Erectile problems are a sensitive topic for many men – but they can be more than just a question of potency. Often, erectile dysfunction (ED) is caused by a serious underlying condition that should be detected and treated early.
But what actually causes erectile dysfunction? Is it reversible and easily treated? And when should a doctor be consulted?
How does an erection occur?
An erection is a complex process in which the nervous system, blood vessels, hormones, and muscles work closely together. In addition to neural and vascular control, testosterone also plays a crucial role in erections. This hormone not only influences libido but also supports the production of nitric oxide (NO), which is essential for the dilation of blood vessels in the penis.
Nervous system as a trigger
Sexual stimuli activate the central nervous system, particularly the hypothalamus, which sends signals via the spinal cord to the penile nerves ( Porst et al. 2013 ). These nerves release nitric oxide (NO) – a key molecule that relaxes blood vessels and increases blood flow to the penis ( Andersson & Wagner, 1995 ).
blood vessels and erectile tissue
The release of NO relaxes the smooth muscle cells in the penile arteries, allowing more blood to flow into the corpora cavernosa . Simultaneously, venous outflow is reduced, so that blood remains in the penis and an erection is maintained ( Andersson & Wagner, 1995 ).
What is erectile dysfunction?
Erectile dysfunction is diagnosed when a man is unable to achieve or maintain an erection regularly for at least six months . This requires that over 70% of intercourse attempts are unsuccessful and that the man experiences significant 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 stiffness
Erectile dysfunction (ED) becomes more common with age: 52% of all men between 40 and 70 years of age report symptoms 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 noticed as a sexual problem, it can also indicate an underlying condition such as cardiovascular disease, diabetes mellitus, or hormonal disorders ( Dong & Zhang, 2011 ).
Causes of erectile dysfunction
Erectile dysfunction can have both physical and psychological causes. Often, several factors are involved.
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Cardiovascular diseases: Arteriosclerosis describes narrowed or hardened blood vessels, which classically can lead to circulatory disorders in the heart. However, if arteriosclerosis occurs in the penile 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 even before the heart shows noticeable signs of disease ( Montorsi et al., 2005 ).
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Diabetes mellitus : Diabetes mellitus describes the inability to successfully absorb sugar from the blood into the cells. Prolonged high blood sugar levels can lead to direct damage to the blood vessels and, similar to arteriosclerosis, to impaired blood flow to the penis. Diseases such as diabetes mellitus and arteriosclerosis are responsible for approximately 45% of the physical causes of erectile dysfunction (ED) ( Causes » Diseases » Internists on the Net » , nd ).
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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) secretion and even vasoconstriction ( 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 achieving and maintaining an erection. Testosterone replacement therapy has also been shown to 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 negatively affects testosterone levels. A persistently low testosterone level can, in turn, impair libido and erectile function, thus establishing a close link between psychological stress and hormonal factors ( Khan et al., 2023 ).
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Side effects of medications: Certain medications, such as some blood pressure medications, antidepressants, painkillers, and sedatives, can cause erectile dysfunction as a side effect. If ED occurs, you should discuss your current medication and possible alternatives with your doctor ( 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: Staying Healthy and Productive 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. Often, a combination of several measures 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 erections. A balanced diet rich in fruits, vegetables, healthy fats, and protein can also help reduce risk factors such as obesity or high blood pressure. Furthermore, abstaining from smoking and excessive alcohol consumption can contribute to maintaining vascular health and improving potency ( Esposito et al. 2004 ). Certain dietary supplements, such as L-arginine, omega-3 fatty acids, or ginseng, can also be beneficial, as they promote blood circulation or have anti-inflammatory effects. However, they do not replace medical treatment and are only useful as a complement 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 article " The best foods for men – How to optimize your diet ".
Treatment of underlying diseases
Since erectile dysfunction is often a symptom of an underlying condition, treating the cause should be the primary focus. For example, if diabetes mellitus or high blood pressure impairs blood flow, targeted therapy for these conditions can improve erectile function. A medical evaluation is therefore essential to take individually appropriate measures – be it optimizing blood sugar levels, adjusting blood pressure medication, or treating hormonal imbalances ( Viigimaa, 2014 ).
Drug therapy
PDE-5 inhibitors such as sildenafil (Viagra) or tadalafil (Cialis) are the best-known and often first-line drug treatment option for erectile dysfunction (ED). These drugs 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, it is also possible to inject medications such as papaverine or prostaglandins directly into the corpora cavernosa of the penis, which lead to increased blood flow and an erection. Whether and which drug therapy is suitable should always be discussed with a doctor ( McMahon, 2019 ; Wang et al., 2023 ).
Hormonal therapy
Testosterone deficiency can also be a cause of erectile dysfunction. In such cases, testosterone replacement therapy may be beneficial. Before treatment, hormone levels in the blood are 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, performance anxiety, or fear of failure can also contribute to erectile dysfunction (ED). Cognitive behavioral therapy or talk therapy can help break negative thought patterns and strengthen self-confidence regarding one's own sexuality. Relaxation techniques such as meditation or mindfulness exercises can also be beneficial.
Modern therapeutic approaches
In addition to traditional treatments, there is a growing number of innovative approaches showing promising results. These include shockwave therapy, in which high-energy sound waves are used to improve blood flow in the penis and stimulate vascular regeneration. Another option is PRP (platelet-rich plasma) injections, which utilize the body's own growth factors to revitalize penile tissue. 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 on an individual basis. A medical examination helps to identify the causes of erectile dysfunction (ED) and to 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, sex therapy can also be beneficial, especially when psychological factors or relationship dynamics play a role. Specialized sex therapists help to identify and overcome performance anxiety, fears, or communication problems within 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 achieve and maintain an erection. One of testosterone's main functions is the regulation of nitric oxide (NO) production, which is essential for blood flow to the penis. When testosterone levels drop, this can significantly impair sexual performance. The influence of testosterone on erections is highly complex and not yet fully understood ( 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 a reduced interest in sex ( Pencina et al. 2023 ).
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Erectile function : Studies show that testosterone is indirectly involved in erectile function, particularly 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 there is a clinically relevant testosterone deficiency. TRT improves libido and, in some patients, erectile dysfunction, and surveys indicate increased sexual activity. However, if erectile dysfunction is purely vascular or due to another underlying condition, TRT has no demonstrable effect ( Yeap et al. 2024 , Pencina et al. 2023 ).
For a deeper understanding of the effects of hormonal fluctuations on your health, read our article “ Hormonal Fluctuations: Understanding the Ups and Downs 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. Therefore, ED should always be medically evaluated to identify and address potential health risks early on. You can also take proactive steps yourself. A healthy lifestyle with plenty of exercise supports your cardiovascular system and reduces the risk of diabetes and obesity. Additionally, you can have your testosterone levels checked to gain insight into your hormonal balance and intervene early. Knowing your individual risk factors and taking proactive measures can not only improve your 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 the comfort of your home. This provides valuable insights into your health and enables you to take targeted steps to actively support your well-being.
