Update information about Impotence & Erectile Dysfunction

Data about impotence  |  How is an erection generated?  |  Self-diagnosis of impotence  |  Reasons for impotence  |  Symptoms of impotence  |  Medical diagnosis of impotence  |  Treatment for impotence  |  Explanation in the video about impotence  |  Common questions about impotence

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Data about impotence that maybe you didn’t know, and should

• Although impotence can occur at any age in sexually active men, its frequency increases with age. Around 10-25% of men under 40 suffer from impotence, in comparison with 40% at age 40, 50% of men in aged 50 and above, and 70-95% of men aged 70 and above.
• In Britain alone, more than 16.5 million men have been diagnosed with impotence.
• While in the past it was common to think that impotence is mainly caused by mental factors, such as performance anxiety, today it is already known that over 80% of cases of impotence stem from physical factors and various diseases. For example, up to 75% of men with diabetes and 79% of those suffering from obesity also suffer from impotence. By 2009, studies ¹ had already reported on more than 8 million men in the US alone that were suffering from impotence due to diabetes and obesity.
• Recent studies ² show that cardiovascular diseases are among the most common physical risk factors for impotence, not only among older men, but also among young men under the age of 40.
• Smoking cigarettes and using drugs are risk factors for impotence that are more common in the young population than in the older population.
• There are quite a few drugs for which impotence may be a side effect, such as various types of drugs to lower high blood pressure, diuretic pills, antidepressants, antipsychotic drugs, drugs to treat benign enlargement of the prostate gland, antacids, sleep medication and sedatives, and more.
• Men who suffer from impotence have a 192% higher risk of developing depression.
• Unfortunately, only 30% of men suffering from impotence seek professional advice.

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How is an erection generated?

The penis comprises two cylindrical bodies called the corpora cavernosa that are essentially the erectile bodies. These bodies are composed of cavities of many blood vessels (creating a tunnel-like appearance), and whose walls are made of muscle tissue. An erection occurs when:

• Sexual stimulation passes like an electrical signal to the brain (as nerve stimulation), and from there to the penis – through nerve centers located along the spine. The sexual stimulation can be sensory (as a result of contact), mental (as a result of sexual thoughts/fantasies), visual (as a result of sight) or even as a result of a taste or smell that has an arousing effect.
• The nerve stimulation sent to the penis causes the nerve cells to release a neurotransmitter called Nitric Oxide (NO), which enters the smooth muscle cells that surround the cavities and blood vessels in the corpora cavernosa. NO causes the release of a molecule called cGMP in the muscle cells; this molecule activates a chain of biochemical reactions that cause calcium ions to be released from the muscle cells. As a result, there is a relaxation of the muscles enveloping the spaces and the blood vessels in the corpora cavernosa.
• When the smooth muscles become relaxed, they enable the blood vessels in the penis to expand, thereby enabling increased blood flow to the corpora cavernosa. In this way, the penis fills with blood and becomes stiff, while thickening, elongating and becoming erect.
• Simultaneously, when the erectile bodies fill with blood, the tissue encompassing them (tunica albuginea) stretches, thereby compressing and pressing on the veins beneath it, whose role is to draw the blood out of the erectile bodies. In this way, the veins are “locked”, the blood cannot leave the erectile bodies, and the erection is kept hard throughout the sexual activity. The tunica albuginea can be stretched effectively due to the network of collagen protein fibers of which it is composed, which give it strength and flexibility, and it is an integral part of the erection mechanism.
• An erection ends when, after ejaculation or when there is a break in sexual activity, an enzyme called PDE5 is secreted and breaks down the cGMP molecule. As a result, the blood vessels return to their usual state, the tunica albuginea returns to its relaxed state, the venous system return to drain the blood from the erectile bodies, and the penis gradually returns to its relaxed, flaccid state.
• PDE5 enzyme activity is the basis for the development of drugs for treating erectile dysfunction which are called “PDE5 inhibitors”; the famous Viagra is of this drug family. The drugs inhibit the enzyme, thereby delaying the breakdown of the cGMP molecule. The blood vessels in the penis dilate for a longer time, and this, in effect, facilitates increased blood flow to the erectile bodies for the period of time that the drug is active in the body.

