Is my erectile dysfunction physical or psychological?
Most erectile dysfunction has more than one cause, so the European guideline advises caution with a strict split into physical and psychological types and suggests the terms primary organic and primary psychogenic instead. Physical causes include vascular, hormonal and nerve problems. In one German study, erectile dysfunction affected 19.2% of men aged 30 to 80.
Why is erectile dysfunction rarely just physical or just psychological?
Erectile dysfunction is the persistent inability to get and keep an erection firm enough for satisfactory sex. It is commonly divided into organic, psychogenic and mixed types, but the European guideline advises using this split with caution because most cases have mixed causes.
For that reason, it suggests the terms primary organic and primary psychogenic erectile dysfunction, which describe the main cause without implying it is the only one. Whatever the balance, erectile dysfunction can affect psychological health and has a significant impact on the quality of life of men and their partners.
What physical causes and medicines are linked with erectile dysfunction?
Known physical causes include problems with blood vessels, hormones and nerves, and erectile dysfunction is associated with chronic health conditions. Reported risk factors include age, diabetes, abnormal blood fats, high blood pressure, heart and blood vessel disease, obesity, metabolic syndrome, lack of exercise, smoking and drug use.
Injuries can also be responsible, including a fracture of the pelvis or of the penis. Some heart medicines have been shown to harm erectile function, while newer ones have a neutral or even beneficial effect.
Several groups of medicines are linked with erectile dysfunction, including some blood pressure medicines, such as thiazide diuretics and beta-blockers, antidepressants such as SSRIs and tricyclics, antipsychotics and antiandrogens, which include GnRH analogues and 5-alpha-reductase inhibitors.
Recreational drugs and anabolic steroids are also listed, as is excessive alcohol intake. Lifestyle and drug-related risk factors like these can be changed before, or at the same time as, specific treatment for erectile dysfunction.
What psychological causes are recognised?
The European guideline describes a generalised type, such as low arousability or problems with sexual intimacy, and a situational type, linked to a partner, to performance or to distress. Psychosocial treatments include sexual skills training, marital therapy and psychosexual education.
"The integration of CBT with pharmacological treatment for ED has demonstrated empirical efficacy and is regarded as a best-practice approach" Source 1, p. 52
Cognitive behavioural therapy (CBT) is recommended in group or couple format, even when delivered online. The partner is included when therapy is indicated, and it works best combined with medical treatment. The American guideline adds that referral to a mental health professional should be considered for men being treated for erectile dysfunction.
How is the main cause worked out?
Both guidelines start with a thorough medical, sexual and psychosocial history and a physical examination. The European guideline makes a strong recommendation for laboratory tests, including blood glucose, blood fats and total testosterone, to find reversible risk factors, and the American guideline recommends measuring testosterone in the morning.
A validated questionnaire is used to measure how severe the erectile dysfunction is and how well treatment works. Explaining how sexual response works is often the first step in treatment, and it has been shown to leave men with erectile dysfunction more satisfied sexually.