5.5.

5 Psychopathological and psychosocial assessment

Mental health issues and psychological distress are frequently comorbid with ED [451]. This is most
evident for depression and anxiety related disorders, but may also include transitory states of altered mood
(i.e., dysfunctional affective states resulting from a specific life stressor or crisis) [338, 452, 453]. Relationship
factors, including lack of satisfaction with the partner, poor sexual relationships, length of the relationship,
or feeling emotionally disconnected from the partner during sex, have been related to erectile difficulties
and dysfunction [452, 454, 455]. In contrast, intimacy was found to be a protective factor in ED [329, 456].
Additionally, the cognitive factors underpinning organic and non-organic ED must also be assessed. Cognitive
factors include male dysfunctional thinking styles and expectations about sexuality and sexual performance.
These expectations result from the sexuality norms and stereotypes, shared by a given culture. Expectations
emphasising high sexual performance in men, result in anxiety, which acts as a maintenance factor for ED [457,
458]. Unrealistic expectations about male sexual performance may further align with internal causal attributions
regarding the loss of erection (i.e., men attribute the loss of erection to themselves [sense of personal
inadequacy]), thereby worsening ED [457, 459]. Likewise, poor self-esteem and cognitive distraction from erotic
cues, are expected to negatively affect ED [460, 461].
Psychosexual assessment in ED cases include a clinical interview considering all the previous
topics. Clinicians are expected to collect information on the individual’s psychopathological symptoms, life
stressors, relationship dynamics, cognitive style, and cognitive distraction sources [460]. Also, self-reported
measures are frequently used within the psychosocial context. These may include measurement scales such
as the Brief Symptom Inventory [462] for measuring psychopathology symptoms, the Sexual Dysfunctional
Beliefs Questionnaire [463] or the Sexual Modes Questionnaire [464] for measuring dysfunctional cognitive
styles in men. It is worth noting that most literature follows a heteronormativity view. There is recent evidence
suggesting that men who have sex with men present specific psychological risks associated with erectile
capability regarding anal sex; minority stress, i.e. stress steaming from conflicting sexual identity, was
associated with increased erectile difficulties in these men [465]. Therefore, professionals must tailor their
assessment in the context of sexual minorities.

Figure 5: Psychopatholgical and psychosocial assessment

Collect evidence for Evaluate psychosexual history and

specific life stressors relaonship factors

Evaluate dysfunconal thinking

Consider role of Consider cultural
style and expectaons regarding
partner background
sexuality and erecle funcon

Decide on referral to (sexual)

psychotherapy

Include psychosexual aspects as

outcomes for treatment efficacy
- relationship/intimacy
- sexual satisfaction
- well-being
- flexible thinking style and
expectations

SEXUAL AND REPRODUCTIVE HEALTH - LIMITED UPDATE 2022 55

Table 12: Indications for specific diagnostic tests for ED

Primary ED (not caused by acquired organic disease or psychogenic disorder).

Young patients with a history of pelvic or perineal trauma, who could benefit from potentially curative
revascularisation surgery or angioplasty.
Patients with penile deformities that might require surgical correction (e.g., Peyronie’s disease and congenital
penile curvature).
Patients with complex psychiatric or psychosexual disorders.
Patients with complex endocrine disorders.
Specific tests may be indicated at the request of the patient or their partner.
Medico-legal reasons (e.g., implantation of penile prosthesis to document end-stage ED, and sexual abuse).

Table 13: Specific diagnostic tests for ED

Nocturnal Penile Tumescence and Rigidity (NTPR) using Rigiscan®

Vascular studies
- Intracavernous vasoactive drug injection
- Penile dynamic duplex ultrasonography
- Penile dynamic infusion cavernosometry and cavernosography
- Internal pudendal arteriography
Specialised endocrinological studies
Specialised psycho-diagnostic evaluation

5.5.6 Recommendations for diagnostic evaluation of ED

Recommendations Strength rating

Take a comprehensive medical and sexual history in every patient presenting with erectile Strong
dysfunction (ED). Consider psychosexual development, including life stressors, cultural
aspects, and cognitive/thinking style of the patient regarding their sexual performance.
Use a validated questionnaire related to ED to assess all sexual function domains (e.g., Strong
International Index of Erectile Function) and the effect of a specific treatment modality.
Include a focused physical examination in the initial assessment of men with ED to identify Strong
underlying medical conditions and comorbid genital disorders that may be associated with ED.
Assess routine laboratory tests, including glucose and lipid profile and total testosterone, to Strong
identify and treat any reversible risk factors and lifestyle factors that can be modified.
Include specific diagnostic tests in the initial evaluation of ED in the presence of the Strong
conditions presented in Table 11.

5.6 Treatment of erectile dysfunction

5.6.1 Patient education - consultation and referrals
Educational intervention is often the first approach to sexual complaints, and consists of informing patients
about the psychological and physiological processes involved in the individual’s sexual response, in ways the
patient can understand. This first level approach has been shown to favour sexual satisfaction in men with ED
[466]. Accordingly, consultation with the patient should include a discussion of the expectations and needs
of the patient’s and their sexual partner. It should also review the patient’s and partner’s understanding of ED
and the results of diagnostic tests, and provide a rationale for treatment selection [467]. Patient and partner
education is an essential part of ED management [467, 468], and may prevent misleading information that can
be at the core of dysfunctional psychological processes underpinning ED.

5.6.2 Treatment options

Based on the currently available evidence and the consensus of the Panel, a novel comprehensive therapeutic
and decision-making algorithm (Figure 6) for treating ED, which takes into account the level of invasiveness of
each therapy and its efficacy, has been presented. This newly-developed treatment algorithm was extensively
discussed within the guidelines panel as an alternative to the traditional three-level concept, to better tailor
a personalised therapy to individual patients, according to invasiveness, tolerability and effectiveness of the
different therapeutic options and patients’ expectations. In this context, patients should be fully counselled with
respect to all available treatment modalities.

56 SEXUAL AND REPRODUCTIVE HEALTH - LIMITED UPDATE 2022