Erectile Dysfunction in a Young Man

Clinical Scenario

Michael Chen, 30, books a video consultation for a personal problem. He has been experiencing erectile dysfunction for 3 months — unable to maintain erections during sex with his new partner. Crucially, he still gets normal morning erections and can achieve erections when masturbating alone. He entered this relationship after a 2-year gap, is stressed at work, and shares a house with friends (lacking privacy). He has no medical conditions and takes no medications. He is embarrassed and has started avoiding intimacy, which is straining the new relationship.

What This Case Tests

Differentiating psychogenic from organic erectile dysfunction; identifying preserved morning erections as a key diagnostic indicator; addressing performance anxiety as the likely cause; discussing the contribution of stress, relationship novelty, and environmental factors; managing a sensitive consultation with a young man without immediately reaching for PDE5 inhibitors.

Common Mistakes Trainees Make

The three most common mistakes are: prescribing sildenafil immediately without adequate assessment (a young man with preserved morning erections almost certainly has psychogenic ED, and medication treats the symptom not the cause), not asking about morning erections and masturbation (the two key questions that differentiate psychogenic from organic ED), and being so focused on the physical assessment that you miss the psychological and relational dimensions.

The Consultation Challenge

Michael has psychogenic erectile dysfunction. The clinical evidence is clear: preserved morning erections and the ability to achieve erections during solo masturbation prove that the vascular, neurological, and hormonal pathways are intact. The problem is situational — it occurs only with his partner, in the context of a new relationship, performance pressure, and environmental stress.

Start by creating a safe space. Michael has used a vague booking reason because he is embarrassed. Use normalising language: "This is something a lot of men experience, especially in new relationships. I'm glad you've come to talk about it."

Take a structured sexual history. The key diagnostic questions are: does he get morning erections? (Yes — this essentially rules out organic ED in a 30-year-old.) Can he achieve erections during masturbation? (Yes — confirms intact erectile function.) When did the problem start? (3 months ago, coinciding with the new relationship.) Is it consistent or variable? (Variable — suggesting psychogenic cause.) Are there contributing stressors? (Work stress, new relationship anxiety, shared housing lacking privacy.)

Explain the diagnosis clearly. "The fact that you get normal morning erections and can achieve erections on your own tells me that physically everything is working correctly. What's happening is performance anxiety — your brain is getting in the way. This is extremely common, especially when you're with someone new and feeling pressure to perform."

Management should address the cause, not mask the symptom. First-line for psychogenic ED is psychosexual therapy or CBT — addressing the anxiety cycle. Practical advice includes: reducing pressure around sex (sensate focus exercises, taking intercourse off the table temporarily), addressing environmental factors (privacy, timing), stress management, and open communication with his partner. If PDE5 inhibitors are discussed, frame them as a confidence bridge, not a long-term solution.

Assess for contributing factors: alcohol use (common in new relationships and worsens ED), recreational drugs, pornography use (can contribute to partner-specific ED), and relationship dynamics.

Time check: Spend the first 3 minutes creating safety and taking the sexual history. By minute 6, explain the psychogenic diagnosis with the morning erection evidence. Address the performance anxiety cycle between minutes 7-9. Use the remaining time for management (psychosexual therapy, practical advice, and whether a short PDE5 course is appropriate as a confidence builder).

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you ask the two critical differentiating questions: morning erections (preserved = psychogenic) and erections during masturbation (preserved = intact function). They look for a structured sexual history covering onset, pattern, contributing factors (stress, relationship, environment), alcohol and drug use, and assessment of relationship dynamics. A trainee who does not ask about morning erections misses the key diagnostic feature.

Clinical Management and Medical Complexity: Examiners expect management that addresses the cause: psychosexual therapy or CBT referral, practical advice (sensate focus, communication with partner, addressing environmental factors), and lifestyle modification. PDE5 inhibitors may be appropriate as a short-term confidence bridge, but prescribing them as the sole intervention without addressing the underlying anxiety scores poorly. Demonstrating awareness that medication treats the symptom, not the cause, is what differentiates a good consultation.

