Common Causes

What causes erectile dysfunction?

More than 90 percent of all ED can be traced to a physical (organic) cause. This cause is usually due to slow and steady decrease of blood flow to the penis, which eventually leads to inadequate and inefficient blood storage in the penis after it becomes erect. This is commonly referred as a venous leak. Most men with this condition will complain of an inability to maintain and erection. As the condition progresses, an erection will no longer be obtained as well and men may stop responding to medications such as Cialis, Levitra and Viagra.

Difficulty in getting or maintaining an erection is often a predictor of vascular problems elsewhere in the body, including heart disease. Other factors that can effect your erection include:

  • High cholesterol
  • Cigarette smoking (which constricts the blood vessels leading to the penis)
  • Excessive alcohol
  • Diabetes (as many as 60 percent of diabetic men have erection problems at some point)
  • Heart disease
  • Certain prescription drugs, particularly blood pressure and cardiovascular medications, as well as some tranquilizers and antidepressants
  • Radiation therapy to treat prostate or rectal cancer
  • Pelvic surgery (bladder, colon, rectal)
  • Spinal surgery
  • Radical prostate cancer surgery (60 percent of men, after all types of radical prostatectomy, have impotence)
  • Stroke or neurological disease, including Parkinson’s, Alzheimer’s, and multiple sclerosis
  • Trauma to the pelvic area from car or motorcycle accident
  • Hormone imbalance

Drug induced (medication)

Many prescription medications can cause problems with erections, but the ones that are the most commonly associated with this complaint are anti-hypertensive (blood pressure) medications, beta blockers, and anti-depressants. These cause ED by interfering with the nerve impulses or blood flow to the penis. Important: Medications should never be changed without your doctor’s permission. Talk to your doctor about any concerns you have regarding the potential effects of medication on ED.

Alcoholism and Smoking

Alcoholism disrupts hormone levels and can lead to permanent nerve damage, causing impotence. Smoking may lead to vascular disease or other health problems, which may cause ED. Tobacco is a major cause of erectile dysfunction; in my practice, over 68% of all of my patients either smoke or have a history of tobacco smoking.

Peyronie’s Disease (acquired penile curvature or bent penis)

Peyronie’s disease is an inflammatory condition of unknown cause, and while typically affecting men in their 50’s and 60’s, is also seen in much younger men. Deformity or narrowing of the penile shaft is usually associated with this condition. In some circumstances, it can be subtle and will only be noted during an erection. Fibrosis/scarring of the penile tissue will cause erection problems by allowing blood to leak back into the circulation (venous leak).

Many patients report significant pain with an erection, which typically lasts for six to twelve months. Most treatments, including anti-inflammatory medication, Vitamin E, Verapamil, Colchicine, are unfortunately ineffective. For men also suffering from Erectile Dysfunction and Peyronie’s Disease, insertion of the Internal Penile PumpTM is the best option. For most men, this should be considered early in order to prevent permanent penile shortening and deformity as well as to restore potency.

Physical or Nerve (neurologic) Trauma

ED can result from physical or neurological trauma to the body. These include pelvic fracture, spinal cord injuries, brain injuries or tumors, stroke, birth defects or muscular diseases. Patients with neurological diseases such as those caused by diabetes, Parkinson’s disease, Alzheimer’s, brain tumors, lumbar disc herniation, multiple sclerosis can all have Erectile Dysfunction.

Psychological Problems

While most Erectile Dysfunction is physically caused, the psychological aspects are still present in many patients. It is normal for a man who suffers from erectile dysfunction to have a psychological reaction to a loss of a normal bodily function (erections). The primary problem, however, is physical, and for most men, restoring potency will do wonders for their psychological wellbeing.

Many men under stress may experience some performance anxiety and have unreliable erections on a temporary basis. If the condition persists, then the patient should be evaluated by an expert. Depression or anxiety disorders and the medications used to treat these conditions can also cause Erectile Dysfunction.


