Patient Case: Erectile Dysfunction
Patient Case: Erectile Dysfunction
Mr. XXX a 71-year old widower that you followed in your clinic for many years. He has a past history of hypertension, type-2 diabetes mellitus, and gastroesophageal reflux disease. He currently does not smoke (quit 11 years ago) and admits to heavy alcohol use in the past (quit 16 years). He presents complaining that “I have lost my nature.” He states that at most times he cannot get an erection. On the times that he does have an erection, they are very soft. This problem began approximately 14 months ago and has slowly worsened. It is a source of embarrassment for him. He still has a strong sexual desire and this problem has caused strain in his current relationship. He is very active walking two miles per day and is an avid golfer.
Medications: glipizide XL 10mg po q day, omeprazole 20mg po q day, hydrochlorothiazide/triamterene 25mg/37.5mg po q day
Physical Exam: Blood pressure 160/92 mmHg, pulse 86, respiratory rate 20 bpm. HEENT: no thyromegaly. CV: 2/6 systolic murmur along the left sternal border radiating to the axilla. RESP: Clear lungs. ABD: normal exam. RECTAL: good sphincter tone, normal prostate. GU: normal male genitalia, testicles are descended with normal size and consistency. EXT: peripheral pulses are normal, no edema present. NEURO: normal monofilament testing, normal cremasteric reflex.
Laboratory: Normal chemistries except an elevated random glucose at 246. Baseline EKG shows normal sinus rhythm with left ventricular hypertrophy and no evidence of prior myocardial infarction.
- What are Mr. K’s risk factors for ED?
Hypertension, type 2 diabetes, antihypertensive medications, atherosclerosis
- What are Mr. K’s treatment options?
The first steps in the treatment of ED are to modify any reversible causes of ED. Mr. K has previously discontinued smoking and alcohol consumption. These are important reversible causes of ED and a strong effort to convince patients to abstain from both tobacco and alcohol should be made. Mr. K can be switched from hydrochlorothiazide to another antihypertensive that is less closely associated with erectile dysfunction (e.g., an angiotensin converting enzyme inhibitor or calcium channel blocker). Importantly, Mr. K’s hypertension and diabetes should be aggressively controlled. Mr. K’s treatment options include PDE type 5 inhibitors or vacuum constriction device. Mr. K is a good candidate for both forms of therapy. He should be given his choice of therapy after discussing the risks and benefits for both. Even though he is not currently taking nitrates, if you prescribe a PDE type 5 inhibitor, he needs to be counseled on the dangers of using nitroglycerin in combination with sildenafil.
- Should testosterone levels be obtained routinely in the initial evaluation of ED?
Endocrine abnormalities account for less than 5% of all causes of ED. Androgen deficiency typically manifests as erectile dysfunction accompanied by a diminished libido and hypogonadism. Mr. K admits to a normal libido and has normal genitalia and secondary sex characteristics on physical exam. Given the low prevalence of androgen deficiency and the lack of supporting findings on initial evaluation, measurement of testosterone levels in Mr. K may be of limited value. However, there is evidence to support addition of testosterone to PDE type 5 inhibitors in men with low normal testosterone values.
Courtesy of Clyde Watkins, MD