Low Testosterone and Erectile Dysfunction: Understanding the Complex Connection

By Arsenal Men's Health Clinical Team | Reviewed by Courtney LaSumner Bass, NP

Category: Testosterone Therapy | Sexual Health
Reading Time: 12 minutes
Last Updated: December 2025

Key Takeaways

• Erectile dysfunction affects approximately 18% of American men over age 20, with prevalence increasing significantly with age

• Low testosterone is rarely the direct cause of erectile dysfunction—ED is primarily a vascular condition

• However, low testosterone creates multiple indirect pathways that contribute to erectile difficulties

• When both conditions coexist, a comprehensive treatment approach addressing hormones AND blood flow typically produces the best outcomes

• Evidence-based treatment protocols can significantly improve sexual function for men experiencing both conditions

Introduction: A Common Question Utah Men Ask

If you're a man experiencing sexual performance concerns, you've likely wondered whether your testosterone levels might be to blame. It's a logical connection to make—testosterone is the quintessential male hormone, associated with virility, strength, and sexual prowess. So when erections become inconsistent or difficult to maintain, hormone levels are often the first suspect.

The relationship between testosterone and erectile function is more nuanced than most men realize. While these two conditions frequently coexist, the connection between them isn't as straightforward as simply "low hormone = poor erections." Understanding this relationship is crucial for effective treatment.

At Arsenal Men's Health, we've guided over 1,200 Utah men through evidence-based protocols that address the full spectrum of factors affecting sexual performance. This comprehensive guide will break down exactly what the research tells us about how testosterone influences erectile function—and what you can actually do about it.

The Scope of Erectile Dysfunction: You're Not Alone

Before diving into the testosterone connection, let's establish just how common erectile difficulties actually are among American men.

Prevalence Statistics

Research from the Johns Hopkins Bloomberg School of Public Health, published in The American Journal of Medicine, found that erectile dysfunction affects over 18 million men in the United States—approximately 18.4% of the male population aged 20 years and older.¹ The landmark Massachusetts Male Aging Study found that roughly 52% of men experience some form of erectile dysfunction, with complete ED affecting approximately 10% of men aged 40-70.²

The relationship with age is particularly striking:

• Ages 20-40: Approximately 5% prevalence³

• Ages 40-49: Approximately 22% prevalence²

• Ages 50-59: Approximately 40% prevalence⁴

• Ages 60-69: Approximately 49% prevalence²

• Ages 70+: Significantly elevated rates³

The 2021 National Survey of Sexual Wellbeing, representing the first nationally representative update on ED prevalence in nearly two decades, confirmed that severity remains highest in older age groups—with approximately 52% of men aged 75 and older meeting diagnostic criteria for ED.⁵

The Hidden Burden

What these statistics don't capture is the psychological toll. Erectile difficulties significantly impact mood, interpersonal relationships, and overall quality of life. Many men suffer in silence, with research indicating that most individuals who meet criteria for ED have not sought medical care for this concern.⁵

Understanding Testosterone's Role in Male Sexual Function

Testosterone is the primary androgen circulating in the male body, playing a pivotal role in numerous physiological processes across multiple organ systems including bone, muscle, and fat metabolism.⁶ In the context of sexual function, testosterone serves several critical roles.

The Biological Functions

Libido Regulation: Testosterone enhances sexual desire by acting on specific regions of the brain responsible for sexual motivation. There's a well-established connection between low testosterone levels and diminished sex drive.⁷

Tissue Development: During puberty, testosterone drives the development of male sexual characteristics, including penile growth and development of erectile tissue.

Nitric Oxide Signaling: Testosterone appears to influence the nitric oxide-cGMP pathway, which is fundamental to the erection process. Animal studies suggest androgens help maintain the structure and function of smooth muscle tissue in the penis.⁸

Neurotransmitter Modulation: Testosterone influences dopamine and other neurotransmitters involved in sexual arousal and response.

