This document provides information on impotence, including its definition, causes, examinations, investigations, and treatments. It begins by defining impotence as the inability to perform or engage in sexual intercourse. It then discusses various clinical definitions and perspectives from medicine and law. The document outlines many potential causes of impotence including physical, psychological, drug-related factors and various medical conditions. It describes examinations, tests, and evaluations used to assess impotence involving medical history, physical exams, blood tests, imaging, and more. Finally, it discusses treatment options for impotence ranging from lifestyle changes and counseling to oral medications, injections, and other therapies.

1. Dr M Balaji Singh
ACS medical college and Hospital, Chennai
Courtesy :DR. Krishna Govind Lodha ( slideshare)
Dr Priyatham kasaraneni ( slideshare)
IMPOTENCY – clinical and
forensic aspects

2. definition
IMPOTENCY-
This means inability to perform or take part in
sexual intercourse.

3. Clinical definition
Impotency :
The consistent inability to obtain and
maintain penile erection sufficient to
complete satisfactory sexual
performance

4. Supreme court – definition on
impotency
Consummation ;the action of making a marriage or relationship
complete by having sexual intercourse.

5. SEXUAL DYSFUNCTION
 Is an impairment either in desire for sexual
gratification or in the ability to achieve it.
 In sexual intercourse
the male partner- active partner
female partner - passive partner.
 Male - develops and maintain penile erection
sufficient enough to accomplish the act.
 impotence refers to male
and sexual dysfunction to female.

6. Marriage and sex
 Marriage without sex is an anathema (something dislikes).
 Sex is the foundation of marriage
 A harmonious sexual activity it necessary for any marriage to
continue for long.
 sexual activity in marriage has an extremely favorable influence on a
women's mind and body.
 The result being that if she does not get proper sexual satisfaction,
it will lead to depression and frustration."

7. Impotency and Law
 Impotency is a ground for matrimonial relief under all
personal laws. ...
 Similar provisions are there under the Indian Divorce
Act & Parsi and Muslim Marriage Acts.
 In all marriage acts, impotency can be a ground of
annulment.
 It has to be understood that imperfect and partial
intercourse is not consummation.
Jul 25, 2017

8. Bride gets divorce on impotence plaint
Read more at:
http://timesofindia.indiatimes.com/articleshow/
51502776.cms?utm_source=contentofinterest&
utm_medium=text&utm_campaign=cppst

10. Woman in Noida alleges husband is
impotent, seeks divorce
 The woman, who filed a complaint with the women’s police, said that she got married
on November 19, 2015, in Noida and went on a honeymoon trip to Goa, when she
discovered that her husband was ‘impotent’.
 She had advised her husband to consult a doctor and she was assured by him and his
family members.
 The woman has also mentioned that she was tense for almost six months, as her
husband avoided a physical relationship.
 The matter will be forwarded to court for counselling.
 The case was registered on the basis of a complaint filed by the woman.”
 A case has been registered under sections 498A (husband or relative of husband of a
woman subjecting her to cruelty) and 420 (cheating) of IPC have been registered.

11. No criminal case on impotent husband
 Where it is proved that a husband has not refused or neglected to
maintain his wife, a criminal Court, acting under the section, has no
jurisdiction to make an order upon the husband for her maintenance on
the ground that the husband has been guilty of cruelty to her.
 But that is a very different thing from holding that no evidence of cruelty
can be admitted in a proceeding under the section to prove, not indeed
cruelty as a ground for separate maintenance, but the conduct and acts of
the husband from which the Court may draw the inference of neglect or
refusal to maintain the wife.

13. medico legal importance of
IMPOTENCY AND STERILITY:-
civil
 Nullity of marriage and
divorce.
 Adultery
 Contested paternity and
legitimacy
 Suit for adoption-
where the alleged father
pleads impotency or sterility as
his defense
 Claim for damages
where loss of the sexual
function is claimed as the
result of assault or accident.
Criminal
 Adultery
 Rape
 Un-natural sexual offences
 for the want of property
In cases where a sterile women
puts forward a suppositious child,
as her own to claim property

14. Other related terms
 FRIGIDITY :-Refers to women who are sexually
nonreactive i.e.. the inability to initiate or maintain
the sexual arousal.
 PREMATURE EJACULATION:-Means ejaculation
occurs immediately after penetration or even before
penetrative sexual inter course.