Damage to each of these mechanisms (the anatomical, nervous, hormonal or the one related to the role of the blood vessels) can damage the mechanisms responsible for creating and maintaining a stiff erection, which manifests as impotence.

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How do I know if I suffer from impotence?

Although impotence is a very common problem, it is important to understand that it is only one component of a whole complex of male sexual dysfunction disorders, and sometimes it is easy to confuse it with other problems in sexual function that may occur in parallel, such as: decreased libido, problems related to ejaculation (such as premature ejaculation and delayed ejaculation), anorgasmia (inability to reach orgasm) and more.

The clearest symptom of impotence is an erection problem, or, in other words, the inability to achieve a stiff erection or the inability to maintain a stiff erection throughout sexual activity. (See below for details about the symptoms of impotence.)  However, it is important to understand that there is a difference between one occasion to a few isolated occasions of no erection (such as on a background of drinking alcohol, drug consumption, great stress, problems in a relationship or simply because of fatigue or when distracted), and the development of a continuous pattern of chronic erectile dysfunction.

If you suspect that you suffer from impotence, it is always important to consult with the physician treating you in order to reach the correct diagnosis and obtain the most appropriate treatment. A full medical diagnostic evaluation is also important if there are accompanying health problems such as cardiovascular disease, diabetes, high blood pressure, and more, since in many cases impotence is a symptom of these problems, occasionally long before they are known about.

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What are the reasons for impotence?

Impotence problems can occur due to a range of different health conditions which are important to diagnose and treat. It is acceptable to divide the causal factors in to physical ones (organic), psychological/mental (psychogenic) ones, or a combination of both.

Physical causes of impotence

Around 8 out of 10 cases of impotence have an organic cause, most due to conditions which cause a decrease in blood flow to the penis:

• Cardiovascular disease – This is the most common cause of impotence in men over the age of 40, and it is known that around 50% of cases of impotence are due to this. In many cases, this is the process of calcification of the arteries which bring blood to the penis – a process that causes their hardening and stenosis, and as a result, blood flow to the penis is reduced. In such a situation, it will often be possible to achieve a partial erection, or it will take a long time to achieve a full erection. Risk factors for calcification of the arteries include obesity, high blood pressure, hyperlipidemia, arteriosclerosis, smoking and the lack of physical exercise. Occasionally, these risk factors lead to impotence even before they manifest as cardiac disease.

• Leakage of blood from the penis (“venous leakage”) – blood leakage from the erectile bodies during sexual activity usually happens with increasing age, due to the age-dependent erosion of the collagen protein fibers in the tunica albuginea – the tissue that envelops the erectile bodies and “locks” the blood in the organ during the sexual act. Although the problem is called venous leakage, it is not necessarily linked to the veins themselves, but rather the functioning of the tunica albuginea, that due to collagen fiber erosion, strength and flexibility are lost and it cannot compress the veins in the erectile bodies effectively in order to “lock” them. Due to this blood escapes from the erectile bodies via the venous blood vessels, and the erection weakens and is lost. The inability to maintain the erection (losing the erection too quickly) is in many cases an early symptom of impotence.

• Neurological factors – These conditions may damage different points along the nerve conduction pathway from the brain (where the initial sexual stimulation arrives) through the spinal cord to the penis, and as a result manifest as erectile dysfunction. Neurological factors include:
  • Parkinson’s Disease
  • Multiple Sclerosis
  • Stroke
  • Damage to the spinal cord (as a result of a slipped disc or surgery)
  • Surgeries or radiation treatment to the pelvis

• Diabetes – This is a disease that can damage both the functioning of the blood vessels and nerve conduction to the penis. The diabetic process causes early hardening of the arterial blood vessels that lead blood to the penis, and as a result, to the loss of their flexibility and their ability to expand in order to facilitate increased blood flow to the penis during an erection. Diabetic neuropathy is a condition where the high blood sugar levels cause nerve damage, including damage to the nerves controlling an erection.

