Does a patient with a 15-year history of erectile dysfunction, characterized by erections not lasting long enough, who experiences nocturnal erections, has hypertension and hyperlipidemia, but no other significant medical history, meet the criteria for treatment with sildenafil?

Does This Patient Meet Criteria for Sildenafil?

Yes, this patient meets criteria for sildenafil treatment—he has documented erectile dysfunction (erections not lasting long enough) for 15 years, preserved nocturnal erections suggesting psychogenic or vascular rather than neurogenic etiology, controlled cardiovascular risk factors (hypertension and hyperlipidemia), and no absolute contraindications. 1

Critical Safety Verification Before Prescribing

Before writing the prescription, you must verify the following absolute contraindications:

• Confirm the patient is NOT taking nitrates in any form (oral, sublingual, transdermal, or recreational)—concurrent use causes potentially fatal hypotension 1, 2
• Assess cardiovascular fitness: Ask if he can walk 1 mile in 20 minutes or climb 2 flights of stairs without symptoms. If unable, refer to cardiology before prescribing 1
• Verify he does NOT have: unstable angina, uncontrolled hypertension, recent MI/stroke (within 2 weeks), severe heart failure (NYHA Class III-IV), or high-risk arrhythmias 2

Since this patient has controlled hypertension and hyperlipidemia without other high-risk features, he falls into the low-risk cardiovascular category and can safely receive sildenafil 2

Why This Patient Is a Good Candidate

Preserved nocturnal erections are a favorable prognostic indicator suggesting intact erectile tissue and neurovascular pathways, which predicts good response to PDE5 inhibitors 1. The presence of nocturnal erections indicates that:

• Penile vasculature and smooth muscle are functionally responsive 1
• The nitric oxide pathway is sufficiently intact to respond to pharmacologic enhancement 1
• The erectile dysfunction likely has a significant vascular or psychogenic component rather than pure neurogenic or hormonal etiology 1

Recommended Starting Regimen

Start sildenafil 50 mg taken approximately 1 hour before anticipated sexual activity, maximum once daily 3, 2

Dose Titration Strategy

• If 50 mg provides inadequate response after at least 5 separate attempts with proper technique, increase to 100 mg (maximum dose) 3
• If 50 mg causes intolerable side effects, reduce to 25 mg 3
• An adequate trial requires at least 5 separate attempts at each dose level before declaring failure 1, 3

Critical Patient Education Points

Many apparent treatment failures result from incorrect use rather than true medication inefficacy 1, 3:

• Sexual stimulation is mandatory—sildenafil enhances the erectile response to sexual arousal but does not cause spontaneous erections 1, 3
• Avoid taking with large or fatty meals—this delays absorption and reduces efficacy 1
• Limit alcohol consumption—heavy alcohol use impairs erectile function independent of medication 1
• Timing matters—take approximately 1 hour before anticipated sexual activity 3

Special Considerations for This Patient

Hypertension and Antihypertensive Medications

Sildenafil is safe and well-tolerated in patients taking antihypertensive medications, including those on multidrug regimens 4, 5, 6. The combination causes additive but not potentiating blood pressure decreases, which are clinically insignificant 4, 6:

• Mean peak reductions are only 10/7 mm Hg systolic/diastolic 7
• No increase in adverse events compared to patients not taking antihypertensives 5, 6
• Incidence of hypotension, orthostatic hypotension, and syncope <2%, same as placebo 7

If the patient is taking an alpha-blocker specifically, ensure he is stable on that therapy first, and consider starting sildenafil at 25 mg to minimize orthostatic hypotension risk 6

Hyperlipidemia

Hyperlipidemia is a shared risk factor for both erectile dysfunction and cardiovascular disease, reflecting underlying endothelial dysfunction 8. Sildenafil remains highly effective in this population and may actually improve endothelial function 8.

Expected Efficacy

This patient should expect a 69% chance of successful sexual intercourse attempts versus 33% with placebo 1. Improvement in erections occurs in 73-88% of patients versus 26-32% with placebo 9, 1.

Sildenafil shows dose-dependent efficacy: 50 mg is significantly more effective than 25 mg, though 100 mg shows less additional benefit over 50 mg 9, 2

Common Adverse Effects

The most frequent side effects are transient and mild-to-moderate 1, 3:

• Headache (16%) 7
• Flushing (10%) 7
• Dyspepsia 1
• Nasal congestion 1
• Abnormal vision 3

Serious adverse events occur in <2% of patients, with no significant difference from placebo 2, 7

When to Reassess or Escalate

Before declaring treatment failure, ensure the following modifiable factors have been addressed 1, 3:

• Completed at least 5 separate attempts at maximum dose (100 mg) with proper technique 1, 3
• Adequate sexual stimulation is occurring 1
• Not taking medication with large meals 1
• Heavy alcohol use has been addressed 1
• No relationship issues interfering with sexual activity 1

If sildenafil fails after an adequate trial at maximum dose, consider switching to a different PDE5 inhibitor (tadalafil or vardenafil) before proceeding to second-line therapies 1, 3

Emergency Nitrate Protocol

If this patient requires emergency nitrate administration while on sildenafil, wait at least 24 hours after the last sildenafil dose before giving nitrates, under close medical supervision with continuous monitoring 1, 3

Follow-Up Recommendations

Schedule follow-up at 4-12 weeks to assess 3, 2:

• Treatment effectiveness and patient satisfaction
• Adverse effects and tolerability
• Cardiovascular health stability
• New medications or health status changes
• Proper technique and timing of medication use