Top 3 erectile dysfunction causes

The relationship

ED is not only a bedroom problem. It is also a health signal. In 2011, a meta study of 12 prospective cohort studies with 36,744 men found that men with ED had a 1.48 times higher risk of future cardiovascular disease, a 1.46 times higher risk of coronary heart disease, and a 1.35 times higher risk of stroke [2]. The same review linked ED to a 1.19 times higher all cause death rate. This held even after adjusting for standard risk factors like smoking and high blood pressure [2]. In plain terms, trouble getting hard can point to trouble in the arteries that also feed the heart and brain.

Pelvic floor strength matters too. In a 2004 randomized controlled trial, men with chronic ED were split into two groups. One group learned targeted pelvic floor muscle training with biofeedback. The other group only got lifestyle advice. After three months, the training group had stronger erections and better ability to maintain rigidity during sex compared with the advice-only group [3]. Later work in 2005 confirmed that focused pelvic floor practice can restore erectile function in many men, even after years of ED [6].

Mind state matters as well. A 2022 systematic review looked at men with diagnosed anxiety disorders and found that the median erectile dysfunction rate was 20.0 percent, and the ED in that group tended to be more severe [4]. This pattern is often called psychological erectile dysfunction. Worry about performance spikes stress hormones, tightens arteries, and kills the erection before full pressure is reached [4].

How it works

Blood flow and pressure: vascular ED

An erection needs open arteries and healthy vessel lining. The inner vessel lining is called the endothelium, which is a thin layer of cells that control vessel tone and blood flow. During arousal the endothelium in penile arteries releases nitric oxide, a gas signal that relaxes smooth muscle in erectile tissue so blood can rush in and fill the corpora cavernosa, the main erectile chambers [1]. If arteries are stiff from plaque, also called atherosclerosis, less blood gets in and pressure never hits full strength [1,2]. This is why ED often shows up along with high blood pressure, high cholesterol, or early heart disease [2].

Nerve signal and erection control

The brain sends arousal signals through pelvic nerves to the penis. A key branch is the cavernous nerve. The cavernous nerve runs along the prostate and triggers the chemical release that lets erectile tissue relax and fill with blood. Injury to this nerve, for example after prostate surgery or pelvic trauma, can blunt or block the erection signal and lead to rapid loss of firmness [5]. Reviews in 2021 note that damage to the cavernous nerve is a major driver of erection loss after prostate surgery, and current rehab plans focus on nerve protection and early support of blood flow [5]. Much of the detailed biology comes from animal work and post surgical patients, but the core idea is the same: no signal, no erection [5].

Pelvic floor and ED support

The pelvic floor acts like a valve. During erection, these muscles lift and squeeze at the base of the penis to trap blood inside. When they are weak, blood leaks out early and firmness drops even if inflow is decent. A controlled trial in 2004 taught pelvic floor muscle training with biofeedback. After three months, many men regained functional erections good enough for intercourse, while the lifestyle-only group lagged [3]. Follow up work in 2005 reported that simple daily pelvic floor exercises can restore erectile function without pills for a meaningful share of men [6]. This is why pelvic floor and ED care now includes focused muscle training, not only pills [3,6]. pelvic floor muscle training means repeated squeeze and lift drills for the deep muscles under the pelvis, often taught by a pelvic physical therapist or trained clinician.

Stress brain loop and psychological erectile dysfunction

Sex is also a brain event. Fear of losing the erection raises adrenaline and cortisol. These stress chemicals tighten arteries and shut down the same nitric oxide signal that should relax penile muscle. A 2022 review of men with diagnosed anxiety disorders found a median erectile dysfunction rate of 20.0 percent and noted that ED in that group was often more severe and harder to ignore [4]. This explains why many men can get hard alone but lose firmness with a partner. The mind is scanning for failure, not pleasure [4].

Testosterone, hypogonadism, and the hormonal ED percentage

testosterone is the main male sex hormone made in the testicles. Low levels can reduce sex drive, morning erections, mood, and energy. Chronic low testosterone with symptoms is called hypogonadism. The European Male Aging Study and related work found that sexual symptoms plus total testosterone under about 350 ng per deciliter, which is about 12 nmol per liter, mark men most likely to benefit from therapy [7]. If total testosterone is borderline, checking free testosterone helps. Free testosterone under 100 pg per mL, which is about 10 ng per dL, supports true hypogonadism when symptoms persist [7].

testosterone replacement therapy means doctor prescribed testosterone to bring a low level back into the normal range. A 2017 meta analysis of 14 placebo controlled trials with 2,298 men showed that testosterone therapy raised erection scores on the International Index of Erectile Function, which is a standard questionnaire that scores erection strength and sexual function, by about 2.31 points on average [8]. Men with more severe low testosterone, under 8 nmol per liter, which is about 230 ng per dL, improved the most [8]. Men with milder low testosterone also improved, but less [8]. The hormonal ED percentage is real, but it is a minority. Many men with ED have normal testosterone and still struggle because of blood flow limits, pelvic floor weakness, or stress.

