients in this region could be attributed to: (1) the high prevalence of risk factors; (2) the poor control of those risk factors; (3) the delay in seeking medical advice; and (4) the non-compliance with treatment (1-2). Unfortunately, in Arab countries there are no firm data on the true prevalence of sexual dysfunction.  This prompted several investigators in the region to conduct research to identify the magnitude of the current problem (1-2).

This article integrates recent international guidelines with local experience and also highlights the apparent lack of congruency between available treatment and communication, cultural, and gender norms of Middle East populations that may inhibit treatment seeking. We clarified in our recent publication that strategies for diagnosis and treatment should consider the sociocultural factors that influence diagnosis and treatment seeking and engagement behaviours necessary for successful outcomes. Specifically, the detrimental effects of sexual problems on quality of life and the potential benefits of proper diagnosis and treatment should be more widely communicated to diminish the social disgrace associated with sexual problems and their management (5).

Sexual dysfunction issues unique to our region:

-  Infertility and sexual dysfunction: Infertility is negatively linked to sexuality in couples seeking assisted reproductive technology (ART), suggesting the need for integrated management of psychosexual problems (6). Unique to infertile couples in Egypt, like the Arab and Muslim world, the option of donor insemination is not accepted. The challenge of unsuccessful fertility issues in Egyptians may even further have a detrimental effect on the couple's sexual function. Infertility and sexual dysfunction are associated (7). Lack of sexual awareness and education contribute to this problem. Psychosexual management is warrantied in these couples.

-  Unconsummated marriage: A specific situation urologist face in our region is unconsummated marriage. It is a social challenge for the man to deal with his wife's virginity on the wedding night. Such stress may lead to performance anxiety and failure, accumulating into a full-blown ED situation in an otherwise healthy young man. Unconsummated marriage might occur in men with normal erection due to other causes as premature ejaculation, performance anxiety, lack of desire, hypogonadism, lack of knowledge, social pressure, and female factors (8,9). The most common female factor was vaginismus (10). Particular to our regions, male lack of sexual desire may be related to consanguinity (11).

- Polygamy, motives, and sexual dysfunction: Egypt is among the countries where polygamy is legal (12). Polygamy has a psychosexual impact on the first wife, impacting intimacy with her husband and negatively affecting the dynamics of the family that is peculiar to these parts of the world (13). Non-monogamous female drive to sex includes coping mechanisms to keep the partner, maintain self-esteem, and seek higher levels of sexual pleasure (14). Men seek polygamy for a variety of reasons. For example, in a Turkish study, men reported that they had a second wife because of decreased satisfaction of sexual desires by a wife, falling in love with the second wife, and incompatibility with the first wife (15). In the Asian community, a prevalent polygamous practice has many underlying factors (16). These include prestige, economic advantage, social customs, and exposure to commercial sex. While polygamy may negatively affect wives and children, a couple of studies showed that polygamous men have less ED, less premature ejaculation, lower depression scores, and higher sexual satisfaction (15,17).

Other male sexual problems include Premature Ejaculation: Ejaculation that always or nearly always occurs prior to or within about one minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about three minutes or less (acquired PE). Delayed Ejaculation: Marked delay in ejaculation or marked infrequency or absence of ejaculation on almost all or all occasions (75-100% of the times) of partnered sexual activity without the individual desiring delay persisting for at least 6 months and causing significant distress to the individual. Peyronie’s Disease (PD) is a symptomatic disorder characterized by a constellation of penile symptoms and signs, such as penile pain, curvature, shortening, narrowing, hinge deformity, and palpable plaque with subsequent ED. Priapism is a persistent penile erection for more than four hours and not related to sexual stimulation or relieved by ejaculation. Priapism carries high risk of structural damage to the cavernosal tissue which may lead to permanent ED.

➡️Purpose

The Urologic Egyptian Guidelines on Male Sexual Dysfunction aim to present the contemporary evidence for medical practice in Egypt for the diagnosis and treatment of patients suffering from sexual dysfunction.

➡️Scope

The Urologic Egyptian Guidelines on Male Sexual Dysfunction help and guide clinical practitioners to have knowledge of the incidence, pathophysiology, and strategies for diagnosis and treatment of male sexual problems. This document integrates recent international guidelines with local experts’ opinions based on Egyptian healthcare and socioeconomic circumstances. It also reflects the opinions of experts in Sexual Dysfunction and represents state-of-the art references for all clinicians, as of the publication date.

