【医脉通】2017+BSSM指南：男性勃起功能障碍的管理.pdf

British Society for Sexual Medicine Guidelines on the Management ofErectile Dysfunction in Men2017Geoff Hackett,MD,1Mike Kirby,MD,2Kevan Wylie,MD,3Adrian Heald,MD,4Nick Ossei-Gerning,MD,5David Edwards,MD,6and Asif Muneer,MD,FRCS(Urol)7ABSTRACTBackground:This is an update of the 2008 British Society for Sexual Medicine(BSSM)guidelines.Aim:To provide up-to-date guidance for U.K.(and international)health care professionals managing malesexual dysfunction.Methods:Source information was obtained from peer-reviewed articles,meetings,and presentations.A search ofEmbase,MEDLINE,and Cochrane Reviews was performed,covering the search terms“hypogonadism,”“eugonadal or hypogonadism or hypogonadal or gonadal,”and“low or lower testosterone,”starting from 2009with a cut-off date of September 2017.Outcomes:We offer evidence-based statements and recommendations for clinicians.Results:Expert guidance for health care professionals managing male sexual dysfunction is included.Clinical Translation:Current U.K.management has been largely influenced by non-evidence guidance fromNational Health Service departments,largely based on providing access to care limited by resources.The 2008BSSM guidelines to date have been widely quoted in U.K.policy decision making.Conclusions:There is now overwhelming evidence that erectile dysfunction is strongly associated with car-diovascular disease,such that newly presenting patients should be thoroughly evaluated for cardiovascular andendocrine risk factors,which should be managed accordingly.Measurement of fasting serum glucose,lipidprofile,and morning total testosterone should be considered mandatory in all newly presenting patients.Patientsattending their primary care physician with chronic cardiovascular disease should be asked about erectileproblems.There can no longer be an excuse for avoiding discussions about sexual activity due to embarrassment.Hackett G,Kirby M,Wylie K,et al.British Society for Sexual Medicine Guidelines on the Management ofErectile Dysfunction in Men2017.J Sex Med 2018;XX:XXXeXXX.Copyright?2018,International Society for Sexual Medicine.Published by Elsevier Inc.All rights reserved.Key Words:Erectile Dysfunction;Epidemiology;Risk Factors;Hypogonadism;Diagnosis;Therapy;CoronaryHeart Disease;Cardiovascular Disease;Type 2 Diabetes;Color Duplex Ultrasound;Summary of ProductCharacteristicsINTRODUCTIONThe current U.K.management of erectile dysfunction(ED)islargely evidence-based medicine and this guideline updates theprevious 2008 British Society for Sexual Medicine(BSSM)publication on the management of ED.The major resource usedfor National Health Service(NHS)reference has been the HealthService Circular(HSC)1999,1-3a non-evidence-based documentdefining guidance for good clinical practice,largely on economicgrounds,for those patients qualifying for treatment under theU.K.NHS.Guidance by the National Institute for Health andCare Excellence(NICE)is the strongest influence,but NICE canonly review issues identified by the Department of Health ratherthan those highlighted by clinicians.The guidelines presentedReceived October 11,2017.Accepted January 8,2018.1Heartlands Hospital,Birmingham,United Kingdom;2Prostate Center,London,United Kingdom;3Porterbrook Clinic,Sheffield,United Kingdom;4Salford Royal Hospital,Salford,United Kingdom;5University Hospital,Cardiff,United Kingdom;6General Practice Chipping Norton Health Center,Chipping Norton,UnitedKingdom;7Division of Surgery and Internventional Science,University College London,and National Institute for Health Research,Biometric Research,UniversityCollege Hospital,London,United KingdomCopyright 2018,International Society for Sexual Medicine.Published byElsevier Inc.All rights reserved.https:/doi.org/10.1016/j.jsxm.2018.01.023J Sex Med 2018;-:1e281 here were developed by a multidisciplinary expert panel from theCommittee of the BSSM.The principal aim of these guidelines isto enable physicians and other health care professionals tomanage ED in line with recent evidence,modern research,andclinical opinion,while adhering to the correct interpretation ofcurrent Department of Health regulations.Source informationwas obtained from peer-reviewed articles,meetings,and pre-sentations,A search was performed,covering the search terms“hypogonadism,”“eugonadal or hypogonadism or hypogonadalor gonadal,”and“low or lower testosterone,”starting from 2009with a cut-off date of September 2017.Embase,MEDLINE,andthe Cochrane Central Register of Controlled Trials databaseswere searched,with a limitation to reviews,meta-analyses,ormeta-analysis of randomized controlled trials.A total of 4,202records were identified and screened for relevance,of which 71publications were selected for inclusion.ED BACKGROUNDEpidemiologyED has been defined as the persistent inability to attain and/or maintain an erection sufficient for sexual performance.Although ED is not usually perceived as a life-threateningcondition,it is closely associated with