Erectile Dysfunction Treatment in a 76-Year-Old Post-TURP Patient
Oral PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) are the first-line treatment for your erectile dysfunction, with tadalafil offering the additional advantage of potentially improving any residual urinary symptoms. 1
First-Line Treatment: PDE5 Inhibitors
PDE5 inhibitors are safe and effective in your clinical scenario, as you are 18 months post-TURP with well-controlled blood pressure. 1
Specific Medication Considerations:
Tadalafil (Cialis) is particularly advantageous because it treats both erectile dysfunction and any residual lower urinary tract symptoms from BPH, making it an excellent dual-purpose option. 2
Vardenafil or sildenafil are equally effective alternatives if tadalafil is not suitable. 1
Critical Safety Considerations with Your Blood Pressure Medications:
You can safely use PDE5 inhibitors with your current antihypertensive regimen (perindopril, indapamide, amlodipine), but there is a risk of additive blood pressure lowering. 3
Start with the lowest recommended dose and monitor for symptoms of hypotension (dizziness, lightheadedness, syncope). 3
Avoid volume depletion (ensure adequate hydration), as this increases the risk of symptomatic hypotension when combining PDE5 inhibitors with antihypertensives. 3
Never use PDE5 inhibitors with nitrates - this combination can cause life-threatening hypotension. 1, 3
Dosing Strategy:
Begin with the lowest available dose of your chosen PDE5 inhibitor. 3
Take approximately 60 minutes before sexual activity (for vardenafil and sildenafil); tadalafil can be taken daily at lower doses. 1, 3
If the initial dose is ineffective, uptitrate gradually while monitoring blood pressure. 1
Second-Line Treatment: Intraurethral Alprostadil
If PDE5 inhibitors fail or are contraindicated, intraurethral alprostadil suppositories are the next option, though they are less effective than oral medications. 1
The first dose must be administered under healthcare provider supervision due to a 3% risk of syncope/hypotension. 1
Efficacy is lower than PDE5 inhibitors in real-world use, despite better results in clinical trials. 1
Combination therapy with alprostadil plus a penile constriction device or PDE5 inhibitor shows increased efficacy over alprostadil alone. 1
Third-Line Treatment: Intracavernous Injection Therapy
Intracavernous injection therapy is the most effective non-surgical treatment for ED but is invasive and carries the highest risk of priapism. 1
Key Implementation Points:
The initial dose must be administered under healthcare provider supervision to determine effective dosing and monitor for prolonged erection. 1
Alprostadil (PGE1) monotherapy is most commonly used, though combination therapy (bimix/trimix with papaverine and phentolamine) can increase efficacy or reduce side effects. 1
You must be counseled about priapism risk and have a clear plan for urgent treatment if an erection lasts >4 hours. 1
Do not use more than once in 24 hours. 1
Proper injection technique training is essential to minimize complications and treatment failure. 1
Important Post-TURP Context:
Your TURP procedure 18 months ago has a 10-13% risk of causing erectile dysfunction, which is relevant to understanding the etiology of your current symptoms. 1, 4
The good news is that your erectile dysfunction is not due to ongoing prostatic obstruction, so alpha-blockers or 5-alpha-reductase inhibitors have no role in treatment. 5
Clinical Pitfalls to Avoid:
Do not assume one failed PDE5 inhibitor means all will fail - while data is limited, trying a different PDE5 inhibitor is reasonable before moving to more invasive options. 1
Monitor for sudden vision loss or hearing loss - stop PDE5 inhibitors immediately and seek medical attention if these occur. 3
Ensure adequate blood pressure monitoring when initiating PDE5 inhibitors given your triple antihypertensive regimen. 3