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Clinical Crossroads | Clinician's Corner

A 66-Year-Old Man With Sexual Dysfunction

Abraham Morgentaler, MD, Discussant
JAMA. 2004;291(24):2994-3003. doi:10.1001/jama.291.24.2994.
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DR BURNS: Mr G is a 66-year-old man with a history of hypertension and sleep apnea. He lives in a suburb of Boston with his wife and has commercial indemnity insurance.

Mr G first developed erectile dysfunction (ED) several years ago. Four months ago when he saw his primary care physician for a routine checkup, he asked about using sildenafil (Viagra). He noted decreased libido and difficulty attaining an erection. He had slight urinary urgency, but no difficulty initiating urination. He had no history of diabetes or cardiovascular disease. In the past, he had used a dental device to treat his sleep apnea but was no longer using one. His other past medical history was a colonic adenoma found on a screening colonoscopy in 2001. His medications were aspirin (81 mg daily), hydrochlorothiazide (12.5 mg daily), and ibuprofen (600 mg 4 times a day as needed). His wife had metastatic breast cancer and was doing well with maintenance therapy. He was working part-time and noted considerable stress due to a home renovation project.

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Figure. Mechanism of Erection and Sites of Action of Various Treatment Modalities for Erectile Dysfunction
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Penile erection is achieved through relaxation of smooth muscle cells lining arterial vessels and sinusoidal spaces in the corpora cavernosa, which leads to increased arterial inflow and pressure, decreased venous outflow, and increased intracavernosal pressure. Smooth muscle relaxation is mediated by intracellular generation of cyclic guanosine monophosphate (GMP) from guanosine triphosphate (GTP) via activation of guanylate cyclase by nitric oxide. Treatment modalities for erectile dysfunction (shown in blue) include oral phosphodiesterase type 5 (PDE 5) inhibitors, which inhibit the breakdown of cyclic GMP, and local vasoactive agents. A link between testosterone and nitric oxide synthase has been demonstrated experimentally,83 but the significance of this observation in humans has not been established (indicated by dashed line and question mark). Psychotherapy (not shown) may also be effective in selected individuals with erectile dysfunction.

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