Managing Erectile Dysfunction in Hypertensive Patients

Case 1: A 49-year-old man was referred to our hypertension clinic because of uncontrolled hypertension and patient concerns regarding medication-related erectile dysfunction (ED). He had been taking antihypertensive medication for approximately 8 years, but several medications were discontinued due to side effects and the patient perceived that his sexual performance was declining because of antihypertensive medication. Throat scratchiness led to discontinuation of lisinopril; losartan was associated with dose-related headache and dizziness, permitting only 25 mg daily; amlodipine caused headache; and doxazosin was discontinued due to dizziness. On a combination of hydrochlorothiazide (HCTZ) 25 mg daily, atenolol 50 mg daily, and losartan 25 mg daily during the past 2 years, blood pressures (BPs) were 118 to 132 mm Hg ⁄ 82 to 96 mm Hg. However, erections sufficient to permit successful sexual intercourse had declined from 3 to 4 times to 1 to 2 times per week. He consumed 1 to 3 glasses of wine daily, his body mass index (BMI) was 28 kg ⁄ m, and he exercised on a treadmill for 30 to 60 minutes 3 times each week. He was a nonsmoker. At the time of his referral, BP was 132 ⁄ 98 mm Hg. There were no carotid or femoral bruits, and a 12-lead electrocardiogram (ECG) was normal. Fasting glucose was 108 mg ⁄ dL (normal 70–99 mg ⁄ dL), alanine aminotranferase 42 U ⁄ L (normal <41 U ⁄ L), low-density lipoprotein 80 mg ⁄ dL (normal <100 mg ⁄ dL), highdensity lipoprotein 53 mg ⁄ dL ( 40 mg ⁄ dL), potassium 4.0 mEq ⁄ L (normal 3.5–5.0 mEq ⁄ L), and creatinine was 1.2 mg ⁄ dL (normal 0.7–1.3 mg ⁄ dL). He was advised to consume no more than 1 glass of wine daily and to reduce his calories. Atenolol was changed to nebivolol 20 mg daily without recovery of his prior level of potency or improvement in BP. Prolactin level was 3.8 ng ⁄ mL (normal 2.1–17.7 ng ⁄ mL) and testosterone level was 484 ng ⁄ mL (normal 280–800 ng ⁄ dL). He scored 3 of 27 on a Public Health Questionnaire (PHQ-9) screening scale for depression ( 4 indicates minimal depression). HCTZ was changed to chlorthalidone 25 mg daily, losartan was discontinued, and nebivolol was changed to aliskiren 150 mg twice daily with a follow-up clinic BP of 122 ⁄ 78 mm Hg, but successful erections remained at a 1 to 2 per week level. Case 2: A 61-year-old man with treated hypertension was referred to our hypertension clinic because of perceived medication-related ED. An unknown antihypertensive medication had been initiated 3 to 4 years prior to referral. BPs had been variable depending on the patient’s level of anxiety, and he had speech difficulty under stress for which he had initially been hospitalized for suspicion of transient ischemic attack, a diagnosis which was later retracted. A year prior to referral he was switched to losartan monotherapy with good BP control. However, following initiation of losartan 50 mg daily, his potency level rapidly declined over a month from 5 or 6 erections weekly to 1 or 2 weekly. The patient felt that this decline was medication-related. He was a nonsmoker who consumed 5 glasses of red wine weekly and played golf or tennis most days of the week. BP was 134 ⁄ 82 mm Hg and BMI was 25 kg ⁄ m. The patient was adamant about a change in therapy, and was taken off losartan and started on HCTZ 25 mg daily, which maintained BP control and led to satisfactorily improved erectile function.