What's the next step for an MS (Multiple Sclerosis) patient with erectile dysfunction, currently on 50mg sildenafil (phosphodiesterase type 5 inhibitor), experiencing facial flushing and occasional headaches, with decreased sensation and difficulty achieving orgasm?

From the Guidelines

For an MS patient with erectile dysfunction experiencing side effects on 50mg sildenafil, I recommend maximizing the current treatment by ensuring proper administration, titration, and addressing modifiable factors before considering alternative therapies, as suggested by the American Urological Association 1. To address the patient's concerns, we should first evaluate whether the trial of PDE5 inhibition was adequate, considering factors such as hormonal abnormalities, food or drug interactions, timing and frequency of dosing, lack of adequate sexual stimulation, heavy alcohol use, and the patient’s relationship with his partner. According to high-quality evidence from RCTs, PDE-5 inhibitors, including sildenafil, vardenafil, and tadalafil, have been shown to improve successful sexual intercourse and erections in men with erectile dysfunction, including those with multiple sclerosis 1. Given the patient's experience with sildenafil, including side effects and decreased sensation, trying tadalafil (Cialis) 10mg as needed or 5mg daily may be a suitable alternative, as it has a longer duration of action and may provide more spontaneity and less pressure to perform within a limited timeframe. Additionally, addressing the decreased sensation and difficulty achieving orgasm, which are likely related to MS-associated neurological changes, adding a vibrator or other sensory enhancement devices may help overcome sensory deficits, and psychological approaches like mindfulness techniques can also help focus on existing sensations. If these approaches are unsuccessful, consultation with a urologist specializing in sexual medicine or a physiatrist familiar with MS-related sexual dysfunction would be beneficial for more specialized treatments. Key points to consider:

• Maximizing current treatment with proper administration and titration
• Addressing modifiable factors contributing to erectile dysfunction
• Considering alternative PDE-5 inhibitors, such as tadalafil, if necessary
• Utilizing sensory enhancement devices and psychological approaches to address decreased sensation and difficulty achieving orgasm.

From the FDA Drug Label

The most common side effects with sildenafil tablets include: Nosebleed, headache, upset stomach, getting red or hot in the face (flushing), trouble sleeping, as well as fever, erection increased, respiratory infection, nausea, vomiting, bronchitis, pharyngitis, runny nose, and pneumonia in children. Tell your doctor if you have any side effect that bothers you or doesn't go away

The patient is already experiencing some common side effects of sildenafil, such as headache and flushing. Considering the patient's decreased sensation and difficulty achieving orgasm, it may be necessary to:

• Re-evaluate the patient's treatment plan to address these specific issues.
• Consider alternative treatments or adjustments to the current dosage or medication regimen.
• Monitor the patient's condition closely and adjust the treatment plan as needed to minimize side effects and optimize efficacy. It is essential to consult with the patient's doctor to determine the best course of action, as the FDA drug label does not provide specific guidance on managing these particular side effects in the context of MS-related erectile dysfunction 2, 2, 2.

From the Research

Next Steps for MS Patient with Erectile Dysfunction

The patient is currently experiencing moderate erectile dysfunction, improved with sildenafil, but with side effects such as facial flushing and occasional headaches. The patient is also experiencing decreased sensation and difficulty achieving orgasm.

• The current dose of sildenafil is 50mg, which is the recommended starting dose for men with erectile dysfunction 3.
• However, most men are later titrated to sildenafil 100mg for improved efficacy, with no increase in adverse events 3.
• The patient's experience of decreased sensation and difficulty achieving orgasm may be related to the underlying multiple sclerosis (MS) condition, rather than the sildenafil treatment itself.
• Studies have shown that sildenafil is effective in improving erection quality, treatment satisfaction, anxiety levels, and the sexual experience in men with erectile dysfunction, including those with MS 4.
• However, there is a possible tachyphylaxis effect with sildenafil, where patients may need to increase the dose over time to achieve the same effect 5.
• The patient's side effects of facial flushing and occasional headaches are common adverse events associated with sildenafil, but are generally mild and transient 4, 6.

Potential Treatment Options

• Consider increasing the dose of sildenafil to 100mg, as this may improve efficacy without increasing adverse events 3.
• Alternatively, consider switching to a different phosphodiesterase type 5 inhibitor, such as vardenafil or tadalafil, which may have a different side effect profile 4.
• Address the patient's decreased sensation and difficulty achieving orgasm through other means, such as counseling or other treatments for sexual dysfunction.
• Monitor the patient's response to treatment and adjust the dose or treatment plan as needed to minimize adverse events and optimize efficacy.