Erectile dysfunction psychogenic

Differentiate between organic and psychogenic erectile dysfunction (ED) and describe the etiology and pathophysiology of each. 

Erectile dysfunction Treatment of erectile dysfunction caused by neurogenic, vasculogenic, psychogenic, or mixed etiology. 

Erectile dysfunction of vasculogenic, psychogenic, or mixed etiology - Do not give more than 2 doses within a 24-hour period during initial titration. If there is no response to the initial 2.5 meg dose, the second dose may be increased to 7.5 meg within 1 hour. If additional titration is required, doses in increments of 5 to 10 meg may be given at least 24 hours apart. 

Erectile dysfunction, that is, the inability to maintain penile erection for the successful performance of sexual activity, has both organic and psychogenic causes, including as a sequelae to prostatic surgery. Erectile dysfunction is estimated to affect up to 30 million men in the United States. Previous therapies have included penile implants, and intrape-nile injections of alprostadil (see p. 420). Sildenafil [sil DEN a HI], the first oral drug approved for the treatment of erectile dysfunction in males, was introduced in early 1998. 

The incidence of erectile dysfunction is low in men less than 40 years of age. It increases as men age, likely as a result of concurrent medical conditions that impair the vascular, neurologic, psychogenic, and hormonal systems necessary for a normal penile erection. 

Erectile dysfunction can result from any single abnormality or combination of abnormalities of the four systems necessary for a normal penile erection. Vascular, neurologic, or hormonal etiologies of erectile dysfunction are collectively referred to as organic erectile dysfunction. About 80% of patients with erectile dysfunction have the organic type. Patients who fail to respond to psychogenic stimuli have psychogenic erectile dysfunction. 

Finally, patients must be in the proper mental frame of mind to be receptive to sexual stimuli. Patients who suffer from malaise, have reactive depression or performance anxiety, are sedated, have Alzheimer s disease, have hypothyroidism, or have mental disorders, commonly complain of erectile dysfunction. In most studies, patients with psychogenic erectile dysfunction generally exhibit a higher response rate to various interventions than do patients with organic erectile dysfunction, as their disease is often less severe. 

A medical history should be obtained to identify concurrent medical illnesses that are risk factors for organic or psychogenic erectile dysfunction. If these underlying diseases are not optimally responding to treatment, this should be addressed before specific treatment for erectile dysfunction is initiated. Also, if the patient smokes cigarettes, drinks excessive amounts of ethanol, or uses recreational drugs, these social habits should be discontinued before specific treatment for erectile dysfunction is started. 

For patients with psychogenic erectile dysfunction, psychotherapy may be used as monotherapy, or as an adjunct to specific treatments for the disorder. To enhance the relevance of psychotherapy, both the patient and his partner should be included in the counseling sessions. Also, treatment should be individualized and should address those immediate factors that may be causing performance anxiety or depression, rather than the remote, deep-seated reasons for psychological disorders. The effectiveness of psychotherapy is generally low, and long-term psychotherapy is often necessary. 

A higher percentage of patients with psychogenic and neurogenic erectile dysfunction responded to alprostadil and at a lower dose when compared to patients with vasculogenic erectile dysfunction. 

Psychogenic erectile dysfunction—Erectile dysfunction due to failure of central nervous system to perceive or process sexually stimulating information. 

As indicated earlier, the selective PDE5 inhibitors developed for the treatment of male erectile dysfunction resulting from organic or mixed organic-psychogenic origin have been the most successful PDE inhibitors. The three marketed drugs are sildenafil, vardenafil, and tadalafil (Fig. 17.2). In addition to the treatment of erectile dysfunction, sildenafil has been indicated for the treatment of pulmonary hypertension and female sexual dysfunction. These latter uses are unlabeled uses. 

Although psychogenic erectile dysfunction was historically considered to be the most common cause, mixed disorders are most common. Psychogenic erectile dysfunction can be caused by performance anxiety, strained interpersonal relationships, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia. Several studies have confirmed the strong relationship between depression and sexual dysfunction (Araujo et al. 1998 Shabsigh et al. 1998). 

Psychogenic dysfunction occurs if a patient does not respond to psychic arousal. It occurs in up to 30% of all cases of ED. Common causes include performance anxiety, strained relationships, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia.5 It is postulated that the anxious or nervous man will have excessive stimulation of the sympathetic system, leading to smooth muscle contraction of arterioles and vascular spaces within erectile tissue.6 O Many patients may initially have organic dysfunction, but develop a psychogenic component as they try to cope with their inability to achieve an erection. It has been estimated that up to 80% of ED cases have an organic cause, with many having a psychogenic component as well.1... 

If problems are with erectile ability, ask specific questions related to onset, frequency, and sexual relationships. Does the patient history imply psychogenic, organic, or mixed dysfunction ... 

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