If an erection lasts longer than four hours, it can cause tissue injury, which will result in ED. Causes of priapism include sickle cell anemia, injection therapy for ED that is improperly prescribed or used; illegal drug use or misuse of medications such as Viagra.

Effects of Aging

It is estimated that 65 percent of men over age 65 have some type of ED. Statistically, the number of men experiencing ED rises as their age increases. However, age alone does not cause ED. It is simply that older men are more likely to have the illnesses.

Hormonal Problems

This is a rare cause of erectile dysfunction. It is natural for a man’s hormone level to decrease with age, and studies show that hormonal replacement is rarely successful. Certain diseases, such as kidney failure and liver disease can disrupt the balance of hormones, which control erections. Furthermore, hormonal replacement, more specifically testosterone, has a lot of side effects including stroke, sterility, prostate enlargement, and atrophy of the testicles. Low levels of testosterone can also be a factor.

Low Testosterone and Obesity

Testosterone is a hormone that is produced by the testes in males. It performs many physiological roles in the body, including maintenance of muscle strength and muscle mass, bone density, fat distribution, production of sperm, and regulating sex drive. Testosterone levels hit their highest level in adolescence and early adulthood, and most men have some decrease in their testosterone levels around age 40. For a majority of men, this middle-age drop does not cause any harmful effects.

Obesity also plays a role metabolic syndrome in causing abnormalities in testosterone levels. Accumulation of fat around the waistline, also known as central obesity, ED, cardiovascular disease, diabetes and the metabolic syndrome share another feature in common: low male testosterone. As obesity increases, the levels of the active or free testosterone declines.


Diabetes and Erectile Dysfunction

Diabetes, high blood pressure (hypertension), elevations in blood lipids or cholesterol are considered blood vessel problems and have all been associated with Erectile Dysfunction. The blood vessel abnormalities caused by these diseases affect vessels throughout the body and often produce other symptoms of vascular diseases. Diabetics and patients with hypertension frequently have heart disease. These conditions typically interfere with the ability of the penile vessels to work properly and ultimately cause ED.

ED & Diabetes

Dr. J. Francois Eid discusses the relationship between ED and Diabetes.


Diabetes is one of the most common causes of ED. Men who have Diabetes are three times more likely to have Erectile Dysfunction than men who do not have Diabetes. Among men with ED, those with Diabetes are likely to have experienced the problem as much as 10 to 15 years earlier than men without Diabetes. A recent study of a clinic population revealed that 5% of the men with ED also had undiagnosed Diabetes. The risk of ED increases with the number of years you have Diabetes and the severity of your Diabetes. Even though 20% to 75% of men with Diabetes have ED, it can be successfully managed in almost all men.

In regards to high blood pressure, this makes the heart work harder to pump blood which can prevent blood flow from reaching the penis and in turn prevent an erection. Recent reports say that close to 2 out of 3 men report a change in the quality of their erections if they have high blood pressure.


It is established that Diabetes affects not only peripheral nerve function but peripheral blood flow as well. The association between Diabetes and ED was first documented in 1978. Men with Diabetes have four main risk factors for ED.

First, diabetes can cause damage to nerves (neuropathy) throughout your body-including the nerves to your penis. Damage to penile nerves can interfere with your body’s ability to send messages to and from the penis, which can lead to ED.

Second, Diabetes can aggravate a condition known as atherosclerosis, in which the blood vessels become narrow or harden. Narrowing or hardening of these blood vessels prevent blood flow into and out of your penis, which can cause ED.

Third, men with Diabetes need to control their blood sugar levels. When your blood sugar is not under control, your body does not produce enough Nitric Oxide (NO) and vascular tissues don’t respond as effectively to NO. When enough blood flows into the penis, penile veins close off and block the blood from flowing out. This process results in an erection. If your body does not produce enough NO or if your penile tissues do not respond to NO, the pressure of the blood flowing into your penis is not sufficient to trap the blood, you penis will not get hard.

Finally, about 12% of all men with Diabetes have low levels of the male hormone testosterone, which is required for normal erectile function.

