Erectile Dysfunction
(ED, Impotence)

Erectile Dysfunction (ED, Impotence): Overview

Erectile dysfunction (ED) or impotence is the inability to achieve and maintain a full erection during sexual arousal.  It affects an estimated 10-20 million men, including 25% of men older than 50.

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Men get erections when sexual thoughts, originating in the brain, initiate a flow of nerve signals, some of which are parasympathetic, down the spinal cord to the arteries and smooth muscle in the penis.  The arteries that supply the penis then dilate, and the muscles that control the two rods of sponge – like tissue filling the core of the penis – the corpora cavernosa and the corpus spongiosum – relax.  As they relax, they allow the increased flow of blood through the penile arteries to fill the spongy space with blood.  The increasing pressure in the penis compresses the veins that drain blood from the penis, preventing outflow.  The more blood that fills the penis, the larger and harder the erection will be, because as long as blood is flowing through the arteries, the out flow remains severely restricted.  The penis returns to a flaccid state when the penile arteries constrict, relaxing pressure on the veins and allowing the blood to drain out.

All these activities are under the control of NO molecules.  The nerves that serve the spongy tissue and the penile arteries are rich in NO, so when you become sexually aroused, the NO rich nerves quickly convert L-arginine to No. These NO molecules diffuse to nearby arteries and smooth muscle, causing them to dilate and relax.  Erection is reversed by contraction of the arteries involved, and that in turn occurs with stimulation by other nerves (sympathetic), either with ejaculation, anxiety or other causes of inhibition.

NO can be activated by a number of common substances released from the nerves.  Especially important is the neurotransmitter acetylcholine.

Causes and Development

The cause of ED can be primarily organic, psychogenic in nature, or a mixture of the two.  In 85% of cases affecting men aged 50 and older, organic factors such as vascular disease and atherosclerosis of the penile artery are the cause.

Physical factors include:

  • Systemic diseases (diabetes mellitus, syphilis, alcoholism – abstain for 30 days to see if there is improvement, drug dependency, hypopituitarism, and hypothyroidism, and adrenal insufficiency)
  • Local disorders – prostate enlargement (BPH), congenital abnormalities and inflammatory diseases of the genitalia, prostatitis; vascular disturbances such as aortic aneurysm and atherosclerosis (for example Leriche's syndrome)
  • Neurogenic disorders – multiple sclerosis, spinal cord lesions, pituitary microadenoma with hyperprolactinemia, and cardiovascular accident; drugs such as hypertensives, sedatives, Proscar (finasteride), tranquilizers, and amphetamines.
  • Surgical procedures such as sympathectomy, prostatectomy and castration produce varying effects.  Impotence is usually not induced by transurethral prostatectomy, whereas it almost always occurs after perineal prostatectomy.
  • Impotence is not inevitable with aging, even into the 70s or 80s.  While the amount and force of the ejaculate and thus sexual tension and the need to ejaculate are decreased, the capacity for erection often is retained.
  • Contributing causes include a lack of exercise, smoking, excess alcohol consumption, obesity and increased total cholesterol or reduced HDL levels.

Psychological causes
These can include abnormal fears of the vagina, sexual guilt, fear of intimacy, or depression.  ED may be situational (involving place, time or a particular partner), some perceived competitive defeat, or damage to self-esteem.  Counseling may be required to resolve these issues.  Psychological factors are strongly implicated if the patient has situational impotence, night or morning erections, or can achieve a firm erection by stimulation.

High blood levels of the pituitary gland hormone prolactin caused by pituitary gland disease can cause impotence.  The prescription drug, bromocryptine (Parlodel), can correct the imbalance and enhance sexual desire by reversing this hormonal imbalance.  Testosterone, the principal androgen, regulates sexual function in men and is a sexual libido booster in women as well.  As a supplement, it will only help boost male libido if the blood levels are too low in the first place.  Men with normal testosterone levels do not benefit from supplementation with this hormone.

