The essential feature of erectile disorder is the repeated failure to obtain or maintain erec- tions during partnered sexual activities (Criterion A). A careful sexual history is necessary to ascertain that the problem has been present for a significant duration of time (i.e., at least approximately 6 months) and occurs on the majority of sexual occasions (i.e., at least 75% of the time). Symptoms may occur only in specific situations involving certain types of stimulation or partners, or they may occur in a generalized manner in all types of situa- tions, stimulation, or partners.
Many men with erectile disorder may have low self—esteem, low self—confidence, and a de- creased sense of masculinity, and may experience depressed affect. Fear and/ or avoid- ance of future sexual encounters may occur. Decreased sexual satisfaction and reduced sexual desire in the individual’s partner are common.
In addition to the subtypes ”lifelong/acquired” and “generalized/ situational,” the fol- lowing five factors must be considered during assessment and diagnosis of erectile disorder given that they may be relevant to etiology and/ or treatment: 1) partner factors (e.g., part- ner’s sexual problems, partner’s health status); 2) relationship factors (e.g., poor communi- cation, discrepancies in desire for sexual activity); 3) individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psychiatric comorbidity (e.g., de- pression, anxiety), or stressors (e.g., job loss, bereavement); 4) cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes toward sexuality); and 5) medical factors relevant to prognosis, course, or treatment. Each of these factors may con- tribute differently to the presenting symptoms of different men with this disorder.
The prevalence of lifelong versus acquired erectile disorder is unknown. There is a strong age-related increase in both prevalence and incidence of problems with erection, particu- larly after age 50 years. Approximately 13%—21% of men ages 40—80 years complain of oc— casional problems with erections. Approximately 2% of men younger than age 40—50 years complain of frequent problems with erections, whereas 40%—50% of men older than 60—70 years may have significant problems with erections. About 20% of men fear erectile prob- lems on their first sexual experience, whereas approximately 8% experienced erectile prob- lems that hindered penetration during their first sexual experience.
Erectile failure on first sexual attempt has been found to be related to having sex with a previously unknown partner, concomitant use of drugs or alcohol, not wanting to have sex, and peer pressure. There is minimal evi—2t most of these problems spontaneously re- mit without professional intervention, but some men may continue to have episodic prob- lems. In contrast, acquired erectile disorder is often associated with biological factors such as diabetes and cardiovascular disease. Acquired erectile disorder is likely to be persistent in most men.
The natural history of lifelong erectile disorder is unknown. Clinical observation sup- ports the association of lifelong erectile disorder with psychological factors that are self- limiting or responsive to psychological interventions, whereas, as noted above, acquired erectile disorder is more likely to be related to biological factors and to be persistent. The incidence of erectile disorder increases with age. A minority of men diagnosed as having moderate erectile failure may experience spontaneous remission of symptoms without medical intervention. Distress associated with erectile disorder is lower in older men as compared with younger men.