Welcome to this Decision Guide on Causes of Impotence.

Impotence is when a man has difficulty getting or maintaining an erection. Impotence is also known as erectile dysfunction, or ED. Recent studies show that impotence is a much more common problem than once believed. Many younger men may experience difficulty with erections, and as many as two-thirds of men will develop impotence at some point in their lives.

Recent studies are also changing our notion about why men develop impotence. While it was once believed that psychological problems were the main cause, we now understand that medical factors -- such as poor blood flow, nerve damage, and medication side effects -- play an important role in most cases of impotence.

This guide is intended to help you understand why you may be experiencing impotence. Keep in mind that you should be evaluated by a health care professional if you have persistent symptoms. Our goal is to provide useful information while you are awaiting further evaluation, or add to what you may have already learned at your visit with a doctor. Remember that this guide cannot substitute for an individual evaluation by your health care provider.

Click here to begin.

There are many different sexual problems that men can experience, including

• low sexual drive

• difficulty getting or maintaining an erection

• problems with ejaculation, including early ejaculation, delayed ejaculation, and "dry" orgasm.

This guide is intended to help sort out why you may be having difficulty getting or maintaining an erection.

Pick one of the statements below that best describes your sexual problem.

I have difficulty getting or maintaining an erection.

I have a different sexual problem.

Please visit our Decision Guide on Sexual Problems in Men, which covers several other types of sexual problems.

Difficulty getting or maintaining an erection is called impotence, or erectile dysfunction (ED). Impotence can include

• not getting erections at all

• getting erections some of the time, but not consistently or reliably

• erections that are not firm enough for sexual enjoyment

• erections that fade quickly (without orgasm or ejaculation).

Impotence has many different causes, including

• vascular disease (narrowing or "hardening" of vessels that supply blood to the penis)

• nerve or spinal cord problems

• medication side effects

• after effects of certain types of surgery

• substance abuse

• hormone problems

• stress, anxiety or other psychological causes.

This guide is intended to help you figure out why you may be experiencing impotence. Since impotence in young men may have different causes than impotence in older men, let's start by finding out your age.

How old are you?

I am age 45 or older.

I am younger than 45 years old.

Men of any age can develop medical problems that interfere with their ability to get or keep an erection. However, compared to older men, men under age 45 are more likely to experience psychological causes for their impotence.

Let's start by finding out about stress in your life, since stress is one of the most common types of psychological problems that can interfere with normal sexual function. Common sources of stress include

• distance or strain in the relationship between you and your partner

• job or family related stress

• fear or worries about sex or intimacy

• anxiety about sexual performance

• worries about your body image.

Do you feel that stress or other psychological factors may be affecting your sexual performance?

Yes, I may be suffering from stress.

No, I don't think I am suffering from stress.

Even in men who don't feel stressed, psychological factors can interfere with your ability to get or keep an erection.

Doctors often suspect a psychological cause of impotence in men who get normal erections at some times, but not at others. For example, some men get normal erections when they awake in the morning, or when they see erotic movies or pictures, but not during sex with their usual partner.

Do you get normal erections at some times, but not at others?

Yes, I sometimes get normal erections.

No, I never (or almost never) get normal erections.

This makes a medical (rather than psychological) cause of impotence much more likely. Let's find out more about medical conditions that might be causing your difficulty with erections.

Impotence is a common side effect of many different prescription and non-prescription drugs, but some tend to cause impotence more often than others, including those used to treat

• high blood pressure

• heart conditions

• depression, anxiety, and other psychiatric conditions

• prostate cancer

• enlargement of the prostate gland

• chronic pain

• seizures

• excess stomach acid.

Are you taking any prescription or non-prescription drugs, particularly for one of the conditions listed above?

Yes, I am taking one or more medications.

No, I am not taking medications.

Like prescription drugs, alcohol and recreational drugs can affect your ability to get and keep an erection.

Do you regularly drink alcohol -- even modest amounts -- or take recreational drugs?

Yes, I take alcohol or recreational drugs.

No, I do not drink or take drugs.

Good. So far you've indicated that you don't feel stressed, that you never (or almost never) get normal erections, that you don't take medications, and that you don't use alcohol or drugs.

Several medical conditions can lead to impotence. One of the most common is diabetes. Diabetes may affect your ability to have an erection by damaging both blood vessels and nerves in the penis.

Do you have diabetes?

Yes, I have diabetes.

No, I do not have diabetes.