For example, men who suffer from a sub-optimal libido should avoid alcohol because it decreases the body's ability to produce testosterone (male hormone).  Alcohol not only decreases sexual function in the male but also increases the risk for heart attack, liver disease and prostate abnormalities.  Other drugs which are common causes of impotence include antihypertensives, diuretics, narcotics, antidepressants and tranquilizers.  Marijuana, cocaine and heavy cigarette smoking all decrease sexual capabilities by damaging the tiny blood vessels that supply blood to the penis.

The two most frequently prescribed drugs for the treatment of ulcers are the stomach acid suppressors cimetidine and ranitidine.  Both have been reported to decrease sperm count and produce impotence as one of their side effects.  One of the mechanisms by which this occurs is the overgrowth of candida or other fungi that thrive in a low stomach acid environment secondary to these acid suppressing drugs.  As the candida proliferate, they secrete many steroid hormones which are possibly antagonistic to testosterone and other androgens.  A safer and more effective remedy that has been proven to be more effective than acid suppressing drugs in the treatment of peptic ulcers and hyperacidity is DGL (deglycyrrhizinated licorice).  DGL is licorice without the portion that can affect the adrenal hormones and raise blood pressure.

Men can experience a phenomenon which is similar to the female menopause between the ages of 40 and 55 referred to as the male andropause.  Although controversial and denied by many medical experts, bodily changes accompanied by changes in attitudes and moods occur during this time and a man frequently begins to question his values, accomplishments and the direction of his life (a.k.a. mid-life crisis).  Andropausal men might experience a reduced sexual desire or libido, reduced sexual potency or difficulty developing or maintaining erections, ejaculatory problems, reduced fertility and increased urinary frequency especially at night (nocturia), a weak urinary stream, hesitancy during urination, difficulty starting urination and urinary incontinence.  These changes may be due, at least in part, to a gradual failure of the testicular production of testosterone, the male sex hormone.

Treatment and Prevention

Viagra may help men who have been left impotent by prostate disease, diabetes or atherosclerosis, but some doctors are still prescribing it with caution, if at all.  First, correct any lifestyle problems: reduce alcohol consumption, get sufficient exercise, watch what you eat, stop smoking, optimize your health, and improve your circulation with ginkgo, if needed.  Don't use it with any form of heart disease.  If you decide to try Viagra, discuss it with your spouse first and then work with your doctor to find the lowest effective dose.  A 50mg tablet may be too little or too much.

References and Further Information

"Gingko biloba Extract in the Therapy of Erectile Dysfunction," M. Sohn and R. Sikora, Journal of Sex Education Therapy, Vol.  17, 1991, pp.53-61.

Signs, symptoms & indicators of Erectile Dysfunction (ED, Impotence):

Symptoms - Reproductive - General

Conditions that suggest Erectile Dysfunction (ED, Impotence):


Coronary Disease / Heart Attack

A buildup of plaque in the penile arteries can lead to difficulty achieving or maintaining erection.  A long-running study of over 2,000 men found that erectile dysfunction is associated with a more than threefold higher risk of heart attack.  Lead researcher Dr. Steven J. Jacobsen, a professor of epidemiology at the Mayo Clinic, reported the findings Nov. 11, 2003 at the American Heart Association's annual conference in Orlando, Florida.  According to Jacobsen, "We can't say that it is cause-and-effect, but erectile dysfunction is a marker for future events of cardiovascular disease."  Overall, men with a heart attack from 1979 to 1995 were 3.5 times more likely to have erectile dysfunction in 1996 than men who did not have a heart attack.

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Risk factors for Erectile Dysfunction (ED, Impotence):


Cigarette Smoke Damage

Men with high blood pressure who smoke are 26 times more likely to be impotent than non-smokers.  Even former smokers with high blood pressure (hypertension) are 11 times more likely to be impotent than non smokers. [Study conducted by Dr. John Spangler, MD at Wake Forest University Baptist Medical Center]


Low Male Testosterone Level

Without sufficient testosterone the penile muscles atrophy, with the result that insufficient blood is trapped for developing or maintaining an erection, which in turn leads to poor performance and the anxiety that follows.  One study found that low testosterone is a factor in 20% of men under 30 with erectile problems.


Andropause/Male Menopause

Impotence or erectile dysfunction is one of the most common symptoms of andropause.

