What could be the cause of erectile dysfunction in a man with normal testosterone levels, who can achieve erection during masturbation 2-3 times a day, but not during intercourse, and has a history of excessive consumption of specific types of porn?

Situational Erectile Dysfunction with Preserved Masturbatory Function

This presentation represents psychogenic erectile dysfunction, specifically a situational type where performance anxiety and conditioned arousal patterns from excessive pornography use have created a disconnect between masturbatory function and partnered sexual activity. 1

Primary Diagnosis: Psychogenic ED (Situational Type)

The ability to achieve and maintain erections during masturbation 2-3 times daily with normal testosterone definitively rules out organic erectile dysfunction. 1 The AUA guidelines emphasize that the presence of masturbatory erections indicates intact vascular and neurologic erectile mechanisms, making this a psychological rather than physiological problem. 1

Key Diagnostic Features Present:

• Preserved erectile function during masturbation - confirms intact organic mechanisms 1
• Normal testosterone levels - excludes hypogonadism as a cause 1
• Situational nature - erections fail specifically during intercourse but not masturbation 2
• Lack of arousal during partnered sex ("not getting that kick") - indicates conditioned arousal pattern 2

Underlying Mechanisms

Pornography-Induced Conditioning

The excessive consumption of specific pornography types combined with high-frequency masturbation (2-3 times daily) has created a conditioned arousal pattern where sexual response is triggered only by the specific visual stimuli and masturbatory technique used, not by partnered sexual activity. 3 This represents what the literature describes as an "idiosyncratic masturbatory style" - a pattern of arousal and stimulation not easily replicated during intercourse. 3

Performance Anxiety Component

The repeated failures to maintain erections during intercourse create a self-perpetuating cycle where anticipatory anxiety about erectile failure actually causes the erectile failure. 1, 2 The AUA guidelines note that psychogenic ED frequently involves "loss of self-esteem and other psychosocial stresses" that maintain the dysfunction. 2

Treatment Algorithm

First-Line: Mandatory Masturbation Modification

Immediate suspension or dramatic reduction of pornography use and masturbation frequency is the cornerstone of treatment. 3 The Sexual Medicine Society guidelines emphasize that continuing the current masturbatory pattern will prevent recovery. 3

Specific instructions:

• Complete cessation of pornography viewing for minimum 4-6 weeks 3
• Reduce masturbation frequency to maximum once weekly 3
• If masturbation continues, must "switch hands" and eliminate pornography to approximate partnered stimulation patterns 3

Second-Line: Psychosexual Counseling

Referral to a mental health professional with sexual health expertise should occur immediately, as the AUA guidelines recommend this for men with psychogenic ED to "promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship." 1

The treatment should address:

• Performance anxiety reduction and desensitization 2
• Cognitive-behavioral interventions targeting negative thoughts during partnered sex 2
• Guided sexual stimulation techniques with partner 2
• Relationship counseling if partner dynamics contribute 2

Adjunctive Pharmacotherapy

Consider PDE5 inhibitors (sildenafil, tadalafil, vardenafil) as adjunctive therapy combined with psychosexual counseling, not as monotherapy. 2, 4 The psychiatric literature emphasizes that psychogenic ED responds best to combined psychopharmacology and psychotherapy rather than medication alone. 4

Rationale for combination therapy: The medication provides physiological support to break the anxiety-failure cycle while behavioral modifications address the underlying conditioned arousal pattern. 2, 4

Critical Pitfalls to Avoid

Do Not Treat with Medication Alone

The AUA guidelines make clear that when psychogenic factors predominate, as in this case, addressing the psychological components is essential for successful treatment. 1 Using PDE5 inhibitors without behavioral modification and counseling will likely fail because the underlying conditioned arousal pattern remains unchanged. 2, 4

Do Not Ignore Relationship Factors

The guidelines emphasize that partner involvement in treatment decisions optimizes outcomes. 1 The partner may be experiencing frustration, rejection, or anger that perpetuates the dysfunction. 3

Do Not Overlook Cardiovascular Screening

Despite the clear psychogenic nature, the AUA recommends counseling that ED is a risk marker for cardiovascular disease and warrants basic cardiovascular risk assessment. 1 This is particularly important given the age and should include blood pressure, lipid panel, and glucose screening. 1

Expected Timeline and Prognosis

Recovery requires 4-8 weeks minimum of pornography abstinence and masturbation modification before expecting improvement in partnered sexual function. 3 The literature on situational anejaculation (a related condition) demonstrates that psychosexual counseling can successfully treat situation-specific sexual dysfunction. 5

Prognosis is excellent with adherence to behavioral modifications and counseling, as the intact organic erectile mechanisms ensure physiological capacity for normal function once psychological barriers are addressed. 2, 3