Last updated date: 13-May-2023

Originally Written in English


The failure to achieve or sustain a hard penile erection suitable for satisfying sexual intercourse is described as erectile dysfunction (ED), formerly known as impotence. While this definition does not specify a time span, others have stated that the condition must last at least six months. It's a prevalent disorder in males over 40, with the prevalence rising sharply as they get older and have more comorbidities.

impotence is a common symptom of a variety of underlying diseases and a significant yet underappreciated cardiovascular risk factor. Impotence can be caused by any condition that affects the penile arteries, nerves, hormone production, smooth muscle tissue, corporal endothelium, or tunica albuginea. Impotence is well recognized to be linked to cardiovascular disease, diabetes mellitus, hyperlipidemia, and hypertension, among other conditions. The other common mechanism in these patients seems to be endothelial dysfunction.

While the large proportion of patients with impotence will have organic disease, some, especially younger men, may have a primary psychological condition. Even though the underlying reason is organic, impotence nearly always has psychological ramifications in terms of marriage and interpersonal troubles, societal norms and expectations, loss of self-esteem, guilt, anxiety, and depression, to name a few. Impotence can have a severe emotional impact on both the patient and their spouse, as well as a negative influence on their quality of life. Erectile dysfunction, on the other hand, is virtually usually curable.



It's difficult to get precise figures for the true prevalence of impotence because many people don't seek medical help and many doctors are hesitant to inquire about their sexual health. According to the best available data, impotence affects 53 percent of males in the United States between the ages of 40 and 70. At least 35 to 50 million men in the United States and at least 155 million men worldwide are thought to have Impotence. Due to reporting bias, cultural considerations, and a general failure by many clinicians to inquire about their male patients' sexual health and shame concerns, these figures are likely an underestimation of the real number of males with impotence.

Impotence is recognized to be directly linked to age and the existence of other comorbidities such as diabetes, hypogonadism, and cardiovascular disease. The Massachusetts Male Aging Study's best available data reveals a 53 percent overall prevalence, with the frequency significantly increased with age. Around 45% of men are affected by impotence by the age of 40, and 72% of men will have impotence by the age of 70. The National Health and Social Life Survey, as well as other investigations, supported these findings.


Impotence Pathophysiology

Impotence Pathophysiology

The relaxation of the intracavernosal smooth muscle is a crucial step in penile erection activity. This allows more blood to flow into the corpora cavernosa, which fills up and compresses the emissary veins, limiting venous output. The paraventricular and medial preoptic nuclei of the hypothalamus are responsible for this process. The signals flow from the parasympathetic nervous system to the S2-S4 sacral plexus' parasympathetic nerves, which subsequently move to the penis via the cavernosal nerves. The erectile process is started by nitric oxide released by cavernous nerve terminals, and it is maintained by nitric oxide produced by endothelial cells.

When nitric oxide reaches the smooth muscle, it induces the formation of cyclic guanosine monophosphate (cyclic GMP). Cyclic GMP activates protein kinase G, which opens potassium channels while closing calcium channels. Low intracellular calcium relaxes the smooth muscle tissue in the intracavernosal arteries, leading to increased arterial flow and veno-occlusive activity. Once the erection is established, all of this results in a hard erection with minimal blood flow into or out of the corpora. When cyclic GMP is metabolized by penile phosphodiesterase, the corporal smooth muscle contracts again, and the process repeats. impotence can be caused by pathology resulting from any of these three processes.


Cause of Impotence

Cause of Impotence

Doctors used to attribute impotence to psychological issues or, in the case of older men, the aging process. The medical community's viewpoint has evolved. While becoming aroused takes longer as you get older, regular erectile problems require medical attention. Furthermore, the issue isn't always psychological. Physical issues, according to urologists, are responsible for the majority of long-term occurrences of impotence in men over 50.


Impotence in Older Men 

The blood vessels are mostly involved in erections. And disorders that impede blood supply to the penis are the most frequent causes of impotence in elderly men. Atherosclerosis (hardening of the arteries) and diabetes are two examples. Another cause could be a defective vein in the penis that allows blood to drain too rapidly. impotence can be caused by a variety of conditions, including hormone abnormalities and certain procedures.

The nervous system regulates the blood vessel activities that lead to an erection. Some drugs have the potential to disrupt the nerve signals that cause an erection. Stimulants, tranquilizers, diuretics, antihistamines, and medications for high blood pressure, malignancy, or depression are among them. However, you should only stop taking a prescription if the doctor tells you to. Impotence can be exacerbated by alcohol, tobacco, and illicit drugs like marijuana.


