Download Patient Case: Erectile Dysfunction

Patient Case: Erectile Dysfunction
Mr. K is 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.
Questions/Case discussion:
1. What are Mr. K’s risk factors for ED?
Hypertension, type 2 diabetes, antihypertensive medications,
atherosclerosis
2. 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.
3. 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