World Joumal of ~'
Urology
World J Urol (1983) 1:227-232
© Springer-Verlag1983
Erectile Dysfunction: A Sexological and Psychiatric Review Michiel W. Hengeveld Afdeling Psychiatrie, Academisch Ziekenhuis, Rijnsburgerweg 10, NL-2333 AA Leiden, The Netherlands
Summary. The author, a psychiatrist and sexologist, gives an up-to-date review of the causation and management of erectile disorders. A classification of the various subtypes is presented. The etiology, pathogenesis, and diagnosis are discussed, with emphasis upon the interplay between organic and psychological factors causing and maintaining the erectile dysfunction. Both the general psychological approach and the modern sex therapies are briefly described. The psychological and sexological aspects of the implantation of an erectile prosthesis are discussed,
Non-coital
Coital \ /
Secondary
/
\
/ Always \
Sometimes
/
/erections
/
\
Primary \
Full
Both
\ Partial erections
Both full and partial erections
Fig. 1. Classification of erectile dysfunctions (according to [15])
Erectile dysfunction is the inability to attain or maintain a penile erection sufficient to accomplish coitus or masturbation satisfactorily. The use of the term impotence is discouraged, not only because it is derogatory, but because it is used for various sexual dysfunctions such as lack of desire, and suggests a complete erectile failure, while in many cases this failure is only partial. In this article I will present an up-to-date review of the etiology, diagnosis, and therapy of erectile dysfunctions from the point of view of a psychiatrist and sexologist. Little is known about the prevalence of erectile disorders. Kinsey et al. [19], in their famous report, mention a mean value of 1.6% of all m e n interviewed. With increasing age, however, the percentages rise hyperbolically, from 0.1% in under 20-year-aids to 75% in men over 70 years. The incidence rate is also strongly influenced by the severity of the disturbance. In most relevant literature, however, the nature of the erectile dysfunction is not specified, thus hampering comparison of incidence and the results of various treatments. It is, therefore, important to distinguish various subgroups of erectile disorders. For this purpose I herein present a classification recently proposed in the literature [15]. Classification A first division that can be made is between erectile failure with intercourse alone, erectile failure with
masturbation alone, or erectile failure with both intercourse and masturbation. Further specification can be achieved if a distinction is made between primary or secondary dysfunction. This division depends upon the question whether or not the m a n has previously functioned well sexually. Secondary erectile disorders, often of a transient nature, occur m u c h more frequently than primary erectile disorders, which are generally considered to be indicative of significant pathology. Two other criteria that can be used are specified in the questions: "Is the dysfunction always present or only sometimes?" and "Are the erections achieved (and then lost again) full, partial, or sometimes full, sometimes partial?". Figure 1 illustrates the classification scheme derived from these criteria.
Etiology and Pathogenesis In general a distinction is made between psychogenic and organic erectile failure. Traditionally, sexology authors claim that 90 or 95 % of all erectile disturbances are caused by psychological factors. Sufficient evidence to substantiate this point, however, is not available. The few quantitative studies in this field concern highly selected patient samples. Masters and Johnson [27], for example, found an organic cause in only 2% of their patients with an erectile disorder, while Spark et al. [35] gave this diagnosis in not less than 67% of
228 Table 1. Psychologicalcauses of erectile dysfunctions
Predisposing personality or
Anxiety, fear
of failure, of sex, of disease, of pregnancy, of lust, of intimacy, of women, of ridicule, of rejection, of inflicting injury, after physical injury
Hostility, resentment
towards the partner, toward women
Disgust
towards sex, towards the female sexual organ
Inhibition, shame
due to upbringing
COnS
Immediate organic a[ C a u s e
Pangs of conscience, guilt due to religion, when unfaithful, in widowers Latent homosexuality Poor sex education Psychiatric disorder
depression, psychosis
their cases. Segraves et al. [32], who compared a group of patients referred to a urology department with a group referred to a sex therapy clinic, found an organic etiology in 26% and 4 %, respectively. It is often not clear which criteria have been used to decide whether the cause is organic or psychological. In many cases it is probably not really possible to make this distinction. In many patients with an undeniable organic etiology, secondary psychological problems may play an important role [5, 31, 39], and in patients with a clear psychogenic erectile dysfunction organic factors may be subtly interwined in the pathogenesis [16, 25]. Similar to many other physical and psychological disorders, erectile failure is a multifactorial syndrome, the pure organic and pure psychogenic forms being the extremes of a continuous spectrum. Diabetes mellitus, for example, a disease accompanied by erectile problems in 30%-50% of all male patients, is a typical example of the interplay between somatic and psychological factors. In addition to the neurological or vascular causes, the following psychological problems may be involved: anxiety, fear of future complications, the role of a chronically ill person with daily restrictions, poor body image, and fatigue [38]. All in all, most authors nowadays assume that organic factors play a role in the etiology of far more than 5 or 10% of the erectile disorders.