Natural Decline Patterns

Longitudinal research from the Baltimore Longitudinal Study of Aging demonstrates that serum testosterone levels gradually decline as men age, beginning around age 40. By their 60s and 70s, approximately 20% and 30% of men respectively meet criteria for late-onset hypogonadism.⁹'¹⁰

This natural decline doesn't necessarily mean symptomatic deficiency. Many men maintain adequate erectile function despite testosterone levels in the lower-normal range.

The Critical Question: Does Low Testosterone Directly Cause ED?

Here's where we need to challenge a common assumption. Despite the intuitive connection, the scientific consensus indicates that low testosterone is not typically a direct physiological cause of erectile dysfunction.

The Vascular Reality

Erectile dysfunction is, at its core, a vascular condition. An erection requires a precisely coordinated sequence:

1. Sexual stimulation triggers nerve signals

2. Nitric oxide is released in penile tissue

3. Smooth muscle relaxes, allowing blood vessels to dilate

4. Blood flows into the corpus cavernosum

5. Venous outflow is restricted, maintaining rigidity

The most common cause of ED is compromised blood flow to the penis, often resulting from conditions like high blood pressure, atherosclerosis (hardening of the arteries), elevated cholesterol, or diabetes.¹¹ These vascular issues physically prevent adequate blood from entering and remaining in penile tissue—a problem that isn't solved by simply raising testosterone levels.

What the Meta-Analyses Show

A comprehensive meta-analysis published in European Urology examined 14 placebo-controlled randomized clinical trials enrolling 2,298 participants to evaluate testosterone therapy's effect on erectile function. Using the International Index of Erectile Function (IIEF) as the primary outcome measure, researchers found that testosterone treatment significantly improves erectile function specifically in hypogonadal men—those with clinically low testosterone.¹²

However, the same body of research indicates that men with normal testosterone levels and ED typically don't experience improved erections from testosterone supplementation alone.

A 2024 systematic review and meta-analysis analyzing 28 randomized controlled trials involving 3,461 patients confirmed that testosterone replacement therapy produces statistically significant improvements in IIEF scores (WMD 3.26; 95% CI 1.65-4.88; P<0.0001)—but primarily in men with documented late-onset hypogonadism.⁶

The Bottom Line

Roughly one in three men with erectile dysfunction also have low testosterone.¹³ But correlation doesn't equal causation. These conditions frequently coexist because they share many of the same underlying risk factors—not because one directly causes the other.

The Indirect Pathways: How Low Testosterone Contributes to ED

While testosterone deficiency may not directly prevent erections, it creates several indirect pathways that contribute to erectile difficulties. Understanding these connections is essential for effective treatment.

1. Diminished Libido

Perhaps the most significant way low testosterone impacts erections is through reduced sexual desire. Testosterone is fundamentally linked to libido in men. When testosterone levels drop, many men simply don't think about sex as often or feel the same level of desire.

Erections require arousal—both psychological and physical. If your brain isn't generating those "interested" signals as frequently or intensely, the downstream physiological response (including erection) is less likely to occur.

A Mayo Clinic meta-analysis of 17 randomized placebo-controlled trials found that testosterone showed a large effect on libido (pooled effect size 1.31; 95% CI 0.40-2.25) in men with low testosterone—a substantially stronger effect than on erectile function itself.¹⁴

2. Mood and Mental Health Impact

Low testosterone is strongly associated with depression, anxiety, irritability, and cognitive difficulties. These psychological factors independently contribute to erectile dysfunction.

Mental health conditions create a "psychological block" that interferes with the complex neurological signaling required for erection. Relationship strain from mood changes can further compound the problem, creating a negative cycle.

3. Fatigue and Energy Depletion

Testosterone deficiency commonly causes persistent fatigue, reduced vitality, and diminished sense of well-being. When a man is chronically exhausted, sexual activity often becomes less appealing or achievable—not because of direct erectile impairment, but because the overall physiological state doesn't support it.

4. Body Composition Changes

Low testosterone promotes increased body fat (particularly visceral fat) and reduced muscle mass. Research demonstrates that men with obesity have significantly higher rates of erectile dysfunction, with one study showing ED prevalence of 64.9% among obese men compared to 52.7% in normal-weight men.¹⁵

This creates a compounding effect: low testosterone leads to weight gain, and excess body fat both converts testosterone to estrogen (further lowering T) and contributes to vascular dysfunction that directly impairs erectile function.