many important phys-ical conditions and may affect psychosocial health.As such,EDhas a significant impact on the quality of life of patients andtheir partners.4Several large epidemiological studies have shown a highprevalence and incidence of ED worldwide.4e6In the Massa-chusetts Male Aging Study,the prevalence of ED was 52%innon-institutionalized 40-to 70-year-old men in the Boston area:17.2%,25.2%,and 9.6%for minimal,moderate,and completeED,respectively.4The incidence of ED,calculated fromlongitudinal data in the Massachusetts Male Aging Study,was 26new cases per 1,000 per year.7A large European study of menaged 30e80 years reported a prevalence of 19%.6In theMens Attitude to Life Events and Sexuality Study,whichincluded 20-to 75-year-old men from 8 countries(UnitedStates,United Kingdom,Germany,France,Italy,Spain,Mexico,and Brazil),the ED prevalence,assessed by International Indexof Erectile Function(IIEF),ranged from 22%in the UnitedStates to 10%in Spain.8All studies showed a steep age-relatedincrease.These epidemiological studies provide different esti-mates of the prevalence of ED,which can be explained by themethodological designs in the different surveys.In particular,theestimates were influenced by the development of the IIEF andsimilar assessment tools in 1998,and minor changes in thedefinition of the condition.The age and the socio-economicstatus of the populations also differed between the studies.Risk FactorsPenile erection is a complex neurovascular phenomenon underhormonal control that includes arterial dilatation,trabecularsmooth-muscle relaxation,and activation of the corporal veno-occlusive mechanism.9The development of ED is attributableto neuronal,vascular,hormonal,and metabolic factors,mediatedthrough endothelial and smooth-muscle dysfunction.The riskfactors for ED(age,sedentary lifestyle,obesity,smoking,dyslipidemia,and the metabolic syndrome),are very similar tothe established risk factors for cardiovascular disease.10,11In addition to the risk factors for ED,ED itself is a cardio-vascular risk factor conferring a risk equivalent to a currentmoderate level of smoking.The fact that ED is found morecommonly in men with hypertension,dyslipidemia,acutecoronarysyndrome,diabetesmellitus(DM),metabolicsyndrome,and lower urinary tract symptoms(LUTS)/benignprostatic hyperplasia(BPH)led to the recognition that ED is animportant marker of future cardiovascular risk.10,11ED is asso-ciated with the severity of ischemic heart disease,in terms ofplaque burden,and number of coronary arteries affected.ED isbelieved to be a sentinel marker for future cardiovascular events,occurring 3e5 years before an event,based on the arterial sizehypothesis.10,11The predictive value of ED and coronary artery disease is mostimpressive in younger men aged 40e49 years,where traditionalrisk assessment tools are unhelpful.Data from the OlmstedCounty Study suggested a 50-fold relative risk with incident EDin younger men.12These findings were supported by a long-termstudy from Western Australia where men with incident ED had7 times the cardiovascular risk compared with men withoutED.13In men with DM,incident ED was a better predictor ofcardiovascular events than hypertension,dyslipidemia,andmicroalbuminuria.14ED confers a 1.46 increased risk for cardiovascular dis-ease.11,15A recent meta-analysis of 12 prospective studiesinvolving 36,744 men found ED to be an independent marker ofcardiovascular events such as hospitalization and mortality,16inaddition to conventional risk factors(age,weight,hypertension,DM,dyslipidemia,and smoking).The authors of this findingsuggested that ED should be included in future cardiovascularrisk calculations.11Long-term follow-up from the European Males Aging Studyconcluded that ED and low testosterone independently predictedearly death and that early detection of these 2 conditions rep-resented an opportunity to detect a small number of men at highrisk of early death.17We endorse recent evidence suggesting thatthe practical predictive value of ED now merits re-classificationof ED as an independent risk factor for cardiovascular disease(especially in men younger than 45 years)with modification ofestablished risk calculators.18The Need for ED GuidelinesThe prescription of newer treatment options for ED aregenerally within the scope of primary care practice,and phar-macological agents for oral,intra-cavernosal,and intra-urethraluse are widely available.As a result,treatment strategies haveJ Sex Med 2018;-:1e282Hackett et al been significantly modified and fewer patients require referral tourological surgeons as operative intervention has a minor role inoverall ED management until the condition is deemed end stage.The important links with cardiometabolic disease and theimportance of relationship and psychological issues stronglysuggest that primary care or specialist mens health physicians arebest placed to manage ED.15The availability of effective and safe oral drugs for ED19e21has contributed to an upsurge in