Guidelines –Sexual Medicine
Guidelines on Male Sexual Dysfunction:Erectile Dysfunction and Premature Ejaculation
Konstantinos Hatzimouratidis a ,*,Edouard Amar b ,Ian Eardley c ,Francois Giuliano d ,Dimitrios Hatzichristou a ,Francesco Montorsi e ,Yoram Vardi f ,Eric Wespes g
a 2nd Department of Urology,Aristotle University of Thessaloniki,Thessaloniki,Greece
b Ho
ˆpital Bichat,Paris,France c Pyrah Department of Urology,St.James University Hospital,Leeds,UK
d AP-HP,Neuro-Urology-Andrology,Raymond Poincare
´Hospital,Garches,France e Department of Urology,University Vita-Salute San Raffaele,Scientific Institute H.San Raffaele,Milan,Italy f Department of Neuro-Urology,Rambam Medical Centre and Technion Faculty of Medicine,Haifa,Israel g
Ho
ˆpital Civil de Charleroi,Ho ˆpital Erasme,Urology Department,Brusls,Belgium E U R O P E A N U R O L O G Y X X X (2010)X X X –X X X
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Article info
Article history:
Accepted February 10,2010Published online ahead of print on February 20,2010Keywords:
Erectile dysfunction
Male xual dysfunction Premature ejaculation EAU Guidelines
Abstract
Context:Erectile dysfunction (ED)and premature ejaculation (PE)are the two most prevalent male xual dysfunctions.
Objective:To prent the updated version of 2009European Association of Urology (EAU)guidelines on ED and PE.
Evidence acquisition:A systematic review of the recent literature on the epidemiology,diagnosis,and treatment of ED and PE was performed.Levels of evidence and grades of recommendation were assigned.
Evidence synthesis:ED is highly prevalent,and 5–20%of men have moderate to vere ED.ED shares common risk factors with cardiovascular dia.Diagnosis is bad on medical and xual history,including validated questionnaires.Physical examination and laboratory testing must be tailored to the patient’s complaints and risk factors.Treatment is bad on phosphodiestera type 5inhibitors (PDE5-Is),including sildenafil,tadalafil,and vardenafil.PDE5-Is have high efficacy and safe
ty rates,even in difficult-to-treat populations such as patients with diabetes mellitus.Treatment options for patients who do not respond to PDE5-Is or for whom PDE5-Is are contraindicated include intracav-ernous injections,intraurethral alprostadil,vacuum constriction devices,or implantation of a penile prosthesis.
PE has prevalence rates of 20–30%.PE may be classified as lifelong (primary)or acquired (condary).Diagnosis is bad on medical and xual history asssing intravaginal ejaculatory latency time,perceived control,distress,and interpersonal difficulty related to the ejaculatory dysfunction.Physical examination and laboratory testing may be needed in lected patients only.
Pharmacotherapy is the basis of treatment in lifelong PE,including daily dosing of lective rotonin reuptake inhibitors and topical anaesthetics.Dapoxetine is the only drug approved for the on-demand treatment of PE in Europe.Behavioural techniques may be efficacious as a monotherapy or in combination with pharmacotherapy.Recurrence is likely to occur after treatment withdrawal.Conclusions:The EAU guidelines summari the prent information on ED and PE.The extended version of the guidelines is available at the EAU Web site (www.uroweb/nc/professional-resources/guidelines/online/).
#2010European Association of Urology.Published by Elvier B.V.All rights rerved.
*Corresponding author.2nd Department of Urology,Aristotle University of Thessaloniki,54006,Thessaloniki,Greece.Tel.+302310991543;Fax:+302310676092.E-mail address:kchatzim@ (K.
可交换公司债券
Hatzimouratidis).
