• AACE Male Sexual Dysfunction Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of male sexual dysfunction: a couple's problem--2003 update. Endocr Pract 2003 Jan-Feb;9(1):77-95. [26 references]

This is the current release of the guideline.

This guideline updates a previous version: American Association of Clinical Endocrinologists (AACE), American College of Endocrinology. AACE clinical practice guidelines for the evaluation and treatment of male sexual dysfunction. Endocr Pract 1998 Jul-Aug;4(4):219-35.

Male sexual dysfunction

Diagnosis
Evaluation
Management
Treatment

Endocrinology

Physicians

To present a framework for the evaluation, treatment, and follow-up of the patient and couple who present with sexual dysfunction

Men with sexual dysfunction

Diagnosis/Evaluation

1. Initial assessment of relevant medical, psychological, and hormonal factors of the male patient and his partner
2. Sexual history, medical history, and physical examination
3. Diagnostic tests (i.e., blood chemistry, vascular assessment, sensory studies, nocturnal penile tumescence and rigidity testing)

Treatment/Management

1. Psychological therapy, referral to sex therapist
2. Medical treatment, if applicable: plasma glucose control, hypertension control, tobacco use cessation, hyperlipidemia therapy, alcohol intake decrease or discontinuation, and illicit drug discontinuation
3. Changing or stopping offending medications
4. Testosterone therapy: injection, scrotal/nonscrotal patches
5. Major nonspecific treatment options: yohimbine tablets, vacuum pump devices, venous constriction rings, corpora cavernosal injections of various chemicals, intraurethral drug suppositories, intrapenile arterial or venous surgical procedures, penile implants, or orally administered phosphodiesterase inhibitors (sildenafil)
6. Urology consult for surgical options

Not stated

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Searches of Index Medicus and Pub Med were performed. Articles retrieved were supplemented by material from the personal libraries of the committee members.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Meta-Analyses and Reviews > Randomized controlled studies > Observational studies > Expert opinions (in order of most weight)

Review

Not stated

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Twelve physicians are acknowledged as reviewers in the guideline document.

System of Care for Male Sexual Dysfunction

Step 1: Accurate history (preferably with the couple)

1. Make sure concerns are not just aging-related changes
2. Inquire about relationship problems
3. Question about performance anxiety

   Action: Reassure if A
   Send to sex therapist if B or C
   Do nocturnal penile test if uncertain.

4. Outline medical risk factors and medications

   Action: Change or discontinue medications
   Stop any substance abuse

Step 2: General examination

1. Blood pressure
2. Breasts for gynecomastia
3. Secondary sex characteristics
4. Peripheral circulation
5. Genital examination
   Especially for penile fibrosis, testicular atrophy, bulbocavernosal reflex
6. Rectal examination
   Especially assess prostate

   Action: Follow-up on abnormal findings--that is, cardiovascular findings, suspected endocrine diseases, or abnormal prostate

Step 3: Laboratory tests

1. Plasma glucose
2. Prolactin
3. Free testosterone
4. Luteinizing hormone and follicle-stimulating hormone if testicular atrophy suspected
5. Thyroid-stimulating hormone or free thyroxine (or both) if hypothyroidism is suspected
6. Other tests, depending on history and physical examination

Step 4: Treatments

1. Related to risk factors

   Action: Diagnose diabetes
   Stop any substance abuse
   Change medications
   Treat abnormal hormones (testosterone or prolactin)
   A 3-month testosterone trial, if indicated
   Nocturnal penile tumescence and rigidity testing if risk factors changed and nonresponse may be due to psychologic factors

2. If good erections but early detumescence--venous constriction rings
3. Nonspecific treatments:
   Trial sildenafil
   Trial yohimbine
   Other orally administered drugs, phentolamine, apomorphine (when approved)
   Apomorphine (sublingually)
   Vacuum pump
   Medicated urethral system for erection (intraurethral prostaglandin pellet)
   Penile injections
   • Papaverine and phentolamine
   • Papaverine, phentolamine, alprostadil
   • Alprostadil alone

   Penile implants (as last resort)

4. Surgical referrals (urologist)
   Severe Peyronie's disease
   Penile injections (if not done by endocrinologist)
   Penile implant
   Selected cases of arterial damage or venous ligation

An algorithm for office evaluation of erectile dysfunction is provided in the original guideline document.

