Impotence means that a man's penis doesn't get hard enough to have sexual intercourse. The man cannot get or maintain an erection. The medical term is erectile dysfunction. This condition affects approximately 30 million men in the United States. Erectile dysfunction is not the same as premature ejaculation, which is ejaculating within 1 minute after initiation of intercourse.

The major causes of erectile dysfunction include:

• Vascular (blood vessel) disease — Erections happen when blood collects in the shaft of the penis. Vascular disease can limit the amount of blood flowing to the penis or the amount staying in the penis. Both can result in problems with erections. Blood vessels can be damaged by hardening of the arteries (atherosclerosis) or trauma. Vascular disease is believed to be the most common medical cause of impotence.
• Nerve damage (neuropathy) — Nerves must be working normally for a man to get and keep an erection. Nerves can be damaged by diabetes, multiple sclerosis, prostate surgery or damage to the spinal cord.
• Psychological factors — Psychological issues such as depression, anxiety, guilt or fear can sometimes cause sexual problems. At one time, these factors were thought to be the major cause of impotence. Doctors now know that physical factors cause impotence in most men with the problem. However, embarrassment or "performance anxiety" can make a physical problem worse. Impotence caused only by psychological causes is found most commonly in young men.
• Medications — Many medications cause problems with sexual function, including drugs for high blood pressure, depression, heart disease and prostate cancer.
• Hormonal problems — Abnormal levels of certain hormones, such as testosterone, thyroid hormone and a pituitary hormone known as prolactin, can interfere with erections and sex drive (libido). This is an uncommon cause of impotence.

A man with impotence has a problem either getting an erection or difficulty maintaining one. This usually interferes with sexual activity.

Impotence can happen suddenly or gradually. Some men slowly lose the firmness of their erections or how long the erections last. In other men, especially those whose impotence is largely caused by psychological factors, the problem may occur unpredictably and can improve at any time. Despite their difficulties with erections, men with impotence may continue to have normal orgasm and ejaculation without a full erection.

Your doctor will ask you about your medical history to learn if any medical conditions might be causing the impotence, including vascular, neurological and hormonal disorders. Because vascular disorders affect the entire body, many men who have impotence because of vascular disease also have a history of heart disease, stroke or poor circulation in their legs. Neurological problems can contribute to impotence in men with a history of diabetes and spinal cord injury. They also can cause symptoms in other parts of the body, such as numbness or weakness in legs. In men with abnormal hormone levels, a reduced sex drive often accompanies impotence. Your doctor also will review the medications you take, including over-the-counter products and herbal remedies.

Your doctor will ask about your sex life, including questions about the quality of your sexual relationships.

Your doctor will examine you, including your penis and testes, to look for evidence of medical problems. Your blood may be tested for blood sugar (to check for diabetes), cholesterol and levels of certain hormones.

Occasionally, a doctor may order additional tests, such as a test called a nocturnal penile tumescence study. This is a way to determine how often you get erections while you sleep. Another test that may be done is called a Doppler ultrasound of the blood vessels in the penis, which measures how well the blood is flowing in your penis.

Although your doctor may not be able to give you a specific reason why you have impotence, many of the treatments work well no matter what caused the problem, so extensive testing may not be necessary.

How long your impotence lasts depends upon what causes it and how quickly your treatment starts to work. The important thing to remember is that impotence is treatable in all age groups.

Little is known about how to prevent impotence. However, it can help to avoid cigarette smoking and maintain normal blood pressure and cholesterol levels because smoking and high cholesterol can affect blood vessels. Men with diabetes should work to keep blood sugar levels under control. Because certain medications have been associated with impotence, ask your doctor about possible side effects before you start using any new prescription.

There are many effective treatments for impotence. The most popular is a class of drugs called phosphodiesterase type 5 (PDE5) inhibitors, which includes sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). These drugs, taken in pill form up to 60 minutes before sexual activity, work in approximately 70% of men. They are less effective in men with neurological causes of impotence such as nerve damage from prostate surgery, diabetes or spinal cord injury. PDE5 drugs can cause minor side effects such as flushing and headache, but they have been shown to be safe in most men, including those with heart disease. However, PDE5 drugs can interact with other medications and cause dangerously low blood pressure. They should never be taken with nitroglycerin or other nitrate medications commonly used to treat heart disease. Men with enlarged prostates who take alpha-blocker drugs such tamsulosin (Flomax) or doxazosin (Cardura) should probably avoid certain PDE5 drugs.

If these drugs don't work or cannot be used because of potential side effects, your doctor can recommend other therapies. The drug alprostadil (Caverject, Edex, Muse) causes blood vessels to widen. This can allow blood to flow more freely in the penis, leading to an erection. The drug can be injected with a tiny needle into your penis, or a small pellet (suppository) can be inserted into the opening of the penis. Suppositories like this are effective in approximately two-thirds of men. Injections are effective about 80% of the time.

Taking extra testosterone will not improve erectile dysfunction. For men who have abnormally low levels of the hormone, testosterone replacement may be helpful because it can enhance sexual desire.

Psychological therapy such as counseling, behavioral therapy or couples' therapy can be effective in men whose impotence is caused primarily by psychological factors.

Men who do not benefit from medical or psychological treatment often have success with mechanical or prosthetic devices. External products, known as vacuum erection devices, are safe and highly effective, but many men and their partners find them unappealing. Another option is a surgically placed penile implant. Only 10% of men with impotence choose this option. Vascular (blood vessel) surgery sometimes is recommended for young, healthy men who develop impotence after trauma to the groin. Unfortunately, the long-term success rate of this surgery is not known.

You should speak to your doctor if you have trouble getting or keeping an erection over three months or more. Because of embarrassment or shame, many men with impotence don't talk to their doctors. They hope that the problem will go away on its own. Although impotence caused by psychological factors may get better on its own, treatment is needed if the problem is caused by a physical factor.

In general, the outlook for men with impotence is excellent. Although most cases of impotence have medical causes that cannot be cured, many treatment options will restore sexual function. Several causes of impotence can be cured, including impotence caused by psychological problems, hormonal disorders and traumatic injury to the penile arteries.

American Urological Association
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