What is the best approach to manage a male patient in his late 50s with erectile dysfunction and fecal incontinence?

Management of Erectile Dysfunction and Fecal Incontinence in a Male Patient in His Late 50s

Start with oral PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) as first-line therapy for erectile dysfunction after cardiovascular risk assessment, while simultaneously referring to a colorectal surgeon or gastroenterologist for comprehensive evaluation and management of the fecal incontinence. 1, 2

Erectile Dysfunction Management

Mandatory Initial Assessment

Cardiovascular risk stratification is essential before initiating any ED therapy, as erectile dysfunction is an independent predictor of coronary artery disease and cardiovascular mortality. 1, 2 Perform the following:

• Assess for nitrate use - absolute contraindication to PDE5 inhibitors 2, 3
• Review cardiovascular risk factors: smoking, hypertension, diabetes, hyperlipidemia 1
• Evaluate for autonomic neuropathy - carries 5.0-fold increased risk of ED 1, 2
• Screen for medications contributing to ED: beta-blockers, diuretics, antidepressants, antihypertensives 1
• Obtain focused physical exam: genital examination, secondary sexual characteristics, lower extremity pulses, digital rectal exam if indicated 1

Laboratory Evaluation

Order the following baseline tests:

• Fasting glucose and HbA1c to assess glycemic control 1, 2
• Lipid profile 1
• Total testosterone (or free/bioavailable testosterone if available), especially if patient fails to respond to PDE5 inhibitors 1
• PSA and digital rectal exam if over 50 with >10 year life expectancy 1

First-Line Treatment: PDE5 Inhibitors

All three PDE5 inhibitors have equivalent efficacy and should be offered unless contraindicated. 2, 3 The American Urological Association and American Diabetes Association recommend these as first-line therapy. 1, 2

Dosing options:

• Tadalafil: 5 mg daily or 10-20 mg on-demand 2
• Sildenafil: 25-100 mg as needed, wait 24 hours before nitrate administration if needed 3
• Vardenafil: 5-20 mg as needed 3

Critical safety considerations:

• Absolute contraindication with nitrates - potentially fatal interaction 2, 3
• Common side effects: headaches, flushing, dizziness, nasal congestion, dyspepsia 1
• Efficacy is independent of diabetes duration and glycemic control 2

If PDE5 Inhibitors Fail

Before declaring treatment failure, ensure adequate trial with optimized dosing and timing. 3 If one PDE5 inhibitor fails, try a different one. 3

Second-line options in order of invasiveness:

1. Vacuum erection device (VED) - non-invasive mechanical option, also helps prevent penile length loss 1
2. Intraurethral alprostadil suppositories - less invasive but lower efficacy, first dose must be supervised due to 3% syncope risk 3
3. Intracavernosal injection therapy (alprostadil, papaverine, phentolamine) - highly effective, requires in-office test dose 1, 3
4. Penile prosthesis implantation - for patients not responding to medical therapy 1

Urethral bulking agents have low efficacy and rare cure rates - only consider in patients unable to tolerate more invasive options. 1

Adjunctive Measures

• Psychosexual counseling should be offered, especially for partnered men, to improve long-term adherence and adaptation 1
• Lifestyle modifications: weight loss if obese, smoking cessation, optimize glycemic control 2
• Regular sexual stimulation (including masturbation) may benefit sexual response regardless of method used 1

Fecal Incontinence Management

Initial Evaluation

The presence of fecal incontinence requires comprehensive evaluation to determine the underlying pathophysiology. 4, 5 Key elements include:

• Detailed history: frequency, consistency of stool, ability to distinguish gas from stool, urgency, passive vs. urge incontinence 4, 5
• Obstetric history (if applicable), prior anorectal surgery, trauma, neurologic conditions 4, 6
• Physical examination: digital rectal exam assessing sphincter tone, squeeze pressure, presence of structural defects 4, 6
• Endoscopic assessment to rule out inflammatory bowel disease, rectal prolapse, masses 4

Diagnostic Testing

Anorectal manometry, pudendal nerve latency studies, and electromyography are standard primary evaluation tools. 6 These permit objective assessment and focused therapy. 6

• Pudendal nerve terminal motor latencies (PNTML) are the most important predictor of functional outcome 6
• Consider cinedefecography for idiopathic cases 6

Treatment Algorithm

Conservative management should be attempted first for mild to moderate symptoms:

1. Dietary modifications: fiber supplementation to improve stool consistency 4, 5
2. Medical management: antidiarrheal agents (loperamide) to reduce stool frequency 4, 5
3. Biofeedback therapy: results in 90% reduction in incontinence episodes in over 60% of patients, no side effects, well tolerated 4, 6

Surgical options for refractory cases or structural defects:

• Overlapping anterior sphincteroplasty: 70-90% good to excellent results in patients with sphincter defects and normal pudendal nerve function 6
• Sacral nerve stimulation: for patients failing conservative therapy 5
• Anal sphincter augmentation: for severe cases 5
• Neoanal sphincters or artificial sphincters: last resort before colostomy, but have technical difficulties and lower success rates 4

Referral Strategy

Refer to colorectal surgeon for fecal incontinence evaluation and treatment, especially if conservative measures fail or if structural defects are suspected. 1 The American Society of Clinical Oncology guidelines support referral to colorectal surgeons for fecal incontinence management. 1

Pelvic floor physiotherapy may be beneficial for potential pelvic floor dysfunction symptoms. 1

Common Pitfalls to Avoid

• Failing to screen for nitrate use before prescribing PDE5 inhibitors - can be fatal 2, 3
• Not performing cardiovascular risk assessment in this age group 2, 3
• Declaring PDE5 inhibitor failure without optimizing dose and timing 3
• Overlooking medications that contribute to ED (beta-blockers, diuretics) 1, 3
• Assuming fecal incontinence is purely functional without ruling out structural causes 4, 6
• Delaying referral for fecal incontinence - early intervention improves outcomes 5

Integrated Approach

Both conditions require simultaneous management as they significantly impact quality of life. The erectile dysfunction can be managed by the primary care provider or urologist with PDE5 inhibitors after appropriate cardiovascular screening, while the fecal incontinence requires specialized evaluation by gastroenterology or colorectal surgery. 1, 4 These conditions may share common pathophysiologic mechanisms including autonomic neuropathy, particularly if the patient has diabetes or other systemic conditions. 1