Recommendations of Erectile Dysfunction:

1.  Obtain a thorough medical and sexual history for all patients. (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. (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 (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. (Strong).

5. Consider specific diagnostic tests in the initial evaluation only in the presence of “Indications for specific diagnostic tests” (Strong).

6. Ensure Including changes in diet, increased physical activity, stop smoking, improve overall health at or before treatment of erectile dysfunction. (Strong)

7. Inform patients regarding approved PDE5Is, including discussion of benefits and risks/burdens. (Strong).

8. Use PDE5Is as first-line therapy. The dose should be titrated to provide optimal efficacy. (Strong)

9. Consider early rehabilitation programs (use of PDE5I and VED) post-RP may improve erectile function (Strong).

10. Inform patients that PDE5Is may be more effective if combined with testosterone therapy when indicated. (Strong).

11. Assess patients for, inadequate/incorrect prescriptions, poor sexual stimulation, and fat meals when not advised (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 (Conditional)

13. Perform an in-office injection test. Home therapy after positive office ICI test (Conditional).

14. Alprostadil (PGE1) is the best agent however its cost is a limitation. (Conditional)

15. Use low intensity shockwave treatment (LI-SWT) in patients not candidate for oral vasoactive treatment or non-responders to PDE5Is (Conditional)

16. Intracavernosal stem cell therapy should be considered investigational for treatment of ED (Conditional)

17. Intracavernosal Platelet Rich Plasma should be considered investigational for ED treatment (Conditional)

18. Botulinum Neurotoxin A (BoNT-A): Should be considered investigational for treatment of ED (Conditional).

19. Surgery should be reserved for men in whom less invasive reversible treatment has not succeeded or is contraindicated or undesirable. Strong

20.  Arterial revascularization surgery is offered only to select patients with ED who meet strict clinical and radiographic criteria for surgical success. (Strong)

21. Vascular surgery for veno-occlusive dysfunction is no longer recommended. Strong

22.  Use implantation of a penile prosthesis as third-line therapy if other treatments fail or based upon patient preference Strong.

Recommendations of Premature Ejaculation (PE)

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

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.

25. Use the patient-reported outcomes tools: Premature Ejaculation Diagnostic Tool (PEDT) and Arabic Index of Premature Ejaculation (AIPE) in daily clinical practice. (Conditional)

26. Laboratory or neuro-physiological tests are not routine. They should only be directed by specific findings from history or physical examination. Strong.

27. Define the subtype of PE and discuss patient’s expectations thoroughly before starting any treatment. Strong.

28. Treat the underlying cause (e.g., ED, prostatitis, LUTS, anxiety, hyperthyroidism) as the initial goal for patients with acquired PE. Strong.

29. Consider pharmacotherapy as the first-line treatment for patients with lifelong PE i.e. dapoxetine Strong.

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)

31. Use psychological/behavioural therapies in combination with pharmacological treatment in the management of acquired PE. (Conditional).

32.  Use various behavioural techniques in treating variable and subjective PE (Strong).

33. The on-demand Tramadol is a weak alternative to SSRIs. (Conditional).

34. PDE5Is alone or in combination with other therapies in patients with PE (without ED) may be used. (Conditional).

Recommendations for Delayed Ejaculation (DE)

35. Perform a thorough analysis of the complaint to exclude misdiagnosed other sexual dysfunctions stressing on anorgasmia Strong.

36. Obtain a detailed medical and sexual history to exclude risk factors (medications especially SSRIs, antipsychotics, drug abuse, DM, depression, LUTS, etc) Strong.

37. Define if DE is lifelong or acquired, global or situational. Strong.

38. Assess intravaginal ejaculatory latency time (IELT) (self-estimated) (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 Strong.

40. Request post-coital first voided urine sample to exclude retrograde ejaculation Strong.

41. Use specific questionnaires, specialized laboratory tests and radiologic investigation when indicated only. (Conditional).