Impotence can also be linked to other types of blood vessel (vascular) problems. Poor blood flow to the penis can result from narrowing of blood vessels caused by some combination of high blood pressure, high cholesterol, and smoking. Impotence is also common in men who have had heart attacks or been diagnosed with other types of cardiovascular disease.

Have you been diagnosed with heart or vascular disease, high blood pressure, or high cholesterol?

Yes, I have been diagnosed with one of these conditions.

No, I have not been diagnosed with one of these conditions.

Impotence can develop after surgery on the bladder, prostate gland, or other organs in the pelvis. This surgery may be performed for problems affecting

• the bladder (such as cancer or stones)

• the prostate gland (including benign enlargement or cancer)

• the bowel (such as diverticulitis, colitis, or tumors)

• lymph nodes (for example, as part of cancer surgery).

For example, impotence can be common in men who have exploratory surgery during treatment for testicular cancer; other surgeries in this part of the body, including many not listed above, can also cause impotence.

Have you ever had surgery on the bladder, prostate, or other organs in the pelvis or lower abdomen?

Yes, I've had one of these types of surgery.

No, I have not had surgery.

Sexual function is controlled in part by nerves that travel from the spinal cord through the pelvis into the penis. Damage to these nerves can result in difficulty with erections.

Common causes of nerve injury include

• damage to the spinal cord from trauma, disc problems or surgery

• multiple sclerosis

• radiation treatment for prostate cancer, rectal cancer, bladder cancer or other tumors.

Have you had any of these conditions that may produce nerve damage?

Yes, I have had one of these conditions.

No, I have not had one of these conditions.

Since hormones such as testosterone play an important role in sexual function, certain hormone conditions can affect your ability to have an erection. These types of hormone conditions may also affect your sexual drive.

There are many different symptoms of hormone problems, but common symptoms that might be linked to sexual problems include

• loss of interest in sex, or sexual drive

• sudden weight loss or gain

• a change in your voice

• a change in your pattern of hair growth

• fragile bones (osteoporosis)

• loss of muscle tone or bulk

• loss of peripheral vision ("tunnel vision").

Have you noticed any of these symptoms that might suggest a hormonal problem?

Yes, I've noticed one or more of these symptoms.

No, I have not had any of these symptoms.

Okay. So far you've indicated that you are younger than 45 years old and that you

• don't feel stress is contributing to your impotence

• never (or almost never) get normal erections

• don't take medications

• don't use alcohol or recreational drugs

• don't have diabetes

• don't have heart or vascular disease

• don't have high blood pressure or high cholesterol

• haven't had pelvic surgery

• haven't had spinal cord or nerve injury, and

• don't have symptoms of a hormonal problem.

You should contact your doctor to have a medical evaluation to look for other causes of your difficulty getting and maintaining an erection.

Even if your doctor can't make a specific diagnosis, you may be helped by one or more treatments available to improve problems with erections. Please visit our Decision Guide on Treatment of Impotence.

Contact your doctor for a medical evaluation. If your doctor suspects a hormonal problem, he or she may order blood tests, scans or other tests to confirm the diagnosis. Many hormonal problems, such as testosterone deficiency, respond well to treatment.

Talk to your doctor. You should have a medical evaluation to check for nerve damage. Depending on your symptoms, your may recommend a scan or other tests of nerve function.

Even with nerve damage, you may be helped by one or more treatments available to improve problems with erections. Please visit our Decision Guide on Treatment of Impotence.

Your difficulty with erections may be the result of damage from your surgery. If the surgery was performed recently, your symptoms may improve with time. Otherwise, impotence is likely to continue in the future. Talk to your surgeon about your symptoms and about the possibility that the surgery contributed to your impotence. There may be more than one cause, so even if you had one of these operations, your impotence could be unrelated. That's important, because the choice of treatment and the chances of success may depend on identifying all of the possible contributors to this problem.

You may be helped by one or more treatment available to improve problems with erections. Please visit our Decision Guide on Treatment of Impotence.

Impotence linked to heart or vascular disease may or may not improve with time. However, drugs used to treat impotence may be particularly effective in men who have this type of problem. Please visit our Decision Guide on Treatment of Impotence.

Regardless of whether you would like treatment, men with impotence and one of these underlying conditions should contact their doctor. That's because impotence can be a sign of poor blood flow to other important organs, including the heart. Your doctor may recommend a medical evaluation, including measurement of your blood pressure and cholesterol, and tests to ensure that your heart is working normally.

Diabetes can produce nerve and blood vessel damage all over the body, including nerves and blood vessels that are important for sexual function. Nerve and blood vessel damage is particularly common if your diabetes is poorly controlled.

