What is the best management plan for a 50-year-old male with erectile dysfunction (ED) and occasional nocturia, who is prescribed Tadalafil (tadalafil) 10 mg PO daily PRN and refuses a digital rectal examination (DRE)?

Management of Erectile Dysfunction and Nocturia in a 50-Year-Old Male

Tadalafil 10 mg daily PRN is an appropriate first-line treatment for this patient with multifactorial erectile dysfunction, and behavioral modifications are appropriate for occasional nocturia. 1

Erectile Dysfunction Management

First-Line Treatment: PDE5 Inhibitors

• Tadalafil 10 mg daily PRN is an appropriate starting dose for most patients with erectile dysfunction 2
• Tadalafil has been shown to significantly improve erectile function compared to placebo, with improvements in IIEF-EF scores of 9.4-9.7 points versus 0.9 points for placebo 3
• Daily use of tadalafil provides an alternative to on-demand dosing for couples who prefer spontaneous rather than scheduled sexual activity 4
• Key advantages of tadalafil include:
  • Long half-life (17.5 hours) enabling therapeutic levels with daily administration 3
  • Efficacy independent of diabetes duration, glycemic control, and microvascular complications 4
  • Can be taken without regard to food 2

Optimization of Treatment

• Ensure the patient takes medication properly:
  • Can be taken without regard to timing of meals 2
  • Should be taken at least 30 minutes before anticipated sexual activity 2
  • Entire tablet should be taken (do not split) 2
• If inadequate response to initial dosing, the dose may be increased to 20 mg or decreased to 5 mg based on individual efficacy and tolerability 2
• Verify adequate sexual stimulation is occurring, as this is necessary for PDE5 inhibitors to work 1

Lifestyle Modifications

• Regular exercise, weight reduction, and other lifestyle modifications are appropriate recommendations 1
• These interventions can improve erectile function by addressing underlying vascular and metabolic factors

Nocturia Management

Behavioral Modifications

• Behavioral modifications are appropriate first-line management for occasional nocturia 1
• These include:
  • Limiting fluid intake in the evening
  • Avoiding caffeine and alcohol before bedtime
  • Elevating legs in the evening to mobilize fluid
  • Timing medications that increase urine production for morning use

Additional Benefit of Tadalafil for Nocturia

• Tadalafil 5 mg once daily has been shown to improve nocturia in men with BPH 5, 6
• Studies show significant improvements in:
  • Number of nighttime voids
  • Hours of undisturbed sleep
  • Nocturia-related quality of life 6
• The treatment difference for nocturia between tadalafil and placebo was statistically significant but small (-0.2, p=0.002) 5

Prostate Health Evaluation

PSA Testing

• Obtaining PSA is appropriate in this 50-year-old male with urinary symptoms 4
• PSA testing provides a baseline assessment of prostate health

Digital Rectal Examination (DRE)

• While the patient refused DRE, it is important to document this refusal and the discussion of potential consequences 4
• DRE is recommended as part of the physical examination for men with erectile dysfunction and urinary symptoms 4, 1

Follow-up Plan

Monitoring and Assessment

• The 3-month follow-up plan is appropriate to:
  • Assess treatment efficacy
  • Monitor for side effects (most common: headache, dyspepsia, back pain, myalgia) 2, 3
  • Review PSA and urinalysis results
  • Reconsider DRE if patient is amenable

Treatment Adjustment

• If inadequate response to tadalafil after 3 months:
  • Consider switching to another PDE5 inhibitor 1
  • Consider increasing dose if tolerated 2
  • Evaluate for testosterone deficiency if not previously assessed 1
  • Consider second-line treatments such as vacuum devices or intracavernosal injections if PDE5 inhibitors fail 1

Long-term Considerations

• Continuation rates for tadalafil once daily are high (86.3% at 6 months) 7
• Tadalafil once daily can restore normal erectile function in men with incomplete response to as-needed PDE5 inhibitors 8

Precautions and Contraindications

• Verify the patient is not taking nitrates, which are absolutely contraindicated with PDE5 inhibitors 1, 2
• Use with caution if the patient is on alpha-blockers 1
• Monitor for side effects, particularly headache (reported in up to 15% of patients), dyspepsia (10%), back pain (6%), and myalgia (3%) 2, 3