5. Shared Risk Factors

Many conditions that cause low testosterone also independently cause erectile dysfunction:

• Type 2 Diabetes: Up to 51.3% of men with diabetes experience ED¹; diabetes is also a major cause of secondary hypogonadism

• Obesity and Metabolic Syndrome: Drive both hormonal and vascular dysfunction

• Cardiovascular Disease: Damages blood vessels needed for both testosterone production and erections

• Hypertension: Compromises blood flow throughout the body

• Sleep Disorders: Disrupt testosterone production and contribute to fatigue/mood issues

Nearly 90% of men with erectile dysfunction have at least one risk factor for cardiovascular disease.¹

Recognizing the Signs: Symptoms of Each Condition

Erectile Dysfunction Symptoms

• Difficulty achieving erection

• Difficulty maintaining erection during sexual activity

• Reduced firmness of erections

• Needing more stimulation to achieve erection

• Decreased frequency of morning erections

Low Testosterone Symptoms

• Decreased libido (sex drive)

• Fatigue and reduced energy

• Loss of muscle mass or difficulty building muscle

• Increased body fat, especially around the midsection

• Mood changes: irritability, depression, difficulty concentrating

• Sleep disturbances

• Reduced bone density

• Decreased motivation and sense of well-being

• Hot flashes or night sweats (in severe deficiency)

When They Overlap

Men with both conditions often experience a cluster of symptoms that creates a significant impact on quality of life. The combination of reduced desire, mood disturbances, fatigue, AND erectile difficulties can be particularly frustrating and may affect intimate relationships substantially.

The Diagnostic Process: Getting Proper Evaluation

Accurate diagnosis is essential before treatment. At Arsenal Men's Health, our evaluation process includes:

Comprehensive Medical History

Understanding symptom onset, severity, and pattern. Are erections absent entirely, or just inconsistent? Are morning erections still occurring (suggesting intact vascular capacity)? What medications are you taking? What's your stress level and sleep quality?

Laboratory Testing

Testosterone Panel:

• Total testosterone (optimal: typically 500-1000 ng/dL, though reference ranges vary)

• Free testosterone (the biologically active fraction)

• SHBG (sex hormone-binding globulin)

• LH and FSH (helps distinguish primary vs. secondary hypogonadism)

Metabolic Markers:

• Complete blood count

• Comprehensive metabolic panel

• Lipid panel

• Fasting glucose and HbA1c

• PSA (in appropriate patients)

Determining the Root Cause

If both low testosterone and erectile dysfunction are present, identifying whether they share a common cause is critical. A man with uncontrolled diabetes, for example, needs metabolic management as the foundation of his treatment—ED medications and testosterone replacement may help symptoms but won't address the underlying driver.

Evidence-Based Treatment Approaches

When Low Testosterone Is the Primary Issue

If low libido is the dominant concern and testosterone levels are clearly deficient, testosterone replacement therapy (TRT) often produces substantial improvement in sexual interest and satisfaction.

The meta-analysis evidence supports that TRT significantly improves:

• Sexual desire/libido (strongest effect)¹²'¹⁴

• Erectile function in hypogonadal men¹²

• Overall sexual satisfaction⁶

TRT Administration Options:

• Intramuscular injections: Often considered most effective, with one meta-analysis showing intramuscular injection of 1,000mg testosterone producing significant sexual function improvement¹⁶

• Transdermal gels: Daily application providing steady hormone levels

• Transdermal patches: Applied daily

• Subcutaneous pellets: Implanted every 3-6 months

When Erectile Dysfunction Requires Direct Treatment

For most men with ED—particularly those with vascular or structural causes—phosphodiesterase type 5 (PDE5) inhibitors remain the first-line treatment:

• Sildenafil (Viagra®): Effective for approximately 4 hours per dose

• Tadalafil (Cialis®): Long-acting, effective for up to 36 hours

• Vardenafil: Similar duration to sildenafil

• Avanafil (Stendra®): Rapid onset with potentially fewer side effects

These medications work by enhancing the nitric oxide signaling pathway, allowing blood vessels to dilate more effectively during sexual arousal.