15. Epidemiology
 Estimated to affect 152millions men worldwide
 Non-diabetic men 0.1-18.4% prevalence
In a study of 541 diabetic males
 35% in diabetic men
 5.7% in 20-24 year olds
 52.4% in 55-59 years olds

17. Functional
anatomy of
penis

27. CAUSES OF IMPOTENCY IN MALE
1.AGE:- earlier than puberty - spermatozoa are not usually found- a boy is
sterile but not impotent before puberty.
II.MALFORMATION:- Absence or non development of penis constitutes
absolute impotence.
Certain malformation - intersexuality – cause impotency.
hypospadias and epispadias- result in sterility.
III. LOCAL& GENERAL DISEASES:- gonorrhea ,syphilis etc. may cause
temporary impotence.
Large hernia, elephantiasis or large hydrocele - mechanical obstacle-
temporary impotence.
mumps, testicular atrophy, diseases of testes, epididymis- sterility.

28. Impotency………causes
IV. INJURIES :-Injury to head, spinal cord, cauda equina may result in impotence.
Injuries to testicles will in time cause sterility.
Exposure to X-RAYS, without proper protection, may lead to sterility
Chronic alcoholisim & addiction to narcotics like opium cause impotence.
V. PSYCHIC CAUSES:-
Fear of impotence or fear of inability to complete the act may also cause
temporary impotence but soon is overcome.
Eg.- First night impotence Emotional disturbance Hypocondriasis Timidity

29. VI. OPERATIONS: amputation of the penis renders impotency
 Vasectomy renders a male sterile but not impotent.
 Lithotomy may cause sterility from injury to ejaculatory ducts.
Other causes
 Varicocele:- local rise of temperature- temporary sterility.
 Endocrine disorders :-rare, treatable. hyperprolactinemia is readily treatable.
 Infections - Acute and chronic genital tract infections
 acute orchitis or epididymitis - obstruction in the efferent ejaculatory ducts.
 Chlamydia trachomatis - Unilateral epididymal obstruction
 antibodies to sperm, a potential cause of male infertility.
Appropriate assessment of a semen sample including tests like presence of seminal
Fructose, neutral alpha-glucosidase and pH go a long way in differentiating between
obstructive and non-obstructive azoospermia.

30. priapism
As a complication of
prostate biopsy

31. Infection - impotency
 Orchitis- mumps, tuberculosis, syphilis, pancreatitis
 Epididymitis - gonorrhea, tuberculosis, chlamydiae,
ureaplasma, Pseudomonas, coliform, and other
bacterial infections
 Seminal vesiculitis - tuberculosis, trichomoniasis, other bacteria
 Urethritis - gonorrhea, chlamydiae, ureaplasmas,
trichomoniasis

32. Causes of impotency

33. Drug related impotency

34. Co morbid conditions

35. Other causes
Phimosis
◦ Penile fibrosis
◦ Tumours
◦ Trauma

36. Indications for referral
 Indications are failure of initial treatment,
 Urologist;
 younger patients with a history of pelvic or perineal trauma,
significant penile deformity (e.g., Peyronie disease,
congenital chordee),
 Endocrinologist;
 complicated endocrinopathies (e.g., secondary hypogonadism,
pituitary adenoma),
 Psychiatrist;
complicated psychiatric hypoactive sexual desire),
 Vascular surgeon or neurosurgeon,: vascular or neurosurgical
intervention (e.g., aortic aneurysm, lumbosacral disc disease.

