Erectile dysfunction workup

An otherwise healthy, nonsmoking 53-year-old man complains of erectile dysfunction (ED). His testosterone level is low (237 ng/dL), and his prolactin is slightly elevated (36.7 ng/dL). Complete metabolic panel as well as prostate-specific antigen, follicle-stimulating hormone, thyroid-stimulating hormone, and luteinizing hormone levels are normal. He is self-pay and I don't want to commit to unnecessary MRI of the pituitary. How should I proceed?
—Gail Koelker, MSN, RN-C, FNP, Jefferson, Tex.

Normal values may vary from lab to lab, depending upon the assay. In my lab, the lower level of normal for testosterone is 240 ng/dL, which may indicate that this patient's testosterone is not significantly below a normal value. Does he have loss of libido in addition to diminished erectile ability? I would favor trying any of the oral remedies for ED as an initial approach. That being said, in my lab, the upper normal for prolactin is 15.2 ng/mL. This patient's 36.7 would be twice the normal level and probably should not be ignored. Perhaps a consult with an endocrinologist would be less expensive than an MRI—assuming there was no need for further workup. Certainly the issue of lack of insurance, or underinsurance, is becoming ever more problematic in all our practices.
—David T. Noyes, MD (115-3)

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