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

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

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

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

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

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

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

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