0302-2838/$–e back matter #2010European Association of Urology.Published by Elvier B.V.All rights rerved.
doi:10.1016/j.eururo.2010.02.020
1.Introduction
Erectile dysfunction (ED;or impotence)and premature ejaculation (PE)are the two most prevalent complaints in male xual medicine.The most recent summary of the European Association of Urology (EAU)guidelines on ED was published in 2006.The EAU’s Guidelines Office decided to expand the guidelines to include PE.Therefore,the new guidelines include an update of the ED guidelines and a completely new ction on PE bad on a review of available scientific information,
current rearch,and clinical prac-tice in the field.(The extended version of the guidelines is available at the EAU Web site [www.uroweb/nc/professional-resources/guidelines/online/].)Levels of evi-dence and grades of recommendation also were assigned.The aim of this review is to prent a summary of the 2009update of the EAU guidelines on ED and PE.2.
Erectile dysfunction
2.1.
Definition,epidemiology,and risk factors
ED is the persistent inability to attain and maintain an erection sufficient to permit satisfactory xual perfor-mance [1].ED affects physical and psychosocial health and has a significant impact on the quality of life (QoL)of sufferers and their partners and families.Epidemiologic studies of ED suggest that approximately 5–20%of men have moderate to vere ED [2].The difference in reported incidences is probably due to differences in the methodol-ogy and in the age and socioeconomic status of the study populations.
ED shares common risk factors with cardiovascular dia,including lack of exerci,obesity,smoki
ng,hypercholesterolaemia,and metabolic syndrome [3].The risk of ED may be reduced by modifying the risk factors,particularly exercising or losing weight [4].Another risk factor for ED is radical prostatectomy (RP)in any form (open,laparoscopic,or robotic)becau of the risk of cavernosal nerve injury,poor oxygenation of the corpora cavernosa,and vascular insufficiency.Some 25–75%of men undergoing RP experience postoperative ED.Patients being considered for nerve-sparing RP,ideally,should be potent,and the cavernosal nerves must be prerved to ensure erectile function recovery after RP [5].孔仁玉
2.2.Diagnosis and work-up 2.2.1.
Basic work-up
The basic work-up (minimal diagnostic evaluation)out-lined in Fig.1must be performed in every patient with ED [6].Becau of the potential cardiac risks associated with xual activity,the Second Princeton Connsus Conference [7]stratified patients with ED wanting to initiate or resume xual activity into three risk categories.The low-risk group included asymptomatic patients with fewer than three risk factors for coronary artery dia (excluding male gender),mild or stable angina (evaluated and/or being treated),uncomplicated past myocardial infarction,left ventricular
dysfunction or congestive heart failure (New York Heart Association class I),postsuccessful coronary revascularisa-tion,controlled hypertension,and mild valvular dia.All other patients were included in intermediate-or high-risk categories and required a cardiology consultation prior to engaging in xual activity (xual activity for high-risk patients is not recommended).
2.2.2.
Specific examinations and tests
Although most patients with ED can be managed within the primary care tting,some circumstances,prented in Table 1,require specific diagnostic testing [1].Specific diagnostic tests are prented in Table 2.Nocturnal penile tumescence and rigidity testing using Rigiscan should take place for at least two nights.A functional erectile mechanism is indicated by an erectile event of 60%rigidity recorded on the tip of the penis lasting for 10min [8].The intracavernous injection test provides limited information about vascular status;however,duplex ultra-sound provides a simple (albeit intrusive)way of asssing vascular status.Further vascular investigation is unneces-sary if duplex ultrasound is normal,as indicated by a peak systolic blood flow >30cm/s and a resistance index >0.8.If the ultrasound is abnormal,however,arteriography and dynamic infusion cavernosometr
y and cavernosography should be performed only in patients who are potential candidates for vascular reconstructive surgery [9].
A summary of recommendations for the diagnostic work-up of ED is prented in Table 3.
2.3.
