List of Abbreviations
PD – Peyronie's Disease
PDE5i – phosphodiesterase type 5 inhibitors (G04BE drugs for erectile dysfunction)
NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs
TT – traction therapy
SWT – shockwave therapy
US – ultrasound examination
ED – erectile dysfunction
Terms and Definitions
Peyronie's disease – a condition characterized by fibrous degeneration of the tunica albuginea with plaque formation, capable of leading to penile curvature.
Erectile dysfunction – the inability to achieve and/or maintain an erection sufficient for sexual intercourse.
Semi-rigid penile prosthesis – an implant consisting of two semi-rigid cylinders (Note: Russian definition adjusted for medical accuracy).
Three-component penile prosthesis – an implant consisting of three parts – inflatable cylinders, a pump, and a fluid reservoir.
Plication corporoplasty – a surgical procedure in which individual sutures are placed on the healthy side of the tunica albuginea to shorten it and functionally straighten the penis.
Patch corporoplasty (grafting) – a surgical procedure in which the affected area is incised or excised, and the defect is replaced with a graft material.
Dupuytren's contracture – a connective tissue disorder characterized by fibrous degeneration of the palmar aponeurosis.
Tympanosclerosis is a sclerosing disease of the middle ear leading to hearing loss.
Ledderhose's disease is a connective tissue disorder characterized by fibrous degeneration of the plantar aponeurosis.
Acute phase of Peyronie's disease is a phase of Peyronie's disease characterized by changing symptoms.
Stabilization phase of Peyronie's disease is a phase of Peyronie's disease characterized by unchanged symptoms.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Peyronie's disease is a disorder involving impaired repair of the tunica albuginea, leading to the formation of scars (fibrous plaques) that cause penile curvature or deformity [1].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The exact etiology of the disease has not been established. Trauma to the tunica albuginea is the most likely triggering factor for the development of the disease. In the presence of individual predisposition, single or repeated trauma can trigger processes leading to the development of the disease [2–6]. Peyronie's disease should be distinguished from the consequences of penile fracture, since corpus cavernosum fibrosis develops following a fracture, whereas in Peyronie's disease, fibrosis of the tunica albuginea is primary. Between 16% and 40% of patients report a history of trauma prior to the onset of the disease [6,7]. Genetic predisposition, autoimmune factors, impaired tissue healing processes, and infection are also potential predisposed factors [8–10].
In Peyronie's disease, trauma results in blood extravasation between the outer longitudinal and inner circular layers of the tunica albuginea and the formation of blood clots, which leads to the formation of fibronectin and fibrin, the development of inflammation, and the release of reactive oxygen species; this, in turn, causes a decrease in collagenase activity and promotes collagen synthesis. Ultimately, this cascade leads to the formation of a fibrous plaque and disruption of the normal angioarchitecture of the penis [1,11–13].
Most plaques are located on the dorsal surface of the penis and are often associated with the intercavernous septum, due to the greatest mechanical stress on this part of the tunica albuginea during sexual intercourse. The tunica albuginea has the smallest thickness at the 3 and 9 o'clock positions of the conventional clock face, and is absent over the corpus spongiosum (between the 5 and 7 o'clock positions) [14,15].
1.3 Epidemiology of the Disease or Condition
The prevalence of PD ranges from 0.39% to 20.3% according to various epidemiological studies and is found more frequently in patients with erectile dysfunction and diabetes mellitus. Peyronie's disease can occur at any age, but the peak incidence occurs between 50 and 60 years of age [16–21]. Epidemiological studies of PD have not been conducted in Russia.
1.4 Features of Coding the Disease or Condition
N48.8 Other specified disorders of penis
N48.6 Balanitis
Note: in the English-language ICD-10, Peyronie's disease most closely corresponds to the code N48.6 induration penis plastica (Balanitis).
1.5 Classification of the disease or condition
The course of Peyronie's disease is defined by two phases: the acute phase and the stabilization phase. The acute phase is accompanied by the development and change of symptoms, whereas stabilization is considered to be the absence of changes in symptom severity (pain, degree of curvature) for 3 months [22,23].
