Careful questioning should be able to determine if the patient has actual, organic erectile rigidity failure or some other sexual problem. Items in the history that point towards a psychological aetiology include:   

• Sudden onset of the erectile dysfunction (especially if related to a new partner or a major life-changing event) 
• Situational ED
• Normal erections with masturbation or a different partner
• The presence of good morning erections 
• High daily variability in erectile rigidity. 

 Obvious cases of psychogenic ED should be referred to an appropriate mental health professional.   

Even without obvious psychological issues, involving mental health experts can help deal with associated problems such as reducing performance anxiety, promotion of treatment adherence, improving relationship issues, identifying interpersonal conflicts, and setting realistic expectations for the couple.  

 It is often difficult and awkward for a physician to recommend a mental health evaluation for a patient, especially at their first visit. Here are a few ways to explain and justify a mental health consultation that make it easier for the patient to accept the referral:  

• A mental health assessment is part of our routine evaluation; we recommend for everyone with ED.
• It's just for a one-time evaluation; an opinion. If no problems are found, that's it.
• It's just like a blood test; if everything is normal, we go on and if not, we deal with it.
• We take vital signs (blood pressure and temperature) at every office visit for the same reason; because problems in these areas are not always obvious, yet if not diagnosed and treated they can cause the patient serious harm.
• Most patients with ED will not have an underlying psychological cause, but just having ED will damage relationships, increase stress, diminish self-esteem, and create anxiety; all of which interferes with a successful outcome. 
• Identifying any emotional, anxiety, or relationship issues early means they can be dealt with properly and, if nothing is found, we just go on. 

Psychosexual causes generally having a good response to counselling. One of the most important messages to the public would be that this condition is treatable and men should seek help if they suffer from erectile dysfunction. To prevent the condition, positive, healthy, basic lifestyle choices should be addressed such as smoking, diet, and exercise. It is also paramount to aggressively treat existing medical conditions, such as diabetes, obesity, and hypertension, properly.  

It appears that most causes of erectile dysfunction respond favourably to oral PDE-5 inhibitors. Make sure the patient takes them correctly and try at least two different oral agents before moving on to other therapy. Check a serum, morning testosterone level in all men who fail oral PDE-5 therapy.   

Reference:  

Sooriyamoorthy T, Leslie SW. Erectile Dysfunction. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.