男性性功能障碍诊疗规范---2010 JSM

REPORT Summary of the Recommendations on Sexual Dysfunctions in Menjsm_2062 3572..3588 Francesco Montorsi, MD,* Ganesan Adaikan, MD,† Edgardo Becher, MD,‡ Francois Giuliano, MD, PhD,§ Saad Khoury, MD,¶ Tom F. Lue, MD,** Ira Sharlip, MD,** Stanley E. Althof, PhD,†† Karl-Eric Andersson, PhD,‡‡ Gerald Brock, MD,§§ Gregory Broderick, MD,¶¶ Arthur Burnett, MD,*** Jacques Buvat, MD,††† John Dean, MD,‡‡‡ Craig Donatucci, MD,§§§ Ian Eardley, MD,¶¶¶ Kerstin S. Fugl-Meyer, PhD,**** Irwin Goldstein, MD,†††† Geoff Hackett, MD,‡‡‡‡ Dimitris Hatzichristou, MD,§§§§ Wayne Hellstrom, MD,¶¶¶¶ Luca Incrocci, MD,***** Graham Jackson, MD,††††† Ates Kadioglu, MD,‡‡‡‡‡ Laurence Levine, MD,§§§§§ Ronald W. Lewis, MD,¶¶¶¶¶ Mario Maggi, MD,****** Marita McCabe, PhD,†††††† Chris G. McMahon, MD,‡‡‡‡‡‡ Drogo Montague, MD,§§§§§§ Piero Montorsi, MD,¶¶¶¶¶¶ John Mulhall, MD,******* Jim Pfaus, PhD,††††††† Hartmut Porst, MD,‡‡‡‡‡‡‡ David Ralph, MD,§§§§§§§ Raymond Rosen, PhD,¶¶¶¶¶¶¶ David Rowland, MD,******** Hossein Sadeghi-Nejad, MD,†††††††† Ridwan Shabsigh, MD,‡‡‡‡‡‡‡‡ Christian Stief, MD,§§§§§§§§ Yoram Vardi, MD,¶¶¶¶¶¶¶¶ Kim Wallen, PhD,********* and Marlene Wasserman, MD††††††††† *Department of Urology, San Raffaele Hospital, Milan, Italy; †National University of Singapore Department of Obstetrics and Gynaecology, Singapore; ‡Division of Urology, University of Buenos Aires. Buenos Aires, Argentina; §Raymond Poincare Hospital, Department of Neurouroandrology Garches, Garches, France; ¶Department of Urology, Hopital de la Pitié, Paris, France; **University of California, San Francisco, Department of Urology San Francisco, CA, USA; ††University of Miami School of Medicine Psychiatry, West Palm Beach, FL, USA; ‡‡Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, USA; §§Department of Surgery, University of Western Ontario, London, Ontario, Canada; ¶¶Department of Urology, Mayo Clinic of Jacksonville, Jacksonville, Florida, USA; ***Department of Urology, Johns Hopkins University, Baltimore, MD, USA; †††CETPARP, Le Grand Hunier, Lille, France; ‡‡‡Court Gate House, Harbourneford—South Brent, UK; §§§Department of Urology, Duke University, Durham, NC, USA; ¶¶¶Spire Leeds Hospital, Leeds, UK; ****Centre for Andrology & Sexual Medicine Department of Medicine Karolinska University Hospital, Huddinge, Stockholm, Sweden; ††††Department of Sexual Medicine, Alvarado Hospital, San Diego, CA, USA; ‡‡‡‡Holly Cottage Clinic, Lichfield, UK; §§§§2nd Department of Urology, Papageorgiou General Hospital and Center for the Study of Prostate Diseases (CSPD), Aristotle University of Thessaloniki, Thessaloniki, Greece; ¶¶¶¶Tulane University, Urology Department, New Orleans, LA, USA; *****Erasmus MC Department of Radiation Oncology, Rotterdam, the Netherlands; †††††Department of Cardiology, London Bridge Hospital Cardiology, London, United Kingdom; ‡‡‡‡‡Department of Urology, University of Istanbul Urology, Istanbul, Turkey; §§§§§Department of Urology, Rush University Medical Center, Chicago, IL, USA; ¶¶¶¶¶Department of Surgery/Urology, Medical College of Georgia, Augusta, GA, USA; ******Andrology Unit University of Florence, Florence, Italy; ††††††Department of Psychology, Deakin University, Burwood, Australia; ‡‡‡‡‡‡Australian Centre for Sexual Health, Sydney, Australia; §§§§§§Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; ¶¶¶¶¶¶University of Milan, Department of Cardiovascular Sciences, Centro Cardiologio Monzino, IRCCS, Milan, Italy; *******Department of Urology/Sexual Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; †††††††Concordia University, Department of CSBN/Psychology, Montreal, Quebec, Canada; ‡‡‡‡‡‡‡Private Practice for Urology and Andrology, Hamburg, Germany; §§§§§§§Department of Urology, St Peter Andrology Centre, London, UK; ¶¶¶¶¶¶¶New England Research Institutes, Watertown, MA, USA; ********Valparaiso University Graduate School, Valparaiso, IN, USA; ††††††††Department of Urology, UMDNJ—Hackensack, Hackensack, NJ, USA; ‡‡‡‡‡‡‡‡Department of Urology, Maimonides Medical Center, Brooklyn, NY, USA; §§§§§§§§Department of Urology, Klinikum Universitat Munchen, Munich, Germany; ¶¶¶¶¶¶¶¶Department of Neuro Urology, Rambam Health Care Campus, Haifa, Israel; *********Department of Psychology, Emory University, Atlanta, GA, USA; †††††††††Sexual Health Centre, Sea Point Cape Town, South Africa DOI: 10.1111/j.1743-6109.2010.02062.x A B S T R A C T Introduction. Sexual health is an integral part of overall health. Sexual dysfunction can have a major impact on quality of life and psychosocial and emotional well-being. Aim. To provide evidence-based, expert-opinion consensus guidelines for clinical management of sexual dysfunc- tion in men. 3572 J Sex Med 2010;7:3572–3588 © 2010 International Society for Sexual Medicine Methods. An international consultation collaborating with major urologic and sexual medicine societies convened in Paris, July 2009. More than 190 multidisciplinary experts from 33 countries were assembled into 25 consultation committees. Committee members established scope and objectives for each chapter. Following an exhaustive review of available data and publications, committees developed evidence-based guidelines in each area. Main Outcome Measures. New algorithms and guidelines for assessment and treatment of sexual dysfunctions were developed based on work of previous consultations and evidence from scientific literature published from 2003 to 2009. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of medical literature, and cultural and ethical considerations. Results. Algorithms, recommendations, and guidelines for sexual dysfunction in men are presented. These guide- lines were developed in an evidence-based, patient-centered, multidisciplinary manner. It was felt that all sexual dysfunctions should be evaluated and managed following a uniform strategy, thus the International Consultation of Sexual Medicine (ICSM-5) developed a stepwise diagnostic and treatment algorithm for sexual dysfunction. The main goal of ICSM-5 is to unmask the underlying etiology and/or indicate appropriate treatment options according to men’s and women’s individual needs (patient-centered medicine) using the best available data from population- based research (evidence-based medicine). Specific evaluation, treatment guidelines, and algorithms were developed for every sexual dysfunction in men, including erectile dysfunction; disorders of libido, orgasm, and ejaculation; Peyronie’s disease; and priapism. Conclusions. Sexual dysfunction in men represents a group of common medical conditions that need to be managed from a multidisciplinary perspective. Montorsi F, Adaikan G, Becher E, Giuliano F, Khoury S, Lue TF, Sharlip I, Althof SE, Andersson K-E, Brock G, Broderick G, Burnett A, Buvat J, Dean J, Donatucci C, Eardley I, Fugl-Meyer KS, Goldstein I, Hackett G, Hatzichristou D, HellstromW, Incrocci L, Jackson G, Kadioglu A, Levine L, Lewis RW,MaggiM,McCabeM,McMahonCG,MontagueD,Montorsi P,Mulhall J, Pfaus J, Porst H, Ralph D, Rosen R, Rowland D, Sadeghi-Nejad H, Shabsigh R, Stief C, Vardi Y, Wallen K, andWasserman M. Summary of the recommendations on sexual dysfunctions in men. J Sex Med 2010;7:3572–3588. Key Words. Erectile Dysfunction; Testosterone; Premature Ejaculation; Delayed Ejaculation; Peyronie’s Disease; Priapism; Prostate Cancer; Radical Prostatectomy; Guidelines Introduction The 2009 International Consultation onSexual Dysfunctions was convened in Paris in 2009. It identified the following fundamental concepts as the basis for the management of sexual dysfunctions in men and women: • Sexual health is an integral part of overall health. • Healthcare providers should seek, receive, and impart information related to sexuality. Indi- viduals have the right to receive the highest attainable standard of sexual health, including access to sexual and reproductive healthcare ser- vices, as a fundamental sexual right. • Sexual dysfunctions can have a major impact on quality of life (QoL) as well as psychosocial and emotional well-being. • The three principles for clinical evaluation and management of sexual dysfunctions are (i) adop- tion of a patient-centered framework, with an emphasis on cultural competence in medical practice; (ii) application of evidence-based medicine in diagnostic and treatment planning; and (iii) use of a unified management approach in evaluating and treating sexual problems in both men and women. • Sexual dysfunctions are essentially self-reported conditions. Therefore, diagnostic tests or pro- cedures should not be recommended without controlled clinical data or research-based evi- dence supporting their use. The International Consultation of Sexual Medicine (ICSM-5 (Figure 1) is a stepwise diagnostic and treatment algorithm for sexual dysfunction in men and women. The main goal of the ICSM-5 is to unmask the underlying etiology and/or to indi- cate appropriate treatment options according to men’s and women’s individual needs (patient- centered medicine) using the best available data from population-based research (evidence- based medicine). • Ignorance and knowledge gaps about sexual function and dysfunction are commonplace. Misinformation or myths may lead to uninformed sexual decisions with serious consequences. During the initial phase of assessment, physicians must discriminate Summary of the Recommendations on Sexual Dysfunctions in Men 3573 J Sex Med 2010;7:3572–3588 among sexual concerns, difficulties, dysfunc- tions, and disorders. • For clinical purposes, sexual dysfunctions are categorized into three types according to their etiology: type I, psychogenic; type II, organic; and type III, mixed. Types II and III differ according to the absence or presence of signifi- cant mental (cognitive) or emotional (affect) dis- tress. In type II dysfunctions, resolution of the main symptom adequately diminishes mental and/or