Treatment of erectile dysfunction
Only certain types of ED have the potential to be cured with specific treatments.For psychogenic ED,psychoxual therapy may be given either alone or with another
Table 1–Indications for specific diagnostic tests
Patients with primary erectile disorder (not caud by organic dia or psychogenic disorder)
Young patients with a history of pelvic or perineal trauma who could benefit from potentially curative vascular surgery
Patients with penile deformities (eg,Peyronie’s dia,congenital curvature)that might require surgical correction
Patients with complex psychiatric or psychoxual disorders Patients with complex endocrine disorders
Specific tests may also be indicated at the request of the patient or his partner
For medicolegal reasons (eg,penile prosthesis implant,xual abu)
Table 2–Specific diagnostic tests
Nocturnal penile tumescence and rigidity using Rigiscan Vascular studies
样的成语Intracavernous vasoactive drug injection Duplex ultrasound of the cavernous arteries
Dynamic infusion cavernosometry and cavernosography Internal pudendal arteriography
Neurologic studies (eg,bulbocavernosus reflex latency,nerve-conduction studies)
Endocrinologic studies
Specialid psychodiagnostic evaluation
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therapeutic approach,but this therapy takes time and has had variable results [10].
For posttraumatic arteriogenic ED in young patients,surgical penile revascularisation has a 60–70%long-term success rate [11].
For hormonal caus of ED,testosterone replacement therapy is effective but should be ud only after other endocrinologic caus for testicular failure have been excluded.Although some data suggest that testosterone administration does not cau prostate cancer,it is currently contraindicated in men with a history of prostate carcinoma or with symptoms of prostatism.Clo follow-up is neces-sary,including digital rectal examination,rum prostate-specific antigen testing,and haematocrit asssment
as
Fig.1–Basic diagnostic work-up in patients with erectile dysfunction.ED =erectile dysfunction;IIEF =International Index of Erectile Function.
Table 3–Recommendations for the diagnostic work-up of erectile dysfunction (ED)Recommendations
LE
GR
Clinical u of a validated questionnaire related to ED may help asss all xual function domains and the effect of a specific treatment modality.
3B Physical examination is needed in the initial asssment of ED to identify underlying medical conditions associated with ED.4B Routine laboratory tests,including gluco-lipid profile and total testosterone,are required to identify and treat any reversible risk factors and modifiable lifestyle factors.
4B Specific diagnostic tests are indicated by only a few conditions.4
B
LE =level of evidence;GR =grade of recommendation.
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well as monitoring of the development of hepatic or prostatic dia [12].
Although there is some debate,the u of pro-erectile drugs following RP ems important in achieving erectile function following surgery.Several trials have shown higher rates of recovery of post-RP erectile function in patients receiving any phosphodiestera type 5inhibitor (PDE5-I)or intracavernosal injections (therapeutic or prophylactic).Rehabilitation should start as soon as possible following RP [5].Most men with ED will be treated with options that are not cau specific [1].This approach requires a structured treatment strategy that depends on efficacy,safety,invasiveness,and cost as well as patient and partner satisfaction.The choice of treatment options must consider the effects on patient and partner satisfaction and other QoL factors
as well as efficacy and safety.A treatment algorithm for ED is given in Fig.2.面试如何自我介绍
A summary of recommendations for the treatment of ED is prented in Table 4
.
Fig.2–Treatment algorithm for erectile dysfunction (ED).
PDE5=phosphodiestera type 5.
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2.3.1.First-line therapy
2.3.1.1.Oral pharmacotherapy.Three potent lective PDE5-Is
have been approved by the European Medicines Agency for the treatment of ED [13].They are not initiators of erection and require xual stimulation for an erection to occur.Efficacy is defined as rigidity sufficient for vaginal penetration.
秘制酱牛肉Sildenafil (Viagra),launched in 1998,was the first PDE5-I available.It is effective 30–60min from admi
nistration.A heavy fatty meal may reduce or prolong absorption.It is administered in 25-,50-,and 100-mg dos.The recom-mended starting do is 50mg,which is adapted according to patient respon and side-effects.Efficacy may last for up to 12h.In premarketing studies,after 24wk of treatment in a do-respon study,improved erections were reported by 56%,77%,and 84%of men taking 25,50,and 100mg of sildenafil,respectively,compared with 25%of men taking placebo.The efficacy of sildenafil in almost every subgroup of patients with ED has been well established in pre-and postmarketing studies.
