What is the recommended management for psychological erectile dysfunction?

Management of Psychological Erectile Dysfunction

For men with predominantly psychogenic erectile dysfunction, referral to a psychotherapist is recommended as either an alternative or adjunct to medical treatment for ED. 1

Diagnosis and Assessment

History Taking

• Identify key features suggesting psychogenic etiology:
  • Sudden onset of symptoms
  • Presence of nocturnal/morning erections
  • Situational factors (only with specific partners or contexts)
  • Presence of masturbatory erections
  • Recent major life events or relationship changes
  • Psychological problems (anxiety, depression)
  • Normal physical examination 1

Physical Examination

• Basic examination should include:
  • Blood pressure
  • Genital examination (testicular size, penile fibrosis, foreskin retraction)
  • Assessment for occult deformities or plaque lesions 1

Laboratory Testing

• Measure serum total testosterone in all men with ED
• Consider glucose/hemoglobin A1c and serum lipids
• No other routine serum studies are likely to alter management for psychogenic ED 1

Treatment Algorithm

First-Line: Psychotherapy and Psychosexual Counseling

• Psychotherapy should focus on:
  1. Improving communication about sexual concerns between partners
  2. Reducing anxiety related to sexual situations
  3. Introducing strategies for integrating ED treatments into sexual relationships 1
  4. Working through resistances to medical interventions
  5. Eliminating performance anxiety 2

Second-Line: Pharmacological Treatment

• PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) should be offered even in psychogenic ED
  • 60-65% of men can successfully complete intercourse with these medications 3
  • These medications can help break the anxiety-failure cycle common in psychogenic ED

Third-Line: Combined Approach

• Combination of psychotherapy and pharmacological treatment often yields better outcomes than either approach alone 2
• This integrated approach addresses both psychological barriers and provides physiological support

Special Considerations

Partner Involvement

• When possible, involve the partner in treatment discussions and therapy
• Partner's sexual function and relationship dynamics significantly impact treatment outcomes 1

Addressing Underlying Psychological Conditions

• Screen for and treat comorbid conditions:
  • Depression
  • Anxiety disorders
  • Relationship conflict
  • Body image issues 1, 4

Treatment Adherence

• Performance anxiety is a common reason for discontinuation of medical therapy
• Psychotherapy can improve adherence to medical treatments by addressing psychological barriers 2

Pitfalls to Avoid

1. Overlooking organic factors: Even in seemingly psychogenic cases, screen for medical comorbidities that may contribute to ED
2. Focusing solely on erectile function: Treatment goals should include relationship satisfaction and quality of life
3. Neglecting partner concerns: Partner's involvement improves outcomes
4. Premature discontinuation of therapy: Psychotherapy may require multiple sessions before showing benefits
5. Relying solely on medications: While effective, PDE5 inhibitors without addressing psychological factors often leads to treatment discontinuation

Psychological erectile dysfunction management requires a comprehensive approach addressing both the psychological barriers to sexual function and potentially using pharmacological support to break the cycle of anxiety and erectile failure.