Medical Procedures

Having had a radical prostatectomy

Erectile dysfunction and urinary incontinence are the two most frequently encountered consequences of radical prostatectomy.  While the rate of postoperative urinary incontinence is quite low, the rate of ED is reported as being significantly higher, affecting 10% to 100% of patients.  Since the development of nerve-sparing radical prostatectomy, the incidence of post-operative erectile dysfunction has decreased.

Supplements, Medications, Drugs

Much/some B-complex supplementation

By reducing the level of homocysteine in the blood, and therefore the risk of atherosclerosis, the B vitamins also reduce the risk of developing conditions that can be caused by atherosclerosis, including erectile dysfunction.

Tumors, Malignant

Prostate Cancer

A cancerous prostate gland may interfere with blood flow and nerve impulses to the penis.  That can cause ED; impotence can be one of the signs of prostate cancer.

Erectile Dysfunction (ED, Impotence) suggests the following may be present:



All activity within the body requires adequate hydration – including erection maintenance.  Although dehydration is usually not the only cause, there are various ways in which it can worsen ED.  Dehydration reduces blood volume and causes blood vessels to become narrower, restricting blood flow to all parts of the body, including the penis.  Sexual arousal also requires the right state of mind; even mild dehydration can cause confusion, irritation, tension, anxiety, mood swings, and lethargy, none of which are conducive to getting or maintaining an erection.


Lab Values

High Total Cholesterol

There are several causes of erectile dysfunction, and a high cholesterol level is one.  Cholesterol builds up inside of all of one's arteries.  In the heart it can cause a heart attack.  In the brain it can cause a stroke.  And clogs in the penile artery can cause ED.

Recommendations for Erectile Dysfunction (ED, Impotence):

Amino Acid / Protein


L-Arginine is the primary source of nitrous oxide (NO), an odorless gas made of nitrogen and oxygen that relaxes muscles and increases blood flow to organs – including the heart and penis.  By facilitating blood flow through the erectile tissue of the penis, NO produced from L-arginine can give men erections that are bigger, harder and more frequent.

In a group of 15 men with erectile dysfunction given 2,800mg of arginine per day for two weeks, six were helped, though none improved while taking placebo.  Although little is known about how effective arginine will be for men with erectile dysfunction or which subset of these men would be helped, available research looks promising and suggests that at least some men are likely to benefit. [Int J Impot Res 6: pp.33-6, 1994]

The dose can range from 1 to 3gm with meals, or up to 15gm about 45 minutes before sexual activity.  Arginine is not recommended if you have diabetes, arthritis, cancer, shingles, herpes I (fever blisters, cold sores) or herpes II.

Botanical / Herbal

Herbal Combinations

BetterMAN™ is a clinically tested Chinese herbal supplement that improves sexual performance and prostate health.  In scientific studies, after only 3 bottles of BetterMAN™ over 70% of American men experienced increased ability to attain and sustain an erection, delay ejaculation and desire sex as well as a dramatic decrease in nighttime urinary frequency and urgency.  BetterMAN™ is not a short acting stimulant, but an all-natural long term solution with no side-effects. [The Journal of Urology, Nov. 2000]

Will BetterMAN™ help men who have had prostate surgery?  The results for users vary, depending upon the degree of damage to local nerves caused by the surgery.  Ask your doctor for advice.  In many cases, it takes longer than 3 bottles for BetterMAN™ to work for these users.

This product is manufactured in the U.S. and contains Radix ginseng, Rhizoma dioscoreae, Radix paeoniae alba, Herba epimedii, Cornu cervi pantotrichum, Radix astragali, Poria cocos, Radix morindae officinalis, Fructus corni, Cortex eucommiae, Radix angelicae sinensis, Fructus lycii, Radix Rehmanniae, Rhizoma chuanxiong, Fructus schisandrae, Acanthopanax senticosus, Cynomorium songaricum Rupr., and Cortex cinnamomi.

