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Case #71: Erectile Dysfunction Celine Estrada History of Present Illness • 61 year old male • Complains to primary care physician about “some problems in matters of the bedroom.” • 5 ½ months of temporary, partial erections insufficient for intercourse • Resulting in significant martial discord History of Present Illness (cont.) • Patient’s IIEF-5 score was 5, consistent with severe erectile dysfunction. • No issues with sexual desire, feelings of depression, premature ejaculation, discomfort or pain with ejaculation. • He and his wife would like sex 2x a week, foreplay has been adequate but no positive results. History of Present Illness (cont.) • Pt has tried several alternative treatments (ex. arginine, flaxseed, meal, Ginkgo biloba) • Does not want surgery or injections • Wants to try “some of those little blue pills that everyone is talking about” • On a scale of 0-5, he rates the importance of determining the cause of his problems a “5.” Patient Case Question • Q1: What evidence so far suggests that this patient has primarily organic or psychogenic erectile dysfunction? • A: Primarily organic. IIEF score is 5, adequate foreplay is not enough, alternative treatments had no effect, no decrease in sexual desire, no feelings of depression. PMH + FH Patient Medical History: • DM type 2 x 18 years • HTN x 9 years • PTSD s/p Vietnam war veteran (no current symptoms) • No other history of psychiatric illness • GSW to upper left arm during the war • Fx left arm due to bicycle accident at age 12 • Tetanus booster 6 yrs ago • H/O Kidney infections Family History: Father died recently at age 83 from COPD Mother still alive and well at age 79 Maternal history (+) for stroke and vascular disease No siblings 3 children are alive and well Social History Patient has been married for 37 years and lives at home with his spouse Has a 50 pack-year smoking history but quick smoking 8 years ago Only drinks alcohol socially and has no long-term history of alcohol or recreational drug abuse He recently retired from construction work and plays golf 1-2 times per week Also walks 1 mile on days that he does not golf Watches what he eats because of his diabetes mellitus Denies non-compliance with his medications. Range of Symptoms Denies significant life stressors other than mild performance anxiety Denies recent weight loss Denies blurry vision, chest pain, episodes of dizziness or blackouts, unsteady gait, polyphagia, polydipsia, nocturia, dysuria, hematuria, urinary urgency, or increased urinary frequency Complains of “constantly cold feet” and season allergies (not active at present) Medications + Allergies Medications: Allergies: • Metformin 850 mg po TID • Penicillin (maculopapular rash above waist) • Amlodipine 2.5 mg po QD • Docusate sodium 100 mg po HS • Enalapril 10 mg po QD* • Glyburide 1.25 mg po Q AM • Furosemide 40 mg po BID* • Molds (watery eyes, sneezing) Maculopapular Rash Patient Case Questions • Q2: Does the patient have primary or secondary erectile dysfunction? Secondary ED because pt. has only had issues within recent months • Q3: Which medications is the patient taking for diabetes? Glyburide, Metformin • Q4: Which medications is the patient taking for hypertension? Enalapril, Amlodipine, Furosemide • Q5: In addition to diabetes and hypertension, does this patient have any other risk factors for erectile dysfunction? History of smoking and drinking alcohol. • Q6: Does erectile dysfunction in this patient appear to be primarily neurogenic, vascular, hormonal, or drug-induced? Could be both vascular and drug-induced. Physical Examination General examination: WDWN, alert & coordinated, slightly anxious in NAD Pleasant and cooperative Appears healthy and looks his stated age Weight appears to be within healthy range Vital Signs: BP: 124/80 P: 90 regular RR: 18 T: 97.7°F HT: 5’11” WT: 168 lbs Patient Case Question • Q7: Was the primary care provider’s observation correct that the patient’s weight was within a healthy