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Primary and secondary erectile dysfunction

What is primary erectile dysfunction and secondary erectile dysfunction?

Erectile dysfunction is defined as being unable to consistently achieve or maintain an erection suitable for adequate sexual penetration.

It sometimes is a selective condition, in that it occurs with some partners but not others, and in some cases a man can get an erection but not sustain it for intercourse. Going soft - losing his erection - after penetration can be very humiliating for a man. 

As you probably know, the term erectile dysfunction is often shortened to "ED". And then we have the definitions of primary and secondary ED as follows:

Primary Erectile Dysfunction refers to a situation where a man has never been able to get an erection, while Secondary Erectile Dysfunction is used as a name for the situation where a man has suddenly become impotent, even though he has been able to sustain erections in the past.

It is recommended a man gets medical advice if this situation lasts for two months or longer (and, we would add, provides he is not aware of the cause of his erectile issues - e.g. he knows he feels hostility or anger towards a sexual partner).

Is secondary erectile dysfunction normal - or common?

Most men will have difficulty with erection at some time in their sexual experience. This is very normal and affects up to 10% of all men at any one time. This means that between 20 and 30 million men in the USA alone experience recurring issues of erectile dysfunction.

What causes secondary erectile dysfunction?

The ease of availability of medication for erectile dysfunction has led many people to believe that it is only caused by physical problems. But for most young men, nothing could be further from the truth.

 Erection problems in this group are nearly always secondary erectile dysfunction issues, and this is usually caused by relationship issues such as hostility, guilt, anger, or shame - in other words, things that are relational in nature.

In short, if a man is perfectly able to get and sustain an erection during masturbation, it seems very improbable that the cause of his erectile issues is either physical or medical.

The term given to problems that origin in the mind, at least problems of a sexual nature such as erectile dysfunction, is "psychogenic."

So what does impact on a man's ability to get or maintain an erection? The answer is never simple, because erections are the product of cognitive, physical, behavioral, social and emotional factors.

But what we can say is that the common "psychogenic" causes include:

  • Anxiety - often caused by issues at home, school, university or in the workplace

  • Stress - which can be caused by a myriad of factors

  • Guilt or shame about sex derived from a strict religious upbringing, repressive family values, and inhibiting cultural issues

  • Fatigue or tiredness - arguably just another form of stress

  • Relationship problems (around issues of power, lack of trust, and fear of betrayal in an intimate relationship, as well as hostility)

  • Negative feelings about one's sexual partner can obviously influence sexual responses towards them

  • Depression reduces sexual desire and libido

  • And if the sexual place, time, or person are not right, then sexual functioning is affected - usually manifested as a loss of erection

  • Anxiety about sexual performance, penis size, and so on can impact on a man's ability to keep an erection.

Other pages on this website about the causes of erectile dysfunction and impotence

Home ] ED checklist ] The symptoms of ED ] Psychogenic or organic ED? ] Guidelines for the treatment of Erectile Dysfunction (1) ] Revised guidelines for the treatment of ED (2) ] [ Primary and secondary ED or erectile dysfunction ]

Other sections on erectile dysfunction

Home ] Diagnosis of Erectile Dysfunction ] The Causes of Erectile Dysfunction ] Effects of Erectile Dysfunction On Men and Their Partners ] Treatment for Erectile Dysfunction ]


The physical and non-physical causes of erectile dysfunction can interact.

For example, too much alcohol can reduce a man's capacity for erection. and what's important to note is that one failure can cause more anxiety, which can cause more anxiety in the future.

In short, anxiety can worsen erectile dysfunction in a negative feedback spiral.

The most common physical causes - of both primary and secondary erectile dysfunction - include:

  • Vascular conditions - hyperlipidemia (high levels of cholesterol blocking the arteries to the penis)

  • Alcohol

  • Medications - especially mood altering drugs such as Prozac and other SSRIs

  • Diabetes

  • Abnormal nerve function

  • Testosterone deficiency

  • Removal of prostate gland for cancer where surgery damages the erection nerves.

  • Other surgical procedures on the pelvis

  • Peyronie's disease

  • Illegal drugs

  • Smoking is a definite erection killer due to the damage it causes t the endothelial lining of the blood vessels in the penis.

How does a man get an erection?

The penis has two cylindrical, sponge-like structures that run beside the urethra. These tissue bodies run along the complete length of the penis, and will engorge with blood in response to sexual nerve impulses. The volume of blood flowing to the cylinders increases by about eight times the normal amount. This causes the penis to become engorged - erect and stiff.

There are several stages to sexual arousal: first is sexual desire; next is the communication of the sexual arousal from brain or physical touch receptors to the nerve endings in the penis (which activates the blood flow); finally, the blood vessels which supply blood to the penis must relax and the blood flow into the penis must increase sufficiently to cause an erection. Any problem with any of these three steps will cause failure of erection.

Myths about erections in men

Myth: Men can always have sex, and are always ready for sex

Feeling tired or being worried about life issues will affect a man's sexual desire and functioning. In short, men should not attempt intercourse if they are not in the mood, since erection failure may produce self-perpetuating anxiety. Secondary erectile dysfunction can strike at any time, and in any place.

Myth: Alcohol use invariably causes erectile problems

While it is true that too much alcohol stops a man getting an erection, it's also possible that too using alcohol can smooth the path to sex since it may reduce a man's anxiety enough to promote his erection. However, in older men, even small amounts of alcohol may inhibit a man's erectile capacity. And it's certainly true that over consumption of alcohol adversely affects all the physical systems in the body, including sexual functioning.

Myth: Good sex means a man must have a hard erection

Not true! It's perfectly possible to have good sex with a semi-erect penis - a man can stuff his penis into his partner's vagina and, once in there, it may become harder as his sexual arousal increases.

However, if he starts to lose his erection, in other words if he develops secondary erectile dysfunction, a man may feel further anxiety about his capacity to get an erection in sexual situations. Remember that sexual pleasure for both the man and the woman may come in many forms and can be achieved in innumerable ways; try not to limit your intimate emotional or sexual experiences to situations featuring the erect penis only!

Myth: If the man is normal, his penile erections should happen automatically

Many men need stimulation with partner's hand or mouth on their penis to get an erection sufficiently hard for intercourse. Cultural images make us believe that men are ready for sex both physically and psychologically at any point in time, but as the more perceptive among us realize, this is not true.

Myth: If a man has an erection, he must by definition be ready for sex

Men develop erections in all kinds of non-sexual situations, including during normal sleep. These erections appear to be unrelated to erotic dreams. Oddly, fear (while sleeping or awake) may cause a man to develop an erection, which is definitely not due to sexual arousal or sexual pleasure. Men can also be with a partner and have an erection without either being aroused or having sexual thoughts.

Medication for erectile dysfunction

There are medications for both primary and secondary erectile dysfunction. And although these have been thought of as pills that allow erections to take place almost automatically, the reality is that many factors affect erections, erectile dysfunction is a complicated issue, and medications alone are not always enough.

Viagra, Levitra and Cialis do help men get and maintain an erection by relaxing the smooth muscle of the corpus cavernosum.

Essentially, these medications are able to enhance blood flow into the vascular bodies of the penis by blocking the PDE-5 enzyme, and to the extent that the underlying mechanism of erection remains the same, they will work in cases of ED caused by physical, emotional, relational, and even medication-related erectile dysfunction.

You should always consult with a doctor about which of these medications is most suitable for you. It's also possible that you may find anti-anxiety medication is more suited to your particular needs, since anxiety is a major factor in the development of erectile dysfunction.

And since depression also has a negative affect on sexual desire, arousal and  excitement, taking medication or receiving some other kind of treatment for depression may help to increase sexual desire, and restore good erectile functioning.

Almost all loss of erection is reversible; and you can often simply get back to a previous level of arousal once the particular conditions that helped you get an erection are restored.

Being confident, relaxing, and avoiding performance pressure are key factors here. In other words, be realistic - don't feel you have to satisfy a woman or that your sexual persona as a man depends on being able to bring a woman to orgasm.

Don't expect too much of yourself - you can only make love a certain number of times a day or week! Think about how you might be distracting yourself during sexual activity - your focus should be on your pleasure, not your partner's unless you are accepting or receiving sexual touch. And always avoid alcohol before or during sex.

Since erectile dysfunction can only develop in a relationship, it is a partner issue in the broadest sense. Good sexual health - and hard erections -  flourish in healthy relationships. If you are experiencing repeated erectile dysfunction, especially secondary ED, you need to start by talking to your partner. If you can't communicate with your partner about the most important sexual issues you face, you have probably already identified one part of the problem!

See: The Sexual Male: Problems and Solutions (1999). Richard Milsten, M.D. & Julian Slowinski

Metz & McCarthy: Coping with Erectile Dysfunction (2004). New Harbinger Publications, Inc. Oakland, CA.

The New Male Sexuality (1992). Bernie Zeibergeld, Ph.D.

Checklist to determine the causes of erectile dysfunction

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