Erectile dysfunction (ED) can involve vascular, hormonal, neurological, and psychological factors. Anxiety can contribute to difficulties and make them more distressing, and assessment can help identify useful treatment.
The physical layer
Blood flow and nerve function contribute to erections. Cardiovascular disease and ED share risk factors, so new or persistent ED can be a reason to assess broader health.
Discuss new or persistent ED with a clinician. Medical and sexual history, examination, and selected tests can help identify contributing conditions; the workup should fit the individual.
The hormonal layer
Low testosterone can contribute to ED and reduced sexual desire, but testosterone is only one possible factor. Normal testosterone does not rule out other causes.
Hormone results should be considered alongside symptoms, medicines, vascular and nerve health, and psychological factors rather than used to explain every erection difficulty.
The cognitive layer (the one nobody talks about)
Some men begin worrying about another difficult encounter after an erection problem. Performance anxiety can then contribute to further difficulty; it does not affect every man in the same way.
Worry can make an erection more difficult without making it impossible. A possible pattern is:
- Initial physical issue (could be minor)
- One uncomfortable failure
- Anticipatory anxiety the next time
- Anxiety contributes to further erection difficulty
- Failure again — now reinforced
- Avoidance, withdrawal, relationship strain
The pattern and duration vary. Discussing anxiety, relationship concerns, and physical symptoms can help a clinician identify useful treatment options.
Why daily tadalafil works (when it works)
A clinician may prescribe tadalafil once daily for ED. The labeled starting dose is 2.5 mg; it may be increased to 5 mg based on effectiveness and tolerability. Sexual stimulation is still needed. It can improve erectile function, but it does not guarantee an erection or cure the underlying cause.
Tadalafil must not be used with nitrates or guanylate cyclase stimulators such as riociguat. Other medicines and health conditions also affect whether it is suitable. Discuss dose changes and whether to continue with the prescriber. Treating performance anxiety may also involve counseling; there is no predictable point at which everyone can stop medicine.
What the conversation should cover
- Medical history and examination, including cardiovascular risk factors
- Selected tests for suspected causes, rather than an automatic full hormone panel
- Lifestyle, including sleep, alcohol, exercise, and stress
- Psychological and relationship factors, including performance anxiety
- Medication review; do not stop a prescribed medicine without discussing it with the prescriber
The bottom line
ED treatment should address the factors identified in the assessment. Medicines, counseling, and treatment of contributing conditions may help, but the appropriate combination and response vary. Follow-up can help assess progress and adjust the plan.
Sources
NIDDK: causes of erectile dysfunction; NIDDK: diagnosis of erectile dysfunction; NIDDK: erectile dysfunction; NIDDK: treatment for erectile dysfunction; Cialis prescribing information.