Erectile Dysfunction: AUA Guideline
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Sexual Function/Infertility Erectile Dysfunction: AUA Guideline Arthur L. Burnett, Ajay Nehra, Rodney H. Breau, Daniel J. Culkin, Martha M. Faraday, Lawrence S. Hakim, Joel Heidelbaugh, Mohit Khera, Kevin T. McVary, Martin M. Miner, Christian J. Nelson, Hossein Sadeghi-Nejad, Allen D. Seftel and Alan W. Shindel From the American Urological Association Education and Research, Inc., Linthicum, Maryland Purpose: The purpose of this guideline is to provide a clinical strategy for the Abbreviations and diagnosis and treatment of erectile dysfunction. Acronyms Materials and Methods: A systematic review of the literature using the Pubmed, AEs ¼ adverse events Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was con- ¼ ducted to identify peer-reviewed publications relevant to the diagnosis and AUA American Urological Association treatment of erectile dysfunction. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, ED ¼ erectile dysfunction and Conditional Recommendations with additional statements presented in the EF ¼ erectile function form of Clinical Principles or Expert Opinions. ICI ¼ intracavernous injection Results: The American Urological Association has developed an evidence-based IU ¼ intraurethral guideline on the management of erectile dysfunction. This document is PDE5i ¼ phosphodiesterase type designed to be used in conjunction with the associated treatment algorithm. 5 inhibitors Conclusions: Using the shared decision-making process as a cornerstone for TD ¼ testosterone deficiency care, all patients should be informed of all treatment modalities that are not VED ¼ vacuum erection device contraindicated, regardless of invasiveness or irreversibility, as potential first- line treatments. For each treatment, the clinician should ensure that the man Accepted for publication May 3, 2018. and his partner have a full understanding of the benefits and risk/burdens The complete unabridged version of the associated with that choice. guideline is available at http://jurology.com/. This document is being printed as submitted independent of editorial or peer review by the Key Words: physiological sexual dysfunction, men’s health, cardiovascular editors of The Journal of UrologyÒ. diseases, clinical decision/making, psychological sexual dysfunction BACKGROUND The Panel believes that shared The sexual response cycle is decision-making is the cornerstone of conceptualized as a sequential series the treatment and management of of psychophysiological states that ED, a model that relies on the con- usually occur in an orderly progres- cepts of autonomy and respect for sion. These phases were character- persons in the clinical encounter. It is ized by Masters and Johnson as also a process in which the patient desire, arousal, orgasm, and resolu- and the clinician together determine tion. Erectile dysfunction (ED) can the best course of therapy based on be conceptualized as an impairment a discussion of the risks, benefits in the arousal phase of sexual and desired outcome. Using this response and is defined as the approach, all men should be informed consistent or recurrent inability to of all treatment options that are not attain and/or maintain penile erec- medically contraindicated to deter- tion sufficient for sexual satisfaction, mine the appropriate treatment. including satisfactory sexual Although many men may choose to performance.1,2 begin with the least invasive option, 0022-5347/18/2003-0633/0 https://doi.org/10.1016/j.juro.2018.05.004 ® THE JOURNAL OF UROLOGY Vol. 200, 633-641, September 2018 www.jurology.com j 633 Ó 2018 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 634 AUA GUIDELINE ON ERECTILE DYSFUNCTION the Panel notes that it is valid for men to begin with family history of vascular disease, and substance any type of treatment, regardless of invasiveness use. Key questions regarding ED include identifying or reversibility. Men also may choose to forego the onset of symptoms, symptom severity, degree of treatment. In each scenario, the clinician’s role is bother, specification of whether the problem involves to ensure that the man and his partner have a attaining and/or maintaining an erection, situational full understanding of the benefits and risks/burdens factors (e.g., occurring only in specific contexts, only of the various management strategies (see when with a partner, only with specific partners), the supplementary figure, http://jurology.com/). presence of nocturnal and/or morning erections, the presence of masturbatory erections, and prior use of erectogenic therapy.6 The presence of nocturnal and/ GUIDELINE STATEMENTS or morning erections suggests (but does not confirm) For more information on