range? BMI: kg/m2 = (168/2.2) / (71/39.37)2 = 76.36 / (3.25)2 = 23.495 ≈ 23.5 BMI Healthy weight = 18.5-24.9 BMI Patient is within a healthy range. PCP was correct. Physical Examination: Skin • Marked “crow’s feet” wrinkling around the eyes consistent with long-term smoking • Some dry, yellow scales on forehead, in nasal folds, and on upper lip • Warm and dry without obvious tumors, moles, or other lesions • Normal turgor and skin tone normal in color • Normal nail beds • (-) for diaphoresis • Distribution of hair WNL Physical Examination: HEENT • NC/AT • TMs WNL bilaterally • EOMI • Nose clear • PERRLA • Significant dental work but has most of his permanent teeth • Wears bifocals • Funduscopic exam shows no arteriolar narrowing, hemorrhages, or exudates • Throat without erythema • Moist mucous membranes Physical Examination: Neck/LN, Lungs/Chest Neck/LN: Lungs/Chest: • Supple without cervical, axillary, or femoral lymphadenopathy or masses • Clear to A&P bilaterally • Faint left carotid artery bruit • Thyroid normal size without nodules • (-) JVD • No additional sounds Physical Examination: Cardiac & Abd Cardiac: Abdomen: • RRR • Soft and ND • Normal S1 and S2 • Normal bowel sounds • No m/r/g • No masses or organomegaly • (-) S3 or S4 • Faint bruit Physical Examination: Genit/Rect Genit/Rect: • Normal scrotum • Normal size testes • Non-tender testes without nodules • Penis, circumsized and without discharge, scarring, or other abnormalities • Digital rectal exam showed mildly enlarged prostate but without nodules • (-) occult blood in stool Physical Examination: MS/Ext • Muscle strength 5/5 throughout • Full ROM in all extremities • Peripheral pulses 2+ in upper extremities, 1+ in lower extremities • Ingrown toenail on right great toe • No clubbing or edema • Feet are cold to touch but not cyanotic • No bone pain elicited with palpation Physical Examination: Neuro • A&Ox3 • CNs II-XII intact • DTRs 2+ and equal bilaterally • No sensory/motor deficits • Fixes and follows well with conjugate eye movements • Hearing appears intact • Gait is essentially normal • Babinski downgoing bilaterally Patient Case Question • Q8: Did the physical examination reveal any clinical manifestations consistent with a diagnosis of erectile dysfunction? Cold feet, poor circulation in lower portion of body (1+ peripheral pulses vs 2+ in upper extremities) Laboratory Blood Test Results Na – 141 meq/L Hb – 13.9g/L Chol. – 265 mg/dL K – 4.1 meq/L Hct – 39.5% HDL – 38mg/dL Cl --102 meq/L WBC – 8.9 x 103/mm3 LDL – 120 mg/dL HCO3 – 24 meq/L Plt – 271 x 103/mm3 Trig – 270mg/dL BUN – 14 mg/dL Ca – 8.8 mg/dL HbA1c – 11.8% Cr – 1.1mg/dL Mg – 2.0 mg/dL Testosterone – 700ng/dL Glu – 195 mg/dL Phos – 2.9 mg/dL PSA – 4.0 ng/dL Urinalysis + Duplex Ultrasound, Penis Urinalysis: • Clear, dark amber color • SG 1.028 • pH 6.0 • (-) leukocyte esterase, nitrites, ketones, bilirubin • Protein, trace • Urobilinogen WNL • RBC 2/HPF • WBC 0/HPF Duplex Ultrasound: • Peak systolic velocity = 0.28 m/sec • End diastolic velocity = 0.13 m/sec Patient Case Question • Q9: Are there any laboratory blood test or urinalysis results that support a diagnosis of erectile dysfunction? High levels of cholesterol and triglycerides could cause atherosclerosis, effecting blood flow to the penis. Peak systolic velocity is low (0.28 m/sec), borderline case of arterial dysfunction (vs healthy >0.30 m/sec) Patient Case Question • Q10: The results of the ultrasound study of the penis support a diagnosis of… a. neurogenic erectile dysfunction b. vascular erectile dysfunction c. both neurogenic and vascular dysfunction d. none of the above Patient Case Question • Q11: Is there any reason why the patient should not be prescribed a phosphodiesterase-5 inhibitor? Patient can be prescribed a PHE-5 inhibitor because none of his medications are nitrates or alpha-blockers. PHE-5 is commonly prescribed for men who suffer from erectile dysfunction due to DM and HTN. PHE-5 is also used as a treatment for men with an enlarged prostate, which the pt. has.