Relating to Others: Heavily weighted. Examiners assess whether you normalise the condition, create genuine safety for the discussion, avoid making the patient feel abnormal or deficient, and address the impact on the relationship. Discussing sexuality without awkwardness or euphemism is a specific skill being tested.

Example Opening

Strong opening: "Hello Michael, I can see you've booked in about something personal. Whatever it is, this is a confidential space and I'm here to help. What's been going on?"

When explaining the diagnosis: "I want to share something really reassuring. The fact that you're getting normal morning erections and that things work fine when you're on your own tells me that physically everything is in good working order. What's happening is essentially your brain putting too much pressure on the situation — performance anxiety. It's incredibly common, especially at the start of a new relationship."

When discussing management: "The most effective approach here isn't a tablet — it's addressing the anxiety that's causing the problem. There are practical techniques that work really well, and I can refer you to a specialist who deals with exactly this. Some men also find that a short course of medication helps rebuild confidence while they work on the underlying anxiety."

Avoid: "I'll prescribe some Viagra — that should sort it out." (Treats the symptom, ignores the cause, and medicalises a psychological problem).

How This Appears in the SCA

ED in a young man tests your ability to conduct a sensitive sexual health consultation, differentiate psychogenic from organic causes using clinical features, and offer management that addresses the underlying cause rather than just prescribing medication. Examiners value trainees who can discuss sexuality naturally and without awkwardness.

Key Statistic

Erectile dysfunction affects approximately 1 in 5 men, with prevalence increasing with age. In men under 40, the majority of ED is psychogenic — preserved morning erections are present in over 90% of psychogenic ED cases and absent in the majority of organic ED cases.

Relevant Guidelines

• NICE CG35 (withdrawn but principles apply): Erectile dysfunction
• British Society for Sexual Medicine (BSSM) guidelines on erectile dysfunction management.

Frequently Asked Questions

How do I differentiate psychogenic from organic erectile dysfunction?

The single most important question: does the patient get normal morning erections? Preserved morning erections indicate intact vascular, neurological, and hormonal function — the ED is psychogenic. Additionally, if the patient can achieve erections during masturbation but not with a partner, this confirms situational (psychogenic) ED. Organic ED typically presents with absent morning erections, gradual onset, and consistent failure regardless of context.

Should I prescribe PDE5 inhibitors for psychogenic ED?

PDE5 inhibitors (sildenafil, tadalafil) can be used as a short-term confidence bridge while the underlying psychological cause is addressed. However, prescribing them as the sole intervention without addressing performance anxiety is poor management — it medicalises a psychological problem and creates medication dependence. The examiner wants to see that you address the cause (psychosexual therapy, anxiety management) alongside any pharmacological support.

What is sensate focus and should I recommend it?

Sensate focus is a structured behavioural therapy technique developed by Masters and Johnson. It involves progressive stages of physical intimacy, starting with non-genital touch and gradually progressing, with intercourse explicitly removed from the agenda in early stages. This removes performance pressure and allows the couple to rebuild physical connection without anxiety. Recommending it demonstrates knowledge of evidence-based psychosexual interventions.

How do I discuss pornography use in the context of ED?

Pornography use can contribute to partner-specific ED through desensitisation to real-world sexual stimulation. If relevant, ask sensitively: "Some men find that their habits around pornography can affect things — is that something that might be relevant here?" Frame it non-judgmentally as a recognised contributing factor, not a moral issue. If excessive pornography use is identified, gradual reduction alongside psychosexual therapy is the approach.

When should I investigate ED in a young man further?

Investigate if: morning erections are absent (suggests organic cause), ED is progressive and consistent regardless of context, there are risk factors for vascular disease (diabetes, hypertension, smoking, hyperlipidaemia), there are symptoms of hypogonadism (low libido, fatigue, reduced body hair, gynaecomastia), or there is a history of pelvic surgery or trauma. First-line investigations include: fasting glucose, lipid profile, testosterone (morning sample), and TFTs.