Mental Health Practice Guidelines
The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.
Guideline Title
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.
Bibliographic Source(s)
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]
Guideline Status
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.
FDA Warning/Regulatory Alert
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released. On July 8, 2005, the U.S. Food and Drug Administration (FDA) notified healthcare professionals of updated labeling for Cialis, Levitra and Viagra to reflect a small number of post-marketing reports of sudden vision loss, attributed to NAION (non arteritic ischemic optic neuropathy), a condition where blood flow is blocked to the optic nerve. FDA advises patients to stop taking these medicines, and call a doctor or healthcare provider right away if they experience sudden or decreased vision loss in one or both eyes. Patients taking or considering taking these products should inform their health care professionals if they have ever had severe loss of vision, which might reflect a prior episode of NAION. Such patients are at an increased risk of developing NAION again. At this time, it is not possible to determine whether these oral medicines for erectile dysfunction were the cause of the loss of eyesight or whether the problem is related to other factors such as high blood pressure or diabetes, or to a combination of these problems. See the FDA Web site for more information.
Disease/Condition(s)
Male sexual dysfunction
Guideline Category
DiagnosisEvaluationManagementTreatment
Clinical Specialty
Endocrinology
Intended Users
Physicians
Guideline Objective(s)
To present a framework for the evaluation, treatment, and follow-up of the patient and couple who present with sexual dysfunction
Target Population
Men with sexual dysfunction
Interventions and Practices Considered
Diagnosis/Evaluation Initial assessment of relevant medical, psychological, and hormonal factors of the male patient and his partner Sexual history, medical history, and physical examination Diagnostic tests (i.e., blood chemistry, vascular assessment, sensory studies, nocturnal penile tumescence and rigidity testing) Treatment/Management Psychological therapy, referral to sex therapist Medical treatment, if applicable: plasma glucose control, hypertension control, tobacco use cessation, hyperlipidemia therapy, alcohol intake decrease or discontinuation, and illicit drug discontinuation Changing or stopping offending medications Testosterone therapy: injection, scrotal/nonscrotal patches 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) Urology consult for surgical options
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Searches of Index Medicus and Pub Med were performed. Articles retrieved were supplemented by material from the personal libraries of the committee members.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Meta-Analyses and Reviews > Randomized controlled studies > Observational studies > Expert opinions (in order of most weight)
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Twelve physicians are acknowledged as reviewers in the guideline document.
Major Recommendations
System of Care for Male Sexual Dysfunction Step 1: Accurate history (preferably with the couple) Make sure concerns are not just aging-related changes Inquire about relationship problems Question about performance anxiety Action: Reassure if A Send to sex therapist if B or C Do nocturnal penile test if uncertain. Outline medical risk factors and medications Action: Change or discontinue medications Stop any substance abuse Step 2: General examination Blood pressure Breasts for gynecomastia Secondary sex characteristics Peripheral circulation Genital examination Especially for penile fibrosis, testicular atrophy, bulbocavernosal reflex 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 Plasma glucose Prolactin Free testosterone Luteinizing hormone and follicle-stimulating hormone if testicular atrophy suspected Thyroid-stimulating hormone or free thyroxine (or both) if hypothyroidism is suspected Other tests, depending on history and physical examination Step 4: Treatments 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 If good erections but early detumescence--venous constriction rings 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) Surgical referrals (urologist) Severe Peyronie's disease Penile injections (if not done by endocrinologist) Penile implant Selected cases of arterial damage or venous ligation
Clinical Algorithm(s)
An algorithm for office evaluation of erectile dysfunction is provided in the original guideline document.
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
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.
Potential Harms
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.
Contraindications
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.
Qualifying Statements
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.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical AlgorithmFor information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Bibliographic Source(s)
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]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
1998 (revised 2003)
Guideline Developer(s)
American Association of Clinical Endocrinologists - Medical Specialty SocietyAmerican College of Endocrinology - Medical Specialty Society
Source(s) of Funding
American Association of Clinical Endocrinologists (AACE)
Guideline Committee
American Association of Clinical Endocrinologists (AACE) Male Sexual Dysfunction Task Force
Composition of Group that Authored the Guideline
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
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
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.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Association of Clinical Endocrinologists (AACE) Web site. Print copies: Available from AACE, 1000 Riverside Ave., Suite 205, Jacksonville, FL 32204.
Availability of Companion Documents
The following is available: American Association of Clinical Endocrinologists protocol for standardized production of clinical practice guidelines. Endocrine Pract 2004 Jul/Aug; 10(4):353-61. Electronic copies: Available in Portable Document Format (PDF) from the American Association of Clinical Endocrinologists (AACE) Web site. Print copies: Available from the American Association of Clinical Endocrinologists (AACE), 1000 Riverside Avenue, Suite 205, Jacksonville, FL 32204.
Patient Resources
None available
NGC STATUS
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.
COPYRIGHT STATEMENT
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).
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