➡️Target audience

The target audience refers to those that deliver or implement the recommendations as well as health policymakers and other stakeholders involved in the adoption, adaptation, and transfer of health policies. The target audience of the guideline should not be misunderstood with the beneficiaries of the interventions or target population described in the guideline.

·  Urologists

·  Dermatologists and Andrologists

·  Family medicine and general practitioners

·  Gynaecologists, psychiatrists and endocrinologists

A comprehensive search for guidelines was undertaken to identify the most relevant guidelines to consider for adaptation.

Inclusion/exclusion criteria followed in the search and retrieval of guidelines to be adapted:

• Selecting only evidence-based guidelines (guideline must include a report on systematic literature searches and explicit links between individual recommendations and their supporting evidence)

• Selecting only national and/or international guidelines

• Specific range of dates for publication (using Guidelines published or updated 2015 and later)

•  Selecting peer reviewed publications only

•  Selecting guidelines written in English language

•  Excluding guidelines written by a single author not on behalf of an organization in order to be valid and comprehensive, a guideline ideally requires multidisciplinary input

• Excluding guidelines published without references as the panel needs to know whether a thorough literature review was conducted and whether current evidence was used in the preparation of the recommendations

The following characteristics of the retrieved guidelines were summarized in a table:

• Developing organisation/authors

• Date of publication, posting, and release

• Country/language of publication

• Date of posting and/or release

• Dates of the search used by the source guideline developers

All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least two members. the panel decided a cut-off point or rank the guidelines (any guideline scoring above 50% on the rigour dimension was retained).

Evidence assessment.

According to WHO handbook for Guidelines we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations (18, 19). GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed information on GRADE is available on the following sites:

• GRADE working group: http://www.gradeworkingroup.org

• GRADE online training modules: http://cebgrade.mcmaster.ca/ 

• GRADE profile software: http://ims.cochrane.org/revman/gradepro

Table 1 Quality of evidence in GRADE

Table 2 Significance of the four levels of evidence

Table 3: Factors that determine How to upgrade or downgrade the quality of evidence

The strength of the recommendation.

The strength of a recommendation communicates the importance of adherence to the recommendation.

Strong recommendations.

With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.

Conditional recommendations.

These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.

When not to make recommendations.

When there is lack of evidence on the effectiveness of an intervention, it may be appropriate not to make a recommendation.

Databases searched included four resource categories:

1. Four international guidelines and recommendations, namely European Association of Urology [EAU], American Urological Association Guidelines [AUA], British Society for Sexual Medicine [BSSM], International Society of Sexual Medicine [ISSM] (20 – 24).

2. Review of several guides, reviews, statements, recommendations, and standards (23 – 25).

3. Relevant Egyptian publications.

4. A panel of 10 high-calibre urologists and andrologists representing different universities, institutions and private practice in Egypt.

Adaptation of the Egyptian cultural aspects, the level of urologists’ capabilities and the availability of well-equipped hospitals were considered in the methodology of diagnosis and different treatment modalities.

Recommendations for the diagnosis of Erectile Dysfunction:

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

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)

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):

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

 Recommendations for the treatment of ischemic priapism:

Recommendations for the treatment of non-ischemic priapism

 Recommendations for the treatment of Stuttering priapism

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

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55-  Sari Motlagh R, Abufaraj M, Yang L, Mori K, Pradere B, Laukhtina E, Mostafaei H, Schuettfort VM, Quhal F, Montorsi F, Amjadi M, Gratzke C, Shariat SF. Penile Rehabilitation Strategy after Nerve Sparing Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Trials. J Urol. 2021 Apr;205(4):1018-1030. doi: 10.1097/JU.0000000000001584. Epub 2021 Jan 14. PMID: 33443457.

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59-  Elkamshoushi AM, Badae NM, Kabary MG, Omar SI. Evaluation of daily avanafil efficacy in improving the endothelial function in Egyptian males with erectile dysfunction. Andrologia. 2021 Feb;53(1):e13833. doi: 10.1111/and.13833. Epub 2020 Oct 28. PMID: 33112433.