Psychological Causes Other articles in this issue deal with the anatomy and physiology of erection and the pathophysiology of erectile dysfunction. I will therefore concentrate here on the psychological etiology, as has been extensively described by many authors, albeit in the form of case histories. Using recent handbooks and reviews [1, 6, 15, 22, 25, 27, 30, 38], however, it has been possible to select a number of etiological factors on which there is general concurrence. These are certainly not condi-
Fig. 2. Vicious circles in the pathogenesis of erectile dysfunctions
tions essential to the disorder, but factors that often contribute to its onset or continuation. These psychological causes are presented in Table 1. For the sake of clarity it is important to distinguish between predisposing and immediate causes. The former are the results of early development, upbringing, and possibly the constitution of the individual. The latter consist of the actual factors leading to erectile failure. It is also useful to look not only for factors causing the erectile problems, but also for factors that maintain the disorder. In studying the pathogenesis of erectile dysfunction one encounters vicious circles of organic and psychological causes and their consequences (Fig. 2). It stands to reason that elucidation of the etiology and pathogenesis of erectile disorders requires a sound diagnostic procedure.
Diagnosis In the treatment of each case of erectile disorder, it is essential to take an accurate and extensive sexual anamnesis and biography of the man and, if possible, of his sexual partner. In some cases this in itself will be sufficient to help the patient: the clarifying, informative, and reassuring effects of a detailed discussion of the sexual history can lead to the disappearance of anxiety, guilt, or inhibition. Rather than going into detail here about all the questions that can or should be asked, I refer the reader to the various handbooks available [1, 16, 25, 27]. The most important points are given in Table 2. It is a traditional assumption that the sexual history of the patient allows differentiation between a psychological and an organic etiology. According to most authors [e.g. 5, 6, 22, 25, 38, 40] the data that are essential for this diagnosis are presented in Table 3. The problem is, however, that the sexual history may not be reliable because the patient harbours feelings of shame
229 Table 2. Sexual history in erectile dysfunctions Severity of erectile dysfunction Duration of erectile dysfunction Gradual or sudden onset of dysfunction Intrapersonal or interpersonal conflict as an immediate cause Changes in sexual desire Circumstances and positions in which the dysfunction exists Erections or ejaculations at night Erections upon awakening Erection with masturbation Reactions of the patient and his sexual partner Current erotic and sexual behavior Meaning of sexuality and coitus for the patient and his partner Solutions, alternative sexual activities Ideas about the role of man and woman Complaints of depression or fatigue Quality of the relationship to the partner Psychosexual biography of the patient and his partner
Psychological Tests To date psychological tests do not provide much additional information in the area of etiology and diagnosis of erectile disorders. Some psychologists have attempted to discriminate organic versus psychogenic erectile dysfunction with such tests [2, 8], but others have failed to duplicate their results [26, 33]. Some reasonably reliable and valid psychological tests do exist, however, that record the general sexual function and attitude of the patient or the couple. Examples are the Sexual Interaction Inventory [24], The Derogatis Sexual Function Inventory [28], and the Sexual Experience Scales [13].
Psychosexological Therapies Table 3. Traditional differentation between organic and psychological etiology of erectile dysfunctions
Item
Organic
Psychological
Onset
Gradual a
Sudden
Course
Constant
Varying
Immediate cause
No psychological
Psychological conflict
Circumstances
Dysfunction at all times
Not with all partners
Morning erections
Absent
Present
Masturbation
Erectile dysfunction
Normal erection
a Except in traumatic or surgical causes
or guilt [22]. Masturbation may be concealed or erections experienced upon awakening may be denied. As well as a cause, intrapersonal or marital conflicts may also be the consequence of an organic erectile dysfunction. A varying course, with sufficient erections under certain circumstances, can also point to a mild organic cause of the disorder. An interesting example is the man who loses his erection at the moment he starts to initiate the coitus. Traditionally this is interpreted by psychodynamically oriented sexologists as proof of a psychological cause, because the erection disappears right at the crucial moment psychologically. We now know it may also be a symptom of the "pelvic steal syndrome" [1, 38]: in men with a restricted blood supply to the lower limbs and the pelvic area, muscle activation in the legs and gluteal region leads to a stealing away of the blood necessary for the erection. All in all, in many cases it is not possible to make a diagnosis from the sexual history alone, and medical examinations should be undertaken. For an excellent and critical description of the current methods used in differential diagnosis of psychogenic and organic erectile failure, I refer the reader to Wagner and Green [38].
