New guidelines emphasize importance of lifestyle changes, risk factor modification
Current guidelines on male sexual dysfunction issued by the European Association of Urology (EAU) provide an evidence-based update on the evaluation and management of erectile dysfunction (ED) and premature ejaculation (PE). Sections on ED were revised in March, 2013, based on critical review of literature published through January, 2013. Minor changes to recommendations regarding PE were incorporated in 2014. The latest version of the guidelines can be accessed at www.uroweb.org.
The 54-page document includes discussions pertaining to epidemiology, risk factors, evaluation and management of these common male sexual dysfunction disorders. However, key information, including treatment algorithms and evidence level/recommendation grade ratings, is summarized in simple tabular and algorithmic formats.
Recommendations on treatment of ED are adapted from the Princeton Consensus conferences on sexual dysfunction and cardiac risk. They emphasize the importance of appropriate lifestyle changes, risk factor modification, and early use of pro-erectile treatments in men who have undergone radical prostatectomy. Curable causes of ED (testosterone deficiency, post-traumatic arteriogenic ED) should be treated first and psychological dysfunction may be addressed with counselling when initiating therapy.
An oral phosphodiesterase-5 inhibitor (PDE5I) is recommended as first-line therapy for ED, although the guidelines only review sildenafil, tadalafil, and vardenafil, which are the three PDE5Is approved by the European Medicines Agency for the treatment of ED. The guidelines recommended that patients be encouraged to try all three agents to determine which has the greatest efficacy, while taking into account time to onset, duration of action, and adverse effects.
Intracavernous injection is recommended as second-line therapy for ED along with intraurethral alprostadil, which is less invasive but also less effective. Penile implant is recommended as third-line therapy for men who do not respond to pharmacotherapy or who desire a permanent solution.
The guidelines also emphasize the importance of warning patients seeking treatment for ED that sexual intercourse is a vigorous physical activity and of assessing cardiac fitness prior to prescribing treatment.
Diagnosis of PE is based on medical and sexual history and should include self-estimated intravaginal ejaculatory latency time along with physical examination to identify underlying medical conditions that may be associated with PE or other sexual dysfunction. Lab or neurophysiological tests are not recommended for routine evaluation of PE.
Recommendations on treatment of PE identify the need to first address ED, other sexual dysfunction, or genitourinary infection. Pharmacotherapy is considered the basis of treatment in lifelong PE. Psychological/behavioral therapy for PE may be attempted, but there are no clinical data demonstrating it provides prolonged effect. Recommended pharmacotherapy includes dapoxetine on-demand (a short-acting SSRI approved for treatment of PE in some European countries), off-label daily use of other SSRIs or clomipramine antidepressant, or a topical anesthetic agent. The guidelines note that recurrence of PE is likely with treatment cessation.