1.6 Clinical presentation of the disease or condition
The disease is characterized by two phases: the acute phase and the stabilization phase. The acute phase is characterized by pain at rest and during erection, the onset and progression of penile deformity, the appearance of palpable plaques of the tunica albuginea, and the development of erectile dysfunction. Some patients do not notice plaque formation, but note penile shortening, curvature, and decreased fullness of the penis distal to the maximum angle of curvature, known as the "hinge" effect.
The acute phase is followed by the stabilization phase, the criterion for the onset of which is the absence of symptom progression for 3 months. Pain may persist during this time, but it occurs with strong erections and is associated with stretching of the tunica albuginea. Lateral or ventral deformity generally causes greater discomfort because it makes vaginal penetration difficult. Dorsal deformity causes less discomfort. At the same time, some patients do not complain of any discomfort or impairment during sexual intercourse, even with marked curvature (greater than 60 degrees). The severity and direction of the curvature depend on the size and location of the plaque. In addition to simple single-plane curvature, complex types of curvature may also be present, such as an "hourglass" deformity or a hinge effect due to the loss of axial rigidity of the penis resulting from the deformity.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnosis of a patient with Peyronie's disease involves a physical examination, medical history taking, and instrumental studies. Physical examination should assess plaque location, penile elasticity, tenderness on palpation, and the relationship of the plaque with surrounding tissues (skin, urethra). Patients should be advised to photograph the penis in an erect state in three projections—top, front, and side—against a plain background with good lighting. Instrumental studies include penile color duplex Doppler ultrasound with pharmacological agents (alprostadil) to clarify the severity of erectile impairment.
Criteria for establishing the diagnosis/condition: based on pathognomonic findings: presence of induration of the tunica albuginea on palpation, and penile curvature.
2.1 Complaints and Anamnesis
It is recommended to establish the time of onset of the disease, the presence of a triggering factor, the presence of pain, and its relationship with erections for the purpose of differential diagnosis with the consequences of penile fracture [22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: determining the time from the onset of the disease is necessary to determine the disease stage when planning surgical treatment.
It is recommended to clarify the direction and degree of curvature, as well as the rate of curvature progression during history taking to plan surgical treatment [24].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to take a targeted history regarding erectile function during the initial consultation to allow for an objective assessment and establishment of penile length, in order to determine the severity of future penile shortening [22,24].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to ascertain whether there is a family history of Dupuytren's contracture and plantar fascial fibromatosis to clarify the cause of the disease, since the condition also has a hereditary nature [22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.2 Physical Examination
It is recommended to determine plaque location and tenderness on palpation during the physical examination in order to plan surgical treatment and perform differential diagnosis with other causes of penile tissue induration (neoplasm, urethral stricture, cavernosal fibrosis) [25].
GPP CLOE 4Strength of Recommendation C (Level of Evidence – 4)
Comments: the presence of plaque attachment to surrounding tissues, mobility of the induration, and its relation to the urethra should be assessed. During palpation, it is important to pay attention not only to plaques located in the area of the pendulous penis, but also to palpate the entire accessible length of the corpora cavernosa. Plaque size does not correlate with the degree of penile curvature [26].
It is recommended to measure the stretched penile length from the penopubic angle to the tip of the glans to determine indications for surgical treatment [27,28].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended that the patient take photographs of the penis at home in three projections during an erection for the initial assessment of the direction and severity of penile deformity [29,30].
GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)
Comments: it is advisable to take photographs of the penis against a solid background that contrasts with the penis.
2.3 Laboratory Diagnostics
Specific laboratory tests are not used to diagnose Peyronie's disease.
2.4 Instrumental Diagnostics
It is recommended to perform penile color duplex Doppler ultrasound with pharmacological agents (alprostadil at a single dose of 10 mcg intracavernously) in cases where photography during a full erection is not possible, if the patient complains of erectile dysfunction, and if the patient fails to achieve a full erection during photography attempts, in order to objectively assess penile length and configuration when planning surgical treatment [29,31].
GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)
Comment: penile color duplex Doppler ultrasound with pharmacological agents (alprostadil) (C01EA prostaglandins) at a single dose of 10 mcg intracavernously is used to achieve an erection by dilating cavernous arteries and increasing blood flow to the corpora cavernosa. When using alprostadil, patients should be warned about the possibility of priapism and advised to consult a urologist if the erection persists 3 hours after drug injection.
It is recommended to combine the intracavernous test with penile color duplex Doppler ultrasound to detect signs of vasculogenic erectile dysfunction [32].
Level of Recommendations CLevel of Evidence 3Level of Recommendation C (Level of Evidence – 3)
Comment: prior to administering the vasoactive drug alprostadil (C01EA prostaglandins), signs of cavernous fibrosis should be assessed using grayscale ultrasound. The examination should last at least 20–25 minutes or until maximum erection is achieved, as some patients exhibit a delayed response to the medication.
It is not recommended to routinely perform ultrasound, computed tomography, and magnetic resonance imaging for the diagnosis of Peyronie's disease [29,30,32].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comment: penile ultrasound may be recommended if cavernous fibrosis is suspected or if palpation findings do not allow for a confident diagnosis of Peyronie's disease.
2.5 Other Procedures
The necessity of performing other diagnostic tests is determined in each specific clinical situation in accordance with the patient's condition.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
It is recommended to prescribe non-steroidal anti-inflammatory and antirheumatic drugs to patients in the acute phase of the disease to reduce pain syndrome, if present [48].
GCR BLEL 5Grade of Recommendation B (Level of Evidence – 5)
It is recommended to prescribe phosphodiesterase type 5 inhibitors (PDE5is, G04BE drugs for erectile dysfunction) to patients in the acute phase of the disease to treat concomitant erectile dysfunction [34,35].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comment: the prescription of PDE5is (G04BE drugs for erectile dysfunction) can facilitate sexual intercourse by increasing penile rigidity and functionally reducing the degree of curvature. Furthermore, the use of PDE5is (G04BE drugs for erectile dysfunction) in the acute phase is associated with lesser progression of curvature compared to patients who did not receive such therapy [33–36].
It is recommended to use shock wave therapy (SWT) to reduce disease symptoms in the acute phase of the disease [33,37–41].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comment: it should be noted that SWT has limited efficacy in the acute phase of the disease. A reduction in curvature should not be expected with SWT in either the acute or stable phase.
It is recommended to perform traction therapy in patients with Peyronie's disease to improve erectile function and preserve penile length [42–48].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: despite the limited evidence base and lack of a standardized regimen, traction therapy can modify the course of the disease, producing a moderate positive effect. Moreover, this therapy carries a low risk of side effects. Traction therapy has been studied in the treatment of simple curvatures; its efficacy in complex penile curvatures such as hourglass deformity, hinge effect, and calcified plaques remains unknown.
It is not recommended to use tamoxifen** in patients with Peyronie's disease with the aim of modifying the disease course [33].
GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)
Comment: the administration of vitamin E preparations is not recommended, as it has not shown significant clinical efficacy in the treatment of Peyronie's disease [22,33,47,48].
It is not recommended to use physiotherapeutic procedures, including electrophoresis, for the treatment of Peyronie's disease [22,48].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
It is not recommended to use intralesional injection therapy directly into the plaque for the treatment of Peyronie's disease [47,48].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
3.2 Surgical Treatment
Considering the limited efficacy of conservative therapy, surgical treatment is the preferred method of management. When planning surgical intervention, the patient's somatic status should be taken into account, and the patient must be informed about potential surgical options and complications. Taking photographs of the penis prior to surgery helps assess penile size and the severity of curvature before and after the operation. When planning plication techniques, to make the expected outcome easier for the patient to understand, they should be warned that the penis will be equal in length to its shorter side (the side of the curvature).
It is recommended to offer surgical treatment for significant curvature to patients with a stable stage of the disease in order to restore the ability to engage in a full sexual life [22,51,52].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: significant curvature is defined as curvature that hinders sexual intercourse. As a rule, this is greater than 30 degrees, although the direction of the curvature is also important. Ventral curvature impairs sexual life more severely than dorsal penile curvature.
