Decreased libido in a 54 y/o male

[SAdams2911]

54 y/o male, in good physical condition, presents w/chief complaint of absent libido. History of Type II seminoma in 1999, surgical procedure resulted in removal of 26 cm tumor and one testical, in a monorchidic male. Six weeks regimen daily radiation. Post-tx resulted in testosterone level <.02. Pt. placed on HRT, 200mg q 7-10 days, IM.
Within the last 8 months, pt. reports marked decreased libido and ED. Hormonal levels are within normal limits. HEENT, chest/lungs clear, no clicks, murmurs, rubs noted. Abd. unremarkable, genitourinary constistent with surgical hx, no other remarkable findings. Rectal deferred; PSA unremarkable. Pt. is currently taking atenolol 100 mg bid for frequent PVC's, and has been for 12 years. Pt. is retired firefighter with marked insomnia; has been rx'd Ambien 10mg q noc prn, approx. 3 years.

Chief complaint began approx. 8 months ago, with no other detrimental changes reported in physical or mental health.

Question: Recommendation for restoration of libido and resolution of ED. Pt. was prescribed Cialis at maximum dosage, was fully compliant; reported no change. Suggested course of treatment based on current dx?

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[SAdams2911]

I'm inclined to agree with your assessment. I think stress, depression (I don't believe it's clinical, but most likely situational and transient), and poor self-esteem issues have much to do with it. That was where I believed this was going to go, but wanted to exhaust the somatic possibilities first. Thanks, butterfly...

The reason I decided to use this forum to discuss the gentleman are twofold; one, because he expressed a desire to get a "second opinion"...the average person who may have been experiencing the same issues. And also, I was personally curious to see what the viewers would have to say (as well as any professional colleagues who may happen upon my post).

Thanks so much for your input!

[iam1butterfly]

Then again, there's always that "mental" aspect.
One of my male friends had gone through a brief bout of ED, not long ago.  
As it turned out, he was stressed and somewhat depressed due to some unflattering comments made to him by his girlfriend. Those seemingly innocuous, yet offensive  remarks were enough to undermine his "motivation." It was his opinion that his inability to be aroused had far more to do with what was going on "between the ears" as opposed to what was going on "below the waist."

[SAdams2911]

Thank you for your post! Actually, that had occurred to me; however, the pt. has been taking Ambien for several years, and this is a comparatively recent complaint. Although not a depressant, but a hypnotic, Ambien can contribute to sexual dysfunction...though it's transient, and decreases over time.

Yes, I've ruled out circulatory issues. The pt. is on a mild vasodialator, which caused some concern with the addition of the Cialis...though he's tolerated it well, and has had no complaints of hypotensive related sequelae. I am fishing for a possible resolution for this gentleman, however; as it's primarily a libido problem, rather than circulatory ED.

Thanks for your input, and I'll welcome further discussion of this interesting case study!

[iam1butterfly]

Is it possible that the Ambien is contributing to the ED?
It is a depressant which slows down the central nervous system; thus enabling sleep.
However, depressants can "take the edge off" of a person... quite possibly in more ways than one. Other than that, have you been check out for any underlying circulatory problems? Poor circulation, especially around the pelvic region, can create ED issues.