Erectile Disorder

Clinical picture

• Difficulty obtaining an erection, maintaining one through completion, or achieving rigidity sufficient for penetration.
• Gradual onset, absent morning and nocturnal erections, and consistency across situations point toward an organic vascular cause.
• Abrupt onset with preserved nocturnal erections, or normal function alone or with a different partner, suggests a psychogenic driver.
• Performance anxiety creates spectatoring, in which self-monitoring during sex diverts attention away from erotic stimuli.
• Avoidance of intimacy, relationship conflict, shame, and depressed mood commonly accompany and amplify the dysfunction.
• Men often present first for an unrelated complaint; direct, matter-of-fact inquiry is usually needed to elicit the problem.

Criteria snapshot

• At least one of three symptoms on nearly all occasions of partnered sex: difficulty obtaining or maintaining erection, or decreased rigidity.
• Symptoms must persist for a minimum of about 6 months and occur in roughly 75-100% of sexual encounters.
• The dysfunction must cause clinically significant distress in the individual; distress is required, not merely reduced function.
• Not better explained by a nonsexual mental disorder, severe relationship distress, other stressors, a substance, or a medical condition.
• Specify lifelong versus acquired, generalized versus situational, and severity as mild, moderate, or severe.

Neurobiology

• Erection is a nitric oxide dependent parasympathetic S2-S4 event: NO raises cGMP, relaxing cavernosal smooth muscle for inflow.
• PDE5 inhibitors block cGMP breakdown, amplifying that response but requiring intact nerves, endothelium, and sexual stimulation.
• Endothelial dysfunction makes ED a sentinel marker of coronary disease, typically preceding cardiac events by about 3-5 years.
• Diabetic neuropathy, pelvic surgery, radiation, and spinal cord injury damage the neural and vascular pathways directly.
• Hypogonadism, hyperprolactinemia, and thyroid disease reduce libido and erectile capacity and should be screened biochemically.
• Common iatrogenic causes include SSRIs, thiazides, beta blockers, finasteride, antipsychotics, and chronic opioid therapy.

Psychology

• Performance anxiety triggers sympathetic outflow and catecholamine-mediated vasoconstriction, directly opposing erection.
• A single failure can establish anticipatory anxiety, producing a self-perpetuating cycle of expectation and further failure.
• Spectatoring replaces sensory absorption with self-evaluation, and sensate focus is designed specifically to reverse it.
• Relationship conflict, partner blame, and secrecy about the problem maintain avoidance and worsen outcomes over time.
• Rigid masculinity norms and unrealistic expectations drawn from pornography inflate performance standards and shame.

Differential & comorbidity

• Separate from low sexual desire, premature or delayed ejaculation, and from failures occurring only with one specific partner.
• Screen for cardiovascular disease, diabetes, obesity, obstructive sleep apnea, and metabolic syndrome in every new presentation.
• Review medications and substances: alcohol, tobacco, opioids, stimulants, SSRIs, and antihypertensives are frequent contributors.
• Major depressive disorder and anxiety disorders both cause and result from ED, and SSRIs then compound the dysfunction.
• Treat ED as a cardiovascular red flag: obtain lipids, A1c, and blood pressure and assess exercise capacity before resuming sex.

Pharmacologic treatment

• PDE5 inhibitors are first-line: sildenafil 25-100 mg or tadalafil 10-20 mg as needed, or tadalafil 2.5-5 mg daily.
• Absolute contraindication with nitrates and caution with alpha blockers; counsel on headache, flushing, dyspepsia, and priapism.
• Testosterone replacement is indicated only for hypogonadism confirmed on two morning levels and can augment PDE5 response.
• Second-line options are intracavernosal alprostadil, intraurethral alprostadil, and vacuum erection devices.
• Switch or dose-reduce offending agents: bupropion or mirtazapine for SSRI-induced dysfunction, or add a PDE5 inhibitor.

Psychotherapy

• Sensate focus removes the intercourse demand and rebuilds nondemand touch in graded steps over several weeks.
• CBT targets performance anxiety, catastrophic prediction, and avoidance and improves outcomes when added to PDE5 therapy.
• Couples therapy addresses communication, resentment, mismatched expectations, and the partner's role in maintaining avoidance.
• Mindfulness-based sex therapy reduces spectatoring by training present-moment attention to bodily sensation during sex.
• Combined medical and psychological treatment outperforms either alone, especially in acquired psychogenic presentations.

Adjunct options

• Measure severity and response with the IIEF-5, also called the Sexual Health Inventory for Men, at baseline and follow-up.
• Weight loss, aerobic exercise, smoking cessation, and a Mediterranean diet produce clinically meaningful erectile improvement.
• Treat obstructive sleep apnea with CPAP and optimize glycemic and blood pressure control to improve endothelial function.
• Penile prosthesis implantation is definitive after failure of oral, injectable, and device therapy, with high satisfaction rates.
• Avoid unregulated supplements and internet-sourced tablets, which are frequently adulterated with undisclosed PDE5 inhibitors.

Clinical pearls

• New ED is a cardiovascular warning; work up the heart before writing the prescription.
• Preserved nocturnal and morning erections point toward a psychogenic driver.
• Nitrates plus a PDE5 inhibitor can be fatal; ask about them every single time.