It is recommended to perform plication corporoplasty in patients with sufficient penile length for sexual intercourse in order to preserve erectile function and create a functionally straight penis [22,53–55].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: plication corporoplasty impairs erectile function less than graft substitution of the tunica albuinea, and therefore it can be used in patients with mild to moderate erectile dysfunction [56]. The outcomes of various modifications of plication corporoplasty (Nesbit, Yachia, 16-dot) are comparable, and the choice of surgical intervention depends on the experience and preferences of the surgeon [57–61].
It is recommended to perform augmentation corporoplasty in patients with preserved erectile function in order to preserve penile length at the patient's request [63–64].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: one should consider the high risk of decreased erectile function following surgery due to disruption of the anatomical structure of the corpora cavernosa [65–67]. Autologous grafts or off-the-shelf biological materials (e.g., cadaveric pericardium) can be used for augmentation. When choosing a graft material, one should be guided by its strength and ability to withstand high intracavernous pressure. The use of synthetic grafts is not recommended [63,64,68–75].
It is recommended to place a penile implant (semi-rigid penile prosthesis, three-piece inflatable penile prosthesis) in patients with erectile dysfunction resistant to conservative therapy and concomitant Peyronie's disease to restore penile rigidity sufficient for sexual intercourse [76–79].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
Comment: the choice of penile implant (semi-rigid penile prosthesis or three-piece inflatable penile prosthesis) depends on the patient's ability to operate the prosthesis independently [80]. Patients may experience difficulties locating and using the pump when a three-piece inflatable penile prosthesis is installed. Additionally, the three-piece prosthesis carries a higher risk of infectious complications and device failure. If a residual curvature of less than 30 degrees persists after the placement of a semi-rigid or three-piece penile prosthesis, a spontaneous reduction in curvature can be expected within 6–12 months of device use [78].
It is recommended to assess penile length, rigidity, degree of deviation, and the presence of complex deformity in patients prior to surgery in order to plan the scope of the procedure [76].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to install a semi-rigid penile prosthesis or a three-piece inflatable penile prosthesis in patients with complex penile deformity to preserve the possibility of sexual life and achieve erection [22,78–81].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
It is recommended to perform penile modeling, plication, or tunica albuginea grafting in the event of residual curvature following the placement of a semi-rigid or three-piece inflatable penile prosthesis in order to achieve a functionally straight penis [78–81].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: a functionally straight penis is defined as one whose curvature allows for sexual intercourse without difficulty [76]. Due to the high number of complications associated with the "sliding" technique, its performance is not recommended.
It is not recommended to perform plication corporoplasty in patients with complex penile curvature (hourglass deformity or hinge effect), as this leads to insufficient clinical effect and does not correct the deformity [67].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3.3 Other Treatment
Other treatments for Peyronie's disease, including dietary therapy, are not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to use a penile size-extender and curvature correction device or a vacuum erection device after surgery to reduce residual curvature [42,79,82].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
It is recommended to use phosphodiesterase type 5 inhibitors (G04BE drugs for erectile dysfunction) for concomitant erectile dysfunction in patients after surgery to improve surgical outcomes and prevent recurrence of curvature [22].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
5. Prevention and Dispensary Observation
Prevention of Peyronie's disease has not been developed; dispensary follow-up is not required.
6. Organization of Medical Care
Indications for hospitalization in a medical organization:
1) Planning of surgical intervention.
Indications for patient discharge from a medical organization:
1) Absence of postoperative complications (hematoma, wound dehiscence, purulent-infectious complications).
7. Additional Information
No additional information available.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | The time of disease onset, presence of a triggering factor, pain, and its association with erection were established. | Yes/no |
2. | A targeted anamnesis regarding erectile function was taken. | Yes/no |
3. | Photography of the penis in three projections was performed to determine the direction and severity of the curvature. | Yes/no |
4. | In the presence of erectile dysfunction, penile duplex ultrasonography with a pharmacological test (alprostadil) was performed. | Yes/no |
5. | Patients eligible for surgical treatment were offered surgery during the stable phase of the disease. | Yes/no |
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Appendix A1. Working Group Composition
Gamidov SI, MD, Professor, Associate Professor at the Department of Obstetrics, Gynecology, Perinatology and Reproductology, Institute of Clinical Medicine, Sechenov University, Head of the Andrology and Urology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov.
