Impotence is the inability to achieve or maintain a penile erection sufficient for satisfactory sexual intercourse; ejaculation may or may not be affected. Severity ranges from occasional difficulty to permanent erectile failure. Primary impotence occurs in men who have never had a successful sexual experience, while secondary impotence develops in men who previously achieved satisfactory erections.

Penile erection requires increased arterial blood flow triggered by psychological, tactile, or sensory stimulation and the trapping of blood in penile tissue. Dysfunction arises when any component—psychological, vascular, neurologic, or hormonal—is impaired.

History and physical examination

• Psychosocial history: marital status, partner’s age/health, relationship stress, past marriages, sexual activity, job/lifestyle.

• Medical history: diabetes, hypertension, heart disease, neurologic disorders, surgeries, trauma, alcohol/drug use, smoking, diet, exercise, and urologic issues.

• Symptoms: onset, progression, frequency of erections (spontaneous or nocturnal), ability to ejaculate, orgasm quality, sexual desire, and rating of erection quality (0–10 scale).

• Physical examination: inspect/palpate genitalia and prostate, assess perineal sensory function, test motor strength and reflexes, measure pulses, examine for peripheral vascular disease, auscultate for bruits, evaluate thyroid, and note vital signs.

Medical causes

Special considerations

• Ensure privacy and confidentiality; establish rapport and normalize discussion of sexual health.

• Screen for hormonal abnormalities, vascular insufficiency (Doppler), voiding studies, nerve conduction, nocturnal penile tumescence, and psychological factors.

• Treatments: address underlying cause, counseling (patient and partner), pharmacologic therapy (PDE5 inhibitors), surgical revascularization, correction of venous leaks, or penile prosthesis implantation.

Patient counseling

• Encourage open communication about sexual desires, fears, and anxieties.

• Discuss therapy adherence and management of underlying medical conditions.

• Include partner in counseling to improve sexual function and relational satisfaction.

Geriatric pointers

• Sexual interest and capability persist into old age; rule out organic disease before attempting counseling or interventions.

• Correct misconceptions about age-related sexual decline.

References

1. Hatzimouratidis, K., Amar, E., Eardley, I., Giuliano, F., Hatzichristou, D., Montorsi, F., … Wespes, E. (2010). Guidelines on male sexual dysfunction: Erectile dysfunction and premature ejaculation. European Urology, 57, 804–814.

2. Ruige, J. B., Mahmoud, A. M., De Bacquer, D., & Kaufman, J. M. (2011). Endogenous testosterone and cardiovascular disease in healthy men: A meta-analysis. Heart, 97, 870–875.