• Hormonal causes – Hormones act like chemical messengers that pass messages between cells and body systems, and they have an effect on a range of basic functions, including sexual function.
  • Low levels of the male hormone testosterone – In men, this hormone is involved in the regulation of sexual desire, sperm creation, maintenance of muscle and bone mass, the distribution of body fat, and more. Also, there are testosterone receptors in the erectile bodies of the penis, and the hormone has an important role in maintaining the structure of the erectile bodies and on their functioning. A lack of testosterone could cause a decrease in libido and sexual activity, and could cause impotence, including a decrease in the number of erections and their quality. A decrease in testosterone levels is common, and occurs as part of the natural process of aging. Age-dependent decrease to testosterone levels begins around the age of 35 and occurs gradually at a rate of 1-2% per year.

• • A problem with the thyroid gland – hypothyroidism and an imbalance in the secretion of thyroid hormones can cause a decrease in libido, fatigue, weight gain and a decrease in sperm production, as well as a decrease in the levels of the hormone testosterone, and as a result, erectile dysfunction and fertility problems.
  • Cushing’s disease – a disease that affects the adrenal gland, and manifests itself in high levels of the hormone cortisol, which may cause hormonal imbalance and a decrease to testosterone levels. Also, high levels of cortisol are linked to narrowing of the arteries and reduced blood flow to the penis, and this is another reason why increased secretion of cortisol over time may result in erectile dysfunction.

• • High levels of the hormone Prolactin in the blood – a high concentration of this hormone suppresses the secretion of testosterone in the body, and may result in erectile dysfunction.

Anatomical problems in the penis such as:

• Peyronie’s Disease – a disease that causes the formation of scar tissue and abnormal curvature of the penis
• Micropenis – a condition where, when erect, the penis reaches a length of less than 8 centimeters.
• Anatomical changes in the penis due to trauma (blunt wound)
• Use of medication – In addition to the drugs already mentioned above, anti-psychotic drugs, hormonal drugs, anti-convulsants and allergy drugs (antihistamines) can cause impotence as a side effect.
• Long-distance cycling– Erection problems may be caused by pressure on the nerves innervating the penis due to sitting on a hard bicycle seat for a prolonged period of time.
• Coronavirus (COVID-19) – Clinical studies from recent years have shown that some men who were infected with COVID-19 suffered from sexual dysfunction, and that the infection increases the risk of impotence. Most of these symptoms pass after a short time, but some individuals who have recovered continue to suffer from them long after the virus has disappeared from the respiratory tract. It is not yet clear why this happens, but preliminary studies in animal models indicate that the virus may damage the blood vessels in the penis and testicles, thereby causing reduced blood flow to the organ. The virus may even have an adverse effect on testosterone production. All these factors are linked to erectile dysfunction. However, further research is required to verify this.

Psychological (psychogenic) factors for impotence

Mental/emotional problems are the cause in about 1 in 10 cases of chronic impotence.

Psycho-sexual causes:

• General factors: problems in creating intimacy, problems in sexual arousal, performance anxiety, great mental stress, relationship problems, feeling of guilt etc.
• Psychiatric conditions, such as clinical depression, general anxiety disorder or psychosis

For the most part, psychogenic impotence comprises symptoms that appear suddenly, and the condition could be resolved when the mental problem itself is treated (for example, depression or anxiety). There are men whose response to impotence is increased depression or anxiety; this is likely to create a vicious circle: impotence –> a worsening mental state –> chronic impotence.

Also, in case where they occasionally manage to achieve a hard erection (such as spontaneous erections during the night, a morning erection or an erection through masturbation), it is reasonable to suppose that the cause for impotence is psychological.

What are the symptoms of impotence?

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In most cases, impotence is a problem that develops over time, and usually, the man will experience occasional problems with his erection, with a gradual worsening of erectile function. The symptoms of impotence include:

Difficulty in attaining a hard erection

A persistent inability to achieve an erection sufficiently hard for pleasurable sexual activity is an obvious symptom of impotence. However, contrary to popular belief, impotence is not exactly a condition in which an erection cannot be achieved at all. It is also defined as impotence in situations where achieving an erection is sometimes possible, but not on every occasion when wishing to have sex.

Difficulty in maintaining an erection.

This is a situation in which the man manages to achieve a stiff erection, but it is not maintained for long enough (to achieve penetration or to have satisfying intercourse). Symptoms of impotence are both in cases where the erection “falls” immediately and whether it “comes and goes” intermittently.

Loss of erection before ejaculation

One of the signs that the cause of impotence is psychological is a state of being unable to reach orgasm before the erection is lost. It is possible that the problem is general anxiety, performance anxiety, stress or fear of failure in bed. These are also symptoms of impotence.