Mammaev RU, Urologist, Junior Research Fellow at the Andrology and Urology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov, PhD student at the Department of Obstetrics, Gynecology, Perinatology and Reproductology, Institute of Clinical Medicine, Sechenov University.
Shatylko TV, PhD, Urologist at the Andrology and Urology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov.
Conflict of interest: the authors of the clinical guidelines declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines: specialists with higher medical education in the following specialties:
Urology.
Surgery.
Table 1. Scale for assessing the levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Levels of Evidence (LoE) grading scale for prevention and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing grades of recommendation (GR) for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Clinical Guidelines of the Russian Society of Urology.
Order of the Ministry of Labor and Social Protection of the Russian Federation No. 137n dated March 14, 2018 "On approval of the professional standard "Urologist" (as amended and supplemented).
European Association of Urology Guidelines.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Peyronie's disease is a penile disorder characterized by the development of penile curvature. The exact cause of the disease is often unknown. In this condition, a normal area of the tunica albuginea (the fibrous tissue surrounding the corpora cavernosa—the structures responsible for erections) degenerates into scar tissue (the so-called "plaque"). The altered area disrupts the normal function of the tunica albuginea and can lead to curvature. The disease may also be accompanied by pain around the plaque, to reduce which various treatments can be offered, including non-steroidal anti-inflammatory and antirheumatic drugs, phosphodiesterase type 5 inhibitors (drugs for erectile dysfunction), as well as physical therapies such as extracorporeal shock wave therapy or traction therapy (penile stretching). Sexual activity is not contraindicated in this condition.
Subsequently, a gradual stabilization of the disease occurs, characterized by the cessation of symptom progression (decrease or increase). If, after stabilization, the penile curvature interferes with sexual activity (causes pain during intercourse or prevents successful vaginal penetration), surgical treatment may be performed. Most conservative therapy methods have not shown efficacy in Peyronie's disease, and effective drugs require a prolonged course of treatment and do not guarantee relief from symptoms.
Before surgery, erectile function and the nature of the curvature are assessed. To this end, the doctor may ask you to take three photographs of the penis during an erection—one from the front, one from the top, and one from the side. These photographs are necessary to assess the configuration of the curvature and determine the surgical approach. An investigation with intracavernous injection of an erection-inducing agent may also be performed if photographs or achieving an erection are impossible for any reason.
Depending on the degree of curvature and preserved erectile function, surgical treatment is performed. Plication corporoplasty, in which several non-absorbable sutures are placed on the tunica albuginea, is considered the safest and most effective treatment method. Often, circumcision is performed during this surgery to reduce the rate of postoperative complications. Postoperatively, a reduction in penile length may be noted, the degree of which correlates with the severity of the curvature, as well as the sensation of knots beneath the penile skin.
When erectile function is preserved and the deformity is complex, surgery using a graft made of buccal mucosa, cadaveric pericardium, saphenous vein, etc., may be performed. However, this technique can lead to the development or worsening of erectile dysfunction.
Finally, in cases of complex deformity and erectile dysfunction, penile prosthesis implantation is usually performed. Inflatable and semi-rigid penile prostheses are available, which are equally effective in achieving an erection.
Postoperatively, depending on the chosen procedure, medications to improve erections, penile traction devices, and pain-relieving medications may be prescribed.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
International Index of Erectile Function (IIEF) Questionnaire [62,83,84].
Purpose: assessment of the severity of erectile dysfunction.
Please select only one answer.
