Erectile dysfunction (ED) occurs in 10% of men under 35 years old and 50% or more of men over 60 years old. There are many medical and psychological risk factors for ED and a complex and interactive set of variables can lead to ED.

Some Facts About Erectile Dysfunction

Since the FDA approved sildenafil (Viagra) in 1998, over 100 million men around the world have received prescriptions for it.
ED can have negative effects on men’s self-esteem, relationships with their partners or quality of life.
ED may also be an early warning sign of cardiovascular disease or depression.
In aging men, ED symptoms occur first in their 40s and 50s, but increases in severity in their 60s.
Men over 70 years old have less distress about ED, and men that seek treatment are largely younger and middle-aged.
The prevalence of ED is associated with other medical risk factors such as cardiovascular disease, diabetes, depression, and lower urinary tract symptoms.
Lifestyle factors such as smoking, obesity and lack of exercise can also predict ED.

ED is diagnosed based on self-report and is further classified as having organic causes (vascular, hormonal or neurogenic) or psychological. ED due to psychological reasons is usually made as a diagnosis of exclusion when no organic factors are present.

A Definition of Erectile Dysfunction

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) definition of ED includes:

ED is present for 6 months or more and present for 75-100% of sexual activity.
There is difficulty obtaining an erection.
There is difficulty in maintaining an erection.
There is a decrease in erectile rigidity.
There may be the presence of other male sexual dysfunctions.
- 30% of men with ED report premature ejaculation.
- In older men, ED can occur with low sexual desire or loss of orgasm and ejaculation.

Your First Stop: A Primary Care Physician

The assessment and treatment of ED changed after sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) were approved for the treatment of ED. Although these medications can be very successful in treating symptoms related to ED, risks and disadvantages of the medications should be discussed with a physician.

Primary care physicians, who will prescribe these medications, typically manage ED. Given there is a strong association between ED and medical risk factors, starting with a primary care physician is critical. More rigorous medical or psychological evaluations are usually only conducted after treatment with these medications is not successful.

Physicians are likely to have men undergo a medical history, evaluation (which can include laboratory testing) in order to:

Investigate the hypothalamic-pituitary-gonadal axis and androgen levels.
Analyze serum chemistries, complete blood count (CBC) and lipid profiles.
Conduct a serum prostate-specific antigen (PSA) test based on age and risk status.

A thorough examination should also include evaluating cigarette smoking, alcohol use and prescription drug use (specifically anti-hypertensives or antidepressants). Patients who have endocrine deficiencies, e.g. hypogonadism, should be on hormone replacement therapy prior to initiating therapies for ED.

However, primary care physicians are generally not trained in sexual medicine and do not take detailed sexual histories or use medical or psychological testing to diagnose or treat ED. These are important components of understanding the causes of ED and determining the treatment.

Sexual problems should also be determined in the partner, as these can cause or contribute to ED:

Lack of lubrication.
Low sexual desire.
Painful intercourse.

In addition, psychological factors to be considered include:

Performance anxiety or sexual inhibition.
Quality of the partner relationship.
Sexual or contextual variables, e.g. financial stress.

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It is important that the medical and psychological treatments for ED are combined. There is evidence that a significant number of men with ED discontinue medications such as Viagra or fail to seek help at all due to:

Lack of education and counseling from physicians.
Fear of the side effects of the medications.
If they have a partner who has a concern.
Distrust of the medications.
Failed expectations of treatment using the medications.

To further emphasize the importance of the bio-psycho-social model in the treatment of sexual dysfunctions, it is noteworthy that success rates are lower when medication is used alone. That is due to relationship factors such as:

Couples with significant and chronic marital problems.
Lack of desire in one or both partners.
Significant mental illness in either partner.

Medications used to treat ED may also lose efficacy over time due to other disease states or tolerance of the medications.

Unfortunately, no clinical trials utilizing a combination of medication and sex therapy have been performed, but while medications used to treat ED can restore function, they are not necessarily a cure for sexual happiness and fulfillment.