In the anxious individual, there can be overactivity of the sympathetic system leading to increased smooth muscle tone. Alternatively, signals from the brain of an individual with a psychogenic issue can override the erectogenic parasympathetic output from the sacral spinal cord. Psychosexual therapy can help the individual to deal with issues such as performance anxiety, reduced attraction to his partner (which may or may not be linked to a relationship problem), past sexual trauma, misconceptions about normal sexual function, suppressed feelings about sexuality, fear of sexually transmitted diseases or pregnancy. By enquiring about early morning and spontaneous erections, which all healthy men get, one can eliminate a physical cause for erectile dysfunction. Asking about the sort of situations in which the erectile dysfunction manifests itself can also help. For instance, if he is able to masturbate with an erection while alone, but is unable to perform with a partner suggests a "situational" response. There may be more than one partner with whom the man has sexual contact. Gay and bisexual men in "straight" relationships may have difficulty achieving an erection with a female partner due to feelings of guilt about their true sexual preference.

Does He Have An Endocrinological Cause To His Erectile Dysfunction?

Androgen and prolactin levels are of particular concern. Hyperprolactinaemia occurs secondary to stress, drugs (such as neuroleptics and infertility treatments), cirrhosis, breast manipulation, or pituitary adenoma tumour. A high level of circulating prolactin causes inhibition of gonadotrophin releasing hormone which lowers levels of testosterone. Men with low testosterone levels may exhibit a decrease in sexual interest. Causes of low testosterone include renal failure, hypogonadism, bilateral cryptorchidism, other hypothalamic–pituitary–gonadal axis dysfunctions, Addison’s disease, adrenalectomy, Kleinfelter’s syndrome, cytotoxic therapies, mumps orchitis, and age related testicular degeneration as well as antiandrogen medications (e.g., cyproterone acetate, spironolactone, etc.). Androgens have also been shown to influence the activity of NOS in the corporal smooth muscle, which suggests a more direct effect of low levels of testosterone on erectile function. Approximately 52% of circulating testosterone is bound to albumin, 46% is bound to sex hormone binding globulin (SHBG), and 2% is unbound. Determination of free testosterone is preferred as it represents the most accurate parameter to reflect a real testosterone deficiency in the respective target cells. However, because the methods used most widely for determination of these parameters (e.g., equilibrium dialysis method) have shown poor reliability and high cost, the standard for evaluating testosterone deficiency remains determination of total testosterone, the free androgen index (free T/SHBG * 100%), LH level, and clinical symptoms.