What is the most appropriate next step in managing a 69-year-old man with a 1-year history of erectile dysfunction, normal physical examination, and a history of depression, who has not had a decreased libido?

From the Guidelines

The most appropriate next step in managing this 69-year-old man with erectile dysfunction (ED) would be to prescribe a phosphodiesterase type 5 (PDE5) inhibitor such as sildenafil (Viagra), as recommended by the American Urological Association guideline 1. The patient's normal physical examination and intact libido suggest that a PDE5 inhibitor is an appropriate first-line pharmacological intervention. Given his age and history of depression, it's worth noting that his ED is likely multifactorial, potentially involving vascular, neurological, and psychological components. Before prescribing, it's essential to review his current medications for potential interactions, particularly nitrates which would be an absolute contraindication, as noted in the American College of Physicians' clinical practice guideline 1. The patient should be counseled about potential side effects including headache, flushing, dyspepsia, and nasal congestion. If this approach is unsuccessful, second-line options could include vacuum erection devices, intracavernosal injections, or referral to a urologist for further evaluation. Key considerations in managing ED, as outlined in the AUA guideline 1, include assessing the severity of ED, evaluating for underlying cardiovascular disease, and measuring morning serum total testosterone levels. However, given the patient's normal physical examination and lack of decreased libido, initiating therapy with a PDE5 inhibitor, such as sildenafil, is the most appropriate next step, with careful monitoring for potential side effects and interactions.

From the FDA Drug Label

Sildenafil tablets are a prescription medicine used in adults to treat pulmonary arterial hypertension (PAH). Sildenafil citrate is also marketed as sildenafil citrate tablets, 25 mg, 50 mg and 100 mg for erectile dysfunction

The most appropriate next step in managing a 69-year-old man with a 1-year history of erectile dysfunction, normal physical examination, and a history of depression, who has not had a decreased libido, is Sildenafil therapy.

• Key considerations: The patient has a history of depression, but it has been 10 years since his last episode, and he has not taken sertraline since then.
• Main idea: Sildenafil is a prescription medicine used to treat erectile dysfunction.
• Important note: The patient should be advised to seek immediate medical attention in the event of a sudden loss of vision or hearing while taking sildenafil 2.

From the Research

Patient Assessment

The patient is a 69-year-old man with a 1-year history of erectile dysfunction (ED) and a history of depression. He has not experienced a decrease in libido. The patient's physical examination is normal, and he has no other serious medical conditions.

Treatment Options

The following treatment options are available for the patient:

• Cognitive behavioral therapy
• Couples therapy
• Psychodynamic psychotherapy
• Sertraline therapy
• Sex therapy
• Sildenafil therapy

Relevant Studies

Studies have shown that phosphodiesterase type 5 inhibitors (PDE5is), such as sildenafil, can be effective in treating ED in men with various medical conditions, including those with a history of depression 3, 4, 5, 6. Additionally, PDE5is have been found to be well-tolerated and safe in patients with ED, with minimal side effects 5, 6.

Most Appropriate Next Step

Based on the patient's symptoms and medical history, the most appropriate next step in management would be to consider sildenafil therapy, as it has been shown to be effective in treating ED in men with various medical conditions, including those with a history of depression 3, 4, 5, 6. This is because the patient's ED is likely related to his age and potentially his history of depression, and sildenafil has been found to be effective in treating ED in these populations.

Key Points to Consider

• The patient's history of depression and normal physical examination suggest that his ED may be related to psychological or age-related factors, rather than an underlying medical condition.
• Sildenafil therapy has been shown to be effective in treating ED in men with various medical conditions, including those with a history of depression 3, 4, 5, 6.
• The patient's lack of decreased libido suggests that his ED is not related to a decrease in sexual desire, which is consistent with the use of sildenafil therapy.
• Some studies suggest that PDE5is may have additional benefits, such as reducing the risk of Alzheimer's disease 7.