emotional distress, whereas in type III dysfunctions, complementary psychotherapy is indicated. • Sexual, medical, and psychosocial history is mandatory in every case. • Physical examination and laboratory tests are strongly recommended but not always necessary. • Specialized diagnostic procedures for women are less advanced and less widely used than those for men. Diagnostic procedures with the highest level of evidence should be used, when appropriate. • Improved management of sexual dysfunction depends on physicians’ inclination and ability to educate patients about their sexual function and dysfunction. These principles represent the evolution of sci- entific thinking in the management of sexual dys- function in both sexes. They stem from the work done in the previous consultations and the evi- dence coming from the literature published from 2003 to 2009. In this article, we report the recommendations for every sexual dysfunction described in men. To facilitate reading of this article, levels of evidence and grading for each recommendation were not included but are detailed in the various articles reporting on the work of every committee. Simi- larly, references are not included in this manu- script but are accessible in the articles discussing each topic. Erectile Dysfunction Definition of Erectile Dysfunction Erectile dysfunction (ED) is defined as a man’s consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual activity. A three-month minimum duration of symptoms is accepted for establishment of the diagnosis. In some instances of trauma or surgi- cally induced ED (e.g., following radical pros- tatectomy [RP]), the diagnosis may be made prior to three months. Objective testing (or partner reports) may be used to support the diagnosis of ED, but these measures cannot substitute for the patient’s self-report in classifying the dysfunction or establishing the diagnosis. Evaluation of the Patient with ED The 2009 international consultation supports the view that the general framework for the evaluation of patients with any type of sexual dysfunction should follow the same basic principles. The initial steps of patient evaluation, described below, should be applied uniformly regardless of the final diagnosis. Initiating the Discussion In some circumstances, a single question (e.g., “Do you have questions or concerns about your sexual Figure 1 The steps of the Interna- tional Consultation on Sexual Medicine (ICSM-5). SD = sexual dys- function; QoL = quality of life. 3574 Montorsi et al. J Sex Med 2010;7:3572–3588 functioning?”) may be sufficient to clarify the patient’s primary issue; in other situations, a series of questions is indicated. Sexual inquiry is most often conducted in a face-to-face interview with the patient, although paper-and-pencil question- naires or Internet-based methods may be of value. The style or manner in which sexual inquiry is conducted is important: It should reflect a high level of sensitivity and regard for each individual’s unique ethnic, cultural, and personal background. The aim of taking a sexual history should be ascertaining the severity, onset, and duration of the problem as well as the presence of concomitant medical or psychosocial factors. It is necessary to determine whether the presenting complaint (e.g., ED, anorgasmia) is the primary or major sexual problem or if some other aspect of the sexual response cycle (desire, ejaculation, orgasm) is involved. Other sexual problems may exist as con- comitant disorders (e.g., hypoactive sexual desire) or as secondary disorders to the primary sexual complaint. The medical and sexual history is essential and frequently the most revealing aspect of the assess- ment process. A comprehensive sexual history is essential in confirming the patient’s diagnosis as well as in the evaluation of the patient’s overall sexual function. Questions apply specifically to the evaluation of male arousal, desire, and orgasm/ ejaculation difficulties. In principle, these ques- tions can be addressed to all patients presenting with sexual difficulties. Medical History Although not always definitive, a detailed medical history may provide suggestive evidence for or against the role of specific organic or psychogenic factors and should be obtained in all cases of sexual dysfunction. Documenting a medical history has several goals. First, the physician must evaluate the potential role of underlying or comorbid medical conditions. Sexual dysfunction may be symptom- atic of an underlying medical disorder, such as atherosclerosis or diabetes. Second, the physician must actively investigate the possible association with cardiovascular conditions to differentiate among potential organic and psychogenic causes in the etiology of a patient’s sexual problem. Third, the history helps the physician assess the use of concomitant medications. Some of these medications can either cause or contribute to the patient’s