➡️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