Relationship Between Erectile Function and Sexual Self-Confidence

A Path Analytic Model in Men Being Treated With Tadalafil

A Sontag; X Ni; S E Althof; R C Rosen


Int J Impot Res. 2014;26(1):7-12. 

In This Article

Abstract and Introduction


Sexual self-confidence has been shown to be associated with erectile function (EF) in men receiving PDE-5 inhibitor therapy; however, few studies have investigated the pathways (for example, sexual satisfaction, communication, time concerns and spontaneity) through which improvements in sexual self-confidence occur. This study examined this relationship using a path analysis model in men with ED enrolled in an open-label clinical trial of 20 mg tadalafil, administered on-demand over 12 weeks. International Index of Erectile Function and Psychological and Interpersonal Relationship Scales data were used to assess improvement in EF, sexual confidence and mediating variables. Controlling for baseline measures and covariates, the model indicated that change in sexual self-confidence was significantly associated with changes in EF (P<0.0001), sexual communication conflict (P=0.01), time concerns (P<0.0001) and spontaneity (P<0.0001). The total effect of EF on sexual self-confidence was 0.85, with 0.08 of this relationship indirectly mediated through time concerns and spontaneity. These data suggest that improved sexual confidence in men receiving treatment with a long-acting PDE-5 inhibitor occurs both directly via improved EF and indirectly via improved spontaneity and diminished time concerns.


ED is a complex and multidimensional condition, associated with psychological and relationship concerns, including decreased quality of life, self-esteem, and an increased incidence of depression and interpersonal relationship problems.[1–3] ED is defined as the persistent inability to achieve or maintain an erection sufficient enough for satisfactory sexual performance.[4] Approved PDE-5 inhibitors have an established efficacy and safety profile.[5] However, the multifactorial nature of ED suggests that effective treatment of impaired erectile function (EF) may have benefits that extend beyond improved ability for sexual performance. Previous research indicates that EF improvements in men on PDE-5 inhibitors are associated with improved psychosocial outcomes, including sexual confidence, sexual relationship, depression and quality of life.[6–12]

The relationship between the physiological (that is, erection hardness and maintenance) and various psychosocial (for example, self-esteem, sexual self-confidence and relationships) aspects of ED and its treatment have been studied using statistical modeling of validated patient-reported outcome measures. A cognitive-emotional model for ED was developed and tested with path analysis by Nobre,[13] supporting the role of psychosocial factors on predisposition and maintenance of ED. Earlier psychosocial ED paradigms emphasized the role of performance anxiety, an inhibitory mechanism, in the development and maintenance of sexual dysfunction.[14,15] However, Althof et al.[16] demonstrated that performance anxiety is ameliorated by improved sexual confidence, an excitatory mechanism, in men with ED treated with sildenafil. Their model suggested that sexual confidence might be the main psychosocial driver in ED treatment. In this study, improved sexual confidence was mediated mainly by improvements in erection hardness and maintenance, although other mediating variables were not tested.[16] The mechanisms involved, and the role of specific mediating variables, which may underlie improvements in sexual self-confidence with PDE-5 inhibitor treatment, remain unclear.

The purpose of the current analysis was to explore the links between improved sexual self-confidence and EF through analyses of efficacy outcomes including sexual satisfaction, sexual relationship satisfaction, sexual communication conflict, time concerns and spontaneity. This was achieved by developing a conceptual model of the causal relation among these variables and subsequently testing the strength of this model using path analytical procedures. This analysis builds directly on work by Althof and on a similar investigation examining pathways linking EF with overall quality of life.;[16 17]