Urology Case Challenge: A Sexually Active Construction Worker Has Erection Concerns

Edward D. Kim, MD


January 30, 2023

Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 58-year-old construction site foreman is unable to maintain an erection. The onset was gradual; however, the problem has been progressing for 2 years. With sufficient stimulation, he can obtain a firm erection with a rigidity of approximately 90%. He does not have difficulty with orgasm or ejaculation.

The patient is in a stable, monogamous relationship and has intercourse 2-4 times per month. He does not believe that any significant underlying psychogenic factors are at work. The erections do not improve with self-stimulation or in the morning.

Comorbid conditions include obesity, dyslipidemia, and hypertension. The patient also smokes half a pack of cigarettes per day and does not exercise. His medications include a statin and a calcium-channel blocker, both of which he has used for 5 years. He does not use organic nitrates. His family history includes coronary artery disease.

A review of systems reveals an absence of chest pain or dyspnea upon exertion. The patient has moderate lower urinary tract symptoms (LUTS), characterized by slow stream and hesitancy, and he has mild urinary urgency. However, he does not have a sense of incomplete bladder emptying. He is easily tired, especially in the afternoon, and his libido is mildly decreased.


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