Combination Therapy: When Both Conditions Coexist

Research suggests that many men with both low testosterone and ED benefit most from combination therapy.

Studies have found that some men with low testosterone don't respond adequately to PDE5 inhibitors alone—testosterone replacement may be necessary to restore responsiveness to ED medications. Conversely, men with severe erectile dysfunction may need the addition of PDE5 inhibitors even after testosterone levels are optimized.¹³

A pragmatic approach:

1. Evaluate whether testosterone deficiency is clinically significant

2. If so, initiate TRT and reassess erectile function after hormone stabilization

3. If erectile difficulties persist despite optimized testosterone, add PDE5 inhibitor

4. Address modifiable risk factors throughout

Lifestyle Interventions: The Foundation of Treatment

Regardless of which medications are employed, lifestyle modifications form the foundation of any effective treatment protocol.

Physical Activity

The Johns Hopkins research found that men with erectile dysfunction were significantly less likely to have engaged in vigorous physical activity compared to men without ED.¹ Both cardiovascular exercise and resistance training have been shown to:

• Improve vascular function and blood flow

• Support healthy testosterone production

• Reduce body fat

• Improve mood and energy

• Enhance insulin sensitivity

Recommendation: 150+ minutes of moderate aerobic activity weekly, plus resistance training 2-3 times per week.

Nutritional Optimization

Certain nutritional factors may support testosterone levels:

• Zinc: Essential for testosterone synthesis

• Vitamin D: Deficiency is associated with low testosterone

• Boron: Some evidence suggests it may increase testosterone concentrations; found in nuts, beans, and avocados¹⁷

• Healthy fats: Support hormone production

• Adequate protein: Necessary for muscle maintenance and hormone synthesis

Equally important is avoiding dietary patterns that promote metabolic dysfunction—excess processed foods, refined sugars, and excessive alcohol.

Sleep Quality

Testosterone production is closely linked to sleep. Research from the CDC indicates adults should obtain seven or more hours of sleep nightly. Poor sleep disrupts the natural testosterone rhythm and contributes to fatigue, mood issues, and sexual dysfunction.

Stress Management

Chronic stress elevates cortisol, which directly suppresses testosterone production. Additionally, psychological stress independently contributes to erectile dysfunction through psychological pathways. Effective stress management strategies include mindfulness practices, physical activity, adequate sleep, and professional support when needed.

Limiting Alcohol and Avoiding Tobacco

Excessive alcohol consumption is associated with both low testosterone and erectile dysfunction. Smoking damages blood vessels, directly impairing the vascular function required for erections.

When to Seek Professional Help

Consider evaluation if you're experiencing:

• Persistent erectile difficulties lasting 3+ months

• Reduced sex drive that's impacting your relationship

• Multiple symptoms of low testosterone

• ED combined with cardiovascular risk factors (diabetes, hypertension, obesity)

• ED that's developed suddenly (may indicate underlying medical issue)

• Any concerns about sexual health or hormone levels

Important: Erectile dysfunction can be an early warning sign of cardiovascular disease. In fact, research shows that nearly 90% of men with ED have at least one cardiovascular risk factor.¹ Getting evaluated isn't just about sexual health—it may reveal important information about your overall cardiovascular status.

The Arsenal Men's Health Approach

At Arsenal Men's Health, we understand that sexual health concerns require discretion, expertise, and individualized care. Our approach combines:

Evidence-Based Protocols: Every treatment recommendation is grounded in peer-reviewed research and clinical guidelines.

Comprehensive Evaluation: We don't just check a single testosterone level—we evaluate the complete hormonal picture along with metabolic markers.

Personalized Treatment Plans: Your physiology, goals, and preferences guide your specific protocol.

Ongoing Optimization: Regular follow-up ensures your treatment remains optimized as your needs evolve.

Utah-Licensed Telehealth: Convenient access to expert care from anywhere in Utah.

Discreet, Confidential Care: Your privacy is paramount. Our telehealth model ensures your health decisions remain between you and your provider.