1. Over the past 4 weeks, how often were you able to get an erection during sexual activity1? | 0 - No sexual activity | 1 - Almost never or never | 2 - A few times (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
|---|---|---|---|---|---|---|
2. Over the past 4 weeks, when you had erections with sexual stimulation2, how often were your erections hard enough for penetration? | 0 - No sexual activity | 1 - Almost never or never | 2 - A few times (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
3. Over the past 4 weeks, when you attempted sexual intercourse3, how often were you able to penetrate your partner? | 0 - Did not attempt intercourse | 1 - Almost never or never | 2 - A few times (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
4. Over the past 4 weeks, during sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? | 0 - Did not attempt intercourse | 1 - Almost never or never | 2 - A few times (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
5. Over the past 4 weeks, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? | 0 - Did not attempt intercourse | 1 - Extremely difficult | 2 - Very difficult | 3 - Difficult | 4 - Slightly difficult | 5 - Not difficult |
6. Over the past 4 weeks, how many times have you attempted sexual intercourse? | 0 - Did not attempt intercourse | 1: 1-2 attempts | 2: 3-4 attempts | 3: 5-6 attempts | 4: 7-10 attempts | 5: 11 or more attempts |
7. Over the past 4 weeks, when you attempted sexual intercourse, how often was it satisfactory for you? | 0 - Did not attempt intercourse | 1 - Almost never or never | 2 - A few times (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
8. Over the past 4 weeks, how much did you enjoy sexual intercourse? | 0 - No intercourse | 1 - No enjoyment | 2-Slight pleasure | 3-Moderate pleasure | 4-Great pleasure | 5-Very great pleasure |
9. Over the past 4 weeks, during sexual stimulation or intercourse, how often did you ejaculate4? | 0-No sexual stimulation or intercourse | 1 - Almost never or never | 2-Occasionally (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
10. Over the past 4 weeks, during sexual stimulation or intercourse, how often did you experience orgasm, with or without ejaculation? | 0-No sexual stimulation or intercourse | 1 - Almost never or never | 2-Occasionally (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always |
11. Over the past 4 weeks, how often did you experience sexual desire? | 1 - Almost never or never | 2-Occasionally (much less than half the time) | 3 - Sometimes (about half the time) | 4 - Most times (much more than half the time) | 5 - Almost always or always | |
12. Over the past 4 weeks, how would you rate your level of sexual desire? | 1-Very low or no desire | 2-Low | 3-Moderate | 4-High | 5-Very high | |
14. Over the past 4 weeks, how satisfied were you with your sexual relationship with your female sexual partner? | 1-Very dissatisfied | 2-Moderately dissatisfied | 3-Mixed feelings | 4-Moderately satisfied | 5-Very satisfied | |
15. Over the past 4 weeks, how confident were you that you could achieve and maintain an erection? | 1-Very low | 2-Low | 3-Moderate | 4-High | 5-Very high | |
Key:
26–30 points – no erectile dysfunction.
18–25 points – mild erectile dysfunction.
11–17 points – moderate erectile dysfunction.
6–10 points – severe erectile dysfunction.
Notes:
1Sexual activity includes sexual intercourse, foreplay, and masturbation.
2Sexual stimulation includes activities such as erotic play with a sexual partner, viewing erotic films, photographs, drawings, etc.
3Sexual intercourse is defined as the insertion of the penis into the vagina.
4Ejaculation is defined as the expulsion of semen from the penis.
IIEF-5: International Index of Erectile Function-5 [83].
Purpose: to assess the severity of erectile dysfunction. A abbreviated version of the questionnaire that does not evaluate sexual disorders other than erectile function.
Almost never or never | Rarely (less than half the time) | Sometimes (about half the time) | Frequently (more than half the time) | Almost always or always | ||
|---|---|---|---|---|---|---|
extremely difficult | very difficult | difficult | not very difficult | not at all difficult | ||
- | How often did you get an erection during sexual activity recently? | 1 | 2 | 3 | 4 | 5 |
- | How often recently was your erection sufficient for penile penetration (to begin sexual intercourse)? | 1 | 2 | 3 | 4 | 5 |
- | When attempting sexual intercourse, how often were you able to achieve penile penetration (start intercourse)? | 1 | 2 | 3 | 4 | 5 |
- | How often recently were you able to maintain your erection after penetration? | 1 | 2 | 3 | 4 | 5 |
- | How difficult was it to maintain your erection through to the end of sexual intercourse? | 1 | 2 | 3 | 4 | 5 |
Key:
21-25 points - no erectile dysfunction
16–20 points: mild erectile dysfunction
11–15 points: mild-to-moderate erectile dysfunction
5–10 points: moderate-to-severe erectile dysfunction