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EAU GUIDELINES ON MALE SEXUAL DYSFUNCTION: Erectile Dysfunction and Premature Ejaculation
(Limited text update March 2017)
K. Hatzimouratidis (Chair), F. Giuliano, I. Moncada, A. Muneer, A. Salonia (Vice-chair), P. Verze
Guideline Associates: A. Parnham, E.C. Serefoglu
Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Erectile dysfunction may affect physical and psychosocial health and may have a significant impact on the quality of life (QoL) of sufferers and their partners. There is increasing evidence that ED can also be an early manifestation of coronary artery and peripheral vascular disease; therefore, ED should not be regarded only as a QoL issue, but also as a potential warning sign of cardiovascular disease (CVD).
Table 1: Pathophysiology of erectile dysfunction
Cardiovascular disease (hypertension, coronary artery disease, peripheral vasculopathy, etc.)
Major pelvic surgery (RP) or radiotherapy (pelvis or retroperitoneum)
Degenerative disorders (multiple sclerosis, Parkinson’s
disease, multiple atrophy, etc.)
Spinal cord trauma or diseases
Central nervous system tumours
Type 1 and 2 diabetes mellitus
Chronic renal failure
Surgery (major surgery of pelvis/retroperitoneum)
Surgery of the urethra (urethral stricture, urethroplasty, etc.)
Anatomical or structural
Hyper- and hypothyroidism
Hyper- and hypocortisolism (Cushing’s disease, etc.)
Panhypopituitarism and multiple endocrine disorders
Antihypertensives (thiazide diuretics, etc.)
Antidepressants (selective serotonin reuptake inhibitors, tricyclics)
Antipsychotics (neuroleptics, etc.)
Antiandrogens (GnRH analogues and antagonists)
Recreational drugs (alcohol, heroin, cocaine, marijuana, methadone, synthetic drugs, anabolic steroids, etc.)
Generalised type (e.g., lack of arousability and disorders of sexual intimacy)
Situational type (e.g., partner-related, performance-related issues or due to distress)
Figure 1: Minimal diagnostic evaluation (basic work-up) in patients with erectile dysfunction
ED=erectile dysfunction; IIEF=International Index of Erectile Function.
Table 2: Cardiac risk stratification (based on 2nd Princeton Consensus)
Asymptomatic, < 3 risk factors for CAD (excluding sex)
≤ 3 risk factors for CAD (excluding sex)
Mild, stable angina (evaluated and/or being treated)
Moderate, stable angina
Unstable or refractory angina
Uncomplicated previous MI
Recent MI (> 2, < 6 weeks)
Recent MI (< 2 weeks)
LVD/CHF (NYHA class I or II)
LVD/CHF (NYHA class III)
LVD/CHF (NYHA class IV)
Post-successful coronary revascularisation
Non-cardiac sequelae of atherosclerotic disease (e.g., stroke, peripheral vascular disease)
Hypertrophic obstructive and other cardiomyopathies
Mild valvular disease
Moderate-to-severe valvular disease
CAD=coronary artery disease; CHF=congestive heart failure; LVD=left ventricular dysfunction; MI=myocardial infarction; NYHA=New York Heart Association.
Table 3: Indications for specific diagnostic tests
Primary ED (not caused by organic disease or psychogenic disorder).
Young patients with a history of pelvic or perineal trauma, who could benefit from potentially curative revascularisation surgery or angioplasty.
Patients with penile deformities that might require surgical correction (e.g., Peyronie’s disease, congenital penile curvature).
Patients with complex psychiatric or psychosexual disorders.
Patients with complex endocrine disorders.
Specific tests may be indicated at the request of the patient or his partner.
Medico-legal reasons (e.g., implantation of penile prosthesis to document end stage ED, sexual abuse).