Tadalafil (Cialis)was licend for ED in 2003.It is effective from 30min after administration,but its peak efficacy occurs after about 2h.Efficacy is maintained for up to 36h.Its efficacy is not affected by food.It is administered in 10-and 20-mg dos.The recommended starting do is 10mg,which is adapted according to patient respon and side-effects.In premarketing do-respon studies,im-proved erections were reported after 12wk of treatment by 67%and 81%of men taking 10mg and 20mg of tadalafil,respectively,compared with 35%of men taking placebo.The results were confirmed in postmarketing studies.Tadalafil also improved erections in difficult-to-treat subgroups.Vardenafil (Levitra)was licend for ED in 2003.It is effective 30min from administration.A fatty meal (>57%in fat)reduces its effect.It is administered in 5-,10-,and 20-mg dos.The recommended starting do is
10mg,which is adapted according to the respon and side-effects.In vitro,it is 10-fold more potent than sildenafil;however,this does not necessarily mean greater clinical efficacy.In premarketing do-respon studies,improved erections after 12wk of treatment were reported by 66%,76%,and 80%of men taking 5mg,10mg,and 20mg of vardenafil,respectively,compared with 30%of men taking placebo.
Efficacy was confirmed in postmarketing studies.Vardenafil also improved erections in difficult-to-treat subgroups.
2.3.1.1.1.Choice of or preference for different phosphodiestera type 5inhibitors.The choice of a PDE5-I depends on the
frequency of intercour (occasional u or regular therapy,three to four times weekly)and the patient’s personal experience with the agent.Consideration should be given to which drug better fits the patient’s premorbid xual script with his partner to optimi respon.Patients need to know whether a drug is short or long acting,its possible disadvantages,and how to u it.
2.3.1.1.2.On-demand or chronic u of phosphodiestera type 5inhibitors.Although PDE5-Is were initially introduced as on-
demand treatment,in 2008,tadalafil was also approved for continuous,everyday u in 2.5-and 5-mg dos.Two studies [14,15]asssing daily u of 5-and 10-mg tadalafil for 12wk and daily u of 2.5-and 5-mg tadalafil for 24wk showed that daily dosing was well tolerated and signifi-cantly improved erectile function.Similar results have been found in diabetic patients [16].The studies,however,lacked an on-demand treatment arm.Daily tadalafil provides an alternative to on-demand dosing for couples who prefer spontaneous rather than scheduled xual activity or who have frequent xual activity.Daily dosing overcomes the requirement for dosing and xual activity to be temporally linked.Other studies have shown that chronic but not on-demand tadalafil treatment improved endothelial function,with sustained effects after its discontinuation.This finding was confirmed in another study of chronic sildenafil u in men with type 2diabetes [17].In contrast,a randomid clinical study found that once-daily dosing of vardenafil at 10mg/d did not offer any sustainable effect after cessation of treatment compared with on-demand vardenafil in patients with mild to moderate ED [18].
装卸搬运2.3.1.1.3.Adver events.Common adver events include
headache (10–16%),flushing (5–12%),dyspepsia (4–12%),nasal congestion (1–10%),and dizziness (2–3%)[13].Sildenafil and vardenafil have been associated with visual abnormalities in <2%of patient
s,while tadalafil has been
Table 4–Recommendations for the treatment of erectile dysfunction (ED)Recommendations
LE
GR
Lifestyle changes and risk factor modification must precede or accompany ED treatment.
1b A Pro-erectile treatments must be given at the earliest opportunity after radical prostatectomy.1b A If a curable cau of ED is found,treat the cau first.1b B PDE5-Is are first-line therapy.
1a A Daily administration of PDE5-Is may improve results and restore erectile function.
网上祭英烈1b A Inadequate/incorrect prescription and poor patient education are the main caus of a lack of respon to PDE5-Is.3B Testosterone replacement restores efficacy in hypogonadic nonresponders to PDE5-Is.
1b B Apomorphine can be ud in mild to moderate ED,psychogenic ED,or in patients with contraind
ications to PDE5-Is.1b B A vacuum constriction device can be ud in patients with stable relationship.4C Intracavernous injection is cond-line therapy.1b B Penile implant is third-line therapy.
4
C
LE =level of evidence;GR =grade of recommendation;PDE5-I =phosphodiestera type 5inhibitor.
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