Conclusion: Understanding the Full Picture

The relationship between low testosterone and erectile dysfunction is complex. While testosterone deficiency rarely causes ED directly, it creates multiple pathways that contribute to erectile difficulties—from reduced libido and mood disturbances to the shared metabolic risk factors underlying both conditions.

The most effective treatment approach recognizes this complexity. Rather than assuming one condition causes the other, comprehensive evaluation identifies all contributing factors so treatment can be appropriately targeted.

Whether you're experiencing symptoms of low testosterone, erectile dysfunction, or both, evidence-based treatment options are available. The first step is accurate diagnosis.

Ready to take control of your sexual health? Arsenal Men's Health provides confidential, clinician-led care for Utah men seeking hormone optimization and sexual health solutions.

References

1. Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med. 2007;120(2):151-157. doi:10.1016/j.amjmed.2006.06.010

2. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151(1):54-61. doi:10.1016/s0022-5347(17)34871-1

3. Selvin E, et al. Johns Hopkins Bloomberg School of Public Health epidemiological findings on erectile dysfunction prevalence. Am J Med. 2007.

4. Translational Andrology and Urology. Aging related erectile dysfunction—potential mechanism to halt or delay its onset. 2017.

5. Herbenick D, et al. Erectile dysfunction prevalence in the United States: report from the 2021 National Survey of Sexual Wellbeing. J Sex Med. 2024;21(4):296-303. doi:10.1093/jsxm/qdae015

6. Yang F, et al. An updated systematic review and meta-analysis of the effects of testosterone replacement therapy on erectile function and prostate. Front Endocrinol. 2024;15:1335146. doi:10.3389/fendo.2024.1335146

7. European Urology. 2021 Guidelines on Sexual and Reproductive Health.

8. Aversa A, Isidori AM, Spera G, et al. Androgens improve cavernous vasodilation and response to sildenafil in patients with erectile dysfunction. Clin Endocrinol. 2003;58:632-638.

9. Feldman HA, Longcope C, Derby CA, et al. Age trends in the level of serum testosterone and other hormones in middle-aged men: longitudinal results from the Massachusetts Male Aging Study. J Clin Endocrinol Metab. 2002;87(2):589-98. doi:10.1210/jcem.87.2.8201

10. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Longitudinal effects of aging on serum total and free testosterone levels in healthy men: Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab. 2001;86(2):724-731.

11. Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766-778.

12. Corona G, Rastrelli G, Morgentaler A, Sforza A, Mannucci E, Maggi M. Meta-analysis of results of testosterone therapy on sexual function based on International Index of Erectile Function scores. Eur Urol. 2017;72(6):1000-1011. doi:10.1016/j.eururo.2017.03.032

13. Cleveland Clinic. Does Low Testosterone Cause Erectile Dysfunction? Health Essentials. 2022.

14. Boloña ER, Uraga MV, Haddad RM, et al. Testosterone use in men with sexual dysfunction: a systematic review and meta-analysis of randomized placebo-controlled trials. Mayo Clin Proc. 2007;82(1):20-28. doi:10.4065/82.1.20

15. Alazawi W. Prevalence and risk factors of erectile dysfunction among men attending primary health care centres in Qatar. East Mediterr Health J. 2011;17(7):587-592.

16. Yoo HJ, Kim JH, et al. The effect of testosterone replacement on sexual function in the elderly: a systematic review and meta-analysis. World J Mens Health. 2023;41(4):794-805. doi:10.5534/wjmh.220171

17. Pizzorno L. Nothing Boring About Boron. Integr Med (Encinitas). 2015;14(4):35-48.

Medical Disclaimer: This content is for educational purposes only and does not constitute medical advice. Treatment decisions should be made by a licensed medical provider based on individual evaluation. Results vary based on individual factors including underlying health conditions.

Arsenal Men's Health provides clinician-prescribed men's health optimization services exclusively to Utah residents. All treatments are prescribed by Courtney LaSumner Bass, NP, a board-certified nurse practitioner and military veteran.

Contact Arsenal Men's Health 📞 (385) 666-6292
📧 info@arsenalmenshealth.com
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