What evaluation and management steps are recommended for a healthy 24‑year‑old man who has stopped having normal morning erections?

Evaluation and Management of Loss of Morning Erections in a Healthy 24-Year-Old Male

The sudden loss of morning erections in an otherwise healthy 24-year-old man warrants immediate measurement of morning serum total testosterone and a focused assessment for psychogenic causes, cardiovascular risk factors, and medication effects, because preserved morning erections indicate intact neurovascular function and their absence may signal either organic pathology or significant psychological distress. 1

Initial Diagnostic Approach

History Taking

• Document the onset pattern (sudden vs. gradual), duration, and whether erections are preserved during masturbation or with specific partners, as situational erectile dysfunction with preserved spontaneous erections is pathognomonic for psychogenic etiology. 1, 2

• Screen aggressively for depression, anxiety, performance anxiety, relationship conflicts, and recent life stressors, because these are the most common causes of erectile dysfunction in young men and must be identified before attributing symptoms to organic disease. 1, 2

• Review all current medications, particularly antidepressants (SSRIs, tricyclics), antihypertensives (beta-blockers, diuretics), anxiolytics, and sedatives, as these commonly cause erectile dysfunction and loss of morning erections. 2

• Ask specifically about the presence of libido, because loss of libido combined with erectile dysfunction strongly suggests testosterone deficiency or depression rather than pure psychogenic erectile dysfunction. 1

Physical Examination

• Measure blood pressure, pulse, waist circumference, and body mass index to screen for cardiovascular risk factors, even in a young patient. 1, 2

• Perform a focused genital examination to identify penile plaques, testicular atrophy, or other abnormalities that might suggest organic pathology. 3, 2

Mandatory Laboratory Testing

• Obtain morning serum total testosterone (drawn between 8–10 AM) in every man presenting with erectile dysfunction, regardless of age, because testosterone deficiency occurs in up to 36% of men seeking sexual dysfunction consultation and impairs response to all treatments. 1, 2

• If testosterone is <300 ng/dL, repeat the measurement to confirm hypogonadism before initiating therapy. 1

• Consider fasting glucose or HbA1c and a fasting lipid panel to evaluate for diabetes and dyslipidemia, which are modifiable cardiovascular risk factors even in young men. 1, 2

Distinguishing Psychogenic from Organic Causes

The presence of preserved nocturnal or morning erections indicates intact neurovascular function and strongly points to a psychogenic component, distinguishing it from organic causes such as vascular insufficiency or neurologic disease. 1, 4

• Vasculogenic erectile dysfunction typically shows gradual onset with progressive loss of all erections, including morning erections; preservation of morning erections essentially excludes significant vascular insufficiency as the primary mechanism. 1

• A pattern of situational erectile dysfunction (e.g., only with specific partners or in specific contexts) with preserved spontaneous erections is considered diagnostic for psychogenic etiology. 1, 2

• The absence of cardiovascular risk factors (smoking, diabetes, hypertension, hyperlipidemia) reduces the likelihood of vasculogenic causes in a young, healthy male. 1

Management Algorithm

When Testosterone Deficiency Is Documented (<300 ng/dL)

• Initiate testosterone replacement therapy first in hypogonadal men, as this improves both erectile function and libido and enhances response to PDE5 inhibitors. 1

• Combine testosterone therapy with a PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil), because testosterone alone does not reliably resolve erectile dysfunction and combined therapy yields superior outcomes. 1, 2

• Counsel the patient that testosterone therapy suppresses spermatogenesis; avoid this treatment if he is actively trying to conceive. 1

When Psychogenic Etiology Is Suspected

• Prescribe a PDE5 inhibitor as first-line therapy even for psychogenic erectile dysfunction, because these agents work for both organic and psychogenic causes and should be initiated concurrently with psychological therapy. 1, 2

• Start with the lowest dose and titrate to maximum as needed; educate the patient that sexual stimulation is necessary for the medication to work and that at least five attempts at the maximum tolerated dose should be made before declaring treatment failure. 1, 2

• Refer to a mental health professional for psychosexual counseling or cognitive-behavioral therapy to address underlying anxiety, depression, or performance anxiety. 1, 2

• Involve the partner in both assessment and treatment whenever possible, as this improves treatment adherence, addresses relationship dynamics, and ensures shared decision-making. 1

Lifestyle Modifications (Applicable to All Patients)

• Advise smoking cessation, weight loss if BMI >30 kg/m², regular aerobic exercise, reduced alcohol consumption, and optimization of cardiovascular risk factors (blood pressure, lipids, glucose control), as these interventions reduce cardiovascular risk and improve erectile function. 1, 2

Cardiovascular Risk Counseling

• Inform the patient that erectile dysfunction is an independent risk marker for cardiovascular disease, with predictive strength comparable to cigarette smoking or a family history of myocardial infarction, and that this information should be communicated to his primary care provider. 1, 2, 5

• Erectile dysfunction can precede coronary artery symptoms by 2–5 years, making it an important sentinel marker for underlying vascular disease even in young, asymptomatic men. 1, 5

Critical Pitfalls to Avoid

• Do not delay testosterone testing when loss of libido accompanies erectile dysfunction, as the combination makes testosterone deficiency highly likely and treatable. 1

• Do not assume psychogenic erectile dysfunction requires only counseling; PDE5 inhibitors work for both psychogenic and organic causes and should be initiated concurrently with psychological therapy. 1

• Do not prescribe PDE5 inhibitors to patients on oral nitrates (e.g., nitroglycerin), as this combination causes severe hypotension. 1, 2

• Do not treat erectile dysfunction alone when depression is present; address the underlying psychiatric condition first, recognizing that antidepressants themselves may worsen sexual function. 1

When to Refer to Urology

• Refer if two different PDE5 inhibitors at maximum dose fail after adequate trial (≥5 attempts at the highest dose) for consideration of second-line therapies: intracavernosal injection, intra-urethral alprostadil, or vacuum erection devices. 1

• Refer if there is a history of pelvic or genital trauma, abnormal testicular or penile findings on examination, or abnormal initial screening laboratory results. 2