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A 66 year old man with past medical history of hypertension and type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection. On the times that he does have an erection, they are very soft. He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship. He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been “perfect”. A Hemoglobin A1C 2 weeks ago was 6.0gm% . He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?
A) Obtain Serum Total Testosterone
B) Obtain Nocturnal Penile Tumescence
C) Start Sildenafil
D) Prescribe Vacuum assisted erection device
E) Switch Hydrochlorthiazide to ACE inhibitor
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Answer B.
Nocturnal Penile Tumescence is important to rule in/out psychologic from physiologic etiology...If the patient has an erection during the test this mean that the etiology is psychologic...Treatment varies according to the etiology. First is to know the etiology...
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What is the explaination???...Hydrochlorthiazide is not directly associated with erectile dysfunction(ED). Even though it can produce hyperlipidemia it does not mean that every patient with hyperlipidemia will have ED. And this is not all Hydrochlorthiazides that are associated with such side effect; indapamide does not cause it...In the question they don't specify...I need an explaination naha38...Why do you think it is E??
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http://www.medscape.com/viewarticle/445181_6 . The article gives hctz can cause erectile dysfunction and angiotensin receptor blockers and ACEI are best alternatives with out erectile dysfunction.
Summary
Occurrence of sexual dysfunction in patients with hypertension may not only negatively impact the ability of patients to stay on antihypertensive therapy, but can also lead to deterioration in quality of life. Therefore, it is important for practitioners to be aware of the wide variation in sexual side effects produced by antihypertensive agents and to be willing to discuss potential occurrence of these problems with patients.
Practitioners should consider choosing an antihypertensive therapy with the lowest possible potential for sexual side effects in order to attain an optimum balance between antihypertensive efficacy and quality of life. Recent studies indicate that AIIAs may offer a therapeutic option to prevent or correct erectile dysfunction in patients with hypertension. AIIAs have been shown to positively impact several indices of sexual function and perceived quality of life, effects possibly attributable to blockade of the effects of ANG II in mediating penile detumescence.
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another article http://www.medscape.com/viewarticle/556235_4
As thiazide diuretics are recommended by the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure,[20] but thiazide diuretics themselves may be associated with the development of ED
Of note, a higher percentage of patients on thiazides had severe ED at baseline, which is consistent with studies suggesting that thiazides may exacerbate ED;
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archer explanation
Correct Answer is E
Choice A. Incorrect. ACP does not recommend for or against hormone level measurement in patients presenting with impotence. Such decision should be individualized based on patient characteristics. Routine checking of testosterone levels in all patients with erectile dysfunction is not indicated. It is indicated only if history or physical exam suggest features of hypogonadism. Endocrine abnormalities ( hypogonadism) account for less than 5% of all causes of ED. Androgen deficiency typically manifests as erectile dysfunction accompanied by a diminished libido and hypogonadism. Patient in our case admits to a normal libido and has normal genitalia and secondary sex characteristics on physical exam. Given the low prevalence of androgen deficiency and the lack of supporting findings on initial evaluation, measurement of testosterone levels in this patient is of limited value.
Choice B. Incorrect. NPT testing uses Rigiscan monitor, around the penis and instructing the patient to wear it for 2-3 successive nights. If an erection occurs, which is expected during rapid eye movement sleep, the force and duration are measured on a graph. Inadequate or absent nocturnal erections suggest organic dysfunction, while a normal result indicates a high likelihood of a psychogenic etiology. This test is very rarely performed now but can be helpful in cases where the diagnosis is in doubt. Nocturnal penile tumescence testing is useful in distinguishing psychogenic from organic impotence. This may be indicated if patient reports complete absence of erections but does report presence of nocturnal erections or when psychogenic cause of impotence is strongly suspected. This patient has DM and enough causes to suspect organic impotence and he does not give any history of intact nocturnal erections. So, NPT not indicated to confirm diagnosis.
Choice C. Incorrect. Phosphodiesterase inhibitors or Vacuum assist devices are good choices of therapy for this patient's ED. However, The first step in managing ED is to identify and modify any reversible cause of ED. Such reversible causes include alcoholism, smoking and medications. Several anti-hypertensive medications such as beta blockers, thiazides, spironolactone and alpha blockers can cause erectile dysfunction and decreased libido. Hence, his anti-hypertensive medication can be switched from HCTZ to another drug that is less associated with erectile dysfunction. Such alternatives include ACEI / ARB and Calcium channel blockers.
Choice D. Incorrect. Refer C explanation. Once reversible factors are corrected, either PDI (such as sildenafil) or Vacuum assist devices are good options for treating this patient's ED. PDI is usually first line therapy in patients without any contraindication. He should be counselled about the side effects of each and choice must be given to him to choose b/w these options. Even though, he is not currently taking nitrates, this patient must be strongly counselled against taking nitrates or nitroglycerin if being started on Phosphodiesterase inhibitors.
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Thank you neha38...for your actualization!
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