While there are several medical and surgical interventions for the treatment of esophageal motility disorders, treatment decisions can be controversial due to limited randomized controlled clinical trials.Phosphodiesterase type 5 (PDE5) inhibitors, indicated for the treatment of erectile dysfunction and pulmonary hypertension, can be utilized off-label to treat esophageal motility disorders. The aim of this case report and literature review is to highlight and support the use of PDE5 inhibitors as an option in the treatment of esophageal motility disorders before more invasive interventions are considered. Unfortunately, insurance coverage for the use of PDE5 inhibitors is often denied due to lack of supporting evidence for their efficacy or because of the government regulations set by the Centers for Medicare and Medicaid Services. 1 J Dig Dis. 2019;20:495-499. wileyonlinelibrary.com/journal/cdd 495 monly studied agent, sildenafil, beginning roughly 15 minutes after the administration and lasting roughly 1 hour in duration. 15 Tadalafil, on the other hand, was found to have a significantly longer half-life of 18 hours and provided symptom relief for almost 48 hours postadministration of medication. 20 However, the onset of action was prolonged, at roughly 45 minutes. Safety and adverse events were not closely investigated in these mentioned studies though a mild headache was the most common reported side effect. Interestingly, gastroesophageal reflux disease, an expected side effect from the relaxation of the LES, was not a common complaint. 22 In a retrospective study, Kim et al investigated sildenafil-induced esophageal symptoms in 300 patients taking sildenafil for erectile dysfunction. 25 In total 84 (28%) patients reported adverse effects, the two most common being facial flushing and headache. However, these esophageal symptoms developed sporadically and lasted less than 1 hour, and no patients discontinued the medication due to adverse effects. In a double-blind, placebo-controlled study, Galiè et al investigated the use of sildenafil in patients with pulmonary artery hypertension (PAH) and reported side effects. 26 The most common side effects were headache (95/207), flushing (24/207), and dyspepsia (24/207), and most were considered mild or moderate in severity. Additionally, the authors found no evidence of a relationship between dosage of sildenafil and tolerability in the 12-week study arm. Kim et al and Galiè et al have shown that sildenafil is well tolerated, without serious adverse side effects in patients with erectile dysfunction and PAH. However, caution must be exercised when extrapolating side effect profiles for patients with esophageal motility disorders.Motility disorders of the esophagus can be complex and progressive, and require the combination of clinical, endoscopic, and radiologic assessment for proper diagnosis. As seen in our patient, where motility testing alone did not identify features of classic type III achalasia, distal esophageal spasm, or jackhammer esophagus, barium swallo...