media interest,which has ledto an increase in the number of men seeking help for ED,creating an opportunity to:?Uncover diabetes(as ED may be the first symptom in up to20%8,15).?Detect dyslipidemia,which might not otherwise dictatetreatment according to primary coronary prevention guidelinesbut may be the major reversible component in the patientsED.15?Reveal the presence of hypogonadism,a reversible cause ofED,which can be sometimes managed without the need forspecificEDtherapyandhasotherlong-termhealthimplications.17?Identify occult cardiac disease;ED in an otherwise asymp-tomatic man may be a marker for underlying coronary arterydisease.15,16?Identify associated LUTS/BPH,as severity of LUTS is closelyrelated to ED severity and therapies for one condition maybeneficially or adversely affect the other.8,22Despite the likely presence of such underlying conditions,many men with ED may undergo little or no evaluation beforetreatment,particularly if they seek help from sources such as theInternet.Theearlydiagnosisandmanagementofsuchcardiovascular and endocrine conditions are fundamental to thegeneral practitioner(GP)s role under the quality outcomeframework.Men do not readily visit their GP with medicalproblems and a consultation for ED may represent an importantopportunity for health intervention.15,23All these factors have made the development of U.K.guide-lines for the diagnosis and treatment of ED a necessity toimprove mens health.ED DIAGNOSISInitial AssessmentCase HistoryA detailed description of the problem,including the durationof symptoms and original precipitants,should be obtained.17Other factors that should be identified and recorded are:?Original precipitating factor or factors(if identified)(Table 1).?Predisposing factors(if identified)(Table 1).?Maintaining factors(if identified)(Table 1).?Any subsequent investigations.?Treatment interventions along with the response achieved.?An expression of tumescence and rigidity with quality ofmorning awakening erections,and spontaneous,masturbatory,or partner-related activity erections.?Sexual desire,ejaculatory timing,control,and orgasmicdysfunction.?Previous erectile capacity.?Issues around any sexual aversion or sexual pain.?Partner issues,eg,low sexual desire,menopause,or gyneco-logical pain.Table 1.Pathophysiological causes of erectile dysfunction115PredisposingPrecipitatingMaintainingLack of sexual knowledgeNew relationshipRelationship problemsPoor past sexual experienceAcute relationship problemsPoor communication betweenpartnersRelationship problemsFamily or social pressuresLack of knowledge abouttreatment optionsReligious or cultural beliefsPregnancy and childbirthOngoing physical or mentalhealth problemsRestrictive upbringingOther major life eventsOther sexual problems in theman or his partnerUnclear sexual or genderpreferencePartners menopauseDrugsPrevious sexual abuseAcute physical or mental healthproblemsPhysical or mental healthproblemsLack of knowledge aboutnormal changes of agingOther sexual problems in theman or his partnerOther sexual problems in theman or his partnerDrugsDrugsJ Sex Med 2018;-:1e28BSSM Guidelines on ED3 Concurrent medical,psychiatric,and surgical history shouldalso be recorded,as should the current relationship status(eg,single,married,in a long-term relationship;and age ofpartner)and a history of sexual partners and relationships.Issuesof sexual orientation and gender identity should also be noted.Finally,the patient should be asked about alcohol,smoking,andrecreational drug misuse.The use of validated questionnaires,particularly the IIEF orthe validated shorter version of the Sexual Health Inventory forMen,International Prostate Symptom Score,and Aging MaleSymptom Score may be helpful to assess sexual function domainsas well as the impact of treatments and interventions,but theyare not a replacement for a thorough history and medicalexamination.ExaminationAll patients should have a focused physical examination.Agenital examination is recommended,and this is essential if thereis a history of rapid onset of pain,deviation of the penis duringtumescence,symptoms of hypogonadism,or other urologicalsymptoms(past or present).A digital rectal examination of theprostate is not mandatory in ED but should be conducted in thepresence of genito-urinary or protracted secondary ejaculatorysymptoms.Blood pressure,heart rate,waist circumference,andweight should be measured.15InvestigationsThe choice of investigations depends on the individualcircumstances of the patient.ED is now regarded as an inde-pendent risk factor for cardiovascular disease and can be thepresenting feature of diabetes,11,15so serum lipids and fastingplasma glucose and/or glycated hemoglobin should be measuredin all patients.Hypogonadism is a treatable cause of ED that may also makemen less responsive,or even non-responsive to phosphodiesterasetype 5(PDE5)inhibitors(PDE5Is),15,24therefore all men withED should have serum testosterone measured on a blood fastingsample taken in t