Sexual Problems In Men

Erectile Dysfunction

Even when erectile dysfunction is based on a physical condition, it is always made worse by a downward spiral of anxiety and ever more likely failure to perform. When this cycle of anxiety and failure to perform is broken the majority of men experience a dramatic reduction in erectile difficulty.

Back in 1988, Arnold Melman, Leonore Tiefer, and Ronald Pedersen, published a paper in Urology which evaluated the origin of erectile dysfunction in 406 men. These men were seen in the authors’ Centre For Male Sexual Dysfunction between March 1981 and July 1983.

They were either referred by a doctor or self referred, and initially seen by a urologist for a physical examination and a medical consultation. Those men who said that they could maintain a rigid erection for more than 5 minutes in certain situations were offered psychosexual therapy, as were those with delayed ejaculation.

All other men were scheduled for two nights of evaluation in a private room at the center. They could undergo not only confidential interviews by a psychologist to focus on any possible psychological factors. They also had a physical investigation of erectile capacity during the viewing of a sexually stimulating film and during sleep.

The psychological investigation focused on various factors. These included the men’s psychopathology, incorrect beliefs about sex or sexual activity, emotional states such as depression, anxiety, shame, and anger which might be interfering with sexual performance. There was also relationship analysis for factors like  poor communication, hostility, fear of rejection, and the lack of attraction to his partner.

(The investigators also conducted a separate interview with the man’s primary sexual partner. That way, they could corroborate the facts described by the man, and evaluate further treatment methodologies and options.)

During the investigation into erectile dysfunction, if a man experienced an erection either as he watched a sexually stimulating film or during a night’s sleep, a technician would estimate the quality of his erection, record the degree of erection on a Polaroid photograph if possible, and take a record of the man’s own estimate of the quality of his erection.

In summary, a man’s erectile function was regarded as being normal when his erection was 80% or more of his normal erection capacity, and the erection was sustained for more than 5 minutes.

Another investigative technique used was the measurement of penile blood pressure and blood flow using a blood pressure cuff and ultrasonic flow detectors. By getting the patient to execute 25 pelvic tilts, it was possible to estimate the amount of redistribution of blood or “steal” syndrome. This might have been releavnt to delayed ejaculation.

Diagnoses and treatment for erectile dysfunction and delayed ejaculation

After all the data had been collected, the urologist and psychologist reviewed the data together. They then established a treatment option to be presented to man and his sexual partner. They established five categories of sexual dysfunction:

1 Purely organic: in order to be classified as purely organic, a man’s erection problems had to incorporate the absence of any erections sufficient for penetration, the man and his partner to be in agreement about the absence of normal erections, and there needed to be an absence of any significant psychological or emotional factor.

In addition, perhaps not surprisingly, there also needed to be the presence of some clearly identifiable disease, treatment, or drug which was known to cause erection problems.

2 Primarily organic: in the absence of normal erections, together with the presence of a condition known to be responsible for the loss of erection, a man’s problems could be diagnosed as primarily organic.

3 Primarily psychogenic: a man’s problems would fall into this category when he was experiencing an absence of normal erections, and psychological factors seemed to be responsible for the dysfunction

4 Purely psychogenic: a man’s erection problems would fall into this category when he developed an erection adequate for penetration that lasted for 5 minutes or more, and when there were relevant psychological or emotional factors present, or when his erections returned after he had been interviewed and treated at the sexual dysfunction centre.

5 There was a fifth category in which the origin of erection problems was categorized as unknown: these were men who did not have maximum capacity erections and in whom there was no obvious explanation, either physical or psychological, to explain the absence of normal erections.

A small majority of men (56%) seen at the centre were in their sixth or seventh decade of life: 76.4% of men were married. In total, out of 406 men, 117 (almost 29%), were diagnosed as having organic erectile dysfunction. 161 (39.6%) were diagnosed as having psychogenic erectile dysfunction. 62 or just over 15% were diagnosed as having diminished erectile capacity due to an organic problem that had been made worse by psychological or emotional factors. 40 men (9.9%) had primarily psychological or psychogenic erectile dysfunction with some organic contribution. Finally, 26 men (which equates to 6.4%) had erectile dysfunction of unknown origin.

74% of men with insulin-dependent diabetes had an organic or primarily organic diagnosis, and the other 26% of diabetic men were thought to have erection problems which originated in predominantly psychological causes, even though their diabetes was quite severe.

Analysis of the men who had erection problems that were regarded as being psychological or emotional in origin revealed that only 25% of these men had maximum capacity erections under any circumstances. And 22% did not have maximum erectile capacity in any situation but managed to resume having intercourse after they had been seen at the centre.

Vascular impairment

Vascular impairment was assessed by analysis of the blood flow measurement through the penis. Also take into account was the man’s medical history, and his ability to obtain an erection during the night and/or with visual stimulation.

There was a significant difference between men whose erection problems were regarded as organic in origin and those whose erection problems were regarded as psychological in origin. The results of this investigation will be discussed in a moment.


Hormonal analysis was conducted on 383 of the men. Men with low testosterone had significantly reduced duration of erections at maximum capacity: 3.9 minutes versus 9.2 minutes. Also, the men who had the highest estradiol levels were more likely to be classified as having organic or primarily organic erection problems.

Treatment of erection problems

The majority of men who went through this study were advised to undergo some form of sex therapy including marriage counseling when necessary.

Although about a quarter of men in the study did not wish to pursue any further treatment, some men benefited from the discovery of firm erections during the investigation. Others had renewed sexual interest sparked by the evaluation process, so that erections began to develop at home again.

What does it all mean?

Even back in 1988, frank discussions of male sexual dysfunction in the media had encouraged men and partners to seek help. They were ready to come into sexual clinics and doctors’ offices. 

When lack of erection could be correlated with the use of medication the man’s drugs were changed or the patient motivated to undergow lifestayle changes. For example, smoking was a major cause of erection problems, and men would be encouraged to give up smoking.

The investigators reported that, as they had anticipated, the consequences of type I and type II diabetes were the predominant causes of organic erectile failure in the men in this population.

Other men with impaired glucose tolerance also had organic erectile dysfunction. This led investigators to believe an organic diagnosis could only be made in some situations: i.e. when there was a complete absence of rigid erections, a corroborative history, and the presence of relevant organic factors. They stated that low blood flow in the penis, diabetes, medication, prior pelvic surgery, and other factors, alone or in combination, would not necessarily mean a man had a physical rather than psychological cause for his erection problems.

They also emphasised that it was important to establish true causality. One of the reasons for this was that some organic factors are reversible: for example, abnormally low levels of hormone, smoking, use of drugs, some vascular lesions of the penis, and some problems such as Peyronie’s disease.

Other men, however, had irreversible organic erectile problems, and the team suggested their expectations of treatment should be managed, and treatment adapted accordingly. The study was conducted in the early days of papaverine injections, which had begun to allow return to satisfactory intercourse for men. Viagra had not yet appeared on the market.

The authors noted that psychogenic factors were present in 66% of the cases of erectile dysfunction they had seen. They concluded, in the light of the knowledge available to them at the time, that such patients could best be served by counseling and re-education about the realities of sexual function.

As time has gone by, of course, the situation has changed and we now know that counseling and Viagra (or one of its counterpart medications) probably represents the best possible option for men in this situation, perhaps with the addition of testosterone supplementation where there are indications for such treatment.