Talk to your doctor. Working to bring your blood sugar under good control can help to prevent further diabetes-related problems, and may even help to reverse damage that has already occurred.

Your alcohol or drug use may be causing your sexual problems. Even modest amounts or alcohol, or occasional use of drugs can affect sexual drive and performance. You should stop taking alcohol or drugs to see if this helps your problem.

Contact your doctor if you need help to quit drinking or using drugs.

Your difficulty with erections may be caused by one or more of the drugs you are taking. The only way to be sure is to stop taking that medication to see if your erections improve.

However, contact your doctor before stopping any drug that you are taking on a doctor's recommendation, even if that drug is non-prescription. Some drugs may be unsafe to stop suddenly.

Getting normal erections at some times, but not during sex with your partner can be a sign of a problem in your relationship, or other psychological issue.

Consider talking with your doctor or consulting a professional therapist. Some medications may also be helpful.

Please visit our Decision Guide on Treatment of Impotence.

Stress plays an important role in many different medical problems. It's very helpful to be able to recognize when stress might be affecting your physical or emotional health.

Some people are able to find ways to cope with their stress, such as relaxation techniques, exercise, or getting support from family or friends. Contact your doctor if you need help managing your stress, or if your erections don't improve despite that fact that you are trying to cope with your stress.

Next, let's find out more about medical conditions that might be causing your difficulty with erections.

Impotence is a common side effect of many different prescription and non-prescription drugs, but some tend to cause impotence more often than others, including those used to treat

• high blood pressure

• heart conditions

• depression, anxiety, and other psychiatric conditions

• prostate cancer

• enlargement of the prostate gland

• chronic pain

• seizures

• excess stomach acid.

Are you taking any prescription or non-prescription drugs, particularly for one of the conditions listed above?

Yes, I am taking one or more medications.

No, I am not taking any medications.

Like prescription drugs, alcohol and recreational drugs can affect your ability to get and keep an erection.

Do you regularly drink alcohol -- even modest amounts -- or use recreational drugs?

Yes, I drink alcohol or use recreational drugs.

No, I do not drink or use drugs.

So far you've indicated that you don't take medications, and don't use alcohol or drugs.

Okay, that's helpful and suggests other factors may be contributing to your impotence.

Several medical conditions can lead to impotence. One of the most common is diabetes. Diabetes may affect your ability to have an erection by damaging both blood vessels and nerves in the penis.

Do you have diabetes?

Yes, I have diabetes.

No, I do not have diabetes.

Good.

Impotence can develop after surgery on the bladder, prostate gland, or other organs in the pelvis. This surgery may be performed for problems affecting

• the bladder (such as cancer or stones)

• the prostate gland (including benign enlargement or cancer)

• the bowel (such as diverticulitis, colitis, or tumors)

• lymph nodes (for example, as part of cancer surgery).

Impotence is very common after removal of the prostate gland (radical prostatectomy) for prostate cancer; other surgeries, in this part of the body, including many not listed above, can do this as well.

Have you ever had surgery on the bladder, prostate, or other organs in the pelvis or lower abdomen?

Yes, I've had one of these types of surgery.

No, I have not had surgery.

Okay.

Sexual function is controlled in part by nerves that travel from the spinal cord through the pelvis into the penis. Damage to these nerves can result in difficulty with erections.

Common causes of nerve injury include

• damage to the spinal cord from trauma, disc problems or surgery

• multiple sclerosis

• radiation treatment for prostate cancer, rectal cancer, bladder cancer or other tumors.

Have you had any of these conditions that may produce nerve damage?

Yes, I have had one of these conditions.

No, I have not had one of these conditions.

Since hormones, such as testosterone, play an important role in sexual function, certain hormone problems may affect your ability to have an erection. These types of hormone conditions may also affect your sexual drive.

There are many different symptoms of hormone problems, but common symptoms that might be linked to sexual problems include

• loss of interest in sex, or sexual drive (also called libido)

• sudden weight loss or weight gain

• a change in your voice

• a change in your pattern of hair growth

• fragile bones (osteoporosis)

• loss of muscle tone or bulk

• loss of peripheral vision ("tunnel vision").

Have you noticed any of these symptoms that might suggest a hormonal problem?

Yes, I've noticed one or more of these symptoms.

No, I have not noticed any of these symptoms.

So far you've indicated that you don't take medications, don't use alcohol or drugs, don't have diabetes, haven't had pelvic surgery, haven't had spinal cord or nerve injury, and don't have symptoms of a hormonal problem.

That's good!

