Medical Case: An unpleasant honeymoon

A 32-year-old man develops unexpected erectile difficulties during his honeymoon. Investigations are normal. What is the real diagnosis?

Everything was fine before

James is 32 years old and recently married. He first consulted his family physician two weeks after returning from his honeymoon, deeply concerned about a sudden and unexpected change in his sexual functioning.

The erectile difficulties began on the first night of the trip: adequate desire, initial erection, then a rapid loss of rigidity just before penetration. He attributed it to fatigue from travel. But the same thing happened the following days, leaving the couple unable to complete intercourse during the entire honeymoon.

This sudden failure surprised him because before the wedding he and his wife had enjoyed a stable and satisfying sexual relationship, with no erectile concerns and regular, spontaneous intimacy. James did not seek medical help immediately. He waited for about two weeks, hoping the issue would resolve naturally. He avoided intercourse for a few days, thinking that “removing pressure” might help. When attempts resumed, the same pattern occurred.

He spoke openly with his wife, who was supportive but worried. She encouraged him to get checked “just to rule anything out.” James searched online, reading about hormonal issues, vascular problems, stress-related ED and possible psychological causes. The search made him more anxious than reassured.

His wife remained supportive throughout, although both recognised the growing tension and uncertainty the situation was creating. He finally decided to see his GP.

First medical evaluation

The GP collected a general history, performed a basic physical examination and ordered routine labs. Everything returned normal. Interpreting the situation as possibly transient and functional, the GP suggested lifestyle optimisation, reassurance and over-the-counter supplements commonly used for male sexual wellbeing.

When symptoms persisted, the GP prescribed a low-dose PDE5 inhibitor “to relieve pressure and help restore confidence.” James reported only partial, inconsistent benefit.

Given the persistence of symptoms and their emotional impact, the GP referred him to an andrologist.

Specialist consultation

James now presents to the andrology clinic for a second-level evaluation. He sits tensely in the consultation room, polite, hesitant, visibly embarrassed.

History and psychosocial context

The past months have been demanding:

He denies depressive symptoms but reports heightened stress and “fear of it happening again.” Sexual desire remains present.

Physical examination

Entirely normal. No genital abnormalities, no plaques, no curvature, no neurological deficits.

Laboratory tests

These are the results of the laboratory tests:

Penile Doppler ultrasound

Performed externally a few weeks earlier:

With no vascular or anatomical abnormalities identified, further evaluation focused on his sexual history and patterns of erectile function outside partnered intercourse.

Sexual function details

What would you diagnose?

Discussion

This presentation is highly consistent with psychogenic erectile dysfunction (pED), particularly the situational subtype historically associated with early marital contexts. The abrupt onset during the honeymoon, normal sexual functioning with the same partner before marriage, preserved erectile capacity outside partnered intercourse and normal vascular and endocrine evaluations all converge toward a psychological mechanism rather than an organic one.

Situational pED has long been described in classical frameworks such as Rosen’s classification, and contemporary literature confirms its prominence in younger men facing relational or life-transition stress. The inconsistent response to PDE5 inhibitors in James’s case is also typical; when performance anxiety and cognitive interference dominate the sexual response, pharmacologic support alone is insufficient unless accompanied by psychotherapeutic strategies.

Importantly, this pattern closely mirrors what recent research identifies as unconsummated marriage driven by performance anxiety. A systematic review by Krishnappa et al. (2023) shows that the most frequent etiology of unconsummated marriage in couples with previously normal sexual activity is psychogenic erectile dysfunction, often triggered by symbolic or emotionally charged contexts such as the honeymoon. Their analysis underscores that this condition is not confined to traditional cultural settings but is increasingly observed in Western countries, particularly among young men under significant psychological or relational pressures.

Neurobiological work (Tian et al., 2025) further supports the multidimensional nature of pED: men with psychogenic ED demonstrate alterations in neural networks involved in arousal and emotional regulation, suggesting that psychological triggers translate into measurable changes in central processing.

Why the other diagnoses are less likely

A vasculogenic cause is improbable given normal Doppler findings, preserved erections in non-partnered settings and the patient’s age and health.

Hypogonadism is unlikely with normal testosterone, preserved libido and absence of systemic features.

Hyperprolactinemia is excluded by normal prolactin and would cause persistent, not situational, ED.

The pattern of sudden onset in a symbolic relational context, previous normal functioning with the same partner, normal investigations and growing performance anxiety strongly supports a psychogenic mechanism.

Management

Treatment is most effective when combining medical reassurance with targeted psychosexual intervention:

  • CBT-based sexual therapy to address catastrophic thinking and the fear-of-failure loop;
  • couple-oriented therapy, crucial in early marriage;
  • graduated sensuality exercises, reducing focus on penetration;
  • short-term PDE5 inhibitors to reduce initial anxiety.

This combined approach is supported by multiple reports.

Clinical update: Psychogenic Erectile Dysfunction (2024–2025)

Recent literature emphasises:

  • rising presentations in younger men due to stress and sociocultural expectations;
  • the need for routine psychological assessment in ED workups;
  • neurobiological evidence supporting pED as a disorder of arousal-emotion integration;
  • superior outcomes with combined psychotherapeutic and pharmacologic strategies.

This case illustrates the importance of contextual assessment and the limits of relying solely on biological investigations in young men with ED.

References
  1. Rosen RC. Psychogenic erectile dysfunction. Classification and management. Urol Clin North Am. 2001 May;28(2):269-78. doi: 10.1016/s0094-0143(05)70137-3. PMID: 11402580.
  2. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors. Sex Med Rev. 2017 Oct;5(4):508-520. doi: 10.1016/j.sxmr.2017.05.004. Epub 2017 Jun 20. PMID: 28642047.
  3. Reed-Maldonado AB, Lue TF. A syndrome of erectile dysfunction in young men? Transl Androl Urol. 2016 Apr;5(2):228-34. doi: 10.21037/tau.2016.03.02. PMID: 27141452; PMCID: PMC4837321.
  4. Tian, Z., Ma, Z., Dou, B. et al. Altered gray matter morphometry in psychogenic erectile dysfunction patients: A Surface-based morphometry study. Sci Rep 15, 28661 (2025). https://doi.org/10.1038/s41598-025-14706-5
  5. Krishnappa P, Manfredi C, Jayaramaiah S, Ditonno F, Matippa P, Shah R, Moncada I. Unconsummated marriage: a systematic review of etiological factors and clinical management. J Sex Med. 2023 Dec 22;21(1):20-28. doi: 10.1093/jsxmed/qdad146. PMID: 37952223.
  6. Lidawi G, Asali M, Majdoub M, Rub R. Short-term intracavernous self-injection treatment of psychogenic erectile dysfunction secondary to sexual performance anxiety in unconsummated marriages. Int J Impot Res. 2022 Aug;34(5):407-410. doi: 10.1038/s41443-020-00399-z. Epub 2021 Feb 18. PMID: 33603244; PMCID: PMC9293754.