It was the achievement of Masters and Johnson [27] to show that many patients with erectile problems suffer from only minor sexual concerns and anxieties, and that such patients can be cured with brief and direct treatment methods. Some time ago, there were, broadly speaking, two forms of psychosexological therapy: psychoanalytical individual therapy, and shorter, symptom-oriented treatment. The premise in psychoanalytic theory is that the erectile disol:der represents an underlying subconscious conflict. The dysfunction is seen as a neurotic defense against the emergence of this conflict. The therapy, therefore, is aimed at treating the neurosis according to the normal principles of psychoanalysis [16, 38]. I will not pursue this matter, particularly because, according to most authors, erectile dysfunction rarely forms an indication for an orthodox psychoanalytical therapy. Short-term, symptom-oriented treatments have been used for quite some time by all kinds of physicians [6, 7, 12, 22]. This usually involves randomly selected patients. The physician may use various techniques, adapted to the patient and his partner. The main elements of such treatments are: sexual information, reassurance, encouragement and general psychological support. Besides this, the subject can be trained to use relaxation exercises. Psychotherapeutic discussions about the background of the symptom may also take place. The partner is often included in the therapy with the intention of enhancing communication between the patient and her. Because anxiety often plays a role in the etiology, the therapy may be pharmacologically supported with a low dose of an anxiolytic medication, to be taken one hour before coitus. Endocrine therapy in the absence of demonstrable endocrinopathy is controversial [25, 38]. Reduced performance anxiety is the probable placebo response. Sexual desire may be slightly increased, which could lead to a break-through in the vicious etiological circle. The effects may, however, be counter-productive:
230 an erectile failure when desire is heightened may increase the disappointment. Moreover, there is a risk that the man will be more than ever convinced that he suffers from a physical disorder, which may decrease his acceptance of a psychotherapeutic approach. Furthermore, the endogenous androgen production may be suppressed by the exogenous hormone.
Sex Therapy Masters and Johnson [27] developed a program for the treatment of erectile dysfunctions, which can be characterized as follows: The couple is treated, not only the man, by a mixed-gender couple of co-therapists. The patients stay for two weeks in a pleasant motel near the clinic and follow a intensive daily treatment program. The most essential ingredient of their sex therapy is the Sensate Focus exercises. These are intended to (re)educate the couple to enjoy their bodies, using all senses in a relaxed and erotic way. The aim is to detach sexuality from the atmosphere of inhibition, guilt, and performance anxiety. During this period the couple is ordered to abstain completely from coitus, in an attempt to break through rigid sexual patterns and to prevent disappointing failures. For a clear description of the sensate focus exercises I refer the reader to the illustrated manual of sex therapy by Kaplan [17]. In a subsequent phase of the treatment format the sexual organs are also involved in the exercises. An erection is not striven after, but it may appear and disappear. If this stage is reached, the specific treatment follows. The female partner may then, while astride the man, stimulate him to erection and lower herself onto his phallus, which enters her vagina. The man lies still on his back and does not strive for an orgasm. This exercise is slowly expanded until a successful coitus is achieved. Finally, the goal is reached simply by initially distracting all attention from it. A present-day criticism is, in fact, that this treatment achieves too great an extent of sexual performance. The sex therapy method of Masters and Johnson has attracted many followers within a very short time. I doubt that any sexologist has not been influenced by it. There are very few, however, who apply this technique in its original form. Many variations are applied: for example the treatment is carried out on an outpatient basis, with fewer sessions, by one therapist, and with a more random group of patients. Kaplan [15], with her psychoanalytical background, emphasizes the treatment of underlying intrapersonal or interpersonal conflicts, which can come to light while performing of discussing the sensate focus exercises. Thus many sex therapies develop into couple therapies. For the sake of completeness, I will just mention two other treatment techniques for erectile disorders, stemming from the behavioral therapies: systematic
desensitization of performance anxiety [18] and the rational-emotive approach [11].