Partial erection

As mentioned, impotence can vary with respect to its severity, ranging from a mild disorder to the complete absence of an erection; therefore, even partial erections are a symptom of impotence. One of the recognized ways of assessing erection hardness is through the EHS index (Erection Hardness Score) – a simply applied tool for grading erection hardness on a scale of 0-4:

Score 0 – The penis does not expand and grow

Score 1 – The penis grows but does not become hard at all

Score 2 – The penis becomes hard, but not enough for penetration

Score 3 – The penis is hard enough for penetration, but not fully hard

Score 4 – The penis is fully hard

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How is a medical diagnosis of impotence made?

In the process of the initial diagnosis of impotence, the doctor will perform an in-depth questioning regarding the patient’s general health, including in the context of underlying diseases, identifying signs of hormonal problems, and more. Thereafter, a physical examination will be performed, during which the doctor will assess if there are signs indicating disruption of blood flow to the penis. An examination of the penis will be carried out, as well as a rectal examination.

If there is a suspicion of a specific origin of the problem, the physician will investigate it in more depth. For example, if there is a suspected neurological problem (nervous), the patient will be referred for more in-depth neurological tests; if disruption to normal blood flow to the penis is suspected, it is possible that the patient will be referred for a Doppler ultrasound examination. Should there be a suspected hormonal imbalance, it is possible that the patient will be referred for an in-depth investigation by an endocrinologist.

Read more about the Impotence Test »

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A review of treatments for impotence

Medicinal Treatment

These medicines are the first line of treatment for erectile disorders. They belong to the “PDE5 enzyme inhibitor” drug family, whose use is very common. The mechanism of action: increasing blood flow to the penis by affecting the cGMP molecule involved in the relaxation and dilation of the arterial blood vessels in the penis during sexual stimulation, thereby improving blood flow to the penis and creating a stiff erection (see explanation above). The drugs are mainly effective in cases where there is partial damage to the arterial blood vessels bringing blood to the penis, and they are taken around an hour or two prior to having sex.

Vacuum Pump

This is a cylinder-like device that is used before intercourse. The mechanism of action of the device: when the penis is inserted into the cylinder and the device is activated, there is a pump that sucks out and removes the air from it until a vacuum (empty space) is created. The Vacuum results in elevated blood flow to the penis, thus creating an erection. After removing the device, in order to keep the blood in the erectile bodies, an elastic rubber ring is worn on the base of the penis. The erection is maintained for around 30 minutes, after which, the elastic ring should be removed from the penis.

Penile Injections

The treatment is based on the injection of a drug into the sides of the body of the penis, and is performed by the patient himself. Mechanism of action: the drug contains substances which cause the relaxation of the smooth muscles in the erectile bodies (corpora cavernosa), to dilate the arterial blood vessels and thereby increase blood flow to the penis and create an erection. Injection Treatment was common, especially at the time when no drug treatment for impotence existed.

Urethral Suppositories 

These are tiny suppositories that are inserted into the urethral opening of the penis. Mechanism of action: the drug contains substances which cause the relaxation of the smooth muscles in the erectile bodies, to dilate the arterial blood vessels and thereby increase blood flow to the penis and create an erection – usually within 10-15 minutes. However, the efficacy of the suppositories is less than that of the injections.

Shockwave Treatment

This involves low-energy acoustic waves. Over the years, shock waves have been used for various medical situations, but only in recent years, in Israel, has use of this technology for impotence been developed. The potential mechanism of action: The shock waves transferred to the erectile bodies encourage the formation of new blood vessels through which blood flow to the penis improves. The treatment is performed using a special device for passing shock waves to a number of regions in the body of the penis. The treatment extends over 12 stages and is carried out in private clinics or hospitals.

