Likely Diagnosis: Organic Erectile Dysfunction
This patient most likely has organic erectile dysfunction, not psychogenic ED, based on the absence of morning erections for 6 months—a critical diagnostic feature that strongly suggests underlying physical pathology rather than psychological causes. 1, 2
Key Diagnostic Features
The clinical presentation points definitively toward organic ED:
Absence of nocturnal/morning erections for 6 months is the most important diagnostic clue. The presence of nocturnal and morning erections suggests (but does not confirm) psychogenic ED, while their absence strongly indicates organic pathology. 1, 2
The pattern of losing erections immediately before intercourse, despite achieving them during sexual activity, can occur in both organic and psychogenic ED. However, when combined with loss of spontaneous erections, this points toward progressive organic disease. 1
Gradual onset over 6 months suggests organic pathology, whereas sudden onset would indicate psychogenic causes. 3
Required Initial Evaluation
Perform a comprehensive medical, sexual, and psychosocial history focusing on cardiovascular risk factors, diabetes, medications, and relationship issues. 1
Critical history elements to obtain:
- Age, comorbid conditions (diabetes, hypertension, dyslipidemia, cardiovascular disease), prior surgeries 1
- All medications (many cause ED as adverse effect) 1
- Smoking, alcohol, substance use 1
- Presence of masturbatory erections (if present, suggests some preserved erectile capacity) 1
- Relationship factors and performance anxiety 1
Physical examination should assess:
- Blood pressure and cardiovascular status 1
- Genital examination for penile deformities, plaques (Peyronie's disease), hypogonadism signs 1
Mandatory laboratory testing:
- Morning serum total testosterone level (must be drawn in morning) 1, 2
- Fasting glucose or HbA1c (screen for diabetes) 1, 4
- Fasting lipid profile 4, 5
Critical Counseling Point
Counsel this patient that ED is a sentinel marker for cardiovascular disease and may precede cardiac events by 2-5 years. Even if asymptomatic, cardiovascular risk assessment is warranted. 1, 2
Treatment Algorithm
First-Line Treatment
Initiate oral PDE5 inhibitor therapy (sildenafil, tadalafil, vardenafil, or avanafil) as first-line pharmacologic treatment. These are effective in 60-65% of men with ED, including those with diabetes and hypertension. 2, 4
Critical prescribing instructions to maximize efficacy:
- Trial the medication at least 4-6 times before declaring treatment failure 2
- Take on empty stomach 2
- Allow adequate time before sexual activity (sildenafil: 60 minutes; varies by agent) 6, 7
- Sexual stimulation is required for the medication to work 7
Common pitfall: Many patients try PDE5 inhibitors only once or twice and declare them ineffective. Proper patient education about multiple attempts is essential. 2
Concurrent Interventions
Address modifiable risk factors simultaneously with pharmacotherapy:
- Smoking cessation 2
- Weight loss if overweight 2
- Regular exercise 2
- Optimize diabetes control 2
- Optimize lipid management 2
Psychosexual Component
Consider referral to mental health professional with sexual health expertise, even when organic ED is present. This reduces performance anxiety, improves treatment adherence, and addresses secondary psychological factors that develop after organic ED begins. 1, 2
The loss of erections "immediately before sex" suggests possible performance anxiety overlay on organic disease, making combined medical and psychological treatment particularly important. 1
If Testosterone Deficiency Identified
If morning testosterone <300 ng/dL with symptoms, treat according to testosterone deficiency guidelines. Testosterone replacement may improve erectile function in hypogonadal men. 1
Second-Line Options if PDE5 Inhibitors Fail
- Intracavernosal injection therapy (alprostadil) 4
- Vacuum constriction devices 8
- Referral to urology for specialized evaluation 1, 2
Third-Line Treatment
- Penile prosthesis implantation (reserved for refractory cases) 4
Special Considerations for This Patient
The young patient with persistent ED despite initial treatment warrants specialized urologic evaluation for detailed vascular assessment, comprehensive testosterone workup, and evaluation for conditions like Peyronie's disease. 2
If concomitant erectile dysfunction and premature ejaculation are present, treat the ED first, as PE often improves when ED is successfully managed. 1