What could be the cause of my erectile dysfunction and inability to penetrate, considering my long-term pornography viewing habits and dissatisfaction with my penis size of 12.5 cm?

Erectile Dysfunction Evaluation and Management

Your erectile dysfunction is most likely psychogenic in origin, given your preserved ability to achieve erections with masturbation, the loss of morning erections coinciding with chronic pornography use, and your penis size being completely normal at 12.5 cm—all of which point toward psychological factors rather than organic disease. 1

Understanding Your Situation

Penis Size Concerns

• Your penis size of 12.5 cm (approximately 5 inches) is within the normal range and is not causing your inability to penetrate. 1
• Penis size concerns often reflect body dysmorphic thinking rather than actual anatomical inadequacy, and this psychological distress can directly contribute to erectile dysfunction. 1
• The inability to penetrate is due to erectile rigidity problems, not penile length. 1

Morning Erections as a Diagnostic Clue

• The absence of morning erections over 3-4 years is a critical finding that requires evaluation, but your ability to achieve erections during masturbation strongly suggests a psychogenic component. 1
• The presence of masturbatory erections indicates that your vascular, neurological, and hormonal systems are likely intact—if you can achieve an erection in one context, the erectile machinery works. 1
• True organic erectile dysfunction typically presents with loss of ALL erections (morning, masturbatory, and partnered), whereas situational erectile dysfunction points to psychological factors. 1

Pornography-Induced Erectile Dysfunction

• Chronic, frequent pornography use (5-6 days per week for 5-6 years) can desensitize sexual arousal pathways and create unrealistic expectations that interfere with real-world sexual function. 2
• This pattern often leads to performance anxiety, diminished self-esteem, and perceived failures in sexual situations—all psychological factors that perpetuate erectile dysfunction. 1, 2

Required Medical Evaluation

Essential Testing

• Morning serum total testosterone levels must be measured to rule out testosterone deficiency (defined as <300 ng/dL with symptoms). 1
• Consider screening for glucose/hemoglobin A1c and lipid panel, as these may identify cardiovascular risk factors. 1
• Blood pressure measurement is essential, as hypertension is a common comorbidity. 1

Cardiovascular Risk Assessment

• Erectile dysfunction is a risk marker for underlying cardiovascular disease, and you should be evaluated for cardiovascular risk factors even at a younger age. 1, 3
• This evaluation is particularly important before starting any erectile dysfunction treatment. 1, 4

Physical Examination

• A focused genital examination should assess for penile skin lesions, urethral meatus placement, and any palpable plaques or deformities (though these are unlikely given your history). 1

Treatment Approach

First-Line: Psychosexual Counseling

• Given the strong psychogenic component, referral to a mental health professional with expertise in sexual health should be your primary intervention, either alone or combined with medical treatment. 1, 3
• Psychosexual counseling addresses performance anxiety, unrealistic expectations from pornography use, body image concerns, and helps integrate healthy sexual patterns. 1
• This approach focuses on reducing anxiety during sexual situations and improving sexual confidence. 1, 3

Concurrent Medical Treatment: PDE5 Inhibitors

• An FDA-approved oral phosphodiesterase-5 inhibitor (PDE5i) such as tadalafil or sildenafil should be offered as first-line pharmacological treatment. 1, 3, 4

Dosing Strategy for PDE5 Inhibitors:

• Start conservatively and titrate to maximum dose if needed. 1, 4
• For on-demand use: Take 30 minutes to 1 hour before anticipated sexual activity; effects last up to 36 hours with tadalafil. 4
• For daily use: Tadalafil 2.5-5 mg once daily allows for spontaneous sexual activity at any time. 4
• An adequate trial requires at least 5 separate attempts at maximum dose before declaring treatment failure. 1
• Sexual stimulation is still required for the medication to work—these drugs do not create automatic erections. 4

Critical Instructions for Success:

• Many patients fail PDE5i therapy due to improper use, not drug inefficacy. 5
• Anxiety and unrealistic expectations are common reasons for poor response despite adequate pharmacology. 5
• Avoid excessive alcohol (more than 5 drinks) when using these medications, as it can impair effectiveness and increase side effects. 4

Lifestyle Modifications

• Reduce or eliminate pornography use to allow recalibration of sexual arousal patterns. 2
• Smoking cessation, weight loss, and increased physical activity improve erectile function. 1, 5
• Avoid excessive alcohol consumption. 1

Common Pitfalls to Avoid

Unrealistic Expectations

• Do not expect immediate, perfect erections without addressing the psychological component. 1, 2
• Success requires both physiological support (medication) and psychological work (counseling). 1

Premature Treatment Abandonment

• Many men discontinue PDE5i therapy after 1-2 attempts, but 5 attempts at maximum dose are needed to assess efficacy. 1
• If one PDE5i fails, try a different one before abandoning this drug class. 1

Ignoring the Psychological Component

• Achieving penile rigidity alone does not equal cure—the psychological factors must be addressed for lasting improvement. 6
• Even with "organic" erectile dysfunction, psychological management is beneficial. 6

When to Seek Specialist Referral

• If testosterone deficiency is confirmed, endocrine evaluation is needed. 1
• If PDE5i therapy fails after adequate trials of multiple agents, referral to a urologist for specialized testing may be warranted. 1
• If significant depression, anxiety, or relationship conflict is present, mental health referral is essential. 1, 3

Contraindications and Safety

• PDE5 inhibitors are absolutely contraindicated if you take nitrate medications, as the combination can cause dangerous blood pressure drops. 4
• If you experience chest pain after taking a PDE5i, do not use nitrates for at least 48 hours and seek immediate medical attention. 4
• Rare but serious side effects include priapism (erection lasting >4 hours), sudden vision or hearing loss—seek immediate care if these occur. 4