Taking the stress out of treating erectile dysfunction.

Case description Mr E.P., aged 51 years, comes to your office complaining that he “can’t get it up anymore!” He has noticed over the past year that it takes him longer to achieve an erection and that it is not as firm as it used to be. His erection allows penetration of his partner and lasts long enough to reach ejaculation about 80% of the time. He denies any problems with his libido. His medical history is positive for hypertension, for which he takes 25 mg of hydrochlorothiazide and 100 mg of sustained-release metoprolol daily. He also takes multivitamins and occasional acetaminophen for headaches. He smokes on average 10 cigarettes a day and has done so for the past 30 years. Alcohol consumption consists of 3 to 4 glasses of red wine a week. He used to play recreational hockey but he hardly gets any exercise now. He denies chest pain and has shortness of breath only on extreme exertion. He was adopted and does not have any information about his family history. On examination, his blood pressure is 145/88 mm Hg and his pulse is 75 beats per minute. He is 194 cm tall and weighs 105 kg, so his body mass index is 28 kg/m2. Heart sounds are normal and no cardiomegaly is found on clinical examination. He has normal hair distribution, and genital examination reveals a normal, uncircumcised penis, a normal scrotum, and testicles measuring around 20 cm3 with no nodules. Digital rectal examination revealed a 40-cm3 size prostate with no nodules. Mr E.P. is interested in knowing what is causing his erectile dysfunction (ED) and if the drugs for ED that are advertised on television will work for him.