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• September 2007
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The case of the month

April 2007 case of the month

A 64 years old male patient presents to an Andrology outpatient unit with erectile dysfunction for 10 years. While initially he was able to achieve erections sufficient for intercourse (6 out of 10 times), during the last couple of years he reports progressive loss of normal erections. Today, he is not able to achieve a rigid erection for vaginal penetration and successful intercourse. His medical history revealed type 2 diabetes (well controlled with glibenclamide) and hypertension (well controlled with amlodipine). His friend suggested trying tadalafil. He tried tadalafil 10mg, 3 times with no satisfactory result.

Question 1
What would be the diagnostic work-up in this patient?

1. Rigiscan: 2,27%
2. Triplex ultrasonography: 9,09%
3. Hormonal profile: 29,54%
4. All the above: 40,91%
5. None of the above: 18,19%

Comments:

This is a typical case of organic ED due to diabetes and hypertension. This man reports progressive loss of normal erections and did not respond to tadalafil 10mg. Most of the website visitors suggested that this man should have a complete diagnostic evaluation while about 20% suggested that no specific evaluation was necessary. The latter strategy reflects current guidelines suggesting no specific evaluation in such a typical case proceeding directly to treatment. Hormonal profile is recommended in almost every case with ED since it is quite common in elderly and represents a common cause of non-response to drug therapy. Certainly there is no clear answer and clinicians should individualize diagnostic evaluation in a patient-centred approach.

Question 2

1. Suggest him to try tadalafil 20mg at least 4 times: 9,09%
2. Try another PDE5i. If he still is a PDE5i non responder, suggest intracavernosal injections: 13,64%
3. Prescribe testosterone gel in combination to tadalafil: 15,91%
4. Take a careful medical and sexual history identifying possible reasons for inappropriate use of tadalafil and provide counseling: 38,64%
5. None of the above. The management strategy would be based on the results of diagnostic work-up: 22,72%

Comments:

Most of the answers suggest that this man needs a careful medical history in order to identify reasons for inappropriate use of tadalafil and provide counselling. This man is not a true non-responder. He tried only 10mg of tadalafil instead of the highest recommended dose (20mg) for only 3 times (at least 4 at the highest dose are recommended). Furthermore, no information is given on proper use administration before sexual intercourse (time to T-max is 2 hours) or the presence of adequate sexual stimulation. Addressing these factors are important before considering this man as a non-responder and suggesting another treatment modality