A 49-year-old man comes to the physician to discuss poor sexual performance. He has been unable to sustain erections for the past year. In the last 2 months, he has not had any erections at all, including at night or when he wakes up in the morning. Past medical history is significant for type 2 diabetes mellitus, hyperlipidemia, and chronic exertional buttock and thigh pain. His medications include insulin detemir and atorvastatin. The patient works as a truck driver and leads a sedentary lifestyle. He has smoked 1½ packs of cigarettes daily for the past 30 years. His blood pressure is 134/68 mm Hg and pulse is 78/min. His BMI is 32 kg/m². Heart sounds are normal. There is no evidence of sensory loss over the lower extremities. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: The most likely cause of erectile dysfunction in this patient is peripheral artery disease (PAD). He has multiple risk factors (diabetes mellitus, hyperlipidemia, and cigarette smoking) for atherosclerosis, and his buttock and thigh pain would be typical for intermittent claudication due to aortoiliac PAD. The pain maybe accompanied by weakness of the hip or thigh while walking. Bilateral aortoiliac disease can also lead to erectile dysfunction (ED). Leriche syndrome is the triad of lower-extremity claudication, absent or diminished femoral pulses, and ED. The next step in management is an ankle-brachial index (ABI) measurement to screen for PAD. ABI <0.9 is considered abnormal and has a high sensitivity and specificity for PAD. ED is also a strong predictor for coronary artery disease. Therefore, patients with ED who have 3 or more atherosclerotic risk factors or symptomatic PAD should be screened for cardiovascular disease (eg, exercise or pharmacologic stress test) prior to initiating specific therapy for sexual dysfunction. ankle-brachial index (ABI) (Choice B) Cystoscopy and pelvic ultrasound are typically used for the evaluation of prostate and bladder dysfunction, which are unlikely to be the source of this patient's symptoms. (Choice C) Testosterone deficiency can lead to a decrease in libido and erectile dysfunction; however, patients with testosterone deficiency can usually still achieve nocturnal penile erections. (Choice D) Phosphodiesterase-5 (PDE-5) inhibitors (eg, sildenafil, vardenafil, tadalafil) are the first-line therapy for patients with ED. However, a detailed evaluation for the underlying cause of sexual dysfunction should be performed prior to initiating treatment with PDE-5 inhibitors. (Choice E) Psychosocial factors, including depression and stress, can lead to erectile dysfunction. Furthermore, many medications used to treat depression can cause decreased libido and ED, which can worsen the existing problem. However, this patient's presentation is most suggestive of PAD as the underlying cause of ED. Educational objective: Erectile dysfunction (ED) is often caused by peripheral artery disease (PAD), and is also a strong predictor of coronary artery disease. Patients with ED and atherosclerotic risk factors should receive appropriate diagnostic testing (eg, ankle-brachial index, cardiac stress testing) prior to initiating specific therapy for sexual dysfunction. References: Is erectile dysfunction predictive of peripheral vascular disease? (http://www.ncbi.nlm.nih.gov/pubmed/15006259) Linking erectile dysfunction and coronary artery disease. (http://www.ncbi.nlm.nih.gov/pubmed/16391538) Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23040455)

A 49-Year-Old Man Comes to the Physician to Discuss Poor