Erectile dysfunction (ED) is characterized by an inability to initiate or maintain an erection adequate for sexual intercourse.  Causes can be categorized as organic (eg, hypogonadism, arterial insufficiency, neurologic impairment) or psychogenic.

Psychogenic ED is common in patients with preexisting mood or anxiety disorders but can also occur abruptly following a stressful precipitating event:

• Prolonged illness: Patients may be hesitant or unsure how to initiate sexual activity.

• Severe, acute illness: Patients may believe the illness can be caused or worsened by sexual activity.  This is especially common in those with cardiovascular disease (eg, stroke, myocardial infarction), who are often concerned that sexual activity may strain the heart and lead to further cardiac events.

• Surgical procedures: Patients may be embarrassed by their appearance (eg, surgical scar) or body odor (eg, incontinence, colostomy).

• Loss of loved one: Patients may experience survivor guilt or feel fearful about the future.

Psychogenic ED is often situational, with normal erections at night or during masturbation but impaired erections when with a partner.  This patient has situational ED despite normal libido following an acute, severe illness, suggesting psychogenic sexual dysfunction (ie, performance anxiety) rather than an organic etiology.

(Choice A)  Organic ED is common in patients with cardiovascular disease due to systemic arterial insufficiency and comorbid conditions (eg, diabetes) that impair erectile function.  However, onset typically occurs gradually, rather than abruptly following a stressful event, and nocturnal erections are impaired as well.  In addition, aortoiliac occlusion is often associated with pain in the buttocks, posterior thigh, or calf during exercise; this patient has normal exercise tolerance.

(Choice B)  Bladder neck obstruction (eg, benign prostatic hyperplasia [BPH]) can reduce semen volume.  Laxity of the musculature at the bladder outlet, which can occur following surgical repair of BPH, can lead to retrograde ejaculation of semen into the bladder.  However, erections are typically normal unless the patient is taking a 5-alpha reductase inhibitor (eg, finasteride).

(Choice C)  Some cardiovascular medications, such as beta blockers (eg, metoprolol) and thiazide diuretics, can cause ED, but nocturnal/nonsexual erections are also affected.

(Choice E)  Testosterone deficiency causes ED with decreased libido and loss of nocturnal erections.  This patient's normal libido suggests adequate testosterone levels.

Educational objective:
Psychogenic erectile dysfunction often begins abruptly following severe medical (eg, myocardial infarction) or emotional stressors.  The symptoms are often situational, with normal erections at night or during masturbation but impaired with a partner.  Libido is often normal.