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.
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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