Psychogenic Erectile Dysfunction

Psychogenic erectile dysfunction is the inability to achieve or sustain an erection adequate for intercourse, caused mainly by psychological factors, with normal vascular, neurological and hormonal function.

It is the main cause in men under 40, and many older men have a mixed picture with an organic component.

It responds well to treatment, and most men recover with a combination of sexual therapy and drug support.

Pathophysiology. Anxiety, depression, stress and relationship conflict increase central and peripheral sympathetic tone, which suppresses the parasympathetic nitric oxide mediated relaxation of the cavernosal smooth muscle needed for erection.

Common contributors:

• Performance anxiety and spectatoring (self-monitoring during sex), which sustain a cycle of failure.
• Depression, generalised anxiety, post-traumatic stress and substance misuse (alcohol, cannabis, cocaine).
• Relationship problems, loss of desire, sexual trauma and unrealistic expectations.
• Excessive pornography use, in some men.
• Fear of pregnancy or infection, grief and work stress.

Typical features pointing to a psychological cause: sudden onset linked to a stressful event, situational loss (with one partner but not another), preserved morning or nocturnal erections and erections with masturbation, intact desire, and a younger age. Many men report anxiety about performance, and some have premature ejaculation as a secondary problem.

• Sexual history of onset, course, situations, partner factors and rigidity of erections. Use the International Index of Erectile Function (5-item version): 22 to 25 normal, 17 to 21 mild, 12 to 16 mild to moderate, 8 to 11 moderate, 5 to 7 severe.
• Screen for depression (PHQ-9, score of 10 or more suggests moderate depression) and anxiety (GAD-7, score of 10 or more). Ask about suicidal thoughts when mood is low.
• Examination: blood pressure, body mass index, genital and secondary sexual characteristics, pulses and a neurological screen.
• Blood tests: fasting glucose or HbA1c, lipids, and morning (8 to 11 am) total testosterone. Total testosterone under 8 nmol/L (about 230 ng/dL) is low, and 8 to 12 nmol/L is borderline and repeated with sex hormone binding globulin. Prolactin when libido is low, and thyroid function when symptoms suggest.
• Nocturnal penile tumescence testing, or duplex ultrasound after intracavernosal injection, only when the diagnosis is uncertain or treatment fails.

Differential diagnosis.

• Vasculogenic erectile dysfunction
• Neurogenic erectile dysfunction
• Hypogonadism
• Drug induced erectile dysfunction
• Hypoactive sexual desire disorder
• Premature ejaculation with secondary erectile loss
• Depression related sexual dysfunction
• Peyronie disease

• Education and reassurance, with the couple involved when possible.
• Psychosexual therapy: cognitive behavioural therapy and sensate focus exercises, which lower performance anxiety and are often the key treatment. Treat depression and anxiety in parallel.
• Phosphodiesterase type 5 inhibitor, with the aim of restoring confidence:
  • Sildenafil 50 mg orally 30 to 60 minutes before sex (range 25 to 100 mg), no more than once daily.
  • Tadalafil 10 mg orally before sex (range 5 to 20 mg), effective for up to 36 hours, or 2.5 to 5 mg once daily.
  • Vardenafil 10 mg orally (range 5 to 20 mg), or avanafil 100 mg orally (range 50 to 200 mg), about 15 to 60 minutes before sex.
  • Contraindicated with any nitrate, nicorandil or riociguat. Use with caution with alpha blockers (stable on the alpha blocker, lowest dose first), after recent myocardial infarction or stroke, in unstable angina, severe hypotension, severe liver disease, retinitis pigmentosa and previous non-arteritic anterior ischaemic optic neuropathy.
  • Reduce dose in the older man (sildenafil 25 mg start), with eGFR under 30 (sildenafil 25 mg start, tadalafil no more than 5 mg once every 72 hours), and with strong CYP3A4 inhibitors such as ritonavir, ketoconazole and clarithromycin (sildenafil 25 mg no more often than every 48 hours, tadalafil no more than 10 mg every 72 hours).
  • Each drug should be tried at the highest tolerated dose at least 4 to 6 times with sexual stimulation, before it is judged to have failed.
• Treat any underlying depression or anxiety. When antidepressants cause sexual dysfunction, consider a switch (bupropion 150 to 300 mg daily, or mirtazapine 15 to 45 mg at night) with the prescriber.
• Advise on alcohol, smoking, drug use, sleep and exercise.
• Withdraw the drug after confidence returns, in men whose problem was situational.

Special groups. Young men need a check for organic disease if erectile loss is persistent. Partners need involvement in sexual therapy.

Monitoring. Review at 4 to 6 weeks for response and adverse effects (headache, flushing, dyspepsia, nasal congestion, visual changes, back pain with tadalafil), then at 3 months.

Referral and escalation. Refer to sexual medicine or psychiatry for severe depression, abuse history, or failure of therapy, and to urology for treatment failure with suspected organic disease. Urgent review for suicidal thoughts, or an erection lasting over 4 hours.