Medial Prefrontal Cortex–Amygdala Circuit Involvement in State Anxiety and Psychogenic Erectile Dysfunction: A Task‐Based <scp>fMRI</scp> Study

BACKGROUND: Erectile dysfunction (ED) and anxiety have a well-documented bidirectional relationship, with anxiety affecting up to 37% of men with ED. While vascular and endocrine mechanisms are well studied, the central nervous system underpinnings linking anxiety to psychogenic ED (pED) remain unclear. PURPOSE: To delineate the neural circuitry through which anxiety potentiates erectile dysfunction. STUDY TYPE: Retrospective case-control study. POPULATION: About 62 male patients (Age: 45.4 ± 12.3) with confirmed pED and 64 age- and education-matched healthy male controls (Age: 46.1 ± 14.7). FIELD STRENGTH/SEQUENCE: 3.0 T; T2*-weighted gradient-echo echo-planar imaging sequence. ASSESSMENT: Task-based fMRI was performed using the Hariri picture-matching task with negative and neutral emotional stimuli; state anxiety was measured with the State-Trait Anxiety Inventory (STAI), and erectile dysfunction severity was assessed using the International Index of Erectile Function (IIEF); all assessments were conducted by trained research staff following standardized protocols. STATISTICAL TESTS: Whole-brain activation analysis, seed-based Granger causality mapping, and serial mediation analysis were conducted, with significance set at p < 0.05 and family-wise error correction for multiple comparisons. RESULTS: pED patients showed significant hypoactivation in the right amygdala and occipital cortex during negative emotion processing. In the pED group, amygdala activation significantly correlated with state anxiety (r = -0.54) and ED severity (r = -0.53). Medial prefrontal cortex (mPFC) was identified as the primary upstream regulator of amygdala activity. Elevated state anxiety showed both direct and indirect statistical associations on erectile function via the mPFC-amygdala pathway. CONCLUSION: Dysfunction of the mPFC-amygdala circuit is associated with the relationship between state anxiety and pED. This circuit represents a novel therapeutic target for pED management. STAGE OF TECHNICAL EFFICACY: Stage 3.