A 54-year-old man comes to the office due to difficulty maintaining an erection for the last several weeks. He says, "One night I was having sex with my wife and could not maintain an erection. Since then, it has continued to be a problem." The patient still has morning erections. His medical history is significant for hypertension, coronary artery disease, and depression. He has been married for 20 years but reports that he and his wife have been arguing since he began spending more time at work following a promotion 2 months ago. His current medications include amlodipine, lisinopril, and bupropion. Physical examination is unremarkable. Which of the following is the most likely cause of this patient's erectile dysfunction?

Question

A 54-year-old man comes to the office due to difficulty maintaining an erection for the last several weeks.  He says, "One night I was having sex with my wife and could not maintain an erection.  Since then, it has continued to be a problem."  The patient still has morning erections.  His medical history is significant for hypertension, coronary artery disease, and depression.  He has been married for 20 years but reports that he and his wife have been arguing since he began spending more time at work following a promotion 2 months ago.  His current medications include amlodipine, lisinopril, and bupropion.  Physical examination is unremarkable.  Which of the following is the most likely cause of this patient's erectile dysfunction?

Quizplus · Accepted Answer

The temporal association between this patient's arguments with his wife and subsequent onset of erectile dysfunction (ED) makes psychogenic factors the most likely cause of his ED. The presence of spontaneous nocturnal erections is another important diagnostic clue as this demonstrates the integrity of neurologic reflexes and corpus cavernosa blood flow. Loss of normal nocturnal erections occurs in men with organic ED but is not seen with psychogenic etiologies. ED can be caused by organic factors, psychogenic factors, or a combination of both. Psychogenic causes include performance anxiety, depression, sexual trauma, and/or relationship problems and are typically associated with an abrupt onset triggered by stress, as in this patient. In contrast, men suffering from organic causes of ED (eg, vascular insufficiency) tend to have a slower progression of symptoms, with intermittent ED later becoming more persistent in nature (Choice E). (Choice A) There tends to be an increase in the incidence of ED with advancing age. However, the sudden onset of this patient's dysfunction during a time of relationship and work stress makes a psychogenic cause more likely. (Choices B and C) Antidepressants, particularly selective serotonin reuptake inhibitors, have been associated with sexual dysfunction. However, the norepinephrine-dopamine reuptake inhibitor bupropion has not been associated with sexual dysfunction. Of the antihypertensive agents, thiazide diuretics and sympathetic blockers (eg, clonidine, methyldopa) have the greatest risk for ED. Angiotension-converting enzyme inhibitors (eg, lisinopril) and calcium channel blockers (eg, amlodipine) have the least risk. Educational objective: Psychogenic causes of erectile dysfunction include performance anxiety, depression, sexual trauma, relationship problems, and stress. Important clues include sudden-onset and normal nocturnal erections. __________ References: The 2018 revision to the process of care model for evaluation of erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/30057280)

A 54-Year-Old Man Comes to the Office Due to Difficulty