42. If acquired DE, consider stopping or modifying underlying incriminated drug regimen. Strong.

43. Improving erectile function and maximizing stimulation may trigger ejaculation. (Conditional).

44. Psychosexual therapy can be particularly helpful in primary DE. (Conditional)

45. Testosterone replacement in hypogonadal patients may improve DE. (Conditional)

46. Cabergoline and bupropion could be beneficial for some cases of delayed ejaculation. (Conditional).

47. Use PDE5I treatment significantly improved ejaculation and orgasm Strong.

48. Sympathetic α1 receptor agonists may help ejaculation with variable success rates in non-SCI patients. (Conditional)

49. Use penile vibratory stimulation or electro-ejaculation for sperm retrieval in patients with fertility issues and SCI. Strong.

Recommendations for Peyronie’s Disease (PD)

50. Obtain a detailed history with specific emphasis on various characteristics of PD, such as onset, duration, course, pain, deformity, and ED. (Strong)

51. Perform physical examination, include assessment of palpable plaques, penile length, extent of curvature (self-photograph, or pharmacological-induced erection). Strong.

52. Do not use specific PD questionnaire, ultrasound measurement of plaque size in everyday clinical practice. (Conditional).

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)

54.  Use conservative treatment in patients not fit for surgery or when surgery is not acceptable to the patient. (Conditional).

55.  Consider that intralesional collagenase injection has shown some outcome benefits in PD management. (Strong).

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).

57.  Offer penile traction devices and vacuum devices may reduce penile deformity and increase penile length. (Conditional).

58.  Do not use oral treatment with vitamin E and tamoxifen for signifiant reduction in penile curvature or plaque size. (Strong).

59.    Do not offer other oral treatments in chronic phase of PD (acetyl esters of carnitine, pentoxifylline, colchicine). (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. Strong.

61.    Assess penile length, curvature severity, erectile function (including response to pharmacotherapy in case of ED) and patients’ expectations prior to surgery. 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. 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. (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. Strong.

Recommendations for Priapism

65.    Obtain thorough history, is important in making diagnosis, etiology and type of priapism. Strong

66.    Perform physical examination of the genitalia, the perineum and the abdomen. Strong.

67.    Include laboratory investigations, complete blood count, coagulation profile and arterial blood gases. Strong.

68.    Perform color duplex ultrasound of the penis and perineum for the differentiation between ischemic and non-ischemic priapism. Strong.

69.    Use magnetic resonance imaging of the penis to predict smooth muscle viability in prolonged ischemic priapism. (Strong).

70.    Perform selected pudendal arteriogram when embolization is planned for the management of non-ischemic priapism. Strong.

71.    Start management of ischaemic priapism as early as possible (within four to six hours) and follow a stepwise approach. Strong.

72.    First, decompress the corpora cavernosa by penile aspiration until fresh red blood is obtained. (Conditional).

73.    Proceed to the next step, which is ICI of a sympathomimetic drug, in priapism that persists despite aspiration. 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. 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. Strong.

76.    Perform distal shunt surgical procedures. Result of proximal procedures in case of failure is questionable. 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. Strong.

Recommendations for the treatment of non-ischemic priapism

78.    Non-ischaemic priapism is not an emergency, perform definitive management at the discretion of the treating physician. (Conditional)

79.    Perform superselective arterial embolization, using temporary material for recurrent nonischaemic priapism Strong

80.    Repeat the procedure with temporary or permanent material for recurrent nonischaemic priapism following selective arterial embolization. (Conditional)

81.    Reserve selective surgical ligation of a fistula as a final treatment option when embolization has failed. (Conditional).

Recommendations for the treatment of Stuttering priapism

82.    Treatment of Stuttering priapism, manage each acute episode similar to that for ischaemic priapism. (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. (Conditional)

84.    Initiate treatment with phosphodiesterase type 5 inhibitors in stuttering priapism only when the penis is in its flaccid state.  (Conditional).

85.    Use digoxin, α-adrenergic agonists, baclofen, gabapentin, or terbutaline only in patients with very frequent and uncontrolled relapses stuttering priapism. (Conditional).

86.    Use intracavernous self-injections at home of sympathomimetic drugs until ischaemic priapism has been alleviated. (Conditional).