I am a male who previously felt pleasure and achieved erection when stimulating the perineal area (between the anus and penis), but now I have lost that sensation and erectile response; what could be causing this?

Loss of Perineal Sensation and Erectile Response

You should seek immediate evaluation by a urologist to assess for pudendal nerve injury or compression, as loss of perineal sensation with erectile dysfunction following previous normal function suggests nerve damage that may be reversible if treated promptly.

Understanding Your Symptoms

The perineal area (between the anus and penis) contains the dorsal branch of the pudendal nerve, which is critical for both genital sensation and erectile function 1, 2. Your loss of both pleasurable sensation and erectile response in this area indicates potential nerve involvement rather than a vascular or hormonal problem 3.

Key Neurological Pathways Affected

• Sensory pathways: The pudendal nerve carries sensory information from the perineum that normally triggers reflexive erections through spinal cord pathways 2, 4
• Erectile control: Penile erection requires intact neural pathways, with sensory input from the genitals being "a potent activator of pro-erectile spinal neurons" 2
• Nerve injury consequences: Trauma to the dorsal branch of the pudendal nerve can cause loss of penile sensation, erectile dysfunction, and loss of erogenous response 3

Immediate Evaluation Steps

Your urologist should specifically assess for:

• History of trauma: Any perineal injury, bicycle accidents, prolonged sitting/pressure, or pelvic trauma that may have compressed or injured the pudendal nerve 5, 3
• Timing and progression: Whether the loss was sudden (suggesting acute injury) or gradual (suggesting chronic compression) 5
• Associated symptoms: Penile numbness, pain, changes in ejaculation, or loss of morning/nocturnal erections 5
• Physical examination: Focused genital and perineal examination to identify areas of sensory loss, trigger points, or anatomical abnormalities 5, 3

Critical Diagnostic Considerations

Morning and nocturnal erections are key diagnostic indicators 5:

• If you still have morning erections, this suggests the erectile tissue and vascular supply are intact, pointing toward a sensory/neurological issue
• Complete loss of all erections (including morning erections) suggests more extensive nerve damage or concurrent vascular problems

Treatment Options Based on Cause

If Pudendal Nerve Compression/Injury is Identified

Surgical decompression (neurolysis) can restore function 3:

• In men with traumatic pudendal nerve injury, neurolysis at the inferior pubic ramus achieved complete recovery of erogenous sensation in 83% of patients
• Normal erections were restored in 67% of men with erectile dysfunction from nerve injury
• Mean follow-up showed sustained improvement at 57 weeks post-surgery

If No Clear Nerve Injury is Found

Standard erectile dysfunction evaluation should proceed 5:

• Morning serum total testosterone measurement (testosterone <300 ng/dL with symptoms defines testosterone deficiency) 5
• Assessment for cardiovascular risk factors, as ED is "a risk marker for underlying cardiovascular disease" 5
• Consideration of psychological factors including depression, anxiety, or relationship issues 5

Critical Pitfalls to Avoid

• Don't delay evaluation: Nerve injuries may become irreversible if chronic compression continues without treatment 3
• Don't assume it's purely psychological: Loss of both sensation AND erectile response suggests organic pathology requiring investigation 5
• Don't self-treat with erectile dysfunction medications: If the underlying problem is nerve damage, phosphodiesterase-5 inhibitors may not address the root cause and could delay appropriate treatment 1, 6

Prognosis

Recovery depends on timing and cause 3:

• Acute nerve compression treated early has better outcomes than chronic injury
• Even with established nerve injury, surgical decompression can restore function in the majority of cases
• Concurrent psychological counseling may improve outcomes by addressing performance anxiety that develops secondary to the physical problem 5