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Old 10-17-2011
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Default Endocrine

A 68-year-old man comes to clinic demanding an “erection pill.” He states that over the past few years he has had difficulty maintaining, though he is able to initiate, an erection. He denies pain with ejaculation, premature ejaculation, or any previous penile difficulties. He reports having a good relationship with his spouse and denies any new stressors in his life, though his inability to maintain an erection is causing moderate distress. His past medical history is significant for coronary artery disease, a myocardial infarction 2 years ago, stable angina, diabetes, and benign prostatic hyperplasia. He currently takes a 5-alpha-reductase inhibitor, a biguanide, a beta-blocker, an ACE-inhibitor, a daily aspirin, and a long-acting nitroglycerin preparation. Physical examination reveals diminished pulses in the patient’s lower extremities and dystrophic toenails, but is otherwise unremarkable. Which of the following is the most appropriate treatment for this patient’s erectile dysfunction?








Vascular surgery


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Old 10-18-2011
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ans A. alprostatil. PGE1 analoug. sildenafil s contraindicated in dis pt. also pt has
reynold phenomina..
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Old 10-18-2011
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The correct answer is A. An effective intervention in patients with erectile dysfunction who have a contraindication to sildenafil is alprostadil. Alprostadil is a prostaglandin that causes vasodilatation by direct vascular smooth-muscle relaxation. Trabecular and cavernosal smooth muscle relaxes, allowing blood flow into the lacunar spaces of the penis. It is given as a direct injection or transurethrally and has few systemic side effects, though a small number of patients experience penile pain or priapism.
Testosterone (choice B) can be given to men with hypogonadism. However, a major side effect of testosterone replacement is worsening benign prostatic hyperplasia, inasmuch as testosterone and its metabolites drive prostate growth. Patients with severe BPH or with prostate cancer should not be given testosterone. Patients with moderate BPH should be tried on other agents first. Further, although the etiology of this patient’s erectile dysfunction is not currently known, it is unlikely that hypogonadism is his primary problem. Up to 50% of diabetic men will suffer erectile dysfunction, mainly from neuropathy but also from vascular disease—which is quite likely the case with this patient.
Sildenafil (choice C), which increases nitric oxide levels, causes severe, life-threatening hypotension when given with nitroglycerin derivatives. It is contraindicated in this patient. If it is determined that he does not need nitroglycerin, then sildenafil is an excellent choice for this patient.
Vascular surgery (choice D) is a dramatic intervention in this patient and unlikely to be worth the risk. Vascular surgery for erectile dysfunction has poor results in older men with generalized disease. It is generally reserved for young men with congenital or traumatic erectile dysfunction.
Yohimbine (choice E) is a common ingredient in over-the-counter “enhancement” products. It has not been proven effective in placebo-controlled trials, and is certainly not as efficacious as alprostadil.
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