Difficulty with erections can also be caused by stress, depression, anxiety or other psychological factors. Common triggers for difficulty with erections can include

• distance or strain in the relationship between you and your partner

• job or family related stress

• fear or worries about sex or intimacy

• anxiety about sexual performance

• worries about your body image.

Do you feel that stress or other psychological factors may be affecting your sexual performance?

Yes, I may be suffering from stress.

No, I don't think I am suffering from stress.

Even in men who don't feel stressed, psychological factors can interfere with your ability to get or keep an erection.

Doctors often suspect a psychological cause of impotence in men who get normal erections some of the time, but not all the time. For example, some men notice that they have normal erections when they awaken in the morning, or when they see erotic movies or pictures, but not during sex with their usual partner.

Do you get normal erections at some times, but not at others?

Yes, I sometimes get normal erections.

No, I never (or almost never) get normal erections.

Okay. So far, you've indicated that you are age 45 or older and that you

• don't take medications

• don't use alcohol or drugs

• don't have diabetes

• haven't had pelvic surgery

• haven't had spinal cord or nerve injury

• don't have symptoms of a hormonal problem

• aren't suffering from stress or relationship issues

• never (or almost never) get normal erections.

In most men who fit this description, impotence is usually caused by poor blood flow to the penis (vascular disease). Studies suggest that poor blood flow is the main cause of impotence in up to 70 percent of men. Blood flow problems are particularly common in men who have had heart disease, vascular problems affecting the legs, high blood pressure, and/or high cholesterol. Blood flow problems are also more common in men who smoke.

Impotence caused by poor blood flow may or may not improve with time. However, drugs used to treat impotence may be particularly effective in men who have this type of problem. Please visit our Decision Guide on Treatment of Impotence.

Regardless of whether you would like treatment, men who may have poor blood flow as a cause of their impotence should contact their doctor. That's because impotence can be a sign of poor blood flow to other important organs, including the heart. Your doctor may recommend a medical evaluation, including measurement of your blood pressure and cholesterol, and tests to ensure that your heart is working normally.

Getting normal erections at some times, but not during sex with your partner can be a sign of a problem in your relationship, or other psychological issue.

Consider talking with your doctor or consulting a professional therapist. Some medications may also be helpful. Please visit our Decision Guide on Treatment of Impotence.

Stress plays an important role in many different medical problems. It's very helpful to be able to recognize when stress might be affecting your physical or emotional health.

Some people are able to find ways to cope with their stress, such as relaxation techniques, exercise, or getting support from family or friends. Contact your doctor if you need help managing your stress, or if your erections don't improve despite that fact that you are trying to cope with your stress.

Contact your doctor. You should have a medical evaluation. If your doctor suspects a hormonal problem, he or she may order blood tests, scans or other tests to confirm the diagnosis. Many hormonal problems, such as testosterone deficiency, respond well to treatment.

Talk to your doctor. You should have a medical evaluation to check for nerve damage. Depending on your symptoms, your doctor may recommend a scan or other tests of nerve function.

Even with nerve damage, you may be helped by one or more treatments now available to improve problems with erections. Please visit our Decision Guide on Treatment of Impotence.

Your difficulty with erections may be the result of damage from your surgery. If the surgery was performed recently, your symptoms may improve with time. Otherwise, impotence is likely to continue in the future. Talk to your surgeon about your symptoms and about the possibility that the surgery contributed to your impotence. There may be more than one cause, so even if you had one of these operations, your impotence could be unrelated. That's important, because the choice of treatment and the chances of success may depend on identifying all of the possible contributors to this problem.

You may be helped by one or more of the available treatments to improve problems with erections. Please visit our Decision Guide on Treatment of Impotence.

Diabetes can produce nerve and blood vessel damage all over the body, including nerves and blood vessels that are important for sexual function. Nerve and blood vessel damage is particularly common if your diabetes is poorly controlled.

Talk to your doctor. Working to bring your blood sugar under good control can help to prevent further diabetes-related problems, and may even help to reverse damage that has already occurred.

Your alcohol or drug use may be causing your sexual problems. Even modest amounts of alcohol or occasional use of drugs can affect sexual drive and performance. You should stop taking alcohol or drugs to see if this helps your problem.

Contact your doctor if you need help to quit drinking or using drugs.

Your difficulty with erections may be caused by one or more of the drugs you are taking. The only way to be sure is to stop taking that medication to see if your erections improve. However, contact your doctor before stopping any drug that you are taking on a doctor's recommendation, even if that drug is non-prescription. Some drugs may be unsafe to stop suddenly.