What is the most likely intervention to help a 28-year-old male with erectile dysfunction (ED), normal morning testosterone level, anxiety, and depression, who has failed treatment with Viagra (sildenafil)?

Management of Erectile Dysfunction with Psychological Components

Psychotherapy is the most appropriate intervention for this 28-year-old patient with erectile dysfunction that has failed to respond to Viagra, given his normal testosterone level, anxiety, and stress-related symptoms.

Patient Assessment and Diagnosis

This 28-year-old male presents with:

• Erectile dysfunction unresponsive to Viagra
• Normal morning testosterone level (380 ng/dL)
• Symptoms of anxiety
• Self-reported increased stress at home and work
• Depression related to erectile dysfunction
• Relationship stress due to sexual dysfunction

Recommended Treatment Approach

First-Line Intervention: Psychotherapy

The European Association of Urology (EAU) 2025 guidelines strongly recommend psychosocial interventions, including sexual skills training and cognitive behavioral therapy, as they effectively complement medical ED treatment 1. This patient's presentation strongly suggests psychogenic erectile dysfunction given:

• Young age (28 years)
• Normal testosterone level
• Concurrent anxiety and stress
• Temporal relationship between stress and ED symptoms
• Failed response to PDE5 inhibitor (Viagra)

Psychotherapy should be initiated as the primary intervention because:

• The patient identifies stress as the likely cause
• Anxiety symptoms are present
• The ED is causing depression and relationship strain
• The patient has a normal testosterone level

Evidence for Psychotherapy in ED

Research demonstrates that cognitive behavioral sex therapy (CBST) is highly effective for psychogenic ED. A 2022 randomized controlled trial showed that CBST significantly improved erectile function scores and reduced depression and anxiety compared to placebo 2. The study concluded that CBST and integrated treatments are the treatments of choice for non-organic ED with associated depression and anxiety in young men.

Another study found that integrated treatment with sildenafil and CBST resulted in a 48% success rate for erectile function compared to 29% with sildenafil alone after 4 weeks 3. This suggests that addressing psychological factors is crucial when PDE5 inhibitors alone are ineffective.

Alternative Treatments to Consider

PDE5 Inhibitor Optimization

Before abandoning PDE5 inhibitor therapy completely:

• Ensure adequate trials of sildenafil at maximum dose (100mg) on at least 5 separate occasions 4
• Consider trying a different PDE5 inhibitor (tadalafil or vardenafil) as some patients respond better to alternative agents 4, 5

Testosterone Therapy

Testosterone therapy is not recommended for this patient because:

• His morning testosterone level (380 ng/dL) is within normal range
• The EAU guidelines indicate that testosterone therapy is only helpful for ED patients with low testosterone levels 1

Weight Loss

While weight loss can improve erectile function in overweight patients, there is insufficient information about this patient's BMI to determine if this would be beneficial. This would be a secondary consideration after addressing the psychological factors.

Treatment Algorithm

1. Begin with psychotherapy focused on ED (cognitive behavioral sex therapy)

   • Address performance anxiety
   • Develop stress management techniques
   • Improve communication with partner

2. Optimize PDE5 inhibitor use if continuing pharmacological treatment

   • Ensure proper timing relative to sexual activity
   • Try maximum dose (sildenafil 100mg)
   • Consider alternative PDE5 inhibitor if sildenafil failed

3. Consider combination therapy if single modality is insufficient

   • Integrated approach of psychotherapy plus optimized PDE5 inhibitor use 2

4. Address lifestyle factors as adjunctive treatment

   • Stress reduction techniques
   • Regular physical activity
   • Adequate sleep
   • Moderation of alcohol intake

Common Pitfalls to Avoid

1. Focusing solely on pharmacological treatment when psychological factors are prominent
2. Prescribing testosterone when levels are normal
3. Ignoring the relationship context of sexual dysfunction
4. Failing to adequately trial PDE5 inhibitors before declaring treatment failure
5. Not addressing anxiety and depression that may both contribute to and result from ED

The relationship between ED and depression is bidirectional - ED can cause psychological distress, and depression can contribute to ED 6. Breaking this cycle through psychotherapy is likely to be the most effective approach for this patient.