Clinical Geriatrics

Case Presentation

A 67-year-old man visits his primary care physician with the chief complaint of erectile dysfunction (ED). He has a two-year history of inability to achieve and maintain an erection adequate for vaginal penetration. He has a decrease in the frequency of nocturnal and early morning erections. He has tried sildenafil 50 mg on several occasions without any improvement in his sexual performance. He also reports lethargy, a decrease in his libido, and falling asleep after meals.

He has a history of borderline hypertension and elevated total cholesterol. He is a smoker, approximately one-and-a-half packs per day for the past 30 years. He consumes three to four cocktails each evening. He is a stockbroker and admits to having a moderate amount of stress. He has a very sedentary lifestyle. He is married and describes his marriage as “rocky.”

He has mild shortness of breath on exertion. He denies angina or use of nitroglycerin. He has moderate lower urinary tract symptoms with a decrease in the force and caliber of his urinary stream, hesitancy of urination, post-micturition dribbling, and nocturia times three.  

On physical examination, his height is 68 inches and his weight is 225 pounds. His body mass index is 34.2. The blood pressure is 185/100 mm Hg with a few premature ventricular contractions. On auscultation of the heart, a 4th heart sound was heard. The aortic component of the 2nd heart sound was accentuated. A soft ejection systolic murmur was heard at the base of the heart.

The chest has an increase in anteroposterior diameter with occasional rhonchi. The digital rectal exam reveals a moderately enlarged benign prostate with no masses in the rectal ampulla. The extremities reveal decreased peripheral pulses in the dorsalis pedis and posterior tibilias.    

Laboratory tests show that the urinalysis is normal. Blood urea nitrogen is 22 mg/dL, and creatinine is 1.7 mg/dL. Total cholesterol is 250 mg/dL, and high-density lipoprotein (HDL) is 30 mg/dL, with a cholesterol/HDL ratio of 8.33. The random glucose is 225 mg/dL. Total serum testosterone is 225 ng/dL, and the prolactin level was normal. Prostate-specific antigen (PSA) is 4.5 ng/dL, and free/total PSA is 26%.

Chest x-ray reveals mild cardiomegaly with a prominent left ventricle and evidence of mild emphysema. Resting electrocardiogram (ECG) demonstrates prominent QRS complexes with secondary ST-T changes.

A nuclear stress test was performed; the patient developed chest discomfort and shortness of breath after 5 minutes, and the test was stopped. This test was positive for stress-induced ischemia, which demonstrated shortness of breath after 5 minutes. An angiogram revealed 80% narrowing of the left anterior descending artery. Angioplasty was accomplished with placement of a stent in the left anterior descending artery.  

The patient was diagnosed with coronary artery disease (CAD), hypertension, obesity, diabetes mellitus, androgen deficiency, dyslipidemia, and benign prostatic hyperplasia (BPH). He also has two other comorbid conditions contributing to his ED, including a sedentary lifestyle and smoking. Alcohol may also be a factor that diminishes his sexual performance.

Treatment included metoprolol 50 mg twice daily for high blood pressure, glipizide 5 mg/day for diabetes, and simvastatin 20 mg at bedtime for hypercholesterolemia. For BPH, he was placed on finasteride 5 mg/day and alfuzosin 10 mg/day. For androgen deficiency, he was given testosterone supplements with a topical gel applied each day. He was advised to begin exercise, weight reduction, and smoking cessation programs.

Discussion

This case represents an example of how ED can be a harbinger of other comorbid conditions. A normal erection requires the complex integration between the central nervous system and the smooth muscle cells of the corporal bodies of the penis.