Testosterone and erectile problems

How testosterone affects your erection

Testosterone is not just a "sex hormone". It affects your erectile function on at least four levels:

Libido: testosterone drives spontaneous sexual desire. Without sufficient testosterone, the desire disappears, and without desire, the body is less readily activated.
Morning erections: spontaneous nocturnal and morning erections are an indicator of your hormonal status and vascular function. A decrease often points to hormonal or vascular decline.
NO production: testosterone stimulates the production of the eNOS enzyme in the endothelium, leading to more nitric oxide being produced. Less testosterone means less NO, and less NO means a weaker erection.
Energy and mood: low testosterone is associated with fatigue, irritability, and low mood. This affects not only your physical ability, but also your motivation and self-confidence, factors that strongly influence erectile function indirectly.

Symptoms of low testosterone

Low testosterone is rarely a single symptom. It is a pattern. If you recognise three or more of the following signs, blood testing is worthwhile:

1. Reduced libido
Less spontaneous desire for sex, even with an available and attractive partner.
2. Fewer morning erections
Where you used to wake up with an erection almost daily, it now happens rarely or never.
3. Fatigue
Persistent tiredness that does not improve with more sleep. A feeling as if your battery never fully recharges.
4. Loss of muscle mass
Gradual loss of strength and muscle volume, despite adequate protein intake and exercise.
5. Increase in abdominal fat
Fat storage shifts to the abdomen (visceral fat), which increases the risk of cardiovascular conditions.
6. Irritability or low mood
Mood swings, a short fuse, or a persistent feeling of flatness.
7. Concentration problems
Difficulty with focus, mental sharpness, and memory, often described as "brain fog".
8. Sleep problems
Difficulty staying asleep, less deep sleep, or waking up without feeling rested.

Three profiles

Erectile problems after 40 are rarely exclusively vascular or exclusively hormonal. In practice, we see three profiles:

Predominantly vascular

The blood vessels are the main problem. Testosterone is normal or slightly low. The erection becomes less firm and is lost more quickly. PDE5 inhibitors still work, but less effectively than before.

Predominantly hormonal

Testosterone is clearly low. Libido is reduced, morning erections are absent, fatigue dominates. Vascular function may still be reasonably intact, but without the hormonal signal, the erection does not get started.

Combination (most common after 40)

Both vascular decline and hormonal decrease play a role. This is the most common profile in men over 40. Treating only one component yields suboptimal results.

Blood values: what is measured?

A single testosterone number does not tell the whole story. At REVIVO, we look at the complete hormonal picture:

Total testosterone
Normal range: 8 – 30 nmol/L. Below 8 nmol/L constitutes biochemical hypogonadism. Between 8 and 12 nmol/L is a grey area where symptoms are the guiding factor.
Free testosterone
The biologically active portion. Only 1 to 3% of total testosterone is free. This is often a better indicator than the total figure, especially when SHBG is elevated.
SHBG (sex hormone-binding globulin)
Binds testosterone and renders it inactive. SHBG rises with age. A high SHBG with a normal total testosterone can still cause symptoms due to low free testosterone.
LH and FSH
Hormones from the pituitary gland that regulate testicular production. Low testosterone with high LH points to primary hypogonadism (testicular failure). Low testosterone with low LH points to a central problem (hypothalamus/pituitary).

Four lifestyle pillars for testosterone

Before you think about medication or supplements: lifestyle is the most powerful modulator of your testosterone levels. These four pillars are not optional; they are the foundation.

1. Sleep

Testosterone is primarily produced during deep sleep phases. Men who consistently sleep less than 6 hours per night have up to 15% lower testosterone levels. Prioritise 7 to 8 hours of quality sleep.

2. Strength training

Heavy compound exercises (squats, deadlifts, bench press) stimulate testosterone production acutely and in the long term. Two to three sessions per week is sufficient. Overtraining is counterproductive.

3. Nutrition and weight

Excess weight, particularly visceral abdominal fat, increases the conversion of testosterone to oestrogen via the enzyme aromatase. Every kilogram of weight loss in overweight men can measurably increase testosterone. Focus on adequate protein, healthy fats, and micronutrients (zinc, vitamin D, magnesium).

4. Stress

Chronic stress raises cortisol, which directly suppresses testosterone production. The body chooses survival over reproduction. Structural stress reduction, whether through meditation, exercise, or setting boundaries, is not a luxury but a medical necessity.

Two pathways at REVIVO

Depending on your diagnosis, we offer two paths:

ED pathway: PRP + shockwave

For men with predominantly vasculogenic ED. Focused shockwave therapy for vascular repair, optionally supplemented with PRP when indicated. Including IIEF tracking at baseline and at 1, 3, 6, and 12 months. Under the final responsibility of a registered urologist.

Hormonal referral

For a clearly hormonal profile, low testosterone with matching symptoms, we refer you to a specialised hormone optimisation programme. We do not initiate testosterone therapy ourselves, but provide a targeted referral letter with your blood values and clinical picture.

For the combination profile, vascular and hormonal, both pathways work in parallel. Your physician at REVIVO coordinates and maintains oversight.

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