Differentiating between Physical and Psychological Causes of Erectile Dysfunction
Over the past decades, the medical perspective on the causes of impotence has shifted. Common wisdom used to attribute almost all cases of impotence to psychological factors. Now investigators estimate that between 70% and 80% of impotence cases are caused by medical problems.
It is often difficult to determine if the cause of erectile dysfunction is a physical or psychologic one, or even some combination. The following may be helpful:
Psychological impotence tends to be abrupt and related to a recent situation. The patient may be able to have an erection in some circumstances but not in others. Being unable to experience or maintain an erection upon waking up in the morning suggests that the problem is physical rather than psychological.
Physical impotence occurs gradually but continuously over a period of time. If impotence persists over a three-month period and is not due to a stressful event, drug use, alcohol, or medical conditions, then the patient needs medical attention by a urologist specializing in impotence.
In virtually every case of impotence, there are emotional issues that can seriously affect the man’s self-esteem and relationships, and may even cause or perpetuate erectile dysfunction. Many men tend to fault themselves for their impotence even if it is clearly caused by physical problems over which they have little control.
Anxiety. Anxiety has both emotional and physical consequences that can affect erectile function. It is among the most frequently cited contributors to psychological impotence. Anxiety over sexual performance is often referred to as performance anxiety and may provoke an intense fear of failure and self-doubt. It can sometimes set off a cycle of chronic impotence. In response to anxiety, the brain releases chemicals known as neurotransmitters that constrict the smooth muscles of the penis and its arteries. This constriction reduces the blood flow into and increases the blood flow out of the penis. Simple stress may even promote the release of brain chemicals that negatively affect potency in a similar way.
Depression. Depression is strongly associated with erectile dysfunction. In one study, 82% of men who reported moderate to severe erectile dysfunction also had symptoms of depression. Depression can certainly reduce sexual desire, but it is often not clear which condition came first.
Problems in Relationships
Problems in relationships often have a direct impact on sexual functioning. Partners of men with erectile dysfunction may feel rejected and resentful, particularly if the affected man does not confide his own anxieties or depression. Both partners commonly experience guilt for what they each perceive as a personal failure. Tension and anger frequently arise between people who are unable to discuss sexual or emotional issues with each other. It can be very difficult for the man to perform sexually when both partners harbor negative feelings.
Losing a job or having lower income or education increases the risk for impotence.
Heavy smoking is frequently cited as a contributory factor in the development of impotence, mainly because it accentuates the actions of other disorders of the blood vessels, including high blood pressure and atherosclerosis.
Alcohol has also been implicated in causing impotence. In small doses, alcohol releases inhibitions, but in doses larger than one drink, it can depress the central nervous system and impair sexual function.
Lack of Frequent Erections
Infrequent erections deprive the penis of oxygen-rich blood. Without daily erections, collagen production increases and eventually may form a tough tissue that interferes with blood flow. The spontaneous erection men experience while sleeping or awake may be a natural protection against this process.
American Urological Association
Revision date: July 6, 2011
Last revised: by Jorge P. Ribeiro, MD