Patient Concerns

Question: I am a 43 year old type 2 diabetic. I have tried viagra, cialis and levitra and they no longer work. Currently using the pump which works but it is a little cumbersome. I want to look into my options. Blue cross blue shield of minnesota is my provider.

Answer: Medications such Cialis, Viagra and Levitra only work in 50% of men suffering from diabetes and erectile dysfunction. Cialis is currently the preferred drug since it is the only one that may be taken on a full stomach and lasts for 36 hours. This favors a more romantic and natural sexual interaction. Planning kills the mood!

Other treatment options such as penile self-injection therapy, external vacuum pumps and the medicated urethral system for erection are on rare occasions an effective long-term treatment. A very small percentage of men will continue with these treatments as evidenced by a very high drop out rate and a very low refill rate for these treatments. These procedures require extensive planning which interfere with sexual spontaneity and are really not a realistic long-term treatment for young patients with permanent ED.

Men who do not respond or tolerate oral medications are best treated with an internal penile pump (IPP) commonly known as an inflatable implant. This cures the ED and men no longer have to think about it.

Please explore our website in order to evaluate which option you think is best for you.


ED and the Heart

Studies in the past 15 years have documented that patients with heart disease are at an increased risk of developing ED. The exact mechanism by which this occurs is not entirely known, and several theories were entertained including atherosclerosis of the penile arteries, decreased blood flow to the penis because of decreased cardiac output or perhaps a side effect of the usual heart medications. Among men aged 40 to 49, new heart disease patients were 50 times more likely to have ED compared to men over 70 who were only 5 times more likely to have ED.

Investigators then looked as to whether ED, in the absence of other obvious underlying conditions (following prostate cancer surgery for example), could be a predictor of cardiovascular disease. A 2005 study demonstrated that ED might be closely linked to endothelial dysfunction. This situation occurs when the inner lining of blood vessels becomes inflamed, perhaps from cholesterol deposits, a condition which is closely linked to heart disease, stroke and diabetes.

More recently a study in 2013 found that ED is associated with heart disease and early death in men, both with and without a history of documented cardiovascular disease, suggesting that screening for heart disease in men presenting with the complaint of ED could have perhaps identified early onset of cardiovascular disease. Furthermore men with severe ED and without known or documented history of heart disease had a 35% greater risk of being hospitalized for heart problems and a 93% higher chance of dying than men without ED.

At Advanced Urological Care, all men who present with the complaint of ED, without any previous underlying conditions or obvious reason for having ED, are screened for cardiovascular disease. In this scenario we believe that ED is a symptom and not only a diagnosis, and therefore additional diagnostic studies are warranted, before prescribing ED medications such as Cialis or Viagra.

Prostate Cancer and ED

All types of prostate cancer treatment can cause erectile dysfunction. In the course of removing the cancerous prostate gland, due to their proximity, the nerves responsible for erection are often damaged. Additionally, radiation therapy of the prostate can lead to blockage of blood flow into the penis by damaging the penile arteries. Hormonal therapy will cause lack of desire and arousal as well as the inability to obtain a full erection. Over time, hormonal therapy will cause the penis and testicle to shrink. In addition to ED, which occurs after prostate cancer surgery, men may experience urinary incontinence and/or urine leakage during sexual activity.

According to the American Cancer Society, prostate cancer is least common among Asian men and most common among black men, with figures for white men in-between. Prostate cancer occurs in 1 out of 6 men.

Treatment options include: 

  • Surgery – Da Vinci Robotic or Laproscopic prostatectomy
  • Radiation therapy
  • Hormonal therapy
  • Occasionally chemotherapy
  • Proton therapy, or some combination of these


As previously mentioned, in the process of removing tissue surrounding the cancer, surgery may damage nerve function or interrupt blood flow. Radiation therapy for prostate or bladder cancer also can permanently damage arteries.


