Impotence is defined as the consistent inability of a man to obtain or maintain a firm erection long enough to allow satisfactory sexual intercourse.

Medical professionals often use the term "Erectile Dysfunction" to describe this disorder and to differentiate it from other problems that interfere with sexual intercourse, such as lack of sexual desire and problems with ejaculation and orgasm.

Chances are you are suffering from impotence or Erectile Dysfunction if,

  • You are consistently unable to achieve an erection
  • Your erections are not firm enough to allow vaginal penetration
  • Your erections have the necessary firmness, but only for a brief period
  • Your erection loses its firmness upon penetration

Impotence is one of the most common sexual problems that affect half of all men over 40 years of age, sometime in their lives. Impotence is not a disease, but a secondary condition brought on by other, primary causes. About 85% of impotence problems are due to a physical cause, such as disease, injury, or drug side effects. In around two thirds of cases, there are physical problems affecting the blood supply to the penis or nerve damage.

Once a man fails to become erect a few times, he places more stress on himself to have an erection by sheer will power. When this too fails, he often begins to have a psychological distress that can have an additional effect on erection problems.

impotence can be classified as primary or secondary.

  • Primary impotence:A man has never had successful intercourse with a partner but may achieve normal erections in other situations.
  • Secondary impotence: Despite current impotence problems, there is some history of success with completing intercourse in the past.

Most men will experience occasional impotence, usually resulting from stress, tiredness, anxiety or excessive alcohol or other drug consumption. Worrying about impotence may then set the scene for a more persistent problem due to "fear of failure" known as performance anxiety.

5% of men At age of 40 years
15 to 20% of men At the age of 65 years

Erectile dysfunction may be because of one or more of the following reasons: 

Physical ProblemsMedicines Psychological ProblemsLifestyle

The cause may be physical or psychological. For most men the cause is both physical and psychological.

In 75% of cases of impotence there will be a physical cause.

Physical causes of ED include

  • Diabetes
  • High cholesterol
  • Heart disease
  • Post prostate cancer
  • High blood pressure
  • Alcohol or other drug use
  • Some prescribed drugs
  • Disease of the liver and kidney
  • Surgery to the bladder, prostate gland, lower bowel and spine
  • Poor blood flow to the penis resulting from blocked arteries

Psychological causes of ED include

  • Anxiety or stress
  • Anxiety about sexual performance or sexual identity
  • Fear of sexual contact (from issues such as pregnancy or HIV/Sexually Transmitted Diseases)
  • Psychological trauma or abuse
  • Sexual problems with partner
  • Sexual boredom
  • Depression
  • Lack of communication in the relationship or other relationship issues
  • Grief or the effects of illness of self or family member

As men get older, it's common for them to need greater sexual simulation to have a good, sustained erection. Occasional episodes of Erectile Dysfunction, is common and does not mean there will be persistent problems in the future.

Many men feel embarrassed when they first discuss the issue with their doctor. You will be asked about your general health and about your erections. This will include whether or not you wake up with an erection in the morning and the strength of the erection compared with the past. You shall have to inform about any medicines you are on and about any changes in your life that may be having an influence on your sexual health.

The doctor may also want to talk with you and your partner together about any physical or psychological factors that may be contributing to the problem. 

Sexual Education

The old saying that sex is natural is not true. Some men experience impotence because of lack of sexual education, in other words, they do not know what to do. Usually, once the man is given correct sexual information and any concerns have been discussed then this difficulty is overcome. Having psychological problems with sex does not mean that there is anything wrong with your mental health. Urologist can assist you in the sex therapy. Urologist will take a sexual history and then tailor a set of exercises or correct misinformation to assist you. 

Physical Examination:

A physical examination includes taking the blood pressure and checking the pulses in the legs - an indicator of how healthy the circulation is. The penis and scrotum will be examined. The doctor may request blood tests to look for medical problems, such as anaemia, diabetes, high cholesterol or hormone abnormalities that might be a contributory factor.