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71- Mykoniatis I, Pyrgidis N, Zilotis F, Kapoteli P, Fournaraki A, Kalyvianakis D, Hatzichristou D. The Effect of Combination Treatment With Low-Intensity Shockwave Therapy and Tadalafil on Mild and Mild-To-Moderate Erectile Dysfunction: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial. J Sex Med. 2022 Jan;19(1):106-115. doi: 10.1016/j.jsxm.2021.10.007. Epub 2021 Dec 2. PMID: 34866029.

72-  Kalyvianakis D, Mykoniatis I, Pyrgidis N, Kapoteli P, Zilotis F, Fournaraki A, Hatzichristou D. The Effect of Low-Intensity Shock Wave Therapy on Moderate Erectile Dysfunction: A Double-Blind, Randomized, Sham-Controlled Clinical Trial. J Urol. 2022 Aug;208(2):388-395. doi: 10.1097/JU.0000000000002684. Epub 2022 May 6. PMID: 35830338.

73-  Kalyvianakis D, Mykoniatis I, Memmos E, Kapoteli P, Memmos D, Hatzichristou D. Low-intensity shockwave therapy (LiST) for erectile dysfunction: a randomized clinical trial assessing the impact of energy flux density (EFD) and frequency of sessions. Int J Impot Res. 2020 May;32(3):329-337. doi: 10.1038/s41443-019-0185-0. Epub 2019 Sep 2. PMID: 31474753.

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75-  Rho BY, Kim SH, Ryu JK, Kang DH, Kim JW, Chung DY. Efficacy of Low-Intensity Extracorporeal Shock Wave Treatment in Erectile Dysfunction Following Radical Prostatectomy: A Systematic Review and Meta-Analysis. J Clin Med. 2022 May 14;11(10):2775. doi: 10.3390/jcm11102775. PMID: 35628901; PMCID: PMC9145026.

76-  Towe M, Peta A, Saltzman RG, Balaji N, Chu K, Ramasamy R. The use of combination regenerative therapies for erectile dysfunction: rationale and current status. Int J Impot Res. 2022 Dec;34(8):735-738. doi: 10.1038/s41443-021-00456-1. Epub 2021 Jul 12. PMID: 34253869.

77-  Oudelaar BW, Peerbooms JC, Huis In 't Veld R, Vochteloo AJH. Concentrations of Blood Components in Commercial Platelet-Rich Plasma Separation Systems: A Review of the Literature. Am J Sports Med. 2019 Feb;47(2):479-487. doi: 10.1177/0363546517746112. Epub 2018 Jan 16. PMID: 29337592.

78- Poulios E, Mykoniatis I, Pyrgidis N, Zilotis F, Kapoteli P, Kotsiris D, Kalyvianakis D, Hatzichristou D. Platelet-Rich Plasma (PRP) Improves Erectile Function: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial. J Sex Med. 2021 May;18(5):926-935. doi: 10.1016/j.jsxm.2021.03.008. Epub 2021 Apr 24. PMID: 33906807.

79-  Zaghloul AS, El-Nashaar AM, Said SZ, Osman IA, Mostafa T. Assessment of the intracavernosal injection platelet-rich plasma in addition to daily oral tadalafil intake in diabetic patients with erectile dysfunction non-responding to on-demand oral PDE5 inhibitors. Andrologia. 2022 Jul;54(6):e14421. doi: 10.1111/and.14421. Epub 2022 Mar 17. PMID: 35301742.

80-  Alkandari MH, Touma N, Carrier S. Platelet-Rich Plasma Injections for Erectile Dysfunction and Peyronie's Disease: A Systematic Review of Evidence. Sex Med Rev. 2022 Apr;10(2):341-352. doi: 10.1016/j.sxmr.2020.12.004. Epub 2021 Jul 2. PMID: 34219010.

81- Panunzio A, Labate C, Zacheo F, Orlando R, Rizzo FL, Porcaro AB, Migliorini F, Pagliarulo V, Tafuri A. Platelet-rich plasma intracavernosal injections for the treatment of primary organic erectile dysfunction: a systematic review and meta-analysis of contemporary controlled studies. Int J Impot Res. 2023 Nov 22. doi: 10.1038/s41443-023-00798-y. Epub ahead of print. PMID: 37993601.

82- Fazekas D, Campbell K, Ledesma B, Masterson T. Platelet-rich plasma for erectile dysfunction: a review of the current research landscape. Sex Med Rev. 2023 Sep 27;11(4):369-374. doi: 10.1093/sxmrev/qead032. PMID: 37786350.