Impotence in Younger Men

The most common cause of impotence in younger men is psychosocial issues. Tension and anxiety can arise as a result of poor communication with the spouse or differences in sexual interests. The issue could possibly be due to the following:

  • Depression
  • Fatigue
  • Stress
  • You have the feeling that you aren't good enough.
  • Sexual phobias
  • Parents or peers rejecting you
  • Sexual abuse as a child


Impotence Diagnosis

Laboratory Tests

Impotence Diagnosis

Clinical investigations may be required based on the patient's history and examination findings. Laboratory tests for males with impotence should include fasting glucose level, fasting lipid profile, and, in some circumstances, total testosterone level, according to the International Consultation on Sexual Medicine of the International Society for Sexual Medicine. In selected high-risk individuals or symptomatic patients with LUTS, the American Urological Association and most other guidelines advocate screening for prostate cancer using a digital rectal examination and prostate-specific antigen testing in men seeking treatment for impotence. 

Type 2 diabetes mellitus is undiagnosed in 5-15% of men with impotence, according to studies. Furthermore, impotence has been observed to affect 32-70% of males with type 2 diabetes. Men with type 2 diabetes mellitus develop impotence at a younger age than men without diabetes mellitus, and the age-adjusted risk of complete impotence is about three times higher. A fasting plasma glucose (100-126 mg/dl) and/or glycated hemoglobin (5.7 percent or 6.5 percent, respectively) and, if indicated, a 75 g oral 2-hour glucose tolerance test can be used to determine the presence of underlying impaired glucose tolerance/impaired fasting glucose or type 2 diabetes mellitus.

Screening for low testosterone with a morning total testosterone assay is the test of choice in men with impotence and hypoactive sex drive, inadequate response to phosphodiesterase type 5 inhibitors (PDE5i), delayed ejaculation, and all men with diabetes mellitus, according to the guidelines. Low total testosterone levels in males with impotence are seen in a wide variety of studies, ranging from 12 percent to 37 percent. The testosterone threshold for maintaining an erection is low (159 ng/ml), and impotence is frequently a sign of more severe hypogonadism. Testosterone insufficiency is unlikely if total testosterone levels are less than 346 ng/dL. If total testosterone is less than 346 ng/dL, a second morning venous blood sample, as well as serum luteinizing hormone and prolactin levels, must be collected after at least one week. The level of serum luteinizing hormone, which is high in primary hypogonadism and decreased in secondary hypogonadism, is used to determine the subtype of testosterone insufficiency. In older and obese men, or men with liver cirrhosis, who have chronic, suspicious symptoms and a borderline total testosterone concentration, measuring sex hormone-binding globulin may be beneficial. Hypogonadotropic (secondary) hypogonadism has a causal relationship with hyperprolactinemia. Hypergonadotropic (primary) hypogonadism has a causal relationship with hemochromatosis. Further tests, such as thyroid-stimulating hormone (TSH) and other pituitary hormone levels, pituitary imaging tests, chromosomal analysis, complete blood count, and urinalysis, may be recommended based on the history, physical examination, and the findings of these initial tests.


Psychological Evaluation

Psychological evaluation of males with impotence may provide information on the importance of relationships, cultural and religious elements, depression, and other psychological aspects, according to all guidelines. Patients with co-occurring psychiatric problems or younger males with lifelong main impotence should be referred to a sexual health-focused psychiatrist or psychologist.


Nocturnal Penile Tumescence and Rigidity Testing

Erections in the middle of the night and early in the morning are normal physiological occurrences that occur during rapid eye movement sleep. Organic impotence is usually indicated by reduced or absent nocturnal erections. Using nocturnal penile tumescence and rigidity testing with RigiScan monitoring, the existence, frequency, length, and rigidity of nocturnal erections may be determined. However, nocturnal penile tumescence and rigidity testing are more of historical curiosity, and their current application in the assessment of men with impotence is mostly limited to medico-legal erectile function assessments.


Intracavernous Injection Test

This office test is a physician-administered intracorporal administration of vasoactive medication such as alprostadil, followed by a 10-minute evaluation of penile rigidity or deformity. Psychogenic impotence is indicated by the development of a hard erection within 10 minutes that lasts for 30 minutes. However, because a positive result might be observed in patients with moderate vascular disorders, its value as a diagnostic test is minimal.


Vascular Testing

Vascular Testing

Color duplex Doppler imaging, penile pharmaco-angiography, and dynamic infusion cavernosometry and cavernosography are some of the vascular testing available.