Rates of ED post treatment of prostate cancer vary widely across the world. Although there are many new nerve-sparing techniques aimed at lowering the incidence of impotence I still see upwards of 60% of treated patients having a significant degree of ED. Temporary impotence is also associated with these procedures and recovery can be expected up to the first 18 months following the surgery. Unfortunately fewer than 10% of men will experience a return of their pre prostatectomy erectile function. Clinical trial data obtain for the FDA approval of Viagra, Cialis and Levitra also showed that only 37% of when with ED after prostate cancer surgery responded to oral medications. The majority will need a more advanced treatment.


A significant number (40%) of patients following radiation therapy will also develop erectile dysfunction, especially if pre-treatment with hormone therapy has been prescribed. ED following radiation therapy usually occurs 6 to 12 months after the treatment and is due to blockage of penile arteries and decreased circulation of blood to the penis. More recently, erectile dysfunction after prostate radiotherapy may not be related to dose exposure, research indicates.


“Erectile dysfunction after external beam radiotherapy (EBRT) for prostate cancer is not related to the radiation dose administered to the crura (base) or penile bulb,” according to a study published in the International Journal of Radiation Oncology Biology Physics. Researchers “conducted a randomized dose-escalation trial of EBRT, comparing 68 Gy and 78 Gy doses in 96 patients.” Two years later, “researchers found that 36 percent of the patients…suffer[ed] from erectile dysfunction.”

ED After Prostate Cancer Treatment

Dr. J. Francois Eid discusses ED After Prostate Cancer Treatment.

Peyronie’s Disease and ED

Overview & Causes

Peyronie’s Disease is an inflammatory, benign condition that may cause a curvature, deformity or shortening of the erect penis. This process is produced by scar formation in the fibrous covering of the erectile bodies of the penis. Men may or may not feel tenderness, a lump, or an area of scarring {plaque) in the shaft of the penis. Occasionally, this condition is also associated with pain, and, in some cases, erections and stress on the penis can exacerbate the pain. Many patients with Peyronie’s disease suffer psychological trauma, may experience difficulty with sexual intercourse, and may also suffer from erectile dysfunction. Those who suffer from erectile dysfunction, however, may not notice these symptoms.

Peyronie’s disease occurs more often in men between the ages of 50 and 70, although younger men are not immune. Its’ accurate incidence is unknown, but it is not rare. Studies show that about three percent of men over the age of 40 have scar tissue in their penis labeled as Peyronie’s disease. However, only a minority of these men have significant enough scarring, curvature, erectile dysfunction, or penile shortening to require medical attention.


A French surgeon, Francois de la Peyronie, first described Peyronie’s disease in 1734. The problem was noted in print as early as 1687, in which it was classified as a form of erectile dysfunction. However, Peyonie’s disease is associated with, rather than related to, erectile dysfunction, which is noted and not always present.


Deformity of the penis is the most frequent finding associated with Peyronie’s disease. Often, it is very subtle and only noticed when an erection is provoked. Deformities range from a narrowing of the shaft like an hourglass to a 90-degree bend of the erect penis. In addition, narrowing of the penis may be present proximally towards the base or distally towards the glans. Some men experience decreased erections distal to the area of scarring, and there is a tendency for the penis to buckle under pressure during intercourse.


The cause of Peyronie’s disease is unclear. In my practice, most patients who exhibit symptoms of Peyronie’s disease have elevated serum cholesterol levels or diabetes. Therefore, I believe that Peyronie’s disease is possibly due to obstruction of the small arteries that nurture the nerves of penile tissue or penile tissue itself. Many patients who have undergone treatment for prostate cancer, such as radical prostatectomy or radiation therapy, also develop Peyronie’s disease. In these cases, the disease is most likely due to nerve bruising during surgery, or obstruction of penile blood vessels from surgical trauma or radiation therapy.

Use of vacuum constriction devices, penile injection, urologic instrumentation, and mountain biking may cause direct trauma to the penis and can lead to Peyronie’s disease. Symptoms may also begin after an injury to the penis during sexual intercourse (penile fracture).