37. EXAMINATION IN CASE OF IMPOTENCY
 Before examination, informed consent is obtained.
 The following things are done,
 1. Complete history of previous illness especially with reference to nervous
and mental condition and sexual history should be obtained.
 2. The general examination followed by systemic examination should be
done.
 3. The private parts must be examined for injuries or malformations. 4.
The condition of testes, epididymis, cord & penis should be noted and
private parts tested for sensation .
OTHER EXAMINATION
 Duplex USG
 Chemical stimulation
 Ateriography

38. History taking
 Patient’s description of the problem
 Patient’s and partners expectations
 Duration
 Speed of onset
 Intermittent/progressive?
 History of sexual partners
 Nocturnal erections?
 Libido

39. History…..
 Personal Medical History
 Glycaemic control
 Vascular/neurological disease
 Urological
 Pelvic surgery and trauma
 Drug history
 Anti- hypertensive's
 Androgen antagonists
 Sedatives
 Drugs that cause hyperprolactinaemia (phenolthiazides)
 Alcohol
 Psychological assessment

40. Examination
 General
 Vascular
 Neurological
 Genitalia

41. investigations
 Serum chemistries
 CBC
 LIPID PROFILE
 Diabetic: fasting glucose ,PPBS
 Endocrine
9am Testosterone
Thyroid function tests
Pituitary hormones (LH,FSH,PRL)
PROLACTIN
 Serum PSA (prostate specific antigen)
 URINE FOR glycosuria

44. Nocturnal Penile Tumescence (NPT)
 Five to six erections during sleep ( during rapid
eye movement sleep (REM). – normal.
 Their absence may indicate defective nerve
function or blood supply in the penis.
 measuring changes in penile rigidity and
circumference during nocturnal erection: by
a). Snap gauge and ; b ) strain gauge.
 Significant proportion of men who do not have
sexual dysfunction , with the absence of regular
nocturnal erections.
 Positive results are more important.

45. Penile strain gauge

46. N P T

47. volumetric

48. Penile Biothesiometry
This test uses electromagnetic
vibration to
evaluate sensitivity and nerve
function in the
glans and shaft of the penis.

49. Tests for penile blood flow
 arterial impairment and veno occlusive dysfunction.
 Combined intra cavernous injection and stimulation
(CIS): for evaluation of penile blood flow.
intra cavernous injection of a vasodilator drug + genital or audiovisual
sexual stimulation
- erectile response is observed and rated by an independent
assessor.

50. C I S ……..
 The test is designed to bypass neurologic and hormonal
influences
 It allows the clinician to evaluate the vascular status of
the penis directly and objectively.
 It is the most reliable and least invasive diagnostic
modality for assess

51. C I S

52. Penile plethysmography – a cartoon

53. Duplex ultrasonography
 Cavernous arterial
insufficiency is suggested
when PSV[peak systolic
velocity] is less than 25
cm/sec;
 PSV consistently greater
than 35 cm/sec defines
normal cavernous arterial
inflow.

54. Duplex u/s
examination of
penis

55. Indicated for
1. site-specific vasculogenic leak due to perineal or
pelvic trauma
2. who have had life-long ED (primary ED)
Test results interpreted by ;
 failure to increase intracavernous pressure to the level of
the mean systolic blood pressure with saline
infusion
 or the demonstration of a rapid drop of intracavernous

56. cavernosography

58. Penile Nerves Function
 Tests such as the bulbocavernosus reflex test
are used to determine if there is sufficient
nerve sensation in the penis.
 The physician squeezes the glans of the penis,
which immediately causes the anus to contract
if nerve function is normal.
 Physician assess the latency between squeeze
and contraction by observing the anal
sphincter or by per anal finger palpation.

59. Psycho physiological evaluation
Penile Tumescence and Rigidity Monitor:
 Nocturnal penile tumescence and rigidity (NPTR)
 Recommended criteria for normal NPTR include four to five erectile
episodes per night, mean duration longer than 30 minutes, an increase
in circumference of more than 3 cm at the base and more than 2 cm at
the tip, and maximal rigidity above 70% at both base and TIP.
 Rigiscan: An automated, portable device used for NPTR,

60. Psychological evaluation
 ED is associated with anxiety, depression, low degrees of self-esteem,
negative outlook on life, self-reported emotional stress, and a history of
sexual coercion.
 In the absence of organic risk factors, a primary psychogenic ED causation
may be suspected. Further support for the diagnosis may follow the
confirmation of noncoital erections (i.e., masturbatory, nocturnal or on
awakening)

