Physical vs Psychological Erectile Dysfunction?

Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.¹ The 2025 EAU Guidelines recognize that ED is commonly classified into three groups based on etiology: organic (physical), psychogenic (psychological), and mixed ED. However, this classification should be used with caution as most cases are actually of mixed etiology, leading experts to suggest using the terms “primary organic” or “primary psychological” instead.²

Physical causes of ED include vascular problems (most common), hormonal imbalances, neurological disorders, and anatomical abnormalities. The guidelines identify numerous risk factors associated with physical ED, including age, diabetes mellitus, dyslipidemia, hypertension, cardiovascular disease, obesity, metabolic syndrome, lack of exercise, and smoking.³ Physical examination and laboratory testing are essential components of the diagnostic evaluation to establish the etiology of ED, with studies showing that a thorough initial history and physical examination can accurately identify the cause in many cases.⁴

Psychological factors contributing to ED include depression, anxiety disorders, stress, relationship problems, and sexual performance anxiety. The guidelines emphasize that psychological factors may have a profound impact on erectile function and chosen treatment strategies.⁵ Even in cases with a clear physical cause, psychological factors often develop secondarily as men experience anxiety and loss of sexual confidence following ED episodes. This creates a cycle where physical and psychological factors reinforce each other, complicating treatment.

The guidelines recommend a comprehensive approach to treatment that addresses both physical and psychological aspects. For primary psychological ED, cognitive behavioral therapy has shown effectiveness, especially when combined with medical treatments.⁶ For physical ED, first-line treatments include lifestyle modifications and phosphodiesterase type 5 inhibitors (PDE5Is). The guidelines emphasize that lifestyle changes including physical activity, especially aerobic exercise, and weight loss may improve erectile function in men with ED.⁷

When first-line treatments fail, second-line options include vacuum erection devices, intracavernosal injections, and intraurethral applications. For patients with severe ED who do not respond to other treatments, penile implants represent a third-line therapy with high satisfaction rates (92-100% in patients and 91-95% in partners).⁸ The guidelines describe two main types of penile implants: inflatable (two- and three-piece) and semi-rigid devices, with three-piece inflatable devices often preferred due to more natural erections, though no prospective randomized controlled trials have compared satisfaction rates between implant types.⁹

Regardless of whether ED has primary physical or psychological causes, the guidelines recommend patient education as the first approach to treatment. This includes informing patients about the psychological and physiological processes involved in sexual response and discussing expectations and needs of both the patient and partner.¹⁰ The consultation should review the patient’s understanding of ED, diagnostic test results, and provide a rationale for treatment selection, as this approach has been shown to improve sexual satisfaction in men with ED.