Transcript Case #71: Erectile Dysfunction

Case #71:
Erectile Dysfunction
Celine Estrada
History of Present Illness
• 61 year old male
• Complains to primary care
physician about “some
problems in matters of the
bedroom.”
• 5 ½ months of temporary,
partial erections insufficient
for intercourse
• Resulting in significant
martial discord
History of Present Illness (cont.)
• Patient’s IIEF-5 score was
5, consistent with severe
erectile dysfunction.
• No issues with sexual
desire, feelings of
depression, premature
ejaculation, discomfort or
pain with ejaculation.
• He and his wife would like
sex 2x a week, foreplay has
been adequate but no
positive results.
History of Present Illness (cont.)
• Pt has tried several
alternative treatments (ex.
arginine, flaxseed, meal,
Ginkgo biloba)
• Does not want surgery or
injections
• Wants to try “some of those
little blue pills that everyone
is talking about”
• On a scale of 0-5, he rates
the importance of
determining the cause of his
problems a “5.”
Patient Case Question
• Q1: What evidence so far suggests that this patient
has primarily organic or psychogenic erectile
dysfunction?
• A: Primarily organic. IIEF score is 5, adequate foreplay
is not enough, alternative treatments had no effect, no
decrease in sexual desire, no feelings of depression.
PMH + FH
Patient Medical History:
•  DM type 2 x 18 years
•  HTN x 9 years
•  PTSD s/p Vietnam war
veteran (no current
symptoms)
•  No other history of
psychiatric illness
•  GSW to upper left arm
during the war
•  Fx left arm due to bicycle
accident at age 12
•  Tetanus booster 6 yrs ago
•  H/O Kidney infections
Family History:
 Father died recently at
age 83 from COPD
 Mother still alive and
well at age 79
 Maternal history (+) for
stroke and vascular disease
 No siblings
 3 children are alive and
well
Social History
 Patient has been married
for 37 years and lives at home
with his spouse
 Has a 50 pack-year
smoking history but quick
smoking 8 years ago
 Only drinks alcohol
socially and has no long-term
history of alcohol or
recreational drug abuse
 He recently retired from
construction work and plays
golf 1-2 times per week
 Also walks 1 mile on
days that he does not golf
 Watches what he eats
because of his diabetes mellitus
 Denies non-compliance
with his medications.
Range of Symptoms
 Denies significant life stressors other than mild
performance anxiety
 Denies recent weight loss
 Denies blurry vision, chest pain, episodes of
dizziness or blackouts, unsteady gait, polyphagia,
polydipsia, nocturia, dysuria, hematuria, urinary
urgency, or increased urinary frequency
 Complains of “constantly cold feet” and season
allergies (not active at present)
Medications + Allergies
Medications:
Allergies:
• Metformin 850 mg po TID
• Penicillin (maculopapular
rash above waist)
• Amlodipine 2.5 mg po QD
• Docusate sodium 100 mg
po HS
• Enalapril 10 mg po QD*
• Glyburide 1.25 mg po Q
AM
• Furosemide 40 mg po BID*
• Molds (watery eyes,
sneezing)
Maculopapular Rash
Patient Case Questions
•
Q2: Does the patient have primary or secondary erectile dysfunction?
Secondary ED because pt. has only had issues within recent months
•
Q3: Which medications is the patient taking for diabetes?
Glyburide, Metformin
•
Q4: Which medications is the patient taking for hypertension?
Enalapril, Amlodipine, Furosemide
•
Q5: In addition to diabetes and hypertension, does this patient have any
other risk factors for erectile dysfunction?
History of smoking and drinking alcohol.
•
Q6: Does erectile dysfunction in this patient appear to be primarily
neurogenic, vascular, hormonal, or drug-induced?
Could be both vascular and drug-induced.
Physical Examination
General examination:
 WDWN, alert &
coordinated, slightly anxious in
NAD
 Pleasant and cooperative
 Appears healthy and looks
his stated age
 Weight appears to be within
healthy range
Vital Signs:
BP: 124/80
P: 90 regular
RR: 18
T: 97.7°F
HT: 5’11”
WT: 168 lbs
Patient Case Question
• Q7: Was the primary care provider’s observation
correct that the patient’s weight was within a healthy
range?
BMI: kg/m2 = (168/2.2) / (71/39.37)2
= 76.36 / (3.25)2
= 23.495 ≈ 23.5 BMI
Healthy weight = 18.5-24.9 BMI
Patient is within a healthy range. PCP was correct.
