Which Is First? The Controversial Issue of Precedence in the Treatment of Male Sexual Dysfunctions


Corresponding Author: Emmanuele A. Jannini, MD, Course of Endocrinology and Sexology, Department of Clinical and Applied Sciences and Biotechnologies, University of L'Aquila, L'Aquila, 67100, Italy. Tel: +39 0862433530; Fax: +39 0862433523; E-mail: eaj@iol.it



In male sexual dysfunction (MSD), the presence of sexual comorbidities is relatively frequent. However, what is still a matter of controversy is what the first-line therapy in these patients should be.


Three scientists and the editor of the Controversies section, all experts in the medical treatment of MSD, present different perspectives on the use of phosphodiesterase type 5 inhibitors (PDE5), testosterone and dapoxetine in erectile dysfunction (ED), hypogonadism, and premature ejaculation (PE). The psychological aspects are discussed by an outstanding expert in psychosexology.

Main Outcome Measure

Expert opinion supported by the critical review of the currently available literature.


Testosterone should be used before PDE5s in hypogonadal men with comorbid ED; PDE5s should be used before dapoxetine in PE patients with comorbid ED, and counseling should be offered to all subjects with MSD.


Although the answer to the question “which should be first?” is controversial in almost all MSDs, intuition, experience, and evidence should guide the choice of which treatment should be used first. This decision is highly critical in influencing the therapeutic outcome as well the patient's and couple's adherence to treatment. Jannini EA, Isidori AM, Aversa A, Lenzi A, and Althof SE. Which is first? The controversial issue of precedence in the treatment of male sexual dysfunctions. J Sex Med 2013;10:2359–2369.