A rare form of Peyronie’s Disease is also associated with DePuytren’s contracture of the hand. Risk factors include Paget’s disease of the bone, and rheumatoid arthritis. In some cases, men who are related by blood tend to develop Peyronie’s disease, which suggests that familial factors might make a man vulnerable to the disease.

For year’s urologist have speculated on the potential causes of Peyronie’s disease including infection, inflammation, and immune system disorders. None of these theories are plausible however. For men without any systemic vascular risk factors, vigorous sexual activity causing trauma to the erect penis is the most likely cause the formation of scar tissue.


Clinical Course/Natural History

Typically, an episode of Peyronie’s disease is self-limiting, with the symptoms of pain resolving within 12-18 months. An acute or active phase during the first six months usually ends spontaneously. This phase involves pain of the flaccid penis, and pain with erection or intercourse. Curvature may be moderate, and the plaque or scar tissue may diminish or soften. After about eighteen months, no further deformity or scarring of the penis occurs, and usually the pain disappears. A plaque or hardening of the penis in a specific area may be noticed and is permanent. At this point, no further improvement of the condition will occur. This natural history of Peyronie’s disease results in a stable, non-progressive deformity, which may or may not need further treatment.

For patients following radical prostatectomy, a plaque or scar tissue is usually first noticed at 10 to 12 months following the operation. In addition shrinkage of the flaccid and stretched penis may continue to occur over the next 6 to 12 months after noticing the plaque. These changes are permanent.

Peyronie’s disease is an uncommon condition, which is, in most cases, related to vascular disease or penile trauma. Symptoms, including penile curvature, shortening, and pain, should initially be treated conservatively with the expectation for improvement or resolution. The best option for men with erectile dysfunction or inadequate erections, and penile deformity due to Peyronie’s disease, is placement of an Internal Penile Pump.

Nonsurgical Treatment

Historically, medical experts have recommended waiting at least a year before attempting to correct Peyronie’s disease surgically, as the plaque of the disease may shrink of disappear without treatment. Some researchers have given vitamin E to men with Peyronie’s disease, usually orally in small-scale studies with some reported improvement.

However, no controlled studies have established the effectiveness of vitamin E therapy. Similar inconclusive success has been attributed to the oral application of para-aminobenzoate (PABA), a substance belonging to the family of B-complex molecules.

Researchers have also injected chemical agents such as collagenase, dimethyl sulfoxide, steroids, and calcium channel blockers directly into the plaque. None of these have produced convincing results. Steroids, such as cortisone, have produced unwanted side effects such as atrophy of healthy tissues. Most recently, collagenase, Verapamyl, and interferon injections have also proven to be unsuccessful.

Radiation therapy, in which high energy X-rays are aimed directly at the plaque, has also been used. Like some of the chemical treatments, radiation appears to reduce pain, yet it has no effect on the plaque itself and can cause some unwelcome side effects.

None of the treatments mentioned so far has equalled the body’s natural ability to deal with Peyronie’s disease. Therefore, the only medical treatment that I recommend for this condition includes anti-inflammatory drugs (Viox, Celebrex, Indocin, Motrim) to reduce pain or Cialis, Levitra or Viagra to improve erectile function if either symptoms are present.

Surgical Treatment

Surgical intervention prior to eighteen months after the onset of the disease is not recommended, since progression and/or resolution may subsequently alter the results of the procedure. If the natural history of Peyronie’s plaque has produced significant decrease in erectile function, surgery is required.

Peyronie’s disease has been treated with some success by reconstructive surgery. The removal or pinching of tissue from the side of the penis opposite the plaque, which can cancel out the curvature, is known as the Nesbit procedure. This is the most successful reconstructive procedure for men who maintain excellent penile rigidity, do not suffer from erectile dysfunction, and are unable to have intercourse due to anatomical deformity. The procedure is not recommended for cosmetic purposes alone. This method also causes shortening of the erect penis.