The type of supporting evidence is not specifically stated for each recommendation.

Appropriate recognition and management of disorders of sexual desire, orgasm, and ejaculation through an organized system of care for the couple. The outcome can be cost-effective improvement.

Sildenafil

Side effects are generally mild and tolerable: headaches, hot flashes, heartburn, diarrhea, myalgias, hypotension, and dizziness. The drug may inhibit phosphodiesterase type 6 in the eye, with resultant difficulty in discriminating blue from green, bluish tones in vision, or difficulty seeing in dim light. Whether any adverse effect occurs in diabetic retinopathy or other eye diseases is yet to be determined.

Yohimbine tablets

Major side effects are uncommon, but minor symptoms, including headaches, dizziness, insomnia, and anxiety, may occur in 25% of cases during the first week of treatment. Patients who have blood pressure that is difficult to control might notice a pressure increase.

Alprostadil

The major side effects, which occur in 3 to 10% of patients, are penile pain, cavernosal scarring, or priapism.

Penile implants

Treatment failures attributable to infection, extrusion, or mechanical failure, especially in patients with diabetes, previously were as high as 36%, but better equipment and techniques have reduced these complications.

Sildenafil is contraindicated in patients taking nitrates in any form, inasmuch as severe hypotension and resultant syncope have occurred as well as cardiogenic shock and some deaths.

These guidelines are intended as a general outline but not meant to dictate or delineate any specific treatments for patients. The area of treatment of sexual dysfunction, and especially erectile dysfunction, is a relatively new discipline. Basic physiologic and pathologic data have recently been elucidated, but many controversial issues remain. Whenever possible, the guideline developers have presented a majority opinion, while describing various other possibilities. New advances in technology and treatment will keep this field dynamic and in a state of evolution. Thus, modification of ideas will be necessary as new data become available.

An implementation strategy was not provided.

Getting Better

Effectiveness

• AACE Male Sexual Dysfunction Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of male sexual dysfunction: a couple's problem--2003 update. Endocr Pract 2003 Jan-Feb;9(1):77-95. [26 references]

Not applicable: The guideline was not adapted from another source.

1998 (revised 2003)

American Association of Clinical Endocrinologists - Medical Specialty Society
American College of Endocrinology - Medical Specialty Society

American Association of Clinical Endocrinologists (AACE)

American Association of Clinical Endocrinologists (AACE) Male Sexual Dysfunction Task Force

Taskforce Members: Andre T. Guay, MD, FACE (Co-Chairman); Richard F. Spark, MD, FACE (Co-Chairman); Sudhir Bansal, MD, FACE; Glenn R. Cunningham, MD; Neil F. Goodman, MD, FACE; Howard R. Nankin, MD, FACE; Steven M. Petak, MD, FACE, Jesus B. Perez, MD, FACE

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Association of Clinical Endocrinologists (AACE), American College of Endocrinology. AACE clinical practice guidelines for the evaluation and treatment of male sexual dysfunction. Endocr Pract 1998 Jul-Aug;4(4):219-35.

None available

This summary was completed by ECRI on October 1, 1998. The information was verified by the guideline developer on December 15, 1998. This summary was updated by ECRI on June 25, 2003. The updated information was verified by the guideline developer on July 21, 2003. This summary was updated by ECRI on July 15, 2005 following the FDA advisory on Cialis, Levitra, and Viagra. This summary was updated by ECRI Institute on November 6, 2007, following the updated U.S. Food and Drug Administration advisory on Viagra, Cialis, Levitra, and Revatio.

All rights reserved. No part of these materials may be reproduced or retransmitted in any manner without the prior written permission of American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE).