Peripheral Nerve Injury Peripheral nerve injury is another important cause of ED, especially in patients undergoing prostatectomy. Other causes of peripheral nerve injury include bicycle riding and acute pelvic trauma. Several authors have reported genital numbness and increased the incidence of ED among cyclists. The pathophysiological basis for ED in cyclists is thought to be neurogenic as well as vasculogenic.

A recent systematic review of the literature found that the reported incidence of ED after radical prostatectomy with nerve sparing technique varies widely due to methodology. 50% and 34% for bilateral and unilateral nervesparing surgery, respectively.

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Nerve-sparing techniques are based on the seminal study by Walsh and Donkers in which they identified the path of the nerves to the corpus cavernosa.
They identified the branches of the pelvic plexus traveling through the urogenital diaphragm adjacent to the prostatic capsule and then adjacent to and through the wall of the membranous urethra. Not surprisingly, they found that men with tumors that did not invade the prostatic capsule and were amenable to salvage of this structure had reduced rates of ED.

Recovery and improvement in erectile function after radical prostatectomy has been reported to continue up to and beyond 2 years postoperation, perhaps indicating healing of injured nerves.
Loss of erectile function is also related to anatomical changes in the penis, specifically fibrosis of the penis due to prolonged lack of tumescence. In animal models, histological changes occurring after nerve injury are prevented by regular pharmacologically induced erections.

Psychogenic Risk The number of cases of ED attributed purely to psychogenic etiology have greatly declined in the past several decades. Younger men who complain of ED are more likely to have a psychogenic component than older men. Psychogenic ED is generally classified into generalized and situational pathologies and further subclassified.

This classification scheme has been criticized as it fails to account for advances in neurobiology that have linked certain psychiatric illnesses with neurochemical and neurohormonal derangement. Depression Depression and ED are often comorbid conditions. Several epidemiologic studies report men with ED are more likely to report depression, and that this association is independent of associated comorbidities, demographic factors and medications. In a study of men diagnosed with Major Depressive Disorder but not yet treated, almost half had trouble sustaining an erection and reported decreased sexual desire