Erectile dysfunction: The Daily PANCE Blueprint
A 55-year-old man with well-controlled type 2 diabetes mellitus presents with difficulty obtaining and maintaining erections over the past few months. He takes metformin and glipizide for diabetes. Serum testosterone level is 400 ng/dL (normal 300-1000 ng/dL). Which of the following is the most appropriate next step in management?
A. Continue metformin and glipizide at current doses
B. Add spironolactone 25 mg daily
C. Start sildenafil 50 mg as needed
D. Refer for penile prosthesis implantation
E. Recommend sex therapy for psychogenic ED
Answer and topic summary
The answer is C. Start sildenafil 50 mg as needed
Erectile dysfunction (ED) is the inability to attain or maintain an erection sufficient for satisfactory sexual performance. Causes can be psychogenic, neurogenic, hormonal, arterial, and venogenic. Diagnosis involves history, physical exam, and potential labs like testosterone level. First-line treatment for most organic ED is with phosphodiesterase type 5 (PDE5) inhibitors like sildenafil (Viagra), which acts by increasing cGMP levels, causing increased nitric oxide release and penile smooth muscle relaxation. It can be taken 30 to 60 minutes before anticipated intercourse. It is contraindicated with the use of nitrates because, together, they can cause profound hypotension. In this patient, diabetes is the most likely cause of ED. His normal testosterone level makes hypogonadal ED less likely. Continuing oral diabetes medications alone does not treat his sexual dysfunction. Spironolactone, penile prosthesis, and psychotherapy are not indicated as initial treatments based on his presentation.
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Covered under ⇒ PANCE Blueprint Genitourinary ⇒ ⇒
Also covered as part of the Internal Medicine EOR topic list
