Impotence (ED): What Causes It, Who Gets It, and What Treatment Is Available?

Clinically reviewed by Dr. Ponlawat Pitsuwan, Physician, Doctor Bangkok. Last reviewed: August 2026

If you are reading this, you have probably noticed something is wrong and you have been putting it off. Maybe you are not sure it is serious. Maybe talking to a doctor about it feels uncomfortable. That is the most common reason men wait months before walking through my door.

Here is what I tell them: ED is not just a bedroom problem. In many cases it is your body flagging something about your heart, your blood sugar, or your hormones. Getting it checked is not just about sex. It is about your overall health. At Doctor Bangkok, that conversation is private, straightforward, and in plain English.

What Actually Causes Impotence

An erection depends on three things working together: healthy blood vessels, intact nerves, and hormones in a normal range. If any one of those breaks down, erections suffer.

That is why the causes of ED are so varied. It is rarely one thing. Working out which combination is driving the problem is what a proper consultation is for.

The most common physical causes are cardiovascular disease, diabetes, high blood pressure, and low testosterone. Certain medications cause ED too, including some antidepressants, blood pressure drugs, and prostate treatments. On the psychological side, anxiety, depression, and chronic stress are real drivers, especially in men under 40.

Physical vs Psychological ED: How to Tell the Difference

One question I always ask: do you still get erections in the morning or at night during sleep? If yes, the physical mechanism is working. That points strongly toward a psychological or situational cause rather than a vascular one.

If morning erections have disappeared completely, or if the problem happens regardless of partner or mood, that is more likely to be physical. It does not mean it is harder to treat. It means we need to investigate the body more carefully.

Both types can coexist. A man with mild vascular ED often develops performance anxiety on top of it, and the anxiety makes things worse. I see this pattern regularly with expats in Bangkok, and untangling it early makes a real difference.

Bangkok-Specific Factors That Make ED Worse

Bangkok does specific things to men’s health that are worth being direct about.

Chronic heat raises cortisol, the body’s main stress hormone. Elevated cortisol suppresses testosterone. Lower testosterone means lower libido, weaker erections, and slower recovery. Add Bangkok’s nightlife culture, with regular heavy drinking and late nights, and you have a recipe for hormonal disruption that builds over months.

Relocation stress is real too. Moving countries, building a new social life, adjusting to a different culture: these are chronic stressors that accumulate quietly. Many expats arrive healthy and notice their sexual function declining within six to twelve months. They assume it is age. Often it is lifestyle. Lifestyle causes respond well to lifestyle changes, and the men who make those changes alongside treatment tend to see the best results.

ED as an Early Warning Sign

This is the part most men do not know. ED is frequently the first detectable sign of arterial narrowing. The penile arteries are small and show damage from cholesterol, high blood pressure, and high blood sugar before the larger heart arteries do. Your erections can start failing before your heart shows any obvious sign of disease.

I do not say this to alarm anyone. I say it because men who come in for ED and have not had a blood test in years often leave with a diabetes diagnosis or a cholesterol finding they needed to know about. Getting the ED checked means getting the health check. They are the same appointment.

If you are over 40 with new-onset ED and no obvious psychological cause, do not manage this with pharmacy-bought pills alone. Get assessed.

How Impotence and ED Are Diagnosed at Doctor Bangkok

A lot of men avoid coming in because they do not know what to expect. Here is exactly what happens.

We start with your medical history: how long this has been happening, whether it is getting worse, what medications you are on, and what your lifestyle looks like. No judgment. I have this conversation every week. Then we run blood tests covering testosterone, blood sugar, cholesterol, and blood pressure. Results for most panels come back within 24 hours.

By your follow-up, we have a clear picture of what is driving the problem and a treatment plan that addresses the actual cause.

Treatment Options for Impotence in Bangkok

Treatment depends on cause. There is no single approach that works for everyone.

For most men, PDE5 inhibitors are first-line. These are medications like sildenafil (Viagra) and tadalafil (Cialis). Sildenafil works faster but is more affected by food. Tadalafil lasts longer and can be taken as a daily low dose. The evidence for both is strong. They are safe and effective when prescribed correctly, but they interact with nitrate medications used for chest pain and can cause dangerous drops in blood pressure. Buying them from a pharmacy without a consultation carries real risk.

If low testosterone is confirmed, testosterone replacement therapy (TRT) may be appropriate. Evidence for TRT improving erectile function in men with confirmed low testosterone is moderate to strong. We discuss it carefully because TRT has its own considerations, including effects on fertility.

Shockwave therapy is available in Bangkok and shows promise for vascular ED, particularly in men who have not responded well to medication. The evidence is still emerging. PRP injection therapy is also offered at some clinics, but the evidence remains limited and experimental. I tell patients this clearly.

Lifestyle changes are not optional extras. They are treatment. Better sleep, less alcohol, regular exercise, and lower chronic stress have all been shown to improve erectile function, even without medication.

ED vs Low Libido and Premature Ejaculation

These terms get used interchangeably and they should not be.

ED means you cannot achieve or maintain an erection. Low libido means reduced desire for sex, which is often tied to low testosterone. A man with low libido may still get erections. A man with ED may have completely normal desire but cannot act on it.

Premature ejaculation is a separate condition about ejaculatory timing, not erection quality. It has different causes and different treatments. Some men have more than one of these issues, and it is fine to raise all of them in one appointment. We will work through what is actually present.

DR Ponlawat

Dr. Ponlawat Pitsuwan is a physician at Doctor Bangkok, a private clinic in central Bangkok. He sees expats, residents, and medical tourists for general medicine, wellness consultations, and IV therapy. His focus is straightforward, evidence-based care delivered in plain language.