Physical Examination: Skin
• Marked “crow’s feet” wrinkling around the eyes consistent
with long-term smoking
• Some dry, yellow scales on forehead, in nasal folds, and on
upper lip
• Warm and dry without obvious tumors, moles, or other lesions
• Normal turgor and skin tone normal in color
• Normal nail beds
• (-) for diaphoresis
• Distribution of hair WNL
Physical Examination:
HEENT
• NC/AT
• TMs WNL bilaterally
• EOMI
• Nose clear
• PERRLA
• Significant dental work but
has most of his permanent
teeth
• Wears bifocals
• Funduscopic exam shows
no arteriolar narrowing,
hemorrhages, or exudates
• Throat without erythema
• Moist mucous membranes
Physical Examination:
Neck/LN, Lungs/Chest
Neck/LN:
Lungs/Chest:
• Supple without cervical,
axillary, or femoral
lymphadenopathy or
masses
• Clear to A&P bilaterally
• Faint left carotid artery
bruit
• Thyroid normal size
without nodules
• (-) JVD
• No additional sounds
Physical Examination:
Cardiac & Abd
Cardiac:
Abdomen:
• RRR
• Soft and ND
• Normal S1 and S2
• Normal bowel sounds
• No m/r/g
• No masses or
organomegaly
• (-) S3 or S4
• Faint bruit
Physical Examination:
Genit/Rect
Genit/Rect:
• Normal scrotum
• Normal size testes
• Non-tender testes without nodules
• Penis, circumsized and without discharge, scarring, or other
abnormalities
• Digital rectal exam showed mildly enlarged prostate but
without nodules
• (-) occult blood in stool
Physical Examination:
MS/Ext
• Muscle strength 5/5 throughout
• Full ROM in all extremities
• Peripheral pulses 2+ in upper extremities, 1+ in lower
extremities
• Ingrown toenail on right great toe
• No clubbing or edema
• Feet are cold to touch but not cyanotic
• No bone pain elicited with palpation
Physical Examination: Neuro
• A&Ox3
• CNs II-XII intact
• DTRs 2+ and equal bilaterally
• No sensory/motor deficits
• Fixes and follows well with conjugate eye movements
• Hearing appears intact
• Gait is essentially normal
• Babinski downgoing bilaterally
Patient Case Question
• Q8: Did the physical examination reveal any clinical
manifestations consistent with a diagnosis of erectile
dysfunction?
Cold feet, poor circulation in lower portion of
body (1+ peripheral pulses vs 2+ in upper
extremities)
Laboratory Blood Test Results
Na – 141 meq/L
Hb – 13.9g/L
Chol. – 265 mg/dL
K – 4.1 meq/L
Hct – 39.5%
HDL – 38mg/dL
Cl --102 meq/L
WBC – 8.9 x 103/mm3
LDL – 120 mg/dL
HCO3 – 24 meq/L
Plt – 271 x 103/mm3
Trig – 270mg/dL
BUN – 14 mg/dL
Ca – 8.8 mg/dL
HbA1c – 11.8%
Cr – 1.1mg/dL
Mg – 2.0 mg/dL
Testosterone – 700ng/dL
Glu – 195 mg/dL
Phos – 2.9 mg/dL
PSA – 4.0 ng/dL
Urinalysis +
Duplex Ultrasound, Penis
Urinalysis:
•
Clear, dark amber color
•
SG 1.028
•
pH 6.0
•
(-) leukocyte esterase, nitrites,
ketones, bilirubin
•
Protein, trace
•
Urobilinogen WNL
•
RBC 2/HPF
•
WBC 0/HPF
Duplex Ultrasound:
•
Peak systolic velocity = 0.28
m/sec
•
End diastolic velocity = 0.13
m/sec
Patient Case Question
• Q9: Are there any laboratory blood test or urinalysis
results that support a diagnosis of erectile
dysfunction?
High levels of cholesterol and triglycerides
could cause atherosclerosis, effecting blood flow to
the penis. Peak systolic velocity is low (0.28 m/sec),
borderline case of arterial dysfunction (vs healthy
>0.30 m/sec)
Patient Case Question
• Q10: The results of the ultrasound study of the penis
support a diagnosis of…
a. neurogenic erectile dysfunction
b. vascular erectile dysfunction
c. both neurogenic and vascular dysfunction
d. none of the above
Patient Case Question
• Q11: Is there any reason why the patient should not
be prescribed a phosphodiesterase-5 inhibitor?
Patient can be prescribed a PHE-5 inhibitor
because none of his medications are nitrates or
alpha-blockers. PHE-5 is commonly prescribed for
men who suffer from erectile dysfunction due to DM
and HTN. PHE-5 is also used as a treatment for men
with an enlarged prostate, which the pt. has.