What should I know about Impotence?

Simply defined, impotence is the failure to achieve erection, ejaculation, or both. (1) Men may present with one or a combination of complaints: loss of libido, inability to initiate or maintain an erection, premature ejaculation, ejaculatory failure, or inability to achieve orgasm. The selection and success of therapy is dependent upon understanding the cause, and thus it is necessary to evaluate all aspects of sexual function.

Impotence may be caused by a variety of endocrine, vascular, neurologic, or psychiatric diseases. It may actually be the presenting symptom in some systemic diseases, or can be a side effect caused by certain medications. It was previously thought that most erectile dysfunction was psychologically based. It is now thought that the majority of men with sexual dysfunction actually have a component of underlying organic disease.

A decrease or loss of desire (libido) may be due to hormone deficiency arising from either pituitary or testicular disease, psychological disturbance, or to some types of prescribed or habitually abused drugs. (2) If a hormonal deficiency is suspected, a blood test may be recommended to determine hormonal levels. A condition known as hypogonadism may also result in abnormal erectile function. The minimal level of testosterone necessary for normal erectile function is unknown.

Failure of erection may be caused by a number of conditions, grouped in general into endocrine, drug, local, neurologic, and vascular disorders.

Premature ejaculation is a disorder that seldom has an organic cause. It is usually related to anxiety in a sexual situation, undue pressure placed on oneself concerning sexual performance, or an emotional disorder. Behavioral therapy has been the most successful treatment of this disorder.

Absence of emission may be produced by four major causes. These are retrograde ejaculation, sympathetic denervation, androgen deficiency, or some drugs. Androgen deficiency generally causes a decrease in secretions and volume of ejaculate. These drugs include guanethidine, phynoxybenzamine, phentolamine, and sertraline, which frequently impair ejaculation. Sympathetic denervation may occur as a result of surgery where there is a resultant lack of smooth muscle contraction at the time of ejaculation. Retrograde ejaculation may occur after bladder or neck surgery, or may spontaneously develop in diabetic men.

Absence of orgasm is most frequently due to psychiatric disorder, particularly if libido and erectile function are normal.


The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) / National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIH Publication No. 95-3923, September 1995.

    Experts believe impotence affects between 10 and 15 million American men. About 5 percent of men at the age of 40 and between 15 and 25 percent of men at the age of 65 experience impotence. Diseases--including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease--account for about 70 percent of cases of impotence. Between 35 and 50 percent of men with diabetes experience impotence. Experts believe that psychological factors cause 10 to 20 percent of cases of impotence. These factors include stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. Drug effects account for 25 percent of cases of impotence.

Signs and Symptoms

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Impotence may have one or more than one of the following symptoms; a loss of interest or desire in sexual activity, unable to have an erection or maintain an erection, failure to ejaculate, ejaculation too soon (premature), or unable to have an orgasm.


  • Loss of interest or desire in sexual activity
  • Unable to have an erection
  • Unable to keep an erection long enough
  • Failure to ejaculate
  • Ejaculation too soon
  • Unable to have an orgasm

Treatment Options


    Androgen therapy is of little benefit, except in the patient with hypogonadism, and may, in fact, delay the identification of other conditions. Yohimbine has been used in psychogenic impotence, but works by placebo effect. Aortic obstruction may have to be treated by surgery. The injection of vasoactive substances into the corpora cavernosa may produce erection. Commercially available vacuum devices use a vacuum to produce an erection and a rubber band to restrict venous return. This provides a non-surgical alternative for many patients. Penile prostheses are a therapeutic alternative. Psychotherapy is often beneficial to relieve psychogenic factors. Sildenafil is the first oral agent to have success in treating impotence. The dose is 25-100mg one hour before sexual intercourse and has shown improvement in patients with psychogenic impotence, erectile dysfunction due to spinal cord injury, complications of diabetes mellitus, and radical prostatectomy.

Nutritional Suplementation


It has been established that nitric oxide is involved in the neurotransmission that facilitates smooth-muscle relaxation in the corpus cavernosum that permits penile erection. Abnormal function in this pathway may cause some forms of impotence. (3) Since arginine is the precursor for the synthesis of nitric oxide, supplementation may help to increase the production of nitric oxide and improve erectile function. (4)

Herbal Suplementation


Ashwagandha root, also known as winter cherry or Indian ginseng, is an important herb from the Ayurvedic or Indian system of medicine. Ashwagandha has been traditionally used for the treatment of debility, emaciation, impotence, and premature aging. (5) This dietary supplement is used to enhance mental and physical performance, improve learning ability, and decrease stress and fatigue. Ashwagandha is a general tonic to be used in stressful situations, especially insomnia, overwork, nervousness, and restlessness.

Ashwaghanda is an adaptogen, or substance that helps protect the body against various emotional, physical, and environmental stresses. Ashwagandha is reported to have tonic or adaptogenic effects similar to panax ginseng. (6)


Cordyceps is a unique black mushroom that extracts nutrients from and grows only on a caterpillar found in the high altitudes of Tibet and China. Cordyceps is one of the most valued medicinal agents in the Chinese Materia Medica. Cordyceps has been used in traditional Chinese medicine as the herb of choice in lung and kidney problems, and as a general tonic for promoting longevity, vitality, and endurance. (7) Cordyceps is beneficial in helping individuals with decreased energy restore their capacity to function at a greater level of activity. Cordyceps has been used in humans for centuries as a tonic for improving performance and vitality, with the proposed mechanism of action being improved oxygen consumption by the cardiopulmonary system under stress and increased tissue “steady state" energy levels. Cordyceps may modulate immune function and optimize endocrine systems, increasing physical strength and endurance. (8) , (9)


Rhodiola has long been used in traditional folk medicine in China, Serbia, and the Carpathian Mountains of the Ukraine. In the former Soviet Union, it has long been used as an adaptogen, decreasing fatigue and increasing the body’s natural resistance to various stresses. In Siberia it is said that "those who drink rhodiola tea regularly will live more than 100 years." Rhodiola also has been traditionally used in sexual disorders in men and women.


  1. McConnell JD, Wilson JD. Impotence. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine 14th ed. New York: McGraw-Hill; 1998:286-289.
  2. McConnell JD, Wilson JD. Impotence. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine 14th ed. New York: McGraw-Hill; 1998:286-289.
  3. View Abstract: Rajfer J, et al. Nitric oxide as a mediator of relaxation of the corpus cavernosum in response to nonadrenergic, noncholinergic neurotransmission. N Engl J Med. Jan1992;326(2):90-4.
  4. View Abstract: Moody JA, et al. Effects of long-term oral administration of L-arginine on the rat erectile response. J Urol. Sep1997;158(3 Pt 1):942-7.
  5. Boone K. Withania – The Indian Ginseng and Anti-aging Adaptogen. Nutrition and Healing. Jun1998;5(6):5-7.
  6. View Abstract: Grandhi A, et al. A Comparative Pharmacological Investigation of Ashwagandha and Ginseng. J Ethnopharmaco. Dec1994;44(3):131-35.
  7. Sun YH. Cordyceps sinensis and Cultured Mycelia. Chung Yao Tung Pao. Dec1985;10(12):3-5.
  8. Bao TT, et al. Pharmacological actions of Cordyceps sinensis. Chung Hsi I Chieh Ho Tsa Chih. Jun1988;8(6):352-54.
  9. Chen YP. Studies on Immunological Actions of Cordyceps sinensis. I. Effect on Cellular Immunity. Chung Yao Tung Pao. Sep1983;8(5):33-35.