Male erectile disorder should always be viewed in the broader psychosocial context. The treatment approach should be integrated and should include educational, psychological, and (if indicated) biological components. Treatment of any established underlying condition of erectile dysfunction (e.g., diabetes mellitus) should be a part of the comprehensive management of the disorder.

In 1992, the National Institutes of Health (NIH) issued a consensus statement on impotence (NIH 1992). The general considerations remain valid:

1. Psychotherapy and/or behavioral therapy may be useful for patients with erectile dysfunction without evident organic origin or as an adjunct to medical/urological interventions.

2. Treatment should be individualized to meet the patient’s desires and expectations, preferably including both partners in the treatment plan.

3. Although there are several effective therapies, their long-term efficacy is relatively low and there is a high rate of voluntary discontinuation for all forms of erectile dysfunction treatment.

Patient Education

Patient education is a very important part of the overall management plan. It starts during the very first contact between the patient and treating physician, and it should be a continuous element at each phase in the process of the management of erectile dysfunction. Patient education should focus on the patient’s ideas about and understanding of normal and abnormal erection. Patient education should be tailored to the patient’s specific needs. A review of the anatomy and physiological mechanism of the sexual response is a good starting point for the discussion and helps to dispel misinformation and myths. Common dysfunctional beliefs involve overvalued expectations about male sexual performance, intercourse, and orgasm to the neglect of sexual communication between partners, sex play, pleasure, and satisfaction. Use of books, graphs (e.g., of the sexual response cycle), and audiovisual material is often helpful. Older couples are usually receptive to an educational approach.

The next step in psychoeducation should be discussion of relevant pathophysiology, etiology, and associated lifestyle risks (smoking, substance abuse, alcohol abuse, obesity), again specifically tailored to the patient (i.e., one would not discuss the risks of smoking with a nonsmoker, but one would discuss the advantages of regular exercise with a mildly obese male taking hypolipidemics). Once the evaluation is finished and results of additional tests are obtained, the treatment options should be discussed with the patient. Informed consent for any kind of treatment should be obtained. Participation of the patient’s partner in all steps of psychoeducation is usually useful, as long as the patient agrees to the partner’s participation.

Patient education plays an important role in fostering the therapeutic alliance, in facilitating patient-physician and patient-partner communication, and in enhancing compliance with treatment.

Psychological Treatment Modalities

Althof and Seftel pointed out that the current psychotherapeutic treatment for erectile dysfunction integrates psychodynamic, systems, behavioral, and cognitive approaches within a short-term psychotherapy model. In this model, “[a]n emphasis is placed on sexual equilibrium and context. The guiding principle of treatment is to clarify the meaning of the symptom and understand the context in which it occurs”.

Schiavi (1995) outlined several basic components of psychological treatment: psychoeducational, behavioral, cognitive, psychodynamic, and interpersonal.

The cornerstone of behavioral treatment of erectile dysfunction is systematic desensitization, in which exposure to anxiety-provoking situations is combined with relaxation. The original behavioral treatment program was developed by Masters and Johnson (1970) and consists of structured behavioral assignments that focus on the couple rather than on the patient with the erectile dysfunction. The sequence of behavioral steps is as follows: 1) nongenital sensual stimulation, with an emphasis on mutuality and communication; 2) incorporation of genital pleasuring, during which erectile concerns are minimized; and finally 3) vaginal insertion, usually at the woman’s initiative, with a continued focus on sexual enjoyment, not performance (Schiavi 1995). Most therapists do not follow the format of the Masters and Johnson approach precisely, as the majority of patients are unwilling or unable to give up 2-3 weeks for treatment and are able to do homework assignments of an hour’s duration a few times weekly at most (McConaghy 1993, p. 220). Many therapists have also found satisfactory results working individually with the couple or the patient alone rather than involving a co-therapist.

Systematic desensitization may be used in the treatment of male patients without partners. The sexual anxieties of patients without partners can also be alleviated through education, cognitive correction, and systematic desensitization in imagination (McConaghy 1993, p. 223).