Home treatment using radio waves technology (Vertica)

Treatment with radio waves has existed for years, whether for the purpose of cauterizing tissues with high energy or as a dermatological treatment to improve the appearance of loose skin and wrinkles using low energy radio waves. Vertica®, a medical device for the home treatment of impotence was launched for the first time in 2021. The device is based on the use of low intensity radio waves to rehabilitate the tissue in the penis (the tunica albuginea) which constitutes part of the physiological mechanism of an erection. The tunica albuginea contains collagen protein fibers that give it strength and flexibility. However, with age, the collagen fibers in the tunica albuginea become worn out and weaken. As a result, the tunica cannot effectively block the blood being drained through veins in the erectile bodies during sexual arousal, and as a result, blood leaks out of the penis, and the erection either becomes significantly weaker or it is lost. The mechanism of action of the device: radio waves essentially release low frequency energy (1 megaHertz). When the energy is released, it creates heat that warms the deep tissues. Heating the tunica albuginea tissue in the penis encourages the production of collagen protein whose function is to give the tissue stiffness and firmness, and thereby contributing to the restoration of the physiological erection mechanism.

Penile implant surgery

The implant is constructed from two cylindrical bodies that are implanted into the corpora cavernosa of the penis, and in effect, replace the natural erection mechanism. There are two types of implant:

Semi-rigid implants

On the one hand, they provide the penis with constant rigidity, but on the other hand, they are flexible enough to bend it during the day and then straighten it before having sex.

Inflatable Penile Implants

Constructed from two cylindrical bodies implanted inside the corpora cavernosa of the penis, a pump implanted in the scrotum, and a container implanted in the pelvis which contains fluid. When an erection is desired, pump located in the scrotum is pressed, transferring fluid from the implanted container to the cylindrical bodies that are fill with fluid; they stretch and thicken in the process, and a stiff erection is obtained. Pressing a button on the pump releases the fluid from the cylindrical bodies back into the container, and the penis goes flaccid. An implant of this kind allows for a more natural erection. To read about penile implant surgery in depth

Penile Revascularization (Bypass) Surgery

This surgery is intended for situations of impotence caused a blockage in one main artery carrying blood to the penis, and is only performed when the patient has no other background risk factors. The surgery assists in improving blood flow to the penis by bypassing the area of the blocked artery.

PRP treatment (Platelet-Rich Plasma)

Plasma is the liquid component of the blood which comprises half of its volume. It contains different components of the blood found in a dissolved state; it is rich in platelets that have an important role in clotting of the blood, and also contain blood proteins, among them “growth factors” that assist in the processes of tissue healing following an injury, electrolytes (such as calcium, magnesium and sodium), hormones, oxygen, and more. The mechanism of action of PRP treatment: the treatment is designed to help in situations of impotence by enriching the tissues in the penis with plasma components to make them “healthier” such that they perform their function properly. In order to prepare PRP, a small sample of blood is required from the patient. The blood sample is placed in a centrifuge in order to separate the plasma and the platelets from the other components of the blood. In this way, plasma with a particularly high concentration of platelets (PRP) is obtained, which is injected into the patient’s penis (P-shot).

Stem cell treatment

Stem cells are unique cells that can differentiate into endothelial cells (which line the inner layer of the blood vessels), nerve cells, or smooth muscle cells. The potential mechanism of action of stem cells in cases of impotence: restoration of the natural erectile mechanisms by the growth of healthy tissue generated by the stem cells. So far, the efficacy and safety of stem cell therapy has been proven in some studies of animals and humans with erectile dysfunction. However, more studies are needed to understand the full potential for the treatment of impotence. As of June 2022, there are medical centers that have started experimental treatments for impotence problems by injecting stem cells into the corpora cavernosa of the penis.

Psychotherapy and sexual counselling

These are treatments for impotence with a psychogenic cause, as a result of great stress, anxiety disorder, performance anxiety, depression or problems in the marital relationship that impact emotionally. The treatment methods include psychological treatment, psychotherapy, and professional sexual counselling (either individually or with a partner) from a sexologist.

↩ ^[1] Chitaley K, Kupelian V, Subak L, Wessells H. Diabetes, obesity and erectile dysfunction: field overview and research priorities. J Urol. 2009 Dec;182(6 Suppl):S45-50. doi: 10.1016/j.juro.2009.07.089. PMID: 19846136; PMCID: PMC2864637.

↩ ^[2] Rastrelli G, Maggi M. Erectile dysfunction in fit and healthy young men: psychological or pathological? Transl Androl Urol. 2017 Feb;6(1):79-90. doi: 10.21037/tau.2016.09.06. PMID: 28217453; PMCID: PMC5313296.

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