How to manage erectile dysfunction in a 95-year-old patient?

Managing Erectile Dysfunction in a 95-Year-Old Patient

Oral PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) should be offered as first-line therapy for erectile dysfunction in a 95-year-old patient, provided cardiovascular risk assessment confirms low-risk status and there are no contraindications such as nitrate use. 1

Mandatory Cardiovascular Risk Stratification

Before initiating any ED therapy in a 95-year-old, cardiovascular risk assessment is essential given the patient's age and likely comorbidities. 1

High-risk patients (requiring cardiac stabilization before ED treatment): 1

• Unstable or refractory angina
• Uncontrolled hypertension
• Left ventricular dysfunction/CHF (NYHA class II or higher)
• MI or stroke within previous 2 weeks
• High-risk arrhythmias
• Moderate-to-severe valvular disease

Low-risk patients (eligible for all first-line therapies): 1

• Asymptomatic coronary artery disease with fewer than three risk factors
• Controlled hypertension
• Mild, stable angina
• Successful coronary revascularization
• Uncomplicated past MI
• Mild valvular disease
• CHF (NYHA class I)

Indeterminate-risk patients require cardiology evaluation before proceeding with ED treatment. 1

First-Line Treatment: PDE5 Inhibitors

All three PDE5 inhibitors (sildenafil, tadalafil, vardenafil) have equivalent efficacy and should be offered as first-line therapy unless contraindicated. 1

Critical Safety Considerations:

Absolute contraindication with nitrates: 1

• Wait 24 hours after sildenafil before nitrate administration 1
• Wait 48 hours after tadalafil before nitrate administration 1
• Careful medication history is essential to avoid this potentially fatal interaction 1

Efficacy data: Between 60-65% of men with ED, including those with hypertension, diabetes, spinal cord injury, and other comorbidities, can successfully complete intercourse with PDE5 inhibitors. 2

Optimizing PDE5 Inhibitor Therapy Before Declaring Failure:

Before moving to more invasive therapies, ensure the trial was adequate by addressing: 1

• Proper dosing (titrate to maximum dose)
• Correct timing relative to sexual activity
• Adequate sexual stimulation
• Food or drug interactions
• Heavy alcohol avoidance
• Partner relationship factors and expectations

After re-education and counseling, some men initially classified as non-responders become successful with PDE5 inhibitors. 1

Second-Line Options for Refractory Cases

If an adequate trial of one PDE5 inhibitor fails after optimization, consider: 1, 3

1. Try a different PDE5 inhibitor 1, 3

• Different pharmacokinetic properties may suit individual patients better
• Tadalafil offers longer duration (48-hour window) 4
• Younger men tend to prefer tadalafil; older men may prefer sildenafil or vardenafil 5

2. Intracavernosal injection therapy (alprostadil, papaverine, phentolamine, or combinations) 3, 6, 2

• Highly effective alternative for PDE5 inhibitor failures 2
• Requires in-office test dose before home use 3
• Common side effect: mild to moderate pain during injection 6
• Risk of prolonged erection (>6 hours requires immediate medical attention) 6

3. Intraurethral alprostadil suppositories 1, 3

• Less invasive than injections but lower efficacy 5
• First dose must be administered under healthcare supervision due to 3% risk of syncope 1

4. Vacuum erection devices 3

• Non-pharmacological option
• Only devices with vacuum limiters are recommended 3

Ongoing Monitoring Requirements

Periodic follow-up should assess: 1

• Efficacy of current therapy
• Side effects
• Significant changes in health status
• New medications that may interact or contribute to ED

Common Pitfalls to Avoid

• Failing to screen for nitrate use before prescribing PDE5 inhibitors 1
• Not performing cardiovascular risk assessment in elderly patients 1, 7
• Declaring PDE5 inhibitor failure without optimizing dosing, timing, and addressing modifiable factors 1, 3
• Overlooking medications that contribute to ED (diuretics, beta-blockers, antidepressants) 1
• Neglecting psychological factors that may require combined behavioral and pharmacological approaches 3

Special Considerations for Advanced Age

At 95 years old, the absolute risk of MI during sexual activity remains extremely low (20 chances per million per hour even in post-MI patients), though relative risk increases 2.5-fold during sexual activity. 1 The benefits of treating ED for quality of life must be weighed against cardiovascular status, with treatment proceeding only after appropriate risk stratification and cardiac stabilization if needed. 1, 7