Impotence is treatable in all age groups, and awareness of this fact has been growing. More men have been seeking help and returning to near-normal sexual activity because of improved, successful treatments for impotence. The simplest treatments are "talking" therapies, tablets and Lifestyle changes.

Treatment options for erectile dysfunction can be divided into four broad categories,


Physical Problems

There are many physical causes for temporary or chronic impotence such as,

  • Problems with the blood supply to the penis
  • Side effect of medicines and drugs
  • Disorders of the nervous system
  • Hormonal disorders
  • Other complex or multisystemic diseases

Erection takes place when the arteries of the penis carry blood and engorge the erectile bodies made up of spongy tissue. Medications to treat chronic diseases such as diabetes mellitus, high cholesterol, high blood pressure, renal failure and heart disease destruct of the contractile walls of the veins or provoke hardening, narrowing or blockages of the arteries leading to the penis.

These medications prevent sufficient blood from getting into the penis and staying there for long periods and resultantly you get erections that are quickly lost.

Nervous diseases or damage to the nerves that control the erection process can affect the transmission of signals from the brain to the blood vessels in the penis resulting in inability to have an erection. This occurs in conditions including multiple sclerosis, spinal cord injury and Parkinson's disease. The nerves involved in sexual arousal can also be damaged in surgery to the pelvic area, such as removal of the prostate. In a small number of cases, problems with hormone levels, can also affect erection.

Dr. Dilip Raja Surgeon

Psychological Problems

Psychological problems can also influence the ability to get and maintain erections. Anxiety and guilt are common causes of ED. Unsatisfactory sexual and relationship experiences may lie behind these issues. Stress at work, depression, boredom with current sexual practices, partner conflicts, and unresolved issues about sexual orientation may all cause problems.


The side effects of medicines such as some treatments for high blood pressure can cause ED. Medicines can also affect sexual drive and desire (libido), or cause problems with ejaculation and orgasm. These can have a knock-on effect on erections.


Drinking too much alcohol commonly affects the ability to get and maintain an erection. In the longer term, it interferes with the production of the male hormone testosterone, which can reduce libido. Nicotine damages the circulation, so smoking increases the risk of erection problems. Similarly, being physically inactive, which contributes to poor cardiovascular fitness, may increase the risk of ED.

Lifestyle changes

  • A healthier lifestyle can often be beneficial and can help prevent any further deterioration caused by underlying medical conditions.
  • If you smoke, make a plan to stop.
  • Take moderate intensity exercise (brisk walking for instance) - for half an hour on most days of the week.
  • Eat a balanced diet rich in fruit and vegetables and low in fat.
  • Drink alcohol in moderation.

Aim to reduce stresses in your life by looking at the balance between your work and your home/leisure time. Relaxation techniques may be helpful.


Pharmacological treatment involves delivering medication that can help restore erections. There are several different types of medication and ways of administering them. In general, medical therapy is the most appealing form of treatment and can be highly successful.

Yohimbine (Yocon) Oral Alpha receptor agonist Poor
Testosterone Injection, Patch, Oral Good (only in men with
low testosterone levels)
Prostaglandin E1 (Caverject) Penile injection Dilates penile arteries Very good
Papaverine/ regitine/ prostaglandin Penile injection Dilates penile arteries Very good
Prostaglandin E1
Intraurethral pellet Dilates penile arteries Moderate
Sildenafil (Viagra) Oral Increases penile blood flow Very good
Phentolamine Oral Increases penile blood flow Research only (at this time)


Mechanical treatment involves the use of a vacuum erection device or "pump" along with a constriction ring. The penis is placed in a vacuum tube and the air is pumped out. This creates negative pressure and allows blood to flow into the penis. Once the penis becomes erect, a rubber ring is placed around the base of the penis to prevent the blood from leaving. The vacuum tube is then removed. This non-invasive mode of therapy is effective in treating erectile problems form most causes although the device can be cumbersome to use.


Surgical therapy is the most invasive form of treatment for erectile dysfunction. The penile implant is a very good option for those men who have failed medical therapy or have a severe arterial or venous cause of impotence. The overall results are good in carefully selected patients.

