The Cause of Impotence

When a man’s sexual function declines, all he knows is that he can’t perform and wants the problem fixed right away. Treatment follows diagnosis. The medical history and a series of directed questions, followed by a physical exam and some lab tests, are all that is required. Your physician will ask a series of questions to understand when and why you first started to have sexual problems. He will also want to know your general medical history, current medications, and something about your habits. Then he will do a physical exam, obtain a blood sample for some laboratory tests, review the results, and then determine what treatment is best for you. The types of questions your doctor will ask and the physical exam he will perform are outlined in this post.


When did your sexual problems begin?

For most men, sexual problems evolve as an insidious stuttering process characterized by intermittent loss and restoration of sexual function over several years. As the condition responsible for the original sexual failure becomes more firmly entrenched, a man struggles to maintain some sexual interest and potency. Eventually, he experiences a complete loss of sexual capabilities.

Sometimes, however, an impotent man may describe a different scenario and give a history of sudden loss of sexual potency that then becomes persistent and unremitting, as in the following case: “I can tell you the exact date and time that the problem happened. It was 11:00 P.M. on my wife’s birthday. Four months earlier, on my birthday, sexual function was fine. When her birthday rolled around, I was unable to perform and have been unable to get an erection from that date on.”

Psychologic problems are the most likely cause of impotence for this man and other men with similar histories. With the exception of acute penile or spinal-cord trauma, no physical or physiologic process causes a sudden and permanent disappearance of male sexual function.

When was the last time your sexual function was normal?

Men with sexual problems are frequently so despondent about their loss of potency that they cannot recall a moment when their sexual function was normal. The definition of “normal” may also be elusive. A man of sixty may feel that sexual function was truly satisfactory only when he was in his twenties and capable of prodigious feats of sexual prowess. If he expects treatment to allow him to recapture the sexual glory of his youth, he will be disappointed. A more reasonable baseline estimate for normal sexual function can be obtained by reviewing his level of sexual activity five to seven years ago. It is possible that during those years, he considered sexual function satisfactory if he could make love about once a week or even once every two weeks. If he has no sexual capability now, a more appropriate therapeutic goal may be to aim for a return to weekly or biweekly sexual intercourse.

Do you still have erections?

If a man has fully rigid erections during sleep, when he wakes up in the morning, or under any circumstances, the doctor will assume that the neurologic impulses for triggering an erection and the vascular channels leading to the penile erectile cylinders are intact. If, on the other hand, erections are totally absent, then nerve damage or vascular insufficiency must be suspected. Erections that occur briefly and then fade suggest other diagnoses, including penile venous incompetence, lack of sensate focus, or presbyrectia (the normal pattern of change with aging). Treatments are available for all of these conditions.

Have your feelings toward your partner changed?

Conflict sets the stage for a common, usually reversible, type of male sexual dysfunction. Squabbles, disagreements, and arguments are an inevitable component of any close relationship. Discussion, mediation, some old-fashioned bellowing, or even weeping may be called into play to arrive at a satisfactory resolution. Not all discord is resolved to each partner’s satisfaction.

When waters churned up during an argument are eventually stilled, the calm may be confined to the surface. Bruised feelings, submerged in the interest of restoring harmony, do not disappear; they linger to fester in the fertile fields of the subconscious. It is here, in the subconscious, that gnawing anger, insecurities, and resentments form a powerful coalition to cripple male sexual function.

Sometimes the areas of conflict seem almost childish and superficial, as in the case of Sam, a fifty-two-year-old man who had been impotent for about three years. The circumstances surrounding the development of his impotence were not apparent to him at first, but after reflecting about it, he recalled that just before the age of fifty he had had a passionate desire to own a sports car at a cost somewhere in excess of $40,000. He had discussed this with his wife, who pointed out that they could not afford that sort of indulgence. Not swayed by her logic, he countered that he had worked hard all his life, sacrificed for others, and now, as he was approach carded. Adjustment in the type of antidepressant drug prescribed may help restore normal ejaculation.

Is ejaculation painful?

Some men experience pain when they ejaculate. The anticipation of intense pain with ejaculation is understandably a powerful disincentive to sex. Ejaculatory pain originates in the rectum and passes like a bolt of electricity through the penis at the moment of orgasm. An inflammation or infection in the prostate is often responsible. Treatment with antibiotics or warm baths usually diminishes the inflammation and infection and allow ejaculation to occur without pain.

Is their blood in your semen?

The sudden appearance of bloody seminal fluid is an alarming symptom requiring prompt medical attention and urologic evaluation. Frightened by this symptom, men hope that the problem will go away by itself if they abandon sexual intercourse. This is foolhardy behavior. A visit to the doctor will help uncover the reason for the bloody semen. Often, bladder or prostate infection and occasionally prostate cancer are responsible for the appearance of blood in the semen. Prompt treatment can be instituted and then sexual function will return.

Does your partner enjoy sexual intercourse?

Sexual intercourse should be a shared pleasure. If the partner views sex only as an obligation and merely accommodates the man, then his pleasure will be diminished. For older women who have gone through menopause, sexual intercourse can be unpleasant. This is because the postmenopausal lack of estrogen hormones affects female sexual tissues, resulting in a narrowing or shrinking (atrophy) of the vaginal lining. Further, without estrogen, inadequate mucus is produced by the glands in the crypts of the vagina, and the vagina fails to lubricate normally, making intercourse painful. Treatments include local lubricating ointments or estrogen hormones. The advisability of either of these treatments should be discussed by the woman with her physician or gynecologist.

What form of contraception are you using?

For the younger woman, fear of pregnancy can be a major impediment to her continued enjoyment of sexual intercourse. Some women are likely to shy away from sexual activity unless they can be reassured that they will not become pregnant. A review of the couple’s current contraceptive practices is in order. If fear of impregnation looms as a factor diminishing the enjoyment of sex, alternative contraceptive options should be considered.

Have you had any injury to or inflammation of your testicles?

It is in the testicles that the hormone testosterone is manufactured and then released into the bloodstream. Adequate circulating testosterone levels are needed to maintain sex drive or libido. If the testicles are injured or attacked by a virus, their capacity to generate sufficient testosterone may be diminished. Then serum testosterone levels and sex drive decline. Inflammation of the testis (“orchitis” is the medical term) is usually exquisitely painful and not readily dismissed. However, there are some more furtive forms of testicular inflammation that cause only a flulike illness with characteristic muscle aches and pains. In such cases, the pain is often mistakenly identified as a groin muscle pain and considered merely an integral part of the flu.

When a virus invades the testicle, it causes first a swelling and then a shrinkage in testicular volume. A man may be aware that his testicle is smaller than it used to be. Recollection of “normal” testicular size can be a perilous and slippery slope. The passage of years has a magnifying effect on our memory. In retrospect, the genital size of our youth seems to be more substantial than it actually was.

Are you having trouble sleeping?

Depressed, impotent men have difficulty sleeping (insomnia). They fall asleep readily but cannot stay asleep. They usually say they go to bed at about 11:00 P.M., then wake up in the middle of the night and are unable to fall back to sleep.

While it is true that older men frequently awaken in the middle of the night, they do so to urinate. Usually when they return to bed, they fall asleep promptly. Depressed men do not. Recognition and treatment of the depression is a priority if sexual function is to return.

Routine questions regarding general health are now in order; issues of critical importance relate to a history of high blood pressure (hypertension), diabetes, heart disease, pelvic surgery or X-ray therapy, prescription medications, or other chemical use.