AACE Male Sexual Dysfunction Task Force 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, JD, FACE Jesus B. Perez, MD, FACE Reviewers Bill Law, Jr., MD, FACE Jeffrey R. Garber, MD, FACE Philip Levy, MD, FACE Lois G. Jovanovic, MD, FACE Carlos R. Hamilton, Jr., MD, FACE Helena W. Rodbard, MD, FACE Pasquale J. Palumbo, MD, MACE F. John Service, MD, PhD, FACE Sheldon S. Stoffer, MD, FACE Herbert I. Rettinger, MD, MBA, FACE Talla P. Shankar, MD, FACE Jeffrey I.Mechanick, MD, FACE
ENDOCRINE PRACTICE Vol 9 No. 1 January/February 2003 77
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
Public Service Mission Statement According to a recent survey, the Massachusetts Male Aging Study, 52% of men beyond 40years of age may have some degree of erectile failure. For various reasons, only a small percentage of men seek medical help. This situation is unfortunate because advances in the understanding of male sexual chemistry have led to the development of a wide range of options to help men reclaim their inherent sexual capacity. Sexual problems can affect men of any age but seem to become more commonas men advance in years. Normal male sexual function requires an integrated response between central and local stimuli. Neural signals originating in the brain are transmitted to a thoracolumbar erection center and trigger the psychogenic erection associated with either fantasy or viewing erotic material. This process works in tandem with a reflex erection involving scrotal or genital stimulation,which activates neural impulses in the pudendal nerve that, when transmitted to S4-5 spinal cord sites, stimulate a reflexogenic erection. Although neural signals are crucial, the vigor of a man’s erection is ultimately determined by vascular events governing the flow of blood into the corpora cavernosa. The force with which blood flows into the corpora cavernosa is mediated by an intriguingintracavernosal chemistry sequence involving the enzyme nitric oxide synthase (NOS), nitric oxide (NO), and a second enzyme (adenylate cyclase), which helps generate the cyclic guanosine monophosphate needed to maximize intracavernosal blood flow and increase the pressure within the corpora cavernosa. The role of testosterone in male sexual function remains complex and controversial. Men acquire fullsexual and reproductive competence at adolescence when, in response to pulsatile pituitary luteinizing hormone (LH) secretion, Leydig cell testosterone production surges to adult levels as coincidental pulsatile pituitary folliclestimulating hormone (FSH) secretion initiates and maintains the orderly process of spermatogenesis in testicular Sertoli cells. Thereafter, the role of testosteronebecomes unclear. Some men with below-normal testosterone levels can still have nocturnal erections, but for fully satisfactory sexual and erectile function, a “normal” quotient of testosterone must be present in the bloodstream. As testos-
Abbreviations: AACE = American Association of Clinical Endocrinologists; AIDS = acquired immunodeficiency syndrome; CVA = cerebrovascular accident; DHT =dihydrotestosterone; FDA = Food and Drug Administration; LH = luteinizing hormone; NO = nitric oxide; NOS = nitric oxide synthase; PBI = penile brachial index; PGE1 = prostaglandin E1
MISSION STATEMENTS Guidelines Mission Statement The purpose of these guidelines is to present a framework for the evaluation, treatment, and follow-up of the patient—indeed, of the couple—who presents with sexual...