The surgical methods that remove or expand the plaque, followed by placement of a patch of skin or artificial material, should in my opinion be avoided. This method may cause loss of erectile function, further penile shortening and a loss of penile sensation. Plaque excision and grafting causes a significant reduction in erectile rigidity in the majority of men and urologist who use this technique must inform patients of this risk as well as be prepared to diagnose, evaluate and treat the post-surgical erectile dysfunction. In addition patient must be warned that irreversible shortening of the penis will occur resulting in a smaller penis than that patient would have had if initially treated with a penile prosthesis.

The best option for men who suffer from Peyronie’s disease and erectile dysfunction is to receive an implanted device known as the Internal Penile Pump. This device increases the rigidity of the erect penis as well as improves the curvature without shortening of length. In very rare instances, Internal Penile Pump placement combined with a technique of incisions and grafting (or plication, which is pinching or folding the skin) is indicated if the penile pump alone does not straighten the penis.

Penile Implant Corrects Peyronie’s Penile Curvature

Dr. Eid shows a patient that has had his Peyronie’s disease corrected with a penile implant.


The penile implant overtime will by itself correct the penile curvature which was caused by the Peyronie’s disease. 

Above photos are of patient with Peyronie’s disease (left) and 6 months after Penile Implant (right).

Straightening of Peyronie’s Disease with Penile Implant

This video describes the effectiveness of penile implants to correct severe curvature caused by Peyronie’s disease without losing penile length. Even though the patient was potent, his curvature was so severe that his best option was the use of a penile implant because otherwise he would have lost a significant amount of length. So much so that intercourse would no longer be possible. Indeed the most common complaint following correction of angulation caused by Peyronie’s Disease is inadequate penile size.


Patient Concerns

Question: I have Peyronie’s disease surgery in Cleveland the doctor didn’t remove all the plaque, shouldn’t he had? Should I have all of the plaque removed before I go with prosthesis?


Answer: In the setting of Peyronie’s disease and ED it is always preferable to simply place a penile implant. Any procedure that removes plaque and places graft over the defect or “plicates” the penis will cause penile shortening and put the patient at greater risk of infection, with devastating consequences. Once the implant inserted, the plaque will no longer be palpable and therefore it is not necessary to remove it.

Question: My degree of Peyronie’s disease bend is app 30 degrees to the left. My penis length was 6 inches before the onset 20 years ago. How can the penile pump help correct this and how much of a decrease in bend could I expect? In your opinion, how much of my bend could the pump correct?

Answer: For some patients, the curvature is corrected 100% others are corrected enough to permit sexual activity without difficulty. Patients with Peyronie’s disease in general are best managed conservatively, especially if they are able to have intercourse.  If intercourse is not possible (regardless of the rigidity of the erection) a penile prosthesis is the best option for most. It is better to have a longer penis, which is slightly crooked than a very short straight penis. Penile shortening always occurs with correction on angulation (either with plication, Nesbit procedure or plaque excision) without placement of a penile implant.


Low Testosterone and ED

Understanding Low Testosterone

For most men, low testosterone is not the cause of their erectile dysfunction (ED).


What is Testosterone?

Testosterone is a naturally produced androgen hormone in both males and females, and it is the primary sex hormone in men. It is primarily produced by the testicles and is regulated by the pituitary gland and the hypothalamus. Testosterone is the hormone responsible for the development of male sex organs during the fetal stage and it drives the physical changes and transitions that occur during male puberty. In adult men, testosterone controls and maintains typical adult male characteristics and physical features.

  • Sex hormone produced in testes (reproductive glands)
  • Participates in modulation of sperm production
  • Maintains adult male characteristics and physical features
  • Affects sex drive and feelings of sexual desire
  • Impacts mood, energy level, muscle mass, and bone strength

The Myth of Low Testosterone and Erectile Dysfunction (ED)

Often, erectile dysfunction (ED) or male impotence is misdiagnosed as a testosterone-driven problem. While androgen does play a role in erections, there is a lack of clinical evidence linking low testosterone level to the inability to achieve or sustain an erection. Erectile dysfunction is most often a vascular problem, not a hormonal issue. More recently several well designed prospective studies have shown that even when replacing testosterone in men with ED and “low or borderline levels”, no improvement of erectile function occurs.