After an intracorporal injection of a vasoactive medication (e.g., alprostadil), color duplex Doppler imaging can reveal penile hemodynamics and differentiate arterial insufficiency and veno-occlusive insufficiency from other sources of impotence. Pharmacoangiography should be limited for young men with arterial trauma and poor duplex hemodynamics, or for embolization of high flow priapism caused by an arterio-lacunar fistula after penile or perineal trauma, according to all recommendations. After an intracavernosal administration of a vasodilator medication, the corpora cavernosa is injected with saline and a radio-opaque dye to assess the efficacy of the veno-occlusive mechanism and the location of corporal venous leak. In today's impotence care, these extra diagnostics, vascular reconstructive surgery, and/or venous ligation procedures are rarely performed.


Neurophysiological Testing

Neurophysiological testing has limited clinical usefulness because it can only quantify the perineal nerves' function indirectly by measuring the sacral reflex arc delay and signal amplitude.


Impotence Treatment

Treatment of impotence needs lifestyle changes to lessen the impact of concomitant vascular risk factors, as well as medications alone or in conjunction with psychosexual treatment to cure organic or psychosexual dysfunction. Patients and partners should be informed about its efficacy, advantages, appropriateness, and hazards so that their expectations are reasonable.

Men with impotence have treatment choices that are effective, safe, and well-tolerated. The severity and underlying cause of impotence, the patient's overall health and concomitant condition, and the patient's and their partner's preferences all play a role in the treatment decision. In treatment failures, progression from first-line oral medications to second- and third-line medications is recommended.


Management of Patients with Coronary Artery Disease

Coronary Artery Disease

Dyslipidemia, hypertension, smoking, diabetes, obesity, insufficient physical activity, and a family history of the early development of coronary artery disease are all risk factors for both impotence and coronary artery disease. impotence may be a predictor and antecedent of various types of cardiovascular disease morbidity and mortality since it increases the risk of cardiovascular disease by 1.4 times. Exercise electrocardiography, a coronary artery calcium score, or coronary computed tomography angiography should be used to assess men with established or suspected vasculogenic impotence or numerous vascular risk factors, including diabetes mellitus, for silent myocardial ischemia. 

The Second Princeton Consensus Panel guidelines for the management of impotence in patients with cardiovascular disease are followed by most impotence guidelines, which advocate categorizing patients into one of three risk classifications based on their risk factors: low, intermediate, and high. These risk categories can be utilized to make a treatment decision about whether or not to start or resume sexual activity. Following the proper education and counseling, most men with coronary artery disease can safely resume sexual activity and get impotence treatment. In appropriately diagnosed and counseled individuals, the cardiac risk of sexual activity in males with cardiovascular disease is negligible. In people with or without previously established cardiovascular problems, there is no information that presently approved impotence therapies increase overall cardiovascular risk.


Lifestyle Changes and Risk Factors Modification

Risk Factors Modification

All guidelines recognize that any pharmaceutical or psychological impotence treatment must be preceded or followed by lifestyle changes and risk factor management. Men with concomitant cardiovascular or metabolic diseases, such as diabetes or hypertension, as well as psychological difficulties, may benefit from lifestyle adjustments. Smoking cessation, maintaining healthy body weight, exercising regularly, and managing these disorders properly can all help to prevent the development of impotence. Men who began physical activity in their mid-forties had a 75% lower risk of impotence than those who stayed sedentary, according to the Massachusetts Male Aging Study, and consistent exercise resulted in a considerably lower incidence of impotence over an 8-year follow-up period. Similarly, rigorous exercise and weight loss dramatically improved erectile function in a multicenter, randomized, open-label study of males with obesity. In unresponsive or refractory individuals, treatment of dyslipidemia may improve impotence within 3 months and dramatically boost the response to impotence medications. However, there is conflicting evidence about the benefits of quitting smoking for improving erectile function.


Psychosexual Therapy

The foundation of anxiety differs among patients, hence psychosexual therapy for impotence is not standardized. Relationship troubles, depression, shame, prior sexual abuse, a lack of sexual knowledge, and intimacy issues can all cause anxiety or conflict, which can emerge as impotence. Psychosexual therapies can range from simple sex coaching and education to cognitive and behavioral therapy and are frequently paired with impotence medications in consultation with the physician. A considerable percentage of individuals with organic impotence face unfavorable psychological impacts, which can lead to greater performance anxiety and worse erectile dysfunction.


