A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 49-year-old man comes to the physician because of increasing difficulty achieving an erection for 6 months. During this period, he has had to reduce his hours as a construction worker because of pain in his lower back and thighs and a progressive lower limb weakness when walking for longer distances. His pain resolves after resting for a few minutes, but it recurs when he returns to work. He also reports that his pain is improved by standing still. He is sexually active with 4 female partners and uses condoms irregularly. His father has coronary artery disease and his mother died of a ruptured intracranial aneurysm at the age of 53 years. He has smoked one pack of cigarettes daily for 35 years. He has recently taken sildenafil, given to him by a friend, with no improvement in his symptoms. His only other medication is ibuprofen as needed for back pain. His last visit to a physician was 25 years ago. He is 172.5 cm (5 ft 8 in) tall and weighs 102 kg (225 lb); BMI is 34.2 kg/m2. His temperature is 36.9°C (98.4°F), pulse is 76/min, and blood pressure is 169/98 mm Hg. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference ranges. His hemoglobin A1c is 6.2%. Which of the following is the most likely finding on physical examination?
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A
Decreased bilateral femoral pulsesCorrect. Leriche syndrome (aortoiliac occlusive disease) presents with erectile dysfunction, buttock/thigh claudication, and decreased femoral pulses.
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B
Internuclear ophthalmoplegiaIncorrect. Internuclear ophthalmoplegia indicates a brainstem/MS lesion and is unrelated to vascular claudication and impotence.
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C
Papular rash over the palms and solesIncorrect. A palmar/plantar papular rash suggests secondary syphilis—possible given sexual history but doesn't explain the claudication picture.
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D
Jugular venous distentionIncorrect. JVD reflects right heart failure or volume overload, not aortoiliac disease causing impotence and claudication.
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E
Pulsatile abdominal massIncorrect. A pulsatile abdominal mass suggests abdominal aortic aneurysm, which can coexist with aortoiliac disease but does not directly explain the triad of impotence, claudication, and absent femoral pulses (Leriche syndrome).
↑ Tap an answer to reveal the reasoning
Answer: A. A long-time smoker with chronic hyperlipidemic, hypertensive risk factors presents with the classic triad of Leriche syndrome: erectile dysfunction (impotence), buttock/thigh claudication (worsened by walking, relieved by rest), and decreased or absent femoral pulses. Leriche syndrome is caused by aortoiliac occlusive atherosclerosis, narrowing the distal aorta and common iliac arteries. The reduced pelvic blood flow impairs the internal iliac contribution to penile vasculature (preventing sufficient corporal engorgement), produces classic intermittent claudication of the proximal lower extremities, and results in diminished bilateral femoral pulses on exam.
This explains why sildenafil failed: sildenafil augments NO/cGMP-mediated smooth muscle relaxation, but it requires adequate inflow through the internal iliac/pudendal arteries. With proximal arterial obstruction, even maximal vasodilation cannot deliver enough blood. Standing-still relief is also a clue (he reports improvement with standing); his pain is brought on with walking and improved with rest—classic vascular claudication.
Key distinctions: internuclear ophthalmoplegia (impaired adduction with nystagmus of the contralateral eye) is a sign of MS or brainstem stroke—not vascular impotence. Papular rash on palms/soles suggests secondary syphilis—possible given sexual history, but doesn't explain claudication. JVD points to right heart failure—not related to this presentation. Workup includes ankle-brachial index and CT angiography; management ranges from risk-factor modification and cilostazol to endovascular or surgical revascularization.
**Why each option:**
**A.** Correct. Leriche syndrome (aortoiliac occlusive disease) presents with erectile dysfunction, buttock/thigh claudication, and decreased femoral pulses.
**B.** Internuclear ophthalmoplegia indicates a brainstem/MS lesion and is unrelated to vascular claudication and impotence.
**C.** A palmar/plantar papular rash suggests secondary syphilis—possible given sexual history but doesn't explain the claudication picture.
**D.** JVD reflects right heart failure or volume overload, not aortoiliac disease causing impotence and claudication.