The distinction between behavioral and cognitive components in the treatment of erectile dysfunction is somewhat arbitrary (Schiavi 1995). H. S. Kaplan (1974) was one of the pioneers of cognitive approaches to sexual therapy. Cognitive methods are used to modify faulty beliefs and attitudes. As outlined by Rosen et al. (1994), common cognitive distortions regarding sexual function and performance include the following:

All-or-nothing thinking - the man believes that if any aspect of his sexual performance falls short of perfection, the whole sexual action is a total failure (“I am a complete failure because my erection was not 100% rigid”).
Overgeneralization - the man sees a single negative event as a never-ending pattern (“I had trouble getting erection last night. I will never be able to get an erection during intercourse”).
Disqualifying the positive - the man rejects positive experiences by insisting that they don’t count for some reason. In this manner, the negative belief is maintained, even though everyday experiences may contradict it.
Mind reading - the man arbitrarily concludes that his partner is reacting negatively to him, without checking the accuracy of his belief with his partner (“My partner must think that I am a failure or a poor sexual partner”).
Fortune telling - the man anticipates that things will turn out badly and then is convinced that his prediction is already an established fact (“I will lose my erection during intercourse tonight”).
Emotional reasoning - the man assumes that the negative emotions he is experiencing reflect the way things really are - “I feel it, therefore it must be true.”
Categorical imperatives - the man burdens himself with statements involving “shoulds,” “ought tos,” and “musts.” He is unlikely to live up to the perfectionistic standards he sets and then feels inadequate and guilty.
Catastrophizing - the man grossly exaggerates the consequences of unpleasant events (“If I lose my erection tonight, my partner will leave me”).

In most instances, these beliefs are inaccurate and are associated with feelings of anxiety, anticipation of failure, and fear about what this failure might mean about the man’s self-concept and relationship. The goals of therapy are to help the patient recognize and clarify these cognitive distortions and to see them in a different light (reframing).

The psychodynamic or psychoanalytic theory views erectile dysfunction as a symptom of an unconscious conflict rooted in an early life experience. One of the most frequent psychoanalytic explanations of sexual dysfunction is castration anxiety. Erectile failure serves as a defense against the emergence of castration anxiety. This form of anxiety often involves an unconscious fear of retaliation for potency, because the patient experiences the sexual act as an incestuous transgression with a forbidden love object. However, unresolved anger toward women in general and one’s mother in particular may also be a major source of erectile dysfunction. The goal of psychodynamic psychotherapy for erectile dysfunction is to resolve the unconscious conflict and thus restore erectile capacity. Kaplan (1974) postulated that experiential and /or constitutional factors contribute to organ vulnerability and to individual differences in the tendency to develop erectile difficulties in response to stress (Schiavi 1995). Individual psychodynamic psychotherapy is generally recommended for men with primary or lifelong erectile dysfunction. In these instances, the symptom tends to mirror an intrapsychic developmental failure rather than representing an interpersonal conflict (Althof and Seftel 1995). However, psychodynamic psychotherapy is not recommended in erectile dysfunction with an established organic etiology.

Finally, the interpersonal component of psychological treatment focuses on the couple and their relationship. Erectile dysfunction or other sexual problems may represent the couple’s shared solution to some aspects of their relationship or their adaptation to a recent crisis (Althof and Seftel 1995). Couples’ conflicts may revolve around various issues, such as control, intimacy, power, trust, communication, decline in physical health, and children. Couples therapy is frequently prescribed when dysfunction is secondary, or acquired, and diagnosed as interpersonally rooted. Interpersonal or couples therapy usually employs various concepts and techniques derived from psychoanalysis, cognitive behavioral theory, and interactional theory systems (Schiavi 1995).

Again, modern sex therapy is integrative and eclectic and uses several or all of the abovementioned components. These components may be combined on the basis of the patient’s or couple’s characteristics, the therapist’s theoretical orientation, and the treatment setting. Therapy could be conducted in various settings - in individual settings, as conjoint sex therapy, or in group settings. It should be noted, however, that interest in the use of group therapy for male sexual dysfunction has recently declined (Schiavi 1995).

Psychotherapy could be either a primary treatment modality or an adjunct one. According to Althof and Seftel (1995), psychotherapy improves sexual function in the man or couple by helping them to 1) express and accept difficult feelings regarding onerous life circumstances, 2) find new solutions for old problems, 3) surmount barriers to intimacy, 4) increase communication, 5) lessen performance anxiety, 6) transform destructive attitudes that interfere with lovemaking, and 7) modify rigid sexual repertoires. These are not only outcomes but also goals of good psychological treatment of sexual problems.

Therapy of erectile dysfunction (psychoeducation, psychological, and biological treatment) may frequently be done either by one person or in a collaborative fashion, with a psychiatrist/primary care physician/urologist prescribing medication and a therapist conducting psychotherapy. In the case of collaborative treatment, the information obtained from the therapist may be invaluable. However, one should be fully aware of all advantages and disadvantages of collaborative treatment (Riba and Balon 1999) and of the fact that it has not been firmly established whether collaborative treatment is more efficacious and/or cost-effective than integrated pharmacotherapy and psychotherapy.

