A 64-Year-Old Man Seeks Treatment for Erectile Dysfunction

A 64-year-old man seeks treatment for erectile dysfunction.  He has been in a stable, monogamous relationship for many years.  Over the last 3 years, he has had progressive difficulty attaining and maintaining an erection sufficient for successful intercourse.  He relates that his sexual desire is unchanged, but he no longer has spontaneous morning erections.  His medical problems include type 2 diabetes mellitus, hypertension, hyperlipidemia, and coronary artery disease.
He underwent successful angioplasty of the proximal left anterior descending artery for non-ST elevation myocardial infarction 2 years ago with a drug-eluting stent.  He can walk up 4 flights of stairs and about 6 blocks at a modest pace before he has to stop due to fatigue.  He has occasional episodes of angina while walking at a fast pace or in cold weather.  His current medications include metformin, rosuvastatin, losartan, metoprolol succinate, clopidogrel, low-dose aspirin, and isosorbide mononitrate.
His blood pressure is 124/74 mm Hg, pulse is 64/min, and respirations are 14/min.  His BMI is 31 kg/m².  Cardiopulmonary and abdominal examinations are within normal limits.  Femoral and peripheral pulses are 2+ and symmetric.  Testes are normal size.  Both feet have decreased sensation to pinprick.
Echocardiogram shows ejection fraction of 42%.  He is able to walk on a treadmill to 84% of predicted maximum without chest pain or ECG changes.  His systolic blood pressure does not decrease with treadmill exercise.
Laboratory testing shows normal complete blood count and a morning total serum testosterone of 340 ng/dL.
Which of the following is the best next step in management of this patient?

A) Intraurethral alprostadil
B) Low-dose sildenafil
C) Penile prosthesis
D) Testosterone
E) Yohimbine

Correct Answer:

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