Erectile dysfunction is a sensitive topic for many men – but it can be more than just a question of potency. Often, erectile dysfunction (ED) is caused by a serious underlying medical condition that should be detected and treated early.
But how does erectile dysfunction actually develop? Is it reversible and easy to treat? And when should you see a doctor?
How is an erection produced?
An erection is a complex process in which the nervous system, blood vessels, hormones and muscles work closely together. In addition to nervous and vascular control, testosterone also plays an important role in erection. The hormone not only influences libido, but also supports the production of nitric oxide (NO), which is crucial for the dilation of blood vessels in the penis.
The nervous system as a trigger
Sexual stimuli activate the central nervous system, especially the hypothalamus, which sends signals to the penile nerves via the spinal cord (Porst et al. 2013). These nerves release nitric oxide (NO) – a key molecule that relaxes the blood vessels and increases blood flow to the penis (Andersson & Wagner, 1995).
Blood vessels and corpora cavernosa
The release of NO relaxes the smooth muscle cells in the penile arteries, allowing more blood to flow into the corpora cavernosa (erectile tissue). At the same time, venous outflow is reduced, so that the blood remains in the penis and an erection is maintained (Andersson & Wagner, 1995).
What is erectile dysfunction?
Erectile dysfunction is present when a man regularly cannot get or maintain an erection for at least six months. For this to be the case, more than 70% of coital attempts must be unsuccessful and there must be distress (Salonia et al., 2021, AWMF Working Group).
Symptoms:
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Difficulty getting an erection
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Loss of erection during sexual intercourse
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Reduced erection firmness
ED occurs more frequently with increasing age: 52% of all men between 40 and 70 years of age report signs of erectile dysfunction, while men between 70 and 79 are four times more likely to be affected than men between 20 and 29 (Goldstein et al. 2019). While ED is primarily noticeable as a sexual problem, it can also indicate an underlying medical condition such as cardiovascular disease, diabetes mellitus, or hormonal disorders (Dong & Zhang, 2011)
Causes of erectile dysfunction
ED can have both physical and psychological causes. Often, several factors are involved.
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Cardiovascular diseases: Atherosclerosis describes narrowed or hardened blood vessels, which can classically lead to impaired blood flow to the heart. However, if atherosclerosis occurs in the penile blood vessels, blood flow can also be reduced there, leading to erectile problems. Since the blood vessels in the penis are smaller than the coronary arteries, erectile dysfunction often occurs before the heart shows signs of disease (Montorsi et al 2005).
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Diabetes mellitus: Diabetes mellitus describes the inability to successfully take sugar out of the blood and into the cells. Over time, excessively high blood sugar levels can directly damage the blood vessels and, similar to atherosclerosis, lead to impaired blood flow in the penile blood vessels. Diseases such as diabetes mellitus and atherosclerosis are responsible for approximately 45% of the physical causes of ED (Causes » Diseases » Internisten Im Netz, n.d.).
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Lifestyle factors: Smoking, alcohol, obesity, poor diet, and lack of exercise are independent risk factors for erectile dysfunction. They lead to a disruption in the vascular system, resulting in less nitric oxide (NO) being released and even causing the blood vessels to narrow (DeLay et al 2016).
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Hormonal changes: Low testosterone levels can impair both libido and erectile function, as androgens are important for both erection and its maintenance. It has also been shown that testosterone replacement therapy can improve erectile dysfunction in cases of testosterone deficiency (DeLay et al 2016).
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Psychological stress: Stress, anxiety, and depression can negatively affect libido and reduce motivation (Ndr, 2024, DeLay et al 2016). Chronic stress can increase the production of the stress hormone cortisol, which in turn has a negative effect on testosterone levels. Consistently low testosterone levels can impair libido and erectile function, indicating a close link between psychological stress and hormonal factors (Khan et al., 2023).
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Medication side effects: Certain medications, such as some blood pressure medications, antidepressants, painkillers, and sedatives, can cause erectile problems as a side effect. If ED occurs as a result, you should talk to your doctor about your current medication and possible alternatives (Kaplan-Marans et al. 2022).
Learn more about how stress affects your health and how you can counteract it in our article “Stress under control: Stay healthy and fit as a man.”
Treatment options for ED
Since erectile dysfunction can have various causes, the choice of the right therapy depends on the individual situation. A combination of several measures often leads to the best results.
Lifestyle changes
A healthy lifestyle can positively influence erectile function. Regular exercise promotes blood circulation and supports the cardiovascular system, which plays a central role in erection. A balanced diet rich in fruit, vegetables, healthy fats, and protein can also help reduce risk factors such as obesity or high blood pressure. In addition, quitting smoking and excessive alcohol consumption can help maintain vascular health and improve potency (Esposito et al. 2004). Certain supplements such as L-arginine, omega-3 fatty acids, or ginseng can also have a supportive effect, as they promote blood circulation or have anti-inflammatory effects. However, they do not replace medical treatment and are only useful as a supplement to a healthy lifestyle (Najafabadi et al., 2019).