Research has proven two significant facts dispelling the direct correlation between low testosterone and ED problems:

  • Normal erections do not require normal testosterone levels
  • Increasing testosterone level does not increase frequency or strength of erections

Many times the reduced sexual desire that accompanies ED is misconstrued as low testosterone by a patient or his physician. It is common for men who experience prolonged sexual potency problems or erection difficulties to become disinterested in sex out of depression or avoidance, not a low level of testosterone. A state of resignation sets in men’s minds expressed by the following words: “Why bother…”

Further, age may be a factor in the hasty connection made between ED and low testosterone. As man ages, his testosterone level naturally declines by 1-2% each year. Likewise, aging can play a role in diminished sexual potency and the ability to achieve an erection. While these occurrences may be simultaneous, there is no proof that one causes the other.

Approximately 2% of total testosterone exists in the free or unbound form, and approximately 40% is tightly bound to sex hormone–binding globulin (SHBG). The remaining testosterone is weakly bound to albumin and other proteins. Free and albumin-bound testosterone are considered the active or bioavailable testosterone. Several medical conditions may cause free testosterone to be low when total testosterone appears to be normal. Also total testosterone may be low and free testosterone levels normal. When evaluating and treating men for low testosterone levels it is therefore important to measure both the free and total testosterone before initiating testosterone replacement therapy. Because testosterone levels vary greatly in the same individual depending on when it is measured therapy should not be initiated until several measurements are made.

Normal Verses Low Testosterone Levels

It is important to understand that testosterone is measured as a range, not a scale. Testosterone level is determined through a simple blood test and, since levels fluctuate throughout the day, a true reading can only be achieved with multiple tests on different days at varying times.

Normal male testosterone levels range from 300 to 1,200 nanograms per decileter. If your testosterone level tests at the lower end of this range it does not mean you have a low testosterone level. Again, these numbers are to be used as a range, not a scale, and testosterone level can very significantly by man and even by time of day.

Men are far more likely to have non-problematic, low-normal testosterone than they are to have true low testosterone, below 300 ng/dL.

Symptoms of Low Testosterone

Symptoms of low testosterone can only be diagnosed by a medical professional, but one suffering from a deficiency may notice erectile dysfunction, depression, anxiety, low sex drive, high cholesterol, weight gain, or problems concentrating. However, these symptoms are not specific for low testosterone levels and can be caused by many other factors. If it is determined that the patient is suffering from androgen deficiency, long term TRT may be initiated. Testosterone can be administered in gels, creams, pills, injections, or through an implant underneath the skin. Receiving the hormone orally is generally not the preferred route of delivery, as it is not well absorbed and may lead to complications in other organs such as the heart and liver. Transdermal delivery is currently the best way to replace testosterone.

Low testosterone, registering below 300 ng/dL, can be indicated by any number of the following symptoms:

  • Excessive tiredness and easy fatigue with exertion or exercise
  • Reduced sex drive
  • Fertility issues as the result of lowered sperm count
  • Irritability, moodiness, and depression
  • Body hair reduction
  • Reduced bone strength and/or muscle mass
  • Weight increase and/or increased body fat
  • Hot flashes or excessive sweating

It is important to remember that many symptoms of low testosterone are common aging symptoms, as well associated with conditions such as diabetes, heart disease, and primary depression, the metabolic syndrome, renal disease and hypertension.

 What Causes Low Testosterone?

Low testosterone, confirmed through a blood test, can be caused by a variety of medical issues. Prior to beginning any treatment, your physician will attempt to rule out disease or another serious medical problem as the cause.

Testosterone levels can be lowered by:

  • High blood pressure
  • High cholesterol
  • History of pituitary or thyroid issuesKidney problems
  • Obesity
  • Osteoporosis
  • Pulmonary disease or asthma
  • Steroid exposure
  • Type 2 diabetes

Testosterone Replacement Therapy

Unfortunately, testosterone supplementation does not exist. Studies repeatedly show Androgen Replacement Therapy (ART), also called Testosterone Replacement Therapy (TRT) or Hormone Replacement Therapy (HRT), is an ineffective form of ED treatment.

