The patient’s fear of the upcoming sexual contacts requires his mandatory neutralization (best of all by psychotherapeutic methods), since without this it is difficult to count on a steady recovery of the normal sexual reactions of the man.

Among the erectile dysfunction of organic genesis in men over 45, vasculogenic erectile dysfunctions dominate.

Consider the development of sexual disorders in men with atherosclerotic lesions of the vascular bed of the genitals. The earliest clinical sign of the increasing deterioration of the blood supply to the cavernous bodies is a gradual, for no apparent reason, weakening and shrinking of adequate and parallel (or somewhat later) spontaneous morning erections. At the initial stage (compensation) of the blood supply to the genitals, achieving a full erection is still possible, but it requires some effort. For example, the intensification and lengthening of the period of caress, additional tactile and visual stimulation, a special psychological attitude. Often, patients suffer intimate encounters in the morning, using better spontaneous erections, whereas at the usual time for them, the potency “leaves much to be desired” even if there is a mutual desire for intimacy. As the blood supply to the cavernous bodies deteriorates further, a subcompensation stage begins, when a full-fledged erection no longer develops under any circumstances, which makes coitus more and more difficult.

Therefore, in spite of the preserved libido, sexual intercourse succeeds patients less and less, their duration is significantly shortened. Some patients complain of a feeling of cooling in the perineum and / or numbness of the glans penis. A sharp weakening of an erection 20–40 seconds after the start of copulatory frictions is very characteristic, which is associated with an unfavorable redistribution of blood flow in the pelvic area with a load on the gluteal and femoral muscles during frictional movements. As a result, patients are often forced to interrupt coitus before ejaculation, or ejaculation occurs on the eve of the vagina with virtually no erection. At the stage of decompensation, vasculogenic erectile dysfunctions are so pronounced that they completely rule out the possibility of vaginal coitus. This forces some patients to resort to vestibular sexual intercourse (in the vaginal threshold), petting or masturbation (without erection), while others almost completely abandon all forms of sexual activity. At this stage, many patients have a secondary decrease in sexual desire.

In some cases, even when the first manifestations of insufficiency of blood supply to the genitals appear (torpid, incomplete erection, its periodic weakening during coitus, etc.), reproaches of the woman and fixation of attention on her own sexual reactions lead to an increase in the man’s breakdowns due to the failure of erection according to the mechanisms of anxious expectation of failure, which is significantly facilitated by the deficiency of regional hemodynamics.

Joining secondary neurotic symptoms (obsessive doubts about their sexual abilities and fears of new failed attempts, coitophobia), in turn, contributes to the increase in sexual dysfunction (further weakening of erections, shortening the rhythm of sexual life, and in some cases reducing libido) even in the absence of a gross pathology of genital blood flow. With more pronounced disorders of the blood supply to the cavernous bodies, the formation of psychopathological disorders and neurotic behavior during intimacy almost deprive a couple of opportunities to compensate for the weakening of erections by changing the usual stereotype of sexual contacts, expanding and lengthening foreplay, selecting the most successful time and optimal positions for coitus. As a result, patients minimize attempts at sexual intercourse or avoid sexual contact altogether, since they are assured of their negative result. It has been established that even effective correction of the genital blood flow (with Doppler ultrasound, indicating that hem is improving on the dynamic mechanisms of erection) in most of these patients does not normalize sexual contact until they are afraid to suffer a fusion of coitus. The variant of the course of vasulogenic sexual dysfunctions with the addition of secondary neurotic disorders described by us (VA Domoratsky, 1993, 2004) indicates the need to correct the existing psychopathological disorders in patients with a sexological profile, which should be considered when developing therapeutic tactics.