INSOMNIA .1.

The patient was a 63-year-old male on maintenance hemodialysis secondary to polycystic kidney disease. He smoked one package of cigarettes daily and consumed three to four cups of coffee daily, the last at 3:00 pm. He complained of feeling tired all of the time and that he could not sleep well: he tossed and turned all night and often got up for awhile. He would retire at 11.00 pm, following the completion of a sports show on cable television. He denied the use of alcohol or other recreational drugs. He used an albuterol inhaler four times daily and also took anhydrous theophylline for mild chronic obstructive pulmonary disease. His other medications were calcium carbonate, a multivitamin, and a stool softener. A brief exam while the patient was on dialysis showed only chest hyperresonance to percussion and an increased expiratory phase without wheezing. He was counseled to stop smoking (using transdermal nicotine patches and group therapy), to not watch television for the hour prior to going to bed, to take a warm bath before retiring for the night, and to discontinue his theophylline. He tried these measures for two weeks (though he did not stop smoking) and saw no relief. He was scheduled for an office visit the next day, and an examination revealed no other abnormalities except his easily palpated polycystic kidneys. He was encouraged to exercise daily and to continue the previously mentioned remedies. The social worker was asked to contact his wife to further explore the home situation. His wife revealed that the patient had recently begun to have problems with impotence and that he was very upset by this, although he refused to discuss the problem with her and had begun to withdraw and exhibit depressive behavior. He was seen in the office two weeks later, and an in-depth history brought out the impotence and a closer examination showed signs of primary hypogonadism. His prolactin and TSH levels were normal, FSH and LH were elevated, and the free testosterone was low. He was treated with a depot form of parenteral testosterone, the impotence resolved and he no longer complained of insomnia.