83-  Shaher H, Fathi A, Elbashir S, Abdelbaki SA, Soliman T. Is Platelet Rich Plasma Safe and Effective in Treatment of Erectile Dysfunction? Randomized Controlled Study. Urology. 2023 May;175:114-119. doi: 10.1016/j.urology.2023.01.028. Epub 2023 Feb 1. PMID: 36736914.

84- Reddy AG, Dick BP, Natale C, Akula KP, Yousif A, Hellstrom WJG. Application of Botulinum Neurotoxin in Male Sexual Dysfunction: Where Are We Now? Sex Med Rev. 2021 Apr;9(2):320-330. doi: 10.1016/j.sxmr.2020.05.004. Epub 2020 Jul 5. PMID: 32641225.

85-  Ghanem H, Raheem AA, Abdel Rahman IFS, Johnson M, Abdel- Raheem T. Botulinum neurotoxin and its potential role in the treatment of erectile dysfunction. Sex Med Rev 2018;6(1):135– 42. doi:10.1016/j.sxmr.2017.07.008.

86-   Abdelrahman IFS, Raheem AA, Elkhiat Y, Aburahma AA, Abdel-Raheem T, Ghanem H. Safety and efficacy of botulinum neurotoxin in the treatment of erectile dysfunction refractory to phosphodiesterase inhibitors: Results of a randomized controlled trial. Andrology. 2022 Feb;10(2):254-261. doi: 10.1111/andr.13104. Epub 2021 Oct 7. PMID: 34618409.

87-  El-Shaer W, Ghanem H, Diab T, Abo-Taleb A, Kandeel W. Intra-cavernous injection of BOTOX^® (50 and 100 Units) for treatment of vasculogenic erectile dysfunction: Randomized controlled trial. Andrology. 2021 Jul;9(4):1166-1175. doi: 10.1111/andr.13010. Epub 2021 Apr 20. PMID: 33784020.

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Variant

History and clinical examination

Penile blood appearance

Penile blood gas

findings

Color Duplex

ultrasonography

findings

Ischemic priapism

Tender and rigid corpora cavernosa

Corpus cavernosum

testing: blood is hypoxic

and dark in color

pO2> 30 mmHg

pCO2>60 mmHg

pH<7.25

Minimal or absent blood

flow

Nonischemic priapism

Perineal or

penile trauma; non tender, partially tumescent corpora cavernosa

Corpus cavernosum

testing: blood is

oxygenated and red

pO2<90 mmHg

pCO2<40 mmHg

pH=7.4

similar to normal

arterial blood)

Blood flow is normal to

high in velocity

Stuttering (recurrent)

priapism

Similar attacks

Corpus cavernosum

testing: blood is hypoxic

and dark in color

Blood gases:

pO2<30 mmHg; pCO2>60 mmHg

pH <7.25

Minimal or absent

blood flow during acute

priapism; normal blood

flow otherwise

pCO2, partial pressure of carbon dioxide; pO2, partial pressure of oxygen.

Distal shunts

Example

Technique

Percutaneous distal shunts

Winter (corporoglanular)

shunt large biopsy needle is inserted through glans

Ebbehoj (corporoglanular)

shunt #11 blade scalpel is percutaneously passed

T shunt (corporoglanular shunt)

Modified Ebbehoj using #10 blade scalpel and introducing the scalpel rotating it inside 90°

Open distal shunt

Al-Ghorab

A 1 cm incision is made distal to coronal sulcus with

excision of 5 × 5 mm cone segment of distal tunica

albuginea from each corporal body

Burnett ‘snake’ maneuver

Modification of Al-Ghorab shunt. A Hegar dilator is

used to evacuate ischemic blood through a distal

tunical window

Proximal shunts

Open proximal shunt

Quackels or Sacher (corporospongiosal) shunt

In lithotomy position, bulbocavernosus muscle

is dissected from corpus spongiosum and 1 cm

staggered ellipses of tissue are incised/excised

from spongiosal/corporal bodies, and the defects

anastomosed together

Corporo saphenous vein or superficial/deep dorsal vein shunts

Grayhack shunt

The saphenous vein is ligated and anastomosed

with corpora cavernosa

Barry shunt

The superficial or deep dorsal vein is ligated and

anastomosed to the corpora cavernosa