A 55-year-old-man comes to the office due to erectile dysfunction. He has normal libido but has been unable to maintain a satisfactory erection to have intercourse. The patient often wakes up in the morning with an erection. He has no history of testicular injury or peripheral vision loss. Medical history includes end-stage renal disease resulting from idiopathic focal segmental glomerulosclerosis. Peritoneal dialysis was started 6 months ago due to intractable fluid retention despite high-dose diuretic therapy, and he is being evaluated for possible renal transplant. The patient does not use tobacco, alcohol, or illicit drugs.
Temperature is 37.1 C (98.7 F) , blood pressure is 138/82 mm Hg, pulse is 76/min, and respirations are 12/min. BMI is 25 kg/m². Visual fields are normal on confrontation. Testes are normal in size and consistency, and cremasteric reflex is present. There is trace edema at the ankles and feet.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient's erectile dysfunction?

Question

A 55-year-old-man comes to the office due to erectile dysfunction. He has normal libido but has been unable to maintain a satisfactory erection to have intercourse. The patient often wakes up in the morning with an erection. He has no history of testicular injury or peripheral vision loss. Medical history includes end-stage renal disease resulting from idiopathic focal segmental glomerulosclerosis. Peritoneal dialysis was started 6 months ago due to intractable fluid retention despite high-dose diuretic therapy, and he is being evaluated for possible renal transplant. The patient does not use tobacco, alcohol, or illicit drugs.
Temperature is 37.1 C (98.7 F) , blood pressure is 138/82 mm Hg, pulse is 76/min, and respirations are 12/min. BMI is 25 kg/m². Visual fields are normal on confrontation. Testes are normal in size and consistency, and cremasteric reflex is present. There is trace edema at the ankles and feet.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient's erectile dysfunction?

Quizplus · Accepted Answer

11ec193a_97ce_4d61_853d_45e8a0640c64_MD0002_00 Most men with end-stage renal disease (ESRD) experience sexual dysfunction. Manifestations can include low libido, erectile dysfunction, decreased frequency of intercourse, and infertility. Sexual dysfunction in ESRD is usually multifactorial. Common contributing factors include vascular/vasoactive impairment, peripheral and autonomic neuropathy, gonadal dysfunction, psychological stress, concurrent medications, and medical comorbidities. The initial evaluation of sexual dysfunction in patients with ESRD should include a clinical review for possible contributing factors (eg, medications, vascular disease) and limited laboratory testing (eg, serum testosterone, prolactin levels). Most patients with erectile dysfunction respond to phosphodiesterase inhibitors (eg, sildenafil). This patient's normal nonsexual morning erections suggest a possible psychogenic component, but this is unlikely to be the only factor in a patient with ESRD, and the effectiveness of psychotherapy for sexual dysfunction in men with ESRD is unknown. (Choice A) Impaired gonadal function in ESRD can lead to low serum testosterone levels, decreased libido, and erectile dysfunction. However, this patient has normal libido and a normal serum testosterone level; testosterone supplementation is unlikely to be beneficial. (Choice B) This patient has no clinical features (eg, visual field defects) to suggest a pituitary mass lesion. Men with ESRD often have elevated prolactin levels due to increased production and decreased clearance. The levels can be corrected with dopamine agonists (eg, bromocriptine), but this has not been shown to improve sexual function. (Choice C) Alprostadil (prostaglandin E1) can be administered intraurethrally or injected into the penile shaft and causes vasodilation of the cavernosal arteries. It may be used as second-line therapy in men who fail phosphodiesterase inhibitors but is associated with a risk of local bleeding in uremic men who often have platelet dysfunction. (Choice E) Sexual dysfunction in men with ESRD often improves following renal transplant and may also improve with correction of concurrent anemia and zinc deficiency. However, dialysis does not usually improve sexual function, regardless of modality. Educational objective: Most men with end-stage renal disease experience sexual dysfunction (eg, low libido, erectile dysfunction, decreased frequency of intercourse, infertility). Contributing factors include vascular impairment, peripheral and autonomic neuropathy, gonadal dysfunction, psychological stress, concurrent medications, and medical comorbidities. Most patients respond to phosphodiesterase inhibitors (eg, sildenafil). __________ References: Phosphodiesterase type 5 inhibitor treatment for erectile dysfunction in patients with end-stage renal disease receiving dialysis or after renal transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/23346948)

A 55-Year-Old-Man Comes to the Office Due to Erectile Dysfunction