How to manage erectile dysfunction in a 97-year-old male with a 19-year history?

Management of Erectile Dysfunction in a 97-Year-Old Male with 19-Year History

For a 97-year-old man with longstanding erectile dysfunction, offer oral PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) as first-line therapy after cardiovascular risk stratification, with vacuum erection devices or penile prosthesis as alternatives if oral medications fail or are contraindicated. 1, 2

Cardiovascular Risk Assessment (Critical First Step)

Before initiating any ED treatment in this elderly patient, cardiovascular risk stratification is mandatory:

• Low-risk patients (controlled hypertension, successfully revascularized coronary disease, mild valvular disease, NYHA class I-II heart failure) can proceed with all first-line therapies 1
• High-risk patients (unstable angina, uncontrolled hypertension, recent MI/stroke within 2 weeks, NYHA class III-IV heart failure, high-risk arrhythmias) must have cardiac stabilization before any ED treatment 1
• Intermediate-risk patients require exercise stress testing before treatment initiation 1

Sexual activity increases physical exertion to 3-4 METs, with absolute MI risk remaining extremely low (20 chances per million per hour even in post-MI patients) 1

First-Line Treatment: Oral PDE5 Inhibitors

PDE5 inhibitors should be offered unless contraindicated, regardless of whether ED is organic or psychogenic in origin: 1, 2

• Start with conservative dosing and titrate to maximum dose over at least 5 separate occasions before declaring treatment failure 2
• Success rates are 60-65% for achieving satisfactory intercourse, though efficacy may be lower in very elderly patients 2, 3
• Provide explicit instructions: take on empty stomach, allow adequate time for absorption (sildenafil/vardenafil: 30-60 minutes; tadalafil: up to 2 hours), sexual stimulation is required 1

Absolute contraindications include: 1, 2

• Concurrent nitrate use (any formulation)
• Guanylate cyclase stimulators (riociguat)
• Recent cardiovascular events (within 2 weeks) 1

Suggested safe intervals after PDE5 inhibitor use before nitrate administration in emergencies: 1

• Sildenafil/vardenafil: 24 hours
• Tadalafil: 48 hours

Second-Line Options for PDE5 Inhibitor Failures

If two different PDE5 inhibitors at maximum dose fail, consider: 2

Vacuum Erection Devices

• Technical success rates of 90% initially, declining to 50-64% at 2 years 1
• Particularly appropriate for elderly patients with infrequent intercourse 1
• Only use devices with vacuum limiters to prevent penile injury 1
• Side effects include penile pain, bruising, "cold penis" sensation for partner, and lack of spontaneity 1
• Contraindicated in bleeding disorders 1

Intracavernosal Injection Therapy

• Alprostadil, papaverine, or phentolamine (alone or in combination) 1, 3
• Requires proper patient education and training to minimize complications 1
• Critical warning: Patients must seek immediate care for erections lasting >4 hours to prevent permanent tissue damage 1, 4
• Not recommended more than once per 24-hour period 1

Intraurethral Alprostadil Suppositories

• Less invasive than injections but generally less effective 2

Third-Line Treatment: Penile Prosthesis

For patients failing all medical therapies, penile prosthesis implantation offers definitive treatment: 1, 2

• High patient and partner satisfaction rates (80% for confidence and device rigidity) 1
• Three-piece inflatable devices provide more natural erections; semi-rigid prostheses offer simpler use 1
• Complications include infection (2-16%), mechanical failure (<5%), and persistent perineal pain for 1-2 months 1
• Lifetime guarantee typically covers replacement prosthesis 1

Important Considerations for This Patient Population

Age-Related Factors

• At 97 years, realistic goal-setting is essential—focus on quality of life and patient/partner satisfaction rather than performance metrics 1
• Partner involvement in treatment discussions is strongly encouraged when possible 1

Medication Review

• Evaluate all current medications for ED-causing agents (antihypertensives, antidepressants, antipsychotics) and consider alternatives with lower ED risk 1

Testosterone Assessment

• Measure morning total testosterone only if hypogonadism is suspected clinically or if patient fails to respond to PDE5 inhibitors 1
• Testosterone therapy is NOT indicated for ED treatment in men with normal testosterone levels 1

Follow-Up Protocol

• Review between 4 weeks and 6 months to assess treatment response and adjust therapy 1
• For injection therapy, longer-term follow-up to detect penile fibrosis may be advisable 1

Treatments NOT Recommended

The following should NOT be used for ED treatment: 1

• Trazodone (insufficient efficacy data)
• Yohimbine (no proven benefit in humans)
• Testosterone in men with normal testosterone levels