Conditions linked to it

• Heart and blood vessel disease. ED often tracks with high blood pressure, high cholesterol, and artery plaque. A 2011 meta analysis of 36,744 men found that men with ED had a 1.48 times higher risk of cardiovascular disease and higher risk of stroke and death [2]. Vascular ED is often the first red flag that blood flow to the heart may also be at risk [2].
• Type 2 diabetes and metabolic strain. High blood sugar and central fat harm small arteries and also harm nerves. Men with obesity or diabetes often show weaker response to erection meds and weaker gain from testosterone therapy, which means blood flow injury and nerve injury are already in play [8].
• Nerve injury. Surgery on the prostate or trauma to the pelvis can bruise or cut the cavernous nerve. This shuts off the erection signal. Reviews in 2021 describe cavernous nerve injury as a major reason for ED after prostate surgery and focus on nerve protection and rehab [5].
• Pelvic floor dysfunction. Poor tone or poor timing in the pelvic floor lets blood leak out of the penis early. Trials in 2004 and 2005 showed that pelvic floor muscle training and biofeedback restored rigidity in many men, even when pills had not worked well [3,6].
• Chronic anxiety and trauma. A 2022 systematic review found that men with diagnosed anxiety disorders had a median ED rate of 20.0 percent, and scores pointed to mild to moderate ED severity [4]. This is strong support for psychological erectile dysfunction as a real biologic loop, not “in your head” in a dismissive sense [4].
• Low testosterone and other hormone shifts. Men with proven hypogonadism often show low sex drive, weak morning erections, and poor response to standard ED pills. Testosterone therapy alone can raise erection scores, especially when total testosterone is well under 350 ng per dL and symptoms match [7,8].

Limitations: Research on nerve repair and pelvic floor rehab often comes from men after prostate surgery or from animal studies that model nerve crush or cut. Results in those settings guide care, but they do not always predict your exact outcome if you are a 42 year old man with weight gain and high stress at work.

Symptoms and signals

These are common patterns men report. They can hint at the main driver.

• You cannot get hard at all, even when you are alone and relaxed. This may point toward blood flow or nerve signal trouble.
• You get partly hard but lose firmness fast during sex. This may point toward pelvic floor fatigue or venous leak from weak pelvic floor support.
• You wake up with weak or no morning erections. Morning erection is a normal reflex during deep sleep. Ongoing loss can point toward low testosterone, blood flow limits, or nerve injury.
• You can get hard when alone but go soft with a partner. This often matches psychological erectile dysfunction, where worry kills the signal.
• You feel deep ache in the pelvis, perineum, or base of the penis during arousal. This can point toward pelvic floor tension or a nerve irritation in the pelvis.
• Your penis bends sharply, hurts, or has new hard plaques. Curvature with pain can reduce rigidity and can need in person care from a urologist.
• You get chest tightness or short breath during sex. That can signal heart strain and needs urgent medical attention.
• You had sudden ED right after a pelvis injury or surgery. That can signal nerve trauma and should be checked right away.

What to do about it

This is a fast plan used by many urologists and andrologists. It follows what major groups such as the American Urological Association advise for ED workup and follow up [1].

1. Step 1. Get checked and get numbers.

   You need a focused exam, blood work, and a short mental health screen. Ask for:

   • Total testosterone drawn in the early morning on two different days. If total testosterone is low or borderline, ask for free testosterone. Meta analyses indicate that symptomatic men with total testosterone below 350 ng per dL, which is about 12 nmol per L, are most likely to benefit from treatment. If total testosterone is borderline, free testosterone under 100 pg per mL, which is about 10 ng per dL, supports hypogonadism. In practice, use 350 ng per dL for total or 100 pg per mL for free as decision cutoffs when symptoms persist [7].
   • Fasting glucose, A1C, and lipids. High sugar and high LDL point toward artery injury that can cause vascular ED and heart risk [2].
   • Blood pressure, body weight, and waist size. Extra visceral fat and high pressure strain penile arteries and lower nitric oxide release [1,2].
   • A quick screen for anxiety, sleep debt, or relationship stress. The 2022 review showed a clear tie between clinical anxiety disorders and higher ED rates and worse scores [4].
   • A pelvic floor screen. You should be able to squeeze and lift the pelvic floor on command without breath holding. A trained pelvic floor physical therapist can test this in a few minutes [3,6].