A balanced diet plays a crucial role in sexual health. You can find tips and recommendations in our post “The best foods for men – How to optimize your diet.”
Treatment of underlying medical conditions
Since erectile dysfunction is often a symptom of an underlying medical condition, treating the cause should be the priority. For example, if diabetes mellitus or high blood pressure impairs blood circulation, targeted therapy for these conditions can improve erectile function. Medical assessment is therefore essential to take individually appropriate measures – whether optimizing blood sugar levels, adjusting blood pressure medication, or treating hormonal imbalances (Viigimaa, 2014).
Medication therapy
PDE-5 inhibitors such as sildenafil (Viagra) or tadalafil (Cialis) are the best-known and often the first medication treatment option for ED. These active ingredients improve blood flow to the penis by dilating the blood vessels, thus supporting erectile function. However, they only work with sexual stimulation and are not suitable for every patient. Alternatively, medications such as papaverine or prostaglandins can also be injected directly into the corpora cavernosa of the penis, leading to increased blood flow and erection. However, whether and which form of medication therapy is suitable should always be discussed with a doctor (McMahon, 2019, Wang et al. 2023).
Hormone therapy
A testosterone deficiency can also be a cause of erectile dysfunction. In such cases, testosterone replacement therapy may be useful. Before treatment, the hormone level in the blood is checked to determine whether a deficiency actually exists. Individually tailored hormone replacement therapy can help improve not only erectile function, but also general well-being and libido (Snyder et al. 2016).
Psychotherapy
Psychological factors such as stress, pressure to perform, or fear of failure can also contribute to ED. Cognitive behavioral therapy or talk therapy can help break negative thought patterns and strengthen self-confidence regarding one's sexuality. In addition, relaxation techniques such as meditation or mindfulness exercises can have a supportive effect.
Modern therapy approaches
In addition to classic treatments, there are increasingly innovative approaches that show promising results. This includes shockwave therapy, in which high-energy sound waves are intended to improve blood circulation in the penis and stimulate the regeneration of blood vessels. Another option is PRP injections (Platelet-Rich Plasma), in which the body's own growth factors are used to revitalize the tissue in the penis. Both methods are currently being intensively researched and could represent a complementary treatment option in the future (Wang et al. 2023).
Which treatment is the right one?
The choice of the best therapy should always be made individually. A medical examination helps identify the causes of ED and find a tailored treatment. Seeking professional support early on can sustainably improve not only sexual health, but also overall quality of life. In addition to medical approaches, sexual therapy can also be useful, especially when psychological factors or relationship dynamics play a role. Specialized sex therapists help identify and overcome pressure to perform, anxieties, or communication problems in the partnership (S. Khan et al., 2019).
Why hormone levels are crucial
Testosterone plays a central role in male sexual health. The hormone influences not only libido, but also the ability to get and maintain an erection. One of the main functions of testosterone is the regulation of nitric oxide (NO) production, which is essential for blood circulation in the penis. If testosterone levels drop, this can significantly impair sexual performance. The influence of testosterone on erection is highly complex and has not yet been fully clarified (Brooke et al., 2014).
How testosterone affects sexual function
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Libido and arousal: Testosterone is closely linked to sexual desire. Men with low testosterone levels often report reduced interest in sex (Pencina et al. 2023)
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Erectile function: Studies show that testosterone is indirectly involved in erectile function, especially through NO production, which dilates the blood vessels in the penis.
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Testosterone deficiency as a risk factor: A testosterone deficiency can impair sexual function. Men with reduced testosterone levels have an increased risk of erectile dysfunction (ED) (DeLay et al 2016)
Can testosterone therapy help?
Testosterone replacement therapy (TRT) can improve sexual function – but only if a clinically relevant testosterone deficiency actually exists. TRT improves both libido and erectile dysfunction in some patients and, according to surveys, leads to increased sexual activity. If erectile dysfunction is purely vascular or due to another underlying medical condition, however, TRT has no demonstrable effect (Yeap et al. 2024, Pencina et al. 2023).
For a deeper understanding of how hormonal fluctuations affect your health, read our article “Hormonal Fluctuations: Understanding the Highs and Lows of Testosterone Levels.”
Our Conclusion, Your Knowledge
Erectile dysfunction is not just an isolated sexual problem – it can be a warning sign of serious health conditions. That is why ED should always be medically evaluated in order to identify and address potential health risks early. You can also take active steps yourself and take preventive measures. A healthy lifestyle with plenty of exercise supports your cardiovascular system and reduces the risk of diabetes and obesity. You can also have your testosterone levels tested to gain insight into your hormonal balance and intervene early. Those who know their individual risk factors and consciously take countermeasures can not only improve their quality of life but also prevent serious long-term health consequences.
A key component of prevention is the regular monitoring of key health markers. Adon Health offers innovative blood tests that allow you to conveniently analyze important values – including your testosterone levels – from home. This gives you valuable insights into your health status and allows you to take targeted measures to actively support your well-being.