Table 4: Specific diagnostic tests
Nocturnal Penile Tumescence and Rigidity (NPTR) using Rigiscan®
- Intracavernous vasoactive drug injection
- Penile Dynamic Duplex Ultrasonography
- Penile Dynamic Infusion Cavernosometry and Cavernosography
- Internal pudendal arteriography
Neurological studies (e.g., bulbocavernosus reflex latency, nerve conduction studies)
Specialised psychodiagnostic evaluation
Recommendations for the diagnostic
evaluation of erectile dysfunction
Take a comprehensive medical and sexual history in every patient.
Use a validated questionnaire related to erectile dysfunction to assess all sexual function domains and the effect of a specific treatment modality.
Include a physical examination in the initial assessment of men with ED to identify underlying medical conditions that may be associated with ED.
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.
Include specific diagnostic tests in the initial evaluation only in the presence of the conditions presented in Table 3.
Figure 2: Treatment algorithm for erectile dysfunction
Table 5: Summary of the key pharmacokinetic data for the four PDE5 inhibitors currently EMA-approved to treat erectile dysfunction*
Sildenafil, 100 mg
Tadalafil, 20 mg
Vardenafil, 20 mg
* Fasted state, higher recommended dose. Data adapted from EMA statements on product characteristics.
Cmax: maximal concentration, Tmax: time-to-maximum plasma concentration; T1/2: plasma elimination halftime; AUC: area under curve or serum concentration time curve.
Table 6: Common adverse events of the four PDE5Is currently EMA-approved to treat ED*
* Adapted from EMA statements on product characteristics.
Recommendations for the treatment of erectile dysfunction (ED)
Enact lifestyle changes and risk factor modification prior to or accompanying ED treatment.
Start pro-erectile treatments at the earliest opportunity after radical prostatectomy.
Treat a curable cause of ED first, when found.
Use phosphodiesterase type 5 inhibitors (PDE5Is) as first-line therapy.
Assess all patients for inadequate/incorrect prescriptions and poor patient education, since they are the main causes of a lack of response to PDE5Is.
Use vacuum erection devices as a first-line therapy in well-informed older patients with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED.
Use intracavernous injections as second-line therapy.
Use implantation of a penile prosthesis as third-line therapy.
PREMATURE EJACULATION (PE)
Although PE is a common male sexual dysfunction, it is poorly understood. Patients are often unwilling to discuss their symptoms and many physicians do not know about effective treatments. As a result, patients may be misdiagnosed or mistreated.
PE (lifelong and acquired) is a male sexual dysfunction characterised by the following:
1.Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE);
Recommendations for the diagnostic
evaluation of premature ejaculation (PE)
Perform the diagnosis and classification of premature ejaculation (PE) based on medical and sexual history, which should include assessment of intravaginal ejaculatory latency time (IELT) (self-estimated), perceived control, distress and interpersonal difficulty due to the ejaculatory dysfunction.
Do not use stopwatch-measured IELT in clinical practice.
Do not use patient-reported outcomes in clinical practice.
Include 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.
Do not perform routine laboratory or neurophysiological tests. They should only be directed by specific findings from history or physical examination.
Recommendations for the treatment of premature ejaculation (PE)
Treat erectile dysfunction, other sexual dysfunction or genitourinary infection
Use pharmacotherapy as first-line treatment of lifelong PE.
Use off-label topical anaesthetic agents as a viable alternative to oral treatment with selective serotonin re-uptake inhibitor (SSRIs).
Use tramadol on demand as a weak alternative to SSRI’s.
Do not use PDE5Is in patients with premature ejaculation without erectile dysfunction.
Use psychological/behavioural therapies in combination with drug treatment in the management of acquired PE.
Figure 3: Management of premature ejaculation*
* Adapted from Lue et al. 2004.
ED=erectile dysfunction; PE=premature ejaculation;
IELT=intravaginal ejaculatory latency time; SSRI=selective serotonin receptor inhibitor.
This short booklet text is based on the more comprehensive EAU Guidelines (ISBN 978-90-79754-91-5), available to all members of the European Association of Urology at their website, http://www.uroweb.org/guidelines.