What is the diagnosis and treatment for a 63-year-old male with erectile dysfunction, low dihydrotestosterone (DHT) levels, and normal testosterone levels?

From the Guidelines

To address erectile dysfunction (ED) with low DHT and normal testosterone at age 63, I recommend starting with PDE5 inhibitors like sildenafil (Viagra) 50mg taken 1 hour before sexual activity, or tadalafil (Cialis) 5mg daily or 10mg as needed, as suggested by the most recent guidelines 1. These medications increase blood flow to the penis by relaxing smooth muscles. Since your DHT is low but testosterone is normal, consider consulting with an endocrinologist about potential DHT optimization through 5-alpha reductase modulation. Lifestyle modifications are equally important:

• maintain regular exercise (30 minutes daily)
• follow a Mediterranean diet rich in fruits, vegetables, whole grains, and healthy fats
• limit alcohol to 1-2 drinks per day
• quit smoking if applicable
• manage stress through meditation or yoga. Pelvic floor exercises (Kegels) can strengthen the muscles supporting erection. Low DHT with normal testosterone suggests a potential 5-alpha reductase enzyme issue, which converts testosterone to DHT. This hormonal imbalance can contribute to ED despite normal testosterone levels, making both medication and lifestyle approaches necessary for improvement, as supported by recent studies 1. It's also important to note that testosterone therapy may be indicated if total morning testosterone levels are <300 ng/dL, as suggested by the NCCN guidelines 1. Regular re-evaluation of symptoms and treatment outcomes is crucial to ensure the best possible management of ED, as recommended by the NCCN guidelines 1.

From the FDA Drug Label

The efficacy and safety of tadalafil in the treatment of erectile dysfunction has been evaluated in 22 clinical trials of up to 24-weeks duration, involving over 4000 patients. Tadalafil, when taken as needed up to once per day, was shown to be effective in improving erectile function in men with erectile dysfunction (ED)

The diagnosis for a 63-year-old male with erectile dysfunction, low dihydrotestosterone (DHT) levels, and normal testosterone levels is Erectile Dysfunction (ED). The treatment for this patient would be Tadalafil, which has been shown to be effective in improving erectile function in men with ED. However, it is essential to note that the provided drug labels do not directly address the relationship between low DHT levels and ED, or the effect of tadalafil on DHT levels. Therefore, the treatment decision should be made with caution and under the guidance of a healthcare professional, considering the patient's overall medical history and current condition 2.

From the Research

Diagnosis of Erectile Dysfunction

• A thorough evaluation for erectile dysfunction (ED) involves a complete medical history, including a review of medical risk factors such as hypertension, diabetes, cardiovascular disease, renal failure, and medications, as well as lifestyle risk factors such as obesity and tobacco, alcohol, and illicit drug use 3
• A detailed sexual history, including assessment of duration of ED, loss of libido, and overall sexual satisfaction, is also necessary 3
• Laboratory tests, including testosterone plasma levels, can help predict the efficacy of treatment 4

Treatment of Erectile Dysfunction with Low DHT Levels and Normal Testosterone Levels

• Phosphodiesterase type 5 inhibitors (PDE5-i) are used for the oral treatment of erectile dysfunction (ED) and are safe and effective for patients with ED of various causes 4, 5
• The addition of testosterone to PDE5 inhibitors might benefit patients with ED associated with low testosterone levels, but the patient in question has normal testosterone levels 6
• Daily treatment with PDE5-i is another option in men with ED and documented vascular or prostate disease 4
• Other treatment options, such as intraurethral or intracavernous alprostadil, vacuum constriction devices, and penile prosthesis, may be considered if PDE5-i are not effective 7

Considerations for Treatment

• The patient's age and medical history should be taken into account when selecting a treatment option 3
• The patient should receive meticulous information on the use of PDE5-i and their possible side effects 7
• The evaluation of testosterone plasma levels can help predict the efficacy of PDE5-i, but in this case, the patient has normal testosterone levels 4