DIFFICULT MANAGEMENT PROBLEMS IN DIALYSIS .2. IMPOTENCE

In January of 1992, a 61-year-old white male chronic hemodialysis pati ent complained of impotence. He described a decrease in the rigidity a nd the length of time he could maintain an erection, as well as a decr ease in the frequency of erections. He had been on maintenance hemodia lysis since April, 1989 when he presented with end-stage renal disease (ESRD) of unknown etiology. He had a remote history of renal calculi and pyelonephritis. Prior to starting dialysis, he had been treated fo r hypertension with clonidine and later enalapril. His noninsulin-depe ndent diabetes mellitus was diet controlled for four years prior to hi s being seen at this institution. He had smoked less than five pack ye ars in the remote past. Since starting dialysis he had required no med ication for diabetes or hypertension. Subcutaneously administered eryt hropoietin was used to maintain his hematocrit at 33%-35%. Other routi ne medications included vitamins and phosphate binders. He occasionall y used ibuprofen for capsulitis of the right shoulder, concurrently wi th ranitidine for ulcer prophylaxis. He declined renal transplantation . His only problem on dialysis had been interdialytic weight gains of 3-6 kg. Benign gynecomastia noted after the initiation of dialysis the rapy resolved spontaneously, prior to the development of impotence. Hi s dialysis dosage was considered reasonable, with multiple evaluations yielding an average delivered Kt/V of 1.4. Psychological evaluation f ound him to be well adjusted to dialysis and to have a stable family l ife. He had no prior history of sexual problems and the onset of his p roblem was described as gradual. His sexual dysfunction began more tha n Two years after starting dialysis and affected erectile function rat her than libido. Physical examination revealed a robust appearing, nor motensive 61-year-old man weighing 102 kg, with a height of 1.8 meters . Cardiopulmonary examination was within normal limits. Abdominal exam ination was free of bruits and hepatosplenomegaly. Pulses were full an d equal in the extremities. Rectal examination was unremarkable, with a normal prostate and rectal sphincter tone. Testes were normal in siz e and free of masses. Phallus was normal in appearance and no plaques of Peyronie's disease were detected. Gait was normal and there was no evidence of peripheral neuropathy. After discussion of the various tre atment options, empiric therapy was started at the patient's request w ith testosterone enanthate 200 mg IM every two weeks. Although the pat ient reported a slight improvement shortly after the dose was given an d requested a dosage increase, the overall response to six months of t herapy was unsatisfactory. An endocrinologic evaluation was performed to determine the adequacy of the prescribed dose. This revealed a test osterone level of 351 ng/dl (normal 300-890 ng/dl). Follicle-stimulati ng hormone (FSH) and luteinizing hormone (LH) levels were both found t o be appropriately suppressed at <0.3 mIU/ml (normal LH 0.9-10.6 mIU/m l and FSH 2.4-19.9 mIU/ ml). A serum prolactin level drawn simultaneou sly was mildly elevated at 22.9 ng/ml (normal 0.1-18.1 ng/ml). Thyroid function tests were normal. Intact parathyroid hormone levels during this time period ranged from 13-66 pcg/ml (normal 10-75 pcg/ml) and al uminum levels were 10 mu g/ml (normal 1-39 mu g/ml). No increase in do se of testosterone was given. Of note is that elevations of serum trig lycerides occurring during the testosterone therapy required the addit ion of gemfibrozil for treatment.