Men with confirmed low testosterone levels may be advised to begin a testosterone replacement regimen. Treatment choices include topical gels, pills, injections, and patches. Topical gels, such as AngroGel, Testim or Axyron are most often prescribed and are applied to the shoulders and upper body, allowing the testosterone to be absorbed through the skin.

Whenever testosterone is added to the male human body, it causes a cessation of ones natural testosterone, shrinkage of testicle and sterility. Therefore this should never be given to young men contemplating fatherhood, as the effects of long-term therapy may be permanent.

Small subsets of men actually choose to undergo testosterone replacement therapy, which for some patients restores energy and sex drive. It is important to note that testosterone replacement therapy, or TRT, should only be reserved for the most severe of cases, and this treatment option should always be discussed with Dr. Eid, who can properly diagnose you with a deficiency.

At our office, we will measure the total and free testosterone in your blood, and will likely measure prolactin (to assess the function of the pituitary gland), as well as SHBG, FSH, LH, and thyroid levels. Testosterone levels normally falls between 250-800 nanograms per deciliter of blood. However, this level will vary even for the same person, depending on exercise and time of day, as well as other factors.

Dangers of Testosterone Replacement Therapy

Currently, testosterone cannot be supplemented. Low testosterone treatments are designed to replace the body’s natural production of testosterone and could permanently cease the body’s ability to produce testosterone naturally. Unfortunately, extensive marketing from the pharmaceutical industry encourages the widespread use of testosterone replacement. The aggressive pressure they place on physicians to prescribe testosterone borders on medical irresponsibility. The long-term dangers of inappropriate testosterone use could be far more severe than we know today.

The potential, negative side effects of testosterone treatment should be discussed in detail with your physician. Men must carefully weigh the benefits and risks prior to beginning treatment.

Immediate physical reactions may include:

  • Increased appetite
  • Mood alterations
  • Nausea
  • Vomiting

Note: Men often mistake the increased energy and improved mood they experience while using testosterone replacement as proof of its effectiveness. In reality, the steroidal nature of testosterone is what causes these changes. Once the treatment is stopped, men can experience withdrawal and severe depression, as well as the permanent inability to naturally produce testosterone.


Longer-term effects may include:

  • Permanent dependence on testosterone replacement therapy
  • Difficulty urinating
  • Increase in red blood cell count and thickening of blood
  • Fluid retention, liver problems, blood clots, and stroke
  • Increased growth of prostate tissue
  • Prostate cancer tumor growth
  • Sperm count reduction leading to permanent infertility
  • Permanent irreversible suppression of natural production of testosterone
  • Shrinking of the testicles
  • Increased resistance to testosterone replacement

More severe side effects include priapism (an erection that does not go away, and requires medical attention), liver damage, and swelling. In addition, TRT should be used cautiously, and is not the ideal treatment for most healthy adult men with low normal testosterone levels. It should not be used in patients with heart disease or prostate cancer, those with known prostate problems, or men with high cholesterol. In addition, treatment with testosterone may activate prostate cancer in men with undiagnosed cancer. So men considering this treatment should be screened for prostrate cancer, as well as have future screenings.

Once started, it is extremely difficult to stop testosterone therapy. In essence, complete dependence or even addiction to it may occur over time. The long-term effects of testosterone therapy are continually being studied.

Results and efficacy

Almost all of the clinical trials studying TRT have been inconclusive or have not followed patients long-term, so this treatment option is still a bit experimental in practice, and the treatment should not be administered to anyone not deemed an exceptional candidate. Because of the serious nature of TRT, patients with less severe testosterone deficiencies may look into safer, alternative treatment options. Any man currently taking TRT needs to see their doctor regularly for checkups, and should report any medical issues immediately. In addition, prostate screenings are essential.