sexual difficulties, and a change in medi- cation may result in an improvement in sexual function. Additionally, the use of certain medica- tions may be important contraindications for spe- cific treatments. Medical history may include all medical conditions that could interfere with sexual function. Psychosocial History Potential etiologies for sexual dysfunction include a wide range of organic and medical factors, but multiple psychological or interpersonal factors (e.g., anxiety, depression, relationship distress) can also be causes. A detailed psychosocial assessment is essential in every case of sexual dysfunction. Given the interpersonal context of sexual prob- lems in men and women, the physician should carefully assess past and present partner relation- ships. Sexual dysfunction may affect the patient’s self-esteem and coping ability as well as his or her social relationships and occupational performance. These aspects should be assessed in each case. The physician should not assume that every patient is involved in a monogamous, heterosexual relationship. For this reason, it is advisable to begin the history with broad questions: “Are you sexually active at the moment?,” “Do you have a regular sex partner?” Then ask a follow-up question, such as, “Is this a same-sex or opposite-sex relationship?” The early stages in the development of a problem are often of crucial significance to assessment and treatment.Were there particular times of change in the sexual relationship? If so, what events occurred in the patient’s life at those times? In addition, the physician should ask questions about other relevant aspects of the patient’s life, including interpersonal relationships, occupational status, financial secu- rity, family life, and social support. Physical Examination The etiology or causal factors for sexual dysfunc- tion may or may not be apparent from the patient’s history alone. In specific sexual dysfunctions (e.g., anatomic problems, ED), further investigation by means of a physical examination and selected labo- ratory testing may be of value in confirming or ruling out specific etiologies or comorbidities. In most cases, the physical examination will not iden- tify the specific etiology or cause of sexual dysfunc- tion; however, a focused physical examination is strongly recommended. This examination should include a general screening for medical risk factors or comorbidities that are associated with sexual dysfunction, such as body habitus (secondary sexual characteristics) and assessment of the car- diovascular, neurologic, and genital systems, with particular focus on the genitalia and secondary sex characteristics. Summary of the Recommendations on Sexual Dysfunctions in Men 3575 J Sex Med 2010;7:3572–3588 The physical examination may corroborate aspects of the medical history and can sometimes reveal unsuspected physical findings (e.g., decreased peripheral pulses, hypertension, atrophic testes, penile plaque). In addition to identifying specific etiologies or comorbidities, the physical examination may provide an opportunity to inform the patient about aspects of his sexual anatomy or physiology as well as to provide reassurance about body appearance and function. It should be recog- nized that the physical examination can also be a source of shame, embarrassment, or discomfort for many patients. Every effort should be made to ensure the patient’s privacy, confidentiality, and personal comfort during the examination. The physician should always review the major findings of the examination and should address any questions or concerns of the patient regarding his physical appearance or normality. In some set- tings, it may be advisable for the physician to perform the physical examination in the presence of a nurse or chaperone. Laboratory Testing Recommended laboratory tests for men with sexual problems typically include fasting glucose, cholesterol, lipids, and a hormone profile. As with the physical examination, these tests are per- formed primarily to identify or confirm specific etiologies (e.g., hypogonadism) or to assess the role of potential medical comorbidities or con- comitant illnesses (e.g., diabetes, hyperlipidemia). Additional laboratory tests (e.g., thyroid function) may be performed at the physician’s discretion based on the patient’s medical history and the phy- sician’s judgment. Specialized Testing for ED The classical specialized tests—with the exception of pharmaco-penile duplex ultrasound and mea- surements of nocturnal penile tumescence or sleep-related erections—are not equipped to spe- cifically and accurately assess cavernosal neuro- endothelial function. On the contrary, these tests frequently do not add to data already available from the medical history and assessments based on patient self-report (e.g., self-administered ques- tionnaires, event logs, patient diaries), physical examination, and laboratory testing. At best, t