   This first step is about clarity. You cannot fix what you do not measure [1,2,4,7].

2. Step 2. Treat the main driver instead of guessing.

   Once you have data, match the fix to the cause.

   • Blood flow and heart health: Raise daily movement, reduce waist size, and stop smoking. Even brisk walking and basic strength work improve endothelial nitric oxide release and lower cardiovascular risk, which can raise erection quality and lower long term heart risk [1,2]. Standard ED pills called phosphodiesterase type 5 inhibitors, such as sildenafil, boost the nitric oxide signal and increase penile blood flow for a few hours. They are a first line option in most men without nitrate heart meds [1].
   • Pelvic floor support: Start pelvic floor muscle training. In 2004, men taught targeted pelvic floor drills plus biofeedback had clear gains in erection rigidity and control over ejaculation after three months, better than lifestyle tips alone [3]. A 2005 follow up showed that daily pelvic floor work can restore erectile function in many men who had ED for more than one year [6]. Aim for squeeze, lift, hold, then relax. Repeat several times per day. This is simple and has almost no side effects [3,6].
   • Stress loop and anxiety: If you can get hard alone but not with a partner, you likely have a stress lock. Sex therapy, cognitive behavioral therapy, breathing drills, and slower build up can break the fear spike and lower the adrenaline surge that shuts down penile blood flow. The 2022 review confirmed that anxiety and ED go together and can feed each other [4]. You are not broken. Your stress system is just too hot in the moment [4].
   • Low testosterone: If you meet clear hypogonadism numbers and have classic low drive signs, your clinician may offer testosterone replacement therapy. The 2017 meta analysis pooled 14 placebo controlled trials with 2,298 men. Testosterone therapy raised the erectile function domain score of the International Index of Erectile Function by about 2.31 points compared with placebo [8]. The biggest jump came in men whose total testosterone was very low, under 8 nmol per L, which is about 230 ng per dL [8]. This shows testosterone therapy can help erection strength and sex drive when true low T is present. It also shows that if your testosterone is normal, extra testosterone is unlikely to fix ED on its own [7,8].
   • Nerve injury after prostate surgery or pelvic trauma: You may need early rehab focused on nerve support, erection support devices, and blood flow support while the cavernous nerve heals. Current rehab plans aim to keep oxygen and stretch in the erectile tissue so it does not scar while the nerve recovers [5].
3. Step 3. Monitor and adjust.

   ED is not set in stone. Track erection quality, morning erections, and ability to stay hard during sex. Recheck blood pressure, fasting glucose, and lipids at regular follow up. If you start testosterone therapy, repeat testosterone, blood count, and PSA as advised. If you start a pelvic floor program, reassess squeeze strength and leak control after eight to twelve weeks. If stress is the main block, keep mental health work in play and reassess anxiety scores. The goal is steady function, not a one time fix [1,2,3,4,5,6,7,8].

Myth vs Fact

• Myth: ED means you are not attracted to your partner. Fact: The 2022 anxiety review shows that many men with ED still feel desire, but stress hormones kill the erection before it locks in [4].
• Myth: ED is always low testosterone. Fact: The hormonal ED percentage is small. Most ED in men 35 to 50 is from blood flow, pelvic floor, nerve signal, or stress, not only hormones [1,2,3,4]. Testosterone therapy helps most when total testosterone is clearly below 350 ng per dL with symptoms [7,8].
• Myth: Viagra fixes the root cause. Fact: Phosphodiesterase type 5 inhibitors boost penile blood flow for a short window, but they do not fix artery plaque, pelvic floor weakness, or chronic anxiety [1,3,4]. You still need lifestyle, pelvic floor work, and stress control if those are your drivers.
• Myth: Kegels are just for women. Fact: Male pelvic floor training with biofeedback restored erectile function in controlled trials in 2004 and 2005, even in men who had ED for more than one year [3,6].

Bottom line

ED is not only about testosterone. For most men in their late thirties through late forties, the main causes are blood flow limits, pelvic floor weakness, and the stress loop that shuts the erection off early. Hormones still matter, but true hormonal ED is the minority. The fix is not guesswork. Get numbers. Train what is weak. Protect heart and nerve health. Keep follow up. You can get function back, and you can lower long term health risk at the same time [1,2,3,4,5,6,7,8].