Impotence Oral Pharmacotherapy

Impotence Oral Pharmacotherapy

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, and avanafil) can successfully finish intercourse in 65–70 percent of men with impotence, including those with hypertension, diabetes, spinal cord injury, and other associated medical problems. PDE5 inhibitors selectively inhibit the PDE5 isoenzyme, causing vasodilation, increased corporal blood supply, and erection by increasing the amount of cyclic guanosine monophosphate (cGMP) sufficient for smooth muscle relaxation. Overall efficacy for the various PDE5 inhibitors appears to be similar and is related to impotence severity, with considerably lower efficacy in patients with severe vasculogenic impotence, diabetic impotence, and post-radical prostatectomy. The pharmacokinetic characteristics of sildenafil, tadalafil, vardenafil, and avanafil vary. PDE5 Inhibitors are chosen by patients and physicians based on cost, tolerance, and pharmacokinetic characteristics, such as onset time and duration. PDE5 inhibitors medications can be taken for a long time, and while there is no evidence of tachyphylaxis or tolerance, users may become less responsive as their underlying penile vascular disease worsens. Before pursuing more invasive therapies, most patients would prefer to try another PDE5 inhibitor.

Men who participate in frequent intercourse or see sexual intercourse spontaneity as a significant treatment goal generally choose daily doses with tadalafil since it has similar efficacy and adverse effect rates to on-demand PDE5 inhibitors. Endothelial function and erectile function may be improved or restored with daily dosing. The use of high-dose tadalafil taken daily or on alternate days to treat on-demand tadalafil failures has been documented, but the expense of treatment is prohibitive. PDE5 inhibitors medications side effects are usually temporary, mild to moderate in nature, dose-dependent, and normally fade away after 5-6 weeks of continuing treatment. Headache, face flushing, dyspepsia, muscle or back discomfort, and nasal congestion are the most frequently reported side effects.

Although a causative relationship has not been proved, PDE5 inhibitors have been related to non-arteritic ischemic optic neuropathy. There was no increased incidence of non-arteritic ischemic optic neuropathy in a cohort of 4 million veterans over 50 years old with impotence managed with PDE5 inhibitors. However, vision loss or impairment necessitates quick ophthalmological evaluation and discontinuation of PDE5 inhibitors use.

Co-administration of PDE5 inhibitors medications with short- or long-acting organic nitrates, such as nitroglycerin or isosorbide dinitrate, may aggravate the hypotensive actions of these treatments.


Vacuum Constriction Devices

Inserting the flaccid penis into a vacuum cylinder and creating a vacuum with an integrated hand- or battery-operated vacuum pump to produce significant tumescence or hardness, which is sustained by a constricting ring at the base of the penis, are examples of vacuum constriction devices. Because trabecular smooth muscle relaxation does not happen and blood is retained within the corpora cavernosa distal to the constricting ring, a vacuum constriction device erection is different from a normal erection.

Although 65-70 percent of men eventually learn the use of a vacuum constriction device and perform sexual intercourse, satisfaction percentages range from 28 percent in the short term to 70 percent after a two-year follow-up. Vacuum constriction devices are more common among couples in their forties and fifties, but they require a lot of energy and understanding from both partners. Bruising, blocked and occasionally painful ejaculation, soreness at the ring site, and penile instability due to rotation of the base of the penis are all possible side effects.


Impotence Surgical Treatment

Impotence Surgical Treatment

Patients with substantial penile arterial or venous disease, corporal fibrosis, or Peyronie disease who are either refractory to or not suitable for impotence medications are frequently treated surgically for impotence.

Multi-component inflatable penile implants have a high proportion of patient satisfaction. Prosthetic infection and device failure are infrequent. Infection necessitates the removal of the prosthesis and replacement, either immediately or in stages. In men with penile atherosclerotic disease or corporal veno-occlusive dysfunction, penile arterial revascularization and venous ligation surgery are linked to poor outcomes. With the exception of young men who have a traumatic blockage or stenosis of the internal pudendal or common penile artery due to an anterior open book type pelvic fracture, they are rarely necessary.



The impotence is a common problem that is linked to a lower quality of life for both the patient and their companion. Obesity, lack of physical activity, diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, and cigarette smoking are all risk factors for this disease. Furthermore, impotence is a determinant of subsequent cardiovascular health and silent myocardial ischemia and may be the first indicator of widespread endothelial dysfunction. Most men respond well to impotence medications alone or in conjunction with graded psychosexual therapy to improve and/or restore sexual function. Overall, the selected guidelines show a high level of agreement on impotence management, with few discrepancies.