Most men who come to us about erectile difficulty have already been offered a pill by a website that asked them almost nothing. Sometimes a pill is the right answer. Often it treats the symptom of something measurable — and occasionally that something matters a great deal more than the symptom.
Medically reviewed by Kent Cohen, MD, FACEP — Medical Director, Balanced Bodies: Longevity + Wellness Clinic. Last reviewed October 2026.
An erection is a vascular event
It depends on blood flow, and blood flow depends on the health of your blood vessels and the lining inside them.
That has a consequence most men are never told. The arteries supplying the penis are considerably narrower than the coronary arteries supplying the heart. When vascular disease develops, narrower vessels show it first.
Which is why erectile dysfunction is recognised as an early marker of cardiovascular disease — frequently appearing years before any cardiac symptom. For a man in his forties or fifties, new erectile difficulty is a reason to have blood pressure, lipids and blood sugar checked, not just a reason to get a prescription.
That is the single most useful thing on this page. A website that mails you tablets without checking any of it is not treating you; it is selling you something that also happens to conceal a warning sign.
The common causes, roughly in order
Vascular. High blood pressure, high cholesterol, atherosclerosis, type 2 diabetes. Diabetes in particular affects both blood vessels and nerves.
Medication side effects. Several widely prescribed drug classes contribute, including some blood pressure medications and some antidepressants. Do not stop anything on your own, but do bring the list.
Psychological. Anxiety, depression, stress and relationship difficulty are genuine causes rather than a diagnosis of exclusion. Performance anxiety in particular is self-reinforcing.
Lifestyle. Smoking is strongly associated. So are heavy alcohol use, significant excess weight and physical inactivity.
Sleep apnoea. Common, under-diagnosed, and associated with both erectile difficulty and low testosterone.
Hormonal. Low testosterone can contribute, most often by reducing desire rather than by directly impairing the mechanism. It is on this list — just not at the top of it, which is the opposite of how most clinics present it.
Neurological and surgical. Prostate surgery, pelvic injury, spinal problems, multiple sclerosis.
A distinction worth noticing yourself
If you still have spontaneous morning erections but struggle during sex, the plumbing is working and the cause is more likely psychological or situational. If they have disappeared along with everything else, that points toward a physical cause.
It is not diagnostic on its own, but it is informative, and it is the sort of thing worth mentioning at a consultation.
What an evaluation involves here
A conversation, then blood work: testosterone from a morning sample, blood glucose and HbA1c, a lipid panel, thyroid function, and a full blood count. Plus blood pressure, and a review of your medications.
From there the plan depends on what we find. If testosterone is genuinely low and treatment is appropriate, that is something we treat. If your blood sugar or lipids are the story, that is a different and more important conversation. If what you need is a cardiology referral, a sleep study or a urologist, we will tell you and point you there.
The consultation is free, it is private, and nothing goes to an insurer because we do not bill one. More on the sexual health page.
Book a free consultation or call (678) 919-4845.
Further reading
MedlinePlus: Erectile Dysfunction
This article is general information, not medical advice. Erectile dysfunction can be a sign of serious underlying disease and is worth evaluating properly.