Biological Treatment Modalities

The area of biological treatment modalities of erectile dysfunction underwent its greatest expansion to date during the last decade. The major advantage has been the development of modalities that are less invasive and more convenient to use (e.g., oral medications). I will review various biological modalities, from the mechanical and less convenient ones to the pharmacological and more convenient ones. The advantages and disadvantages of the various treatment modalities have been skillfully summarized in several review articles (Goldstein 1999; Mobley and Baum 1998). Although numerous biological modalities - for instance, intramuscular human chorionic gonadotropin (Buvat et al. 1987) and acupuncture (Kho et al. 1999) - have been found more or less useful in the management of erectile dysfunction, I will limit my review to those methods that have been found to be the most useful or promising.

Mechanical Devices

Vacuum erectile devices When using vacuum erectile device (ErectAid™, Post-T-Vac™, VED™), a flaccid, lubricated penis is placed in a plastic vacuum cylinder. The air surrounding the penis is removed by using a manual or electric pump. The negative pressure around the penis leads to increased inflow into corpora cavernosa and erection. A rubber or plastic band is then placed around the base of penis to maintain the erection, as this band limits the venous outflow. The patient can safely engage in intercourse for 30 minutes, after which the band must be removed (Mobley and Baum 1998). The most common complaints with this device are difficulties in application of the device, lack of spontaneity, discomfort from the tight elastic band, and, in some patients, impaired ejaculation (Schiavi 1995). Further side effects include hematoma, ecchymosis, petechiae, pain, numbness of the penis, pulling of scrotal tissue into the cylinder, and painful or blocked erection. Patients’ initial acceptance (above 80% [Schiavi 1995]) and efficacy rate (90% [Althof and Seftel 1995]) of this method are high; however, in Mobley and Baum’s (1998) experience, most patients stop using this method after several months. Adequate psychological screening and counseling contribute to patient acceptance and satisfaction. Some authors have suggested using this method in combination with psychotherapy in patients with severe performance anxiety and erectile dysfunction. Vacuum erectile devices are not effective in patients with severe Peyronie’s disease or penile curvature, patients with coagulopathy, patients with decreased manual dexterity, or patients with uncooperative partners (Mobley and Baum 1998). However, battery-operated systems are available for men with poor manual dexterity. One of the greatest advantages of vacuum erectile devices is their cost - a onetime expense of $400-$500.

Compression ring The compression ring (Actis Venous Flow Controller™) is used only in conjunction with other treatment methods, such as vacuum erectile devices, alprostadil injections, or intraurethral suppositories (see below). It is used in patients who are unable to maintain an erection adequate for vaginal penetration during treatment with these other modalities.

Surgical Modalities

Surgically implanted penile prostheses Surgically implanted semirigid or inflatable prostheses were the first available treatments for erectile dysfunction of organic etiology. Two types of penile prostheses are available: a multicomponent inflatable penile prosthesis (which can be inflated and stiffened with fluid from a reservoir and a small pump that is implanted within the scrotum) and a semirigid but malleable prosthesis. Penile prostheses are indicated in cases of nonsurgical treatment failure, such as serious side effects, lack of efficacy, and dissatisfaction. They are also indicated in cases of Peyronie’s disease and other penile deformities or injuries. Their advantages include permanent availability, reliability (they are the most reliable treatment of erectile dysfunction - an experienced implanter may achieve a 90%-95% success rate), and freedom from medications and supplies. Disadvantages of penile prostheses include need for surgery, infection (1%-5%), possible urethral perforation during corporeal dilatation precluding device placement, and inadequate sizing, resulting in cosmetic deformity and malfunction. The malleable prosthesis is easy to insert and is indicated for patients with poor manual dexterity. Penile prosthesis implantation is usually associated with a high degree of patient satisfaction. The penile prosthesis could be implanted even in the outpatient setting (Lubensky 1991), making the cost less prohibitive.

Further surgical procedures Vascular surgery is indicated if angiography confirms a focal block. Usually in such surgery, the inferior epigastric artery is harvested and anastomosed to the penile dorsal artery, the deep dorsal vein, or both. This procedure is usually reserved for patients under the age of 60 who are free from diabetes mellitus and cardiovascular disease. Surgery is also used for the correction of penile curvature in Peyronie’s disease.