Ginkgo Biloba

Studies show that taking Gingko biloba herbal extract at 240mg daily (usually a 24% extract) can produce improvement in 6 months or fewer, even if previous medications have failed.  In a study of 20 patients who had received this conventional therapy, 100% regained the ability to have a spontaneous and sustained erection within 6 months of supplementation.  Blood flow into the penis improved within 3 months. [Journal of Sex Education Therapy, Vol. 17, 1991, pp.53-61]


Catuaba has a long history in herbal medicine as an aphrodisiac.  According to Dr. Michael van Straten, noted British herbalist and naturopath, Catuaba is beneficial to men and women as an aphrodisiac, but "it is in the area of male impotence that the most striking results have been reported" and "there is no evidence of side effects, even after long-term use."


Marapuama, also called potency wood, has a history of use for reviving libido, potency, and tonifying the nervous system.  In a study conducted in Paris, France, of 262 male patients experiencing lack of sexual desire and the inability to attain or maintain an erection, 51% of patients with erectile dysfunctions felt that marapuama was beneficial.


An extract of pygeum has shown an ability to improve the capacity to achieve an erection in patients with BPH or prostatitis.


Yohimbe dilates blood vessels, making this herb useful for treating ED.  Although yohimbine (the primary active constituent in yohimbe) has been shown in several double-blind studies to help treat men with ED, negative studies have also been reported.  Somewhat surprisingly, in those it helps, yohimbe appears to help regardless of the cause of ED.  A tincture of yohimbe bark is often used in the amount of 5-10 drops tid.  There are also standardized yohimbe products available for the treatment of ED.  A typical daily amount of yohimbine is 15-30mg.

With the possibility of serious side-effects such as anxiety, panic attacks, hallucinations, elevated blood pressure and heart rate and dizziness, yohimbe bark has been classified by the FDA as an unsafe herb.  Due to the lack of effectiveness and the potential negative side-effects of Yohimbine, the FDA no longer recommends this once prescription drug extract to treat impotence.


In patients with primary and secondary hypogonadism, 78% reported restored and enhanced libido and 22% reported improved erections with the use of Tribulus.

Chinese Medicine


The only placebo-controlled study of acupuncture found that the placebo also produced a large improvement in sexual function that was close to the effect of acupuncture.  Controlled trials with larger groups of men are necessary to better test the efficacy of acupuncture therapy for men suffering from erectile dysfunction. [Scand J Urol Nephrol 31: pp.271-4, 1997]

Laboratory Testing

Test for Hormones

Testosterone is the major hormone produced by men, but does not directly affect a man's erectile ability as much as it does libido or sexual desire.  Men with low testosterone, however, have shown improvement in ED with hormone replacement.  A clinical trial of testosterone for all types of erectile dysfunction is not recommended.

When considering lab testing, a full panel of tests should be considered such as DHEA, testosterone (total and free), DHT, sex hormone binding globulin (SHBG), estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (best taken at 9am to avoid diurnal variations), progesterone and a PSA test for prostate cancer.

Testosterone replacement, preferably applied to the skin or by injection, typically ranges from 25-100mg of natural testosterone per day usually given in two divided doses.

DHEA has been reported to be low in some men with erectile dysfunction.  In one double-blind trial, 40 men with low DHEA levels and ED were given 50mg of DHEA per day for six months.  Significant improvement in both erectile function and interest in sex occurred in the men assigned to DHEA but not in those assigned to placebo.  No significant change occurred in testosterone levels or in factors that could affect the prostate gland. [Urology 53: pp.590-5, 1999]

Physical Medicine

Physical Supports and Devices

The major cause of impotence is leakage through the veins.  This happens when the veins carrying blood out of the penis are not shut completely, allowing blood to be drained out of the penis at the same rate as it enters.  This results in prevention or loss of erection.

There are a variety of bands and rings on the market which help by shutting off the veins externally with a tourniquet effect, hence trapping sufficient blood in your penis to give you a natural, longer and harder erection for successful sexual intercourse within a minute of wearing it.  This type of device will not work if there is restricted blood flow to your penis or if you suffer from serious health problems, such as diabetes, stroke or penile nerve damage.



ED that cannot be linked to physical causes has been successfully treated by hypnosis.  In this trial, three hypnosis sessions per week were used initially, later decreasing to one per month during a six-month period.  Three out of every four men in the trial were helped. [Scand J Urol Nephrol 31: pp.271-4, 1997]

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