Impotence

Published on 23/05/2015 by admin

Last modified 22/04/2025

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Impotence

Impotence is failure in the adult male to sustain an adequate erection for vaginal penetration. Impotence leads to psychological problems, often with marital breakdown. Psychological causes of impotence are common but the most common organic disease is diabetes mellitus. The term ‘loss of libido’ should be reserved for sexual dysfunction relating from a loss of sexual desire or sexual drive.

Causes

Vascular

• Diabetic vascular disease

• Aortoiliac disease (Leriche’s syndrome)

Neurological

• Spinal lesions

• Neuropathies, e.g. diabetes

• Spina bifida

• Pelvic surgery (damage to nervi erigentes)

Endocrine

• Diabetes mellitus

• Hypogonadism

• Hypothyroidism

• Cushing’s syndrome

• Addison’s disease

Drugs

• Antihypertensives

• Antidepressants

• Alcohol

• Oestrogens

• Cocaine

Local Painful Conditions

• Phimosis

• Peyronie’s disease

• Short frenulum

Systemic Disease

• Malignancy

• Cirrhosis

• Chronic renal failure

Psychogenic

• Depression

Other

• Ageing

History

Is there a clear history of stress to account for the onset of impotence? Does the patient experience erections at any time, especially during the night? History of peripheral vascular disease, especially buttock claudication (Leriche’s syndrome)? History of neurological disease? Take a full drug history, including any recreational drugs. Check for a history of diabetes, hypothyroidism, Addison’s disease or Cushing’s disease. Pelvic surgery, e.g. abdominoperineal resection of the rectum with damage to the nervi erigentes. Check for any local, painful conditions of the penis. History of malignant disease. History of chronic renal failure: nausea, lethargy, nocturia, peripheral oedema, pulmonary oedema, dyspnoea, vomiting, hiccups, convulsions.

Examination

Vascular

Check all the pulses in the lower limb. Listen for bruits in the abdomen and pelvis.

Neurological

Carry out a full neurological examination.

Endocrine

There will usually be a clear history of diabetes. Complications may be apparent. Check for peripheral neuropathy. Check for hypothyroidism: weight gain, dislike of cold weather, hoarse voice, lethargy, constipation. Check for Cushing’s syndrome – thin skin, cushingoid facies, abdominal striae, obesity, buffalo hump, hypertension. Check for Addison’s disease – weakness, weight loss, pigmentation of palmar creases and buccal mucosa, hypotension. Examine the testes for hypogonadism. Check for development of male secondary sexual characteristics.

Local painful conditions

Examine the penis for phimosis, Peyronie’s disease or short frenulum.

Systemic disease

Malignant disease may be obvious. Check for chronic renal failure: pallor of skin, peripheral oedema, pericarditis, pleural effusions, hypertension. Check for cirrhosis, liver palms, spider naevi, ascites, leuconychia, flapping tremor, testicular atrophy, Dupuytren’s contracture.