Temperamental. Neurotic personality traits may be associated with erectile problems in col- lege students, and submissive personality traits may be associated with erectile problems in men age 40 years and older. Alexithymiu (i.e., deficits in cognitive processing of emotions) is common in men diagnosed with "psychogenic” erectile dysfunction. Erectile problems are common in men diagnosed with depression and posttraumatic stress disorder.
Course modifiers. Risk factors for acquired erectile disorder include age, smoking to- bacco, lack of physical exercise, diabetes, and decreased desire.
Complaints of erectile disorder have been found to vary across countries. It is unclear to what extent these differences represent differences in cultural expectations as opposed to genuine differences in the frequency of erectile failure.
employed to help differentiate organic from psychogenic erectile problems on the as- ical etiology to the problem. A number of other diagnostic procedures may be employed depending on the clinician’s assessment of their relevance given the individual’s age, co- morbid medical problems, and clinical presentation. Doppler ultrasonography and intra- vascular injection of vasoactive drugs, as well as invasive diagnostic procedures such as dynamic infusion cavernosography, can be used to assess vascular integrity. Pudendal nerve conduction studies, including somatosensory evoked potentials, can be employed when a peripheral neuropathy is suspected. In men also complaining of decreased sexual desire, serum bioavailable or free testosterone is frequently assessed to determine if the difficulty is secondary to endocrinological factors. Thyroid function may also be assessed.
Determination of fasting serum glucose is useful to screen for the presence of diabetes mel- litus. The assessment of serum lipids is important, as erectile disorder in men 40 years and older is predictive of the future risk of coronary artery disease.
Functionai Consequences of Erectiie Disorder
Erectile disorder can interfere with fertility and produce both individual and interpersonal distress. Fear and/ or avoidance of sexual encounters may interfere with the ability to de- velop intimate relationships.
Nonsexual mental disorders. Major depressive disorder and erectile disorder are closely associated, and erectile disorder accompanying severe depressive disorder may occur.
Normal erectile function. The differential should include consideration of normal erec- tile function in men with excessive expectations.
Substance/medication use. Another major differential diagnosis is whether the erectile problem is secondary to substance/medication use. An onset that coincides with the be- ginning of substance/medication use and that dissipates with discontinuation of the sub- stance/medication or dose reduction is suggestive of a substance/ medication-induced sexual dysfunction.
Another medical condition. The most difficult aspect of the differential diagnosis of erec- tile disorder is ruling out erectile problems that are fully explained by medical factors. Such cases would not receive a diagnosis of a mental disorder. The distinction between erectile disorder as a mental disorder and erectile dysfunction as the result of another medical con- dition is usually unclear, and many cases will have complex, interactive biological and psy- chiatric etiologies. If the individual is older than 40—50 years and/ or has concomitant medical problems, the differential diagnosis should include medical etiologies, especially vascular disease. The presence of an organic disease known to cause erectile problems does not confirm a causal relationship. For example, a man with diabetes mellitus can develop erectile disorder in response to psychological stress. In general, erectile dysfunction due to organic factors is generalized and gradual in onset. An exception would be erectile problems after traumatic injury to the nervous innervation of the genital organs (e.g., spinal cord injury).
Erectile problems that are situational and inconsistent and that have an acute onset after a stressful life event are most often due to psychological events. An age of less than 40 years is also suggestive of a psychological etiology to the difficulty.