Penile implant    
Semi-rigid All Excellent - penis always in semi-rigid state
Inflatable All Excellent - penis looks more natural
Arterial Revascularization Discrete arterial blockage Moderate to good
Penile Vein Ligatation Discrete venous leak Poor to moderate


Psychological therapy is very useful in those cases of erectile dysfunction that are a direct result of psychological causes. These patients may also benefit from pharmacologic or combination therapy. Wives and partners are becoming more involved in this treatment process.

  • What is impotence?
  • How does an erection occur?
  • What are the causes of impotence?
  • How is impotence diagnosed?
  • Is there any treatment?
  • What will the future bring?
  • impotence At A Glance

What is impotence?

Impotence is a consistent inability to sustain an erection sufficient for sexual intercourse. Medical professionals often use the term "erectile dysfunction" to describe this disorder and to differentiate it from other problems that interfere with sexual intercourse, such as lack of sexual desire and problems with ejaculation and orgasm.

Impotence can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining impotence and estimating its incidence difficult. Experts believe impotence affects between 10 and 15 million American men. In 1985, the National Ambulatory Medical Care Survey counted 525,000 doctor-office visits for erectile dysfunction.

Impotence usually has a physical cause, such as disease, injury, or drug side effects. Any disorder that impairs blood flow in the penis has the potential to cause impotence. Incidence rises with age: about 5 percent of men at the age of 40 and between 15 and 25 percent of men at the age of 65 experience impotence. Yet, it is not an inevitable part of aging.

Impotence is treatable in all age groups, and awareness of this fact has been growing. More men have been seeking help and returning to near-normal sexual activity because of improved, successful treatments for impotence. Urologists, who specialize in problems of the urinary tract, have traditionally treated Impotence, especially complications of Impotence.

How does an erection occur

The penis contains two chambers, called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. A membrane, called the tunica albuginea, surrounds the corpora cavernosa. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa.

Erection begins with sensory and mental stimulation. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the open spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps to trap the blood in the corpora cavernosa, thereby sustaining erection. Erection is reversed when muscles in the penis contract, stopping the inflow of blood and opening outflow channels. 

What are the causes of impotence?

Since an erection requires a sequence of events, impotence can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area of the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of impotence. Diseases, including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease, account for about 70 percent of cases of impotence. Between 35 and 50 percent of men with diabetes experience impotence.

Surgery (for example, prostate surgery) can injure nerves and arteries near the penis, causing impotence. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to impotence by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

Also, many common medicines produce impotence as a side effect. These include high blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug).

Experts believe that psychological factors cause 10 to 20 percent of cases of impotence. These factors include stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. Such factors are broadly associated with more than 80 percent of cases of impotence, usually as secondary reactions to underlying physical causes.

Other possible causes of impotence are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as insufficient testosterone.

How is erectile dysfunction diagnosed?

Your doctor will probably start by asking you some questions and doing a physical exam. Samples of your blood and urine may be tested for diseases and disorders. Other tests may also be needed. Your doctor will determine which tests are right for you.

Details of Diagnosis:

Patient History

Medical and sexual histories help define the degree and nature of impotence. A medical history can disclose diseases that lead to impotence. A simple recounting of sexual activity might distinguish between problems with erection, ejaculation, orgasm, or sexual desire.

A history of using certain prescription drugs or illegal drugs can suggest a chemical cause. Drug effects account for 25 percent of cases of impotence. Cutting back on or substituting certain medications often can alleviate the problem. 

Physical Examination

A physical examination can give clues for systemic problems. For example, if the penis does not respond as expected to certain touching, a problem in the nervous system may be a cause. Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean the endocrine system is involved. A circulatory problem might be indicated by, for example, an aneurysm in the abdomen. And unusual characteristics of the penis itself could suggest the root of the impotence, for example, bending of the penis during erection could be the result of Peyronie's disease.

Laboratory Tests

Several laboratory tests can help diagnose impotence. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. For cases of low sexual desire, measurement of testosterone in the blood can yield information about problems with the endocrine system.