the American Urological a psychogenic component to ED symptoms that Association (AUA) nomenclature system that was would benefit from further investigation. used to arrive at statement type and body of evi- Vital signs including pulse and resting blood dence strength see table 1 in the supplementary pressure should be assessed. Genital examination unbridged guideline (http://jurology.com/). should include assessment of penile skin lesions and 1. Men presenting with symptoms of ED placement/configuration of the urethral meatus. should undergo a thorough medical, sexual Examination of the penis for occult deformities or and psychosocial history, a physical exami- plaque lesions should occur with the penis held nation, and selective laboratory testing. stretched and palpated from the pubic bone to the (Clinical Principle) coronal sulcus.7 The presence/absence of a palpable 2. For the man with ED, validated ques- plaque should not be taken as definitive evidence for tionnaires are recommended to assess the clinically relevant penile deformity such as Peyro- severity of ED, to measure treatment effec- nie’s Disease. If Peyronie’s Disease is suspected, tiveness, and to guide future management. then additional diagnostic procedures should be (Expert Opinion) undertaken. Digital rectal examination is not 3. Men should be counseled that ED is a risk required for evaluation of ED; however, benign marker for underlying cardiovascular disease prostate hyperplasia is a common comorbid condi- (CVD) and other health conditions that may tion in men with ED and may merit evaluation and warrant evaluation and treatment. (Clinical treatment. Principle) With the possible exception of glucose/hemoglo- 4. In men with ED, morning serum total bin A1c and serum lipids, no routine serum study is testosterone levels should be measured. likely to alter ED management. Serum total (Moderate Recommendation; Evidence Level: testosterone should be measured in all men with ED Grade C) to determine if testosterone deficiency (TD), defined 5. For some men with ED, specialized as total testosterone <300 ng/dL with the presence testing and evaluation may be necessary to of symptoms and signs, is present. For complete guide treatment. (Expert Opinion) information on TD, please see the AUA guideline on 6. For men being treated for ED, referral to the evaluation and management of testosterone a mental health professional should be deficiency.8 considered to promote treatment adherence, Psychological factors (e.g., depression, anxiety, reduce performance anxiety, and integrate relationship conflict) and psychosexual issues may treatments into a sexual relationship. (Mod- be primary or secondary contributors to ED.9,10 erate Recommendation; Evidence Level: Thoughtful discussion of these issues with men Grade C) and their partners is a key component of patient When the man’s presenting concern is ED, a education and can promote acceptance of incorpo- comprehensive evaluation and targeted physical rating a mental health/sexuality expert into the exam should be performed. Given that many men are treatment plan. Psychotherapy and psychosexual uncomfortable broaching sexual concerns with a counseling focus on helping patients and their physician, it is critical that the physician initiate the partners improve communication about sexual inquiry.3 Validated questionnaires may provide an concerns, reducing anxiety related to entering and opportunity to initiate a conversation about ED; during a sexual situation, and introducing strate- examples include the Erection Hardness Score4 and gies for integrating ED treatments into their sexual the Sexual Health Inventory for Men.5 General relationship. For men with predominantly psycho- medical history factors to consider when a man pre- genic ED, providers should offer a referral to a sents with ED are age, comorbid medical and psy- psychotherapist as either an alternative or adjunct chological conditions, prior surgeries, medications, to medical treatment to ED. AUA GUIDELINE ON ERECTILE DYSFUNCTION 635 Risk markers are attributes that predict 8. Men with ED should be informed increased probability of a disease state but are not regarding the treatment option of an FDA- part of the causal pathway; ED is a risk marker for approved oral phosphodiesterase type 5 systemic cardiovascular disease. The Princeton inhibitor (PDE5i), including discussion of Consensus Conference, an inter-specialty meeting benefits and risks/burdens, unless contra- centered on preserving cardiac function and opti- indicated. (Strong Recommendation; Evi- mizing sexual health, has identified ED as a sub- dence Level: Grade B) stantial independent risk marker for cardiovascular 9. When men are prescribed an oral PDE5i disease. Findings from the