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Old 10-17-2011
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A 65-year-old man comes to your clinic complaining of difficulty in maintaining an erection long enough for satisfying intercourse. He has no problems with libido or in attaining an erection and reports a happy marriage of 43 years. His difficulties have been worsening steadily for the past 10 years. He has a history of type 2 diabetes and hypertension that are well controlled on lisinopril and glyburide. Examination reveals normally developed penis and testes. He has decreased pulses in his lower extremities bilaterally, and his neurologic examination is unremarkable. Laboratory studies show Normal LH and Normal testosterone.


Which of the following is the initial management most likely to be effective in treating this patientís erectile dysfunction?



A.

Change his oral hypoglycemic to metformin


B.

Prescribe intracavernous prostaglandin injections


C.

Prescribe oral sildenafil therapy


D.

Prescribe testosterone supplementation therapy


E.

Recommend intensive couples psychotherapy
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Old 10-18-2011
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ans C. oral sildenafil therapy. drug f choce for ED
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Old 10-18-2011
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C.

Prescribe oral sildenafil therapy
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Old 10-18-2011
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The correct answer is C. This man has vasculogenic erectile dysfunction secondary to his hypertension and diabetes. Oral sildenafil now is considered first-line therapy for men with organic erectile dysfunction (ED); doses of 100 mg restore better quality erections in 81% of a general population of men with ED. The pill should be taken on an empty stomach 1 hour before desired intercourse. Sildenafil is a selective inhibitor of phosphodiesterase type 5, which is primarily expressed in the penis. By inhibiting phosphodiesterase, levels of cyclic GMP in the penis increase, causing relaxation of smooth muscle in penile arterioles. This causes increased blood inflow, leading to firmer erections.
Neither of the medications he is taking is likely to cause erectile dysfunction, so changing his hypoglycemic regimen (choice A) is unlikely to be of benefit. Medications are an important consideration in evaluating ED, especially antihypertensives such as beta-blockers and diuretics. Antidepressants, paradoxically, also are strongly implicated in ED. Withdrawal of these agents as appropriate is usually the first step in therapy.
Intracavernous prostaglandin injections (choice B) are highly effective in helping to initiate erections, but these are also cumbersome to use and may cause priapism and cavernous fibrosis. For this reason, they are considered second- or third-line agents.
Testosterone supplementation (choice D), although popular, has not been shown to improve ED in men with normal testosterone levels. This patientís normal levels of testosterone and LH (which stimulates testosterone production) rule out hypogonadism. Men with ED should be screened for low libido and have serum total testosterone and leuteinizing hormone levels checked. If the patient suffers from hypogonadism, he should be started on a trial of transdermal testosterone or weekly intramuscular testosterone depot injections before proceeding with further medications.
For men with a significant component of psychogenic ED, couples therapy (choice E) is an important adjunct to any therapy. Psychogenic factors likely do not play a significant role in this case, although counseling may help him to overcome any performance anxiety he may have developed in recent years. Oral sildenafil also may be helpful to men with psychogenic ED, although at a lower rate.
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