Question of the week # 291

291) A 66 year old man with past medical history of hypertension and  type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection.  On the times that he does have an erection, they are very soft.  He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship.  He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been “perfect”. A Hemoglobin A1C 2 weeks ago was 6.0gm% .  He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

 

13 Responses

  1. answer is start sildenafil

  2. i think e

  3. C. he doesnt have neuropathy.

  4. A

  5. E

  6. Switching one HTN med for another doesn’t seem like it would solve the problem. Now, ADDING an ACE to HTCZ might help with his chronic HTN however, in the interim, Viagra seems to be the appropriate next step to resolve the chief complaint. My $0.02.

  7. B……Before any treatment is important to see if there is a nerve function or blood supply problem and is not a psycological problem. Nocturnal penil tumescence is a easy test to evaluate this. Is normal for a manmto have five to six erections during sleep, especial during REM. Having desire does not mean no a psycological problem.

  8. bbb

  9. C
    Patient has STRONG sexual desire and he reports erection, but soft. It doesn’t seems to be psychological cause. 66y old guy with controlled DM, i would go with Sildenafil.

  10. If a man notices he is having trouble getting or sustaining an erection, and other things in his life are relatively stable, then a conversation with a doctor is in order. A blood test for testosterone is a good next step. If the testosterone level is low, then trying testosterone replacement makes sense. If that doesn’t improve erections, then it’s time to try an ED drug.

    http://www.health.harvard.edu/blog/a-logical-approach-to-treating-erectile-dysfunction-201211275583

    I’d like to check his testosterone levels first just to make sure that it is not to do with atherosclerosis leading to his ED. His peripheral pulses may be full but this patient has DM2, which is considered an equivalent of CAD.

    If testosterone levels are normal, then we can proceed with sildenafil or other PDE5 inhibitors. (Testes and genitalia being normal might throw off this decision though. Any thoughts?)

    Answer A.

  11. E- D/C HCTZ, start ACEI

    • The question is asking ” the most appropriate” and that would be by eliminating the cause of the ED and that would be HCTZ.
      It would have been “appropriate ” to start Sildenafil but NOT most appropriate.

      P.S. An added bonus to starting the ACEI is a great HTN control and a great renal protection from renal failure associated w/DM.

  12. Correct Answer is E.
    The first step in managing ED is to identify and modify any reversible cause of ED. Such reversible causes include alcoholism, smoking and medications. Several anti-hypertensive medications such as beta blockers, thiazides, spironolactone and alpha blockers can cause erectile dysfunction and decreased libido. Hence, his anti-hypertensive medication can be switched from HCTZ to another drug that is less associated with erectile dysfunction. Such alternatives include ACEI and Calcium channel blockers.

    A. incorrect. ACP does not recommend for or against hormone level measurement in patients presenting with impotence. Such decision should be individualized based on patient characteristics. Routine checking of testosterone levels in all patients with erectile dysfunction is not indicated. It is indicated only if history or physical exam suggest features of hypogonadism. Endocrine abnormalities ( hypogonadism) account for less than 5% of all causes of ED. Androgen deficiency typically manifests as erectile dysfunction accompanied by a diminished libido and hypogonadism. Patient in our case 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 this patient is of limited value.

    B. Incorrect. NPT testing uses Rigiscan monitor, around the penis and instructing the patient to wear it for 2-3 successive nights. If an erection occurs, which is expected during rapid eye movement sleep, the force and duration are measured on a graph. Inadequate or absent nocturnal erections suggest organic dysfunction, while a normal result indicates a high likelihood of a psychogenic etiology This test is very rarely performed now. But can be helpful in cases where the diagnosis is in doubt. Nocturnal penile tumescence testing is useful in distinguishing psychogenic from organic impotence. This may be indicated if patient reports complete absence of erections but does report presence of nocturnal erections or when psychogenic cause of impotence is strongly suspected. This patient has DM and enough causes to suspect organic impotence and he does not give any history of intact nocturnal erections. So, NPT not indicated to confirm diagnosis.

    C. Phosphodiesterase inhibitors or Vacuum assist devices are good choices of therapy for this patient’s ED. However, The first step in managing ED is to identify and modify any reversible cause of ED. Such reversible causes include alcoholism, smoking and medications. Several anti-hypertensive medications such as beta blockers, thiazides, spironolactone and alpha blockers can cause erectile dysfunction and decreased libido. Hence, his anti-hypertensive medication can be switched from HCTZ to another drug that is less associated with erectile dysfunction. Such alternatives include ACEI and Calcium channel blockers.

    D. refer C explanation. Once reversible factors are corrected, either PDI (such as sildenafil) or Vacuum assist devices are good options for treating this patient’s ED. PDI is usually first line therapy in patients without any contraindication. He should be counselled about the side effects of each and choice must be given to him to choose b/w these options. Even though, he is not currently taking nitrates, this patient must be strongly counselled against taking nitrates or nitroglycerin if being started on Phosphodiesterase inhibitors.

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