Case 057: Erectile Dysfunction

PATIENT PRESENTATION

Chief Complaint

Patient with erectile dysfunction and decreased libido despite treatment with sildenafil for 6 months.

History of Present Illness

Patient reports that his sexual partner is unsatisfied, and she has encouraged him to seek medical care for erectile dysfunction even though he is taking sildenafil 100 mg once or twice week for the past 6 months. He has variable success with sildenafil. Patient has also noticed a decreased libido.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. Identify medications that this patient is taking which could contribute to the patient’s decrease in libido or erectile dysfunction.

   Hint: See Table 51-2 in PPP

2. When a patient reports that sildenafil is not effective for erectile dysfunction, it may be that the patient needs re-education on how to take it correctly. List 5 key points that all patients should remember to optimize response to sildenafil.

   Hint: See Treatment in PPP

3. Identify key differences among the phosphodiesterase type 5 inhibitors used for erectile dysfunction.

   Hint: See Table 99-5 and Treatment PPP.

4. Would there be any value to switch this patient from sildenafil to a different type 5 phosphodiesterase inhibitor?

   Hint: See Treatment in PPP

5. Assume that this patient is started on intramuscular testosterone cypionate injections every month. Is this medication indicated in this patient?

   Hint: See Treatment in PPP.

FOLLOW-UP

Assume that the patient’s erectile dysfunction does not improve after an adequate treatment trial of testosterone supplementation and a therapeutic dosing regimen of a phosphodiesterase type 5 inhibitor. What other medical treatment options could be considered in this patient?

Hint: See Diagnosis of Cancer and Treatment in PPP

CASE SUMMARY

Global Perspective

The first step in the management of erectile dysfunction is to optimize treatment of diseases that could interfere with vascular, neurogenic, hormonal, or psychogenic factors essential for a penile erection. If the patient is taking medications that could contribute to erectile dysfunction and are not essential, then such medications should be discontinued. For medical treatment, type 5 phosphodiesterase inhibitors are the drugs of first choice. These agents differ in onset and duration of action, side effect profile, and interactions with food. Therefore, one agent may work better in a patient than another agent. Testosterone supplementation is specifically indicated in patients with documented low serum testosterone levels and symptoms of hypogonadism. Many dosage formulations administered by different route are available.

Key References