61. Neurological evaluation
 Target sites for evaluation include peripheral, spinal, and supraspinal centers,
as well as both somatic and autonomic pathways involved in this biologic
response.
 Tests : SOMATIC Nervous system;
 Biothesiometery : affrent sensory function
 Evoked Response-Bulbocavernosus reflux latency: >30-40msec indicate
 neuropathology.
 Dorsal nerve conduction velocity
 Genito cerebral evoked potential

62. Autonomic nervous system:
 Heart rate variability and sympathetic skin responses
 Penile thermal sensory testing
 Corpus cavernous Electro Myologram

63. Hormonal evaluation
 Serum testosterone measurement : The best indicator of androgen status ( The typical
reference range is 280 to 1000 ng/dl).
 Serum Gonadotropin : help to localize the source of the hypogonadism
 Hyperprolactinaemia causes hypogonadism by suppression of gonadotropins-
releasing hormone from the hypothalamus, which impairs pulsatile LH secretion required for serum
testosterone production by the gonads.
 Hyperthyroidism is associated with ED, possibly by increasing aromatization of
testosterone into estrogen or by increasing adrenergic tone (which causes smooth muscle
contractile effects or exerts psycho-behavioral effects

64. Teatment
 Life style modification:
 Quit smoking
 Regular exercise
 Weight control
 Medication change:
 Psychosexual therapy: A variety of interventions are used:
 systematic anxiety reduction/ desensitization,
 sensate focus,
 inter personal therapy,
 cognitive behavioural therapy,
 sex education,
 couples’ communication and sexual skills training.

65. ORAL Therapy:
Phosphodiesterase 5 inhibitors
(PDE5)
◦ Sildenafl (Viagra) 4hr
◦ Tadalafil (Cialis) 17hrs
◦ Vardenafil (Levita) 4 hrs
Pharmacological treatment

67. Intra cavernosal injections
 with prostaglandins
 Alprostadil (prostaglandin E1),PHENTOLAMINE,
PAPAVERIN
 One large RCT found increased rate of satisfactory
erections when Alprostadil injected compared to
placebo .
 Side effects – pain, priapism

68.  Alprostadil via urethral channel
Response rate ~50%
 side effects- local urogenital pain ,
urethral bleed ,hypotension
dizziness
 Effective, but requires sufficient
training
 Nitroglycerin, papevarin, alprostadil etc –
topical use/ trans dermal.

73. PDE5 inhibitors (phosphodiesterase type 5
inhibitor: increases cGMP in the smooth muscle of
the corpuscavernosum, causing prolonged
vasodilation and a firmer, longer-lasting erection
Unlike injection therapy, PDE5 inhibitors
require sexual stimulation for an erection
to occur.

74. Precautions during prescribing
 concomitant use of nitrates is an absolute contraindication PDE5
inhibition potentiates the hypotensive effects of nitrates.

The use of alpha adrenergic blockers also increases the risk for
hypotension and generally should be avoided.

Relative contraindications include MI, stroke, or dysrhythmia within the
past 6 months; poorly controlled hypertension or hypotension;
uncompensated cardiac failure; unstable angina; a predisposition to
priapism; and retinitis pigmentosa.


75. The most common side effects
 headache,
 flushing,
 dyspepsia,
 and nasal congestion.
 The inhibition of phosphodiesterase 6 in the retina by sildenafil may cause
altered color vision–usually a blue tinge—or increased sensitivity to light in
some men.

76. Other Oral Agent
 Yohimbine is an oral alpha-2 adrenergicreceptor blocker that may
improve erectile function better than placebo, particularly in psychogenic
impotence.
 Studies remain ongoing for the use of phentolamine, apomorphine,
dopaminergic, and many other agents.

77. Testosterone replacement
 Improves erectile function and libido
 Preparations
◦ Topical (testim gel)
◦ Im testosterone
◦ Long-acting depots

79. Vacuum devices

81. Penile implants

82. Penile prosthesis

85. Surgical approach

86. Thanking you
A doctors opinion on a person’s potency is
crucial in a criminal / civil case.