Question

RS, a 63 year old college professor, is in the office for a yearly checkup. He feels his is generally healthy, and he doesn’t take any medications. During his physical examination, he tells his prescriber, “I want to try one of the drugs that can help my sex life”. The prescriber assesses RS’s sexual difficulties and prescribes sildenafil.

What teaching is important for RS before he starts the medication?

Follow up

Eleven months later, RS is admitted to the ED with chest pains. After a thorough examination, he is diagnosed with mild coronary disease and is started on Isosorbide dinitrate 40 mg every 12 hours.

A week later RS is back in the ED after falling in his bathroom. He said he suddenly felt dizzy and everything went black. What do you think could have caused this syncope?

One month later RS comes to the office for a follow up appointment and tells the nurse that he wants to try saw palmetto for his prostrate health. He has had a slight increase in difficulty with urination. How will the nurse respond to RS? What assessments are needed?

Answer 1

ANSWER 1: The teaching that is important to give to RS before he starts Sildenafil is as stated:

1. Do not taking Sildenafil twice a day.

2. If you start any other medication while you are using Sildenafil , do let your prescriber know about it.

3. Immediately inform your doctor if you feel dizziness or nausea or pain in chest, numbness or tingling in your chest, neck, jaw or arms.

4. Visit doctor in earliest if you have allergic reactions to Sildenafil or sudden vision loss or you have painful erections lasting for more than 4 hours after taking Sildenafil.

5. Avoid alcohol consumption after taking Sildenafil as it may lower blood pressure and decrease sexual activity.

6. Avoid taking Sildenafil if you are already taking nitrate drugs like nitroglycerin or isosorbide dinitrate or mononitrate for chest pain or heart disease.

7. Avoid taking poppers class of drugs called alkyl nitrites while taking Sildenafil. It may drop blood pressure.

ANSWER 2: As RS was already taking Sildenafil and now he had started Isosorbide dinitrate for mild coronary artery disease, there was a sudden drop of blood pressure and hence syncope in RS as a result of drug interaction of these two drugs. When isosorbide dinitrate or nitroglycerin or poppers are taken while taking Sildenafil as well it results in sudden drop of blood pressure. Hence it should be avoioided to take Sildenafil while on these drugs. So Sildenafil should be stoped immediately.

ANSWER 3: As RS has difficulty in urination and he thinks he should take a herbal treatment of Saw Palmetto which is used to treat benign prostatic hyperplasia to this Nurse will respond by asking RS not to start Saw Palmetto on his own and get an assessment done from a urologist first.

ANSWER 4: Assessment that is needed in RS to rule out prostatic disease are as follows:

1. Ask for symptoms like frequency and urgency of urine.

2. Ask for sympptom like dribbling and nocturnal urination.

3. Assess by doing digital rectal examination (DRE) of patient. In DRE, the urologist will assess prostate size and contour, evaluate for nodules, and detect areas suggestive of malignancy.

4. Urinalysis to examine urine for blood, leukocytes, bacteria , protein and glucose.

5. To check for prostate specific antigen in blood to rule out prostate cancer.

6. Urine culture will be useful to exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate an abnormality.