Medicine>>>>>Geriatrics
Question 15#

A 76-year-old married man consults with you about erectile dysfunction. He has osteoarthritis and hypertension, well controlled on acetaminophen and amlodipine 5 mg daily. He is able to walk 3 miles daily at a moderate pace. He has no evidence of coronary artery disease. He has been monogamous with his wife, who uses an estrogen-containing vaginal cream twice weekly and has not experienced dyspareunia. Over the past 12 months, he has noticed progressive difficulty maintaining an erection during intercourse; for the past 3 months he has been unable to achieve penetration despite the use of vaginal lubricants. His libido is good; he and his wife have a close emotional relationship. Physical examination is unremarkable. In particular, testicular size is normal. There is no evidence of neurological or peripheral vascular disease. Morning serum testosterone level is 800 ng/dL (normal 270-1070).

What is the best next step in this patient’s management? 

A. Refer to cardiologist for exercise testing prior to resuming sexual activity
B. Discontinue amlodipine
C. Prescribe sildenafil 25 to 50 mg po 1 hour before anticipated intercourse
D. Check free testosterone and prolactin level
E. Advise that most patients his age are sexually inactive and further therapy is not beneficial

Correct Answer is C

Comment:

 Although the frequency of sexual intercourse decreases with age, most geriatric patients are physiologically able to function well into their 70s and thereafter. The commonest cause of sexual inactivity is lack of a willing partner either due to death or disability. The second commonest cause is personal disability. This patient should be given a trial of phosphodiesterase (PDE-5) inhibitor. He should be warned about vasodilatory side effects such as headache or hypotension. Certain vasodilators such as nitrates or alpha-blockers cannot be used with PDE-5 inhibitors because of the risk of severe hypotension, but calcium-channel blockers are safe unless the patient reports adverse symptoms.

Patients who can exercise comfortably at a moderate pace do not require further testing before resuming sexual activity; the energy cost of intercourse in a comfortable setting is about 3 metabolic equivalents (METs), analogous to a 3 to 4 miles per hour walk. Vasodilating medications such as ACEIs or CCBs rarely cause erectile dysfunction; if the patient were taking a thiazide, beta-blocker or an agent with anticholinergic activity (such as clonidine), an alternative antihypertensive would be considered. This patient has no features of hypogonadism and requires no further endocrine testing. If his libido were diminished and his serum testosterone in the borderline low range, a free testosterone level might be useful.