Other Tests

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of impotence. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then the cause of impotence is likely to be physical rather than psychological. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results.

Psychosocial Examination

A psychosocial examination, using an interview and questionnaire, reveals psychological factors. The man's sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

Is there any treatment?

Most physicians suggest that treatments for impotence proceed along a path moving from least invasive to most invasive. This means cutting back on any harmful drugs is considered first. Psychotherapy and behavior modifications are considered next, followed by vacuum devices, oral drugs, locally injected drugs, and surgically implanted devices (and, in rare cases, surgery involving veins or arteries).


Experts often treat psychologically based Impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when physical impotence is being treated.

Drug Therapy

Drugs for treating impotence can be taken orally or injected directly into the penis. Oral testosterone can reduce impotence in some men with low levels of natural testosterone. Patients also have claimed effectiveness of other oral drugs, including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone, but no scientific studies have proved the effectiveness of these drugs in relieving impotence. Some observed improvements following their use might be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur. 

Many men gain potency by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and prostaglandin E1 widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, sometimes can enhance erection when rubbed on the surface of the penis.

To review, penile erection is caused by the engorgement of the penis with blood. It has been found that under normal conditions, sexual stimulation leads to the production and release of nitric oxide in the penis. Nitric oxide then activates the enzyme, guanylate cyclase, which causes the production of cyclic guanosine monophosphate (cGMP). It is the cGMP that is primarily responsible for the erection by affecting the amount of blood that the blood vessels deliver and remove from the penis. 

The medication, sildenafil (Viagra) inhibits an enzyme called phosphodiesterase-5 (PDE5) which destroys the cGMP. Thus, sildenafil (Viagra) prevents the destruction of cGMP and allows cGMP to accumulate and persist longer. The longer cGMP persists, the more prolonged the engorgement of the penis. Sildenafil (Viagra) is used for the treatment of erectile dysfunction of either organic (medical condition) or psychogenic (psychological) cause. Research on drugs for treating impotence is expanding rapidly. Patients should ask their doctors about the latest advances. 
Research on drugs for treating impotence is expanding rapidly. Patients should ask their doctors about the latest advances.

Vacuum Devices

Mechanical vacuum devices cause erection by creating a partial vacuum around the penis, which draws blood into the penis, engorging it and expanding it. The devices have three components: a plastic cylinder, in which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis, to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body (see figure 2).

One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after attaining erection and during intercourse.


Surgery usually has one of three goals:

  • To implant a device that can cause the penis to become erect;
  • To reconstruct arteries to increase flow of blood to the penis;
  • To block off veins that allow blood to leak from the penile tissues.

Implanted devices, known as prostheses, can restore erection in many men with impotence. Possible problems with implants include mechanical breakdown and infection. Mechanical problems have diminished in recent years because of technological advances.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa, the twin chambers running the length of the penis. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and pump, which also are surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat. They also leave the penis in a more natural state when not inflated.

Surgery to repair arteries can reduce impotence caused by obstructions that block the flow of blood to the penis. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch area or fracture of the pelvis. The procedure is less successful in older men with widespread blockage.

Is erectile dysfunction just a part of old age?

Erectile dysfunction doesn't have to be a part of getting older. It's true that as you get older, you may need more stimulation (such as stroking and touching) to get an erection. You might also need more time between erections. However, older men should still be able to get an erection and enjoy sex.

What will the future bring

Advances in injectable medications, implants, and vacuum devices have expanded the options for men seeking treatment for impotence. These advances also have helped increase the number of men seeking treatment.

One possible new treatment is a small pellet that a man can insert in the end of his penis. The pellet releases a drug that migrates into the erectile tissue and causes a temporary erection. There is no need for a needle. Ongoing improvements in traditional methods should continue to create more successful and widespread treatment of impotence.

impotence At A Glance

  • Impotence is a consistent inability to sustain an erection sufficient for sexual intercourse.
  • Impotence affects 10 to 15 million American men.
  • Impotence usually has a physical cause.
  • Impotence is treatable in all age groups
  • Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.
Dilip Raja