Results and Counterindications Investigations into the results of psychosexological treatment of erectile dysfunctions are scarce and rather primitive. Few controlled studies have been published; most papers simply report case histories without a substantial follow-up. Assessment and classification of erectile disorders is divergent and the methods used for judging the results of various treatments are often vague. With the current state of affairs, little difference can be shown between the results of the various therapies described above [6, 7, 18, 23, 25, 30]. If the patient group is selected to a certain extent, 60%-80% improve or are cured; in a non-selected patient population, however, such results are only reached in 33%-56%. The few studies which do include follow-up suggest a substantial rate of recurrence of the disorder, particularly in the non-selected group. Apparently, factors related to the patient and to the disorder are more important than factors related to the chosen therapy. Indeed there are indications that certain factors decrease the chance of restoring the erectile function [6, 7, 30]. These factors, shown in Table 4, can be considered as counterindications for psychosexological therapy. Further study of these prognostic factors is strongly indicated. Table 4. Relative counterindicationsto psychosexological therapy of erectile dysfunctions Primary dysfunction Long duration (e.g. more than 2 years) Insidious onset Older age Low sex-drive Homosexual inclinations Slight motivation (also of sexual partner) Mental disorder
Erectile Prosthesis As the intention ofimplantating silicon rods or cylinders in the cavernous bodies of the penis is to substitute for the erection and not for the penis, I prefer to refer to it as an erectile prosthesis instead of a penile prosthesis. In the literature to date, more than 2500 such implantations have been described. Sotile [34] presents a review up to and including 1978. The authors are, on the whole, very enthusiastic: on the average, a good result is achieved in over 90% of the cases. This is only generally described, however, in such terms as "excellent" or "satisfactory", without any specification. Besides, in more than half of the reports n o follow-up
231 period is mentioned. Systematic studies of the subjective, psychosexual results of the operation are almost entirely lacking. I know of only one study [14] in which the sexual and non-sexual effects of the implantation of an inflatable erectile prosthesis were evaluated more thoroughly. Apparently only 30% experienced the erection as being the same as a natural erection, but most patients were more or less satisfied, and said that their partners were, too. The satisfaction of the female partner was directly investigated in only one study [20]. Strikingly enough, of the 60 m e n approached, only 31 consented to an interview between the author and their partner. Many of the other men had never used the erectile prosthesis, or only in an extramarital affair. No more than 13 of the 31 women interviewed were completely satisfied with the results of the operation. Some authors [3, 21, 35] have described patients with serious psychiatric or marital disturbances following the operation.
Indications
All authors concur that the erectile prosthesis should be applied in cases of irreversible organic erectile dysfunction. Sometimes implantation is done only under the condition that the patients sexual desire is unimpaired, and that he is still able to experience genital sensations and orgasms. It is often not clear whether or not a psychiatric or psychological examination should precede the operation. The patient's partner rarely seems to be involved in the preoperative assessment. There is less agreement about whether a psychogenic erectile dysfunction should be considered for this surgical approach. About one-third of the authors are of the opinion that it should, but they seldom mention explicitly whether or not a conservative treatment trial should be carried out prior to surgery. From the sexologist's point of view there are two types of arguments against implanting an erectile prosthesis, particularly in patients with psychogenic erectile failure. First of all, it can be considered as a therapy which focusses to too great an extent on improving coital performance: "Phallic worship is alive and well in the United States today" [10]. This criticism can also be applied to the Masters and Johnson's sex therapy. Secondly, the erectile disorder can be seen as a symptom of an intrapersonal or interpersonal conflict, which cannot be cured by an erectile prosthesis [4, 9, 29, 36, 37]. In contrast to these objections is the view that many intrapersonal and interpersonal disturbances disappear after the operation, because they are more often the consequence than the cause of the erectile failure [10]. For many m e n self-esteem is strongly linked to erectile competence, whether sexologists accept this or not. Seen from this point of view, unsuccessful psychosexological therapy of erectile dysfunction of some duration is
more harmful to the patient than the surgical treatment [37]. I am not aware of any research supporting any of the above-mentioned arguments. An investigation which can answer the question: "In what kind of patient does an erectile prosthesis give the best results?" is, therefore, urgently required.
Conclusions
Erectile dysfunction can vary from a transient coital penile failure in an extramarital affair to long-lasting complete erectile incompetence under all circumstances. It is, therefore, of crucial importance to classify exactly each patient's dysfunction, both for the purpose of choosing the correct therapy, and for making research comparable. The etiology and pathogenesis should always be described as an interplay between various organic and psychological predisposing and immediate factors causing and maintaining the erectile dysfunction. A prerequisite for the correct classification, diagnosis, and therapy of each erectile disorder is an extensive sexual anamnesis and biography of the man and his sexual partner. In most cases various medical examinations should also be carried out for the assessment of the psychological and organic etiology and pathogenesis. Over the past decade, many types of sex therapy have been developed. As far as has been investigated, the effects of such therapies are rather satisfactory in patients subjected to a greater or lesser extent of selection. In a more random group of patients with erectile dysfunction of longer duration, however, the results are rather poor. Clear indications and counterindications for such therapies are not yet available. Erectile prostheses are technically fairly simple to implant. The surgical results of such operations are excellent, but have not been investigated with sufficient care. There is an urgent need for research determining the prognostic indicators: i.e., the factors that determine the results of various kinds of treatments in various kinds of patients with various kinds of erectile failure.
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