We think of erectile dysfunction (ED) as a bedroom issue. But Dr. Tobias Kohler—urologist, Mayo Clinic surgeon, and chair of the Princeton IV consensus guidelines on ED and cardiovascular disease—says it’s often something much more serious: the canary in the coal mine for total-body health.
In this episode of The Dr. Gabrielle Lyon Show, Dr. Kohler breaks down why ED is one of the most important early warning signs for hidden heart disease, what tests every man should ask for, and why lifestyle change can often outperform pills. He also gets brutally honest about the emotional toll ED takes, the hidden dangers of performance-enhancing drugs, and why muscle is a powerful protector of both metabolic and sexual health.
Here’s what every man (and every woman who loves one) needs to know.
Erectile Dysfunction: More Than Just “Performance”
We’ve long known that ED affects quality of life. But new research shows it’s also a powerful predictor of future heart disease, stroke, and early death. According to Dr. Kohler, erectile function is one of the single best markers of overall health in men.
If you’re struggling in the bedroom, it’s often a sign that your blood vessels, including those in the heart and brain, are already under threat.
Why? Because the arteries in the penis are smaller than coronary arteries. That means the same amount of plaque will block blood flow sooner. ED may show up 2–3 years before a heart attack and 1–2 years before a stroke.
And this isn’t just theoretical. A 2019 meta-analysis of over 150,000 men found that ED raised the risk of cardiovascular disease by 43%, heart disease by 59%, and all-cause mortality by 33%.
In another study , researchers looked at blood vessels from different parts of the body, including the aorta, arteries in the gut, and penile arteries, from organ donors ranging in age from 18 to 87. They tested how well these vessels could relax (open up) and contract (tighten) in response to different chemical signals.
What they found is that while blood vessels throughout the body lose some flexibility with age, the blood vessels in the penis start losing their ability to relax much earlier—often by the mid-50s—while similar declines in other vessels don’t show up until much later. That means erectile dysfunction can show up years before you develop more obvious signs of heart disease or other vascular problems.
This early vulnerability is important because it makes ED one of the first visible “check engine lights” for your vascular health. If your erections aren’t what they used to be, it could be a sign that your arteries are already being affected by aging, inflammation, or oxidative stress, long before bigger arteries like those in your heart start causing symptoms. Catching it early opens a window for prevention and treatment before more serious cardiovascular disease develops.
What Should You Do If You Have ED?
Step one: don’t ignore it. ED deserves a full cardiovascular workup.
The new Princeton IV Guidelines —co-chaired by Dr. Kohler—reclassify ED as a “risk-enhancing factor” for atherosclerosis. For men with borderline or intermediate cardiac risk, a coronary artery calcium (CAC) scan is now recommended to unmask hidden plaque.
Blood ceramide levels are another emerging tool: one study found men with moderate-to-severe ED were twice as likely to have actionable ceramide scores, even when traditional cholesterol panels looked normal.
CAC scanning is fast, inexpensive, and more predictive of heart attack than LDL cholesterol. Ceramides, meanwhile, are bioactive lipids that reflect insulin resistance and inflammatory stress, and they improve with lifestyle changes.
Why Lifestyle Changes Work (and Pills Sometimes Don’t)
ED has two major root causes: vascular dysfunction and psychogenic stress.
From a vascular standpoint, everything that harms the heart also harms erections: poor sleep, processed food, sedentary behavior, excess weight, high blood pressure, and insulin resistance. But the reverse is also true. Exercise, weight loss, and clean eating improve both cardiovascular and sexual health.
In fact, one randomized trial found that lifestyle changes alone improved erectile function in about a third of obese men. Another systematic review found that 160 minutes of aerobic training per week significantly improved ED severity, and a meta-analysis found bigger improvements in those starting with the worst function.
Compared with participants not meeting the physical activity guidelines, individuals who had recommended aerobic activities demonstrated a 34% reduction in the odds of having ED. When compared to males with physical activity of less than 150 min/week, the odds of ED in those with physical activity levels of 150-300 min/week and >300 min/week decreased by 22% and 39%, respectively.
Psychologically, stress matters just as much. Dr. Kohler notes that adrenaline is the most powerful anti-erectile molecule nature has ever made. When men are anxious, depressed, or facing performance pressure, the brain shuts down arousal pathways.
In other words, you can biologically get and maintain erections just fine, but your brain doesn’t want you to because of stress, anxiety, or depression. One of the most common examples is the so-called “performance anxiety” where nervousness around sex, for whatever reason, actually makes ED more likely to occur.
PDE5 Inhibitors: Useful, But Not a Magic Bullet
Drugs like sildenafil (Viagra) and tadalafil (Cialis) belong to a class called PDE5 inhibitors. They work by blocking an enzyme in the blood vessel walls that normally breaks down a chemical messenger called cGMP.
cGMP’s job is to relax the smooth muscle in penile arteries, allowing more blood to flow in and stay there, which is essential for a firm erection. By keeping cGMP levels higher for longer, PDE5 inhibitors make it easier to get and maintain an erection in response to sexual stimulation.
They are considered safe and highly effective as a first-line treatment for erectile dysfunction, and they also have benefits for certain other conditions, like benign prostatic hyperplasia (BPH) and pulmonary hypertension.
But they aren’t magic pills—they work best when the rest of your health supports good blood flow and hormone balance. That means optimizing testosterone levels, reducing inflammation, improving cardiovascular fitness, and addressing psychological stress or performance anxiety.
In other words, the medication helps the mechanism work, but you still need a healthy foundation for the best results.
That said, the benefits of these drugs extend well beyond the bedroom. A 2024 meta-analysis of 1.26 million people found that regular PDE5 inhibitor use lowered the risk of major adverse cardiovascular events by 22% and all-cause mortality by 30%.
What About Surgery?
For men who don’t respond to oral medications or can’t take them because of side effects, drug interactions, or underlying health issues, a penile prosthesis offers a proven, long-term solution.
This is a surgically implanted device inside the penis that allows a man to get an erection whenever he chooses, with no need for pills or injections.
There are two main types: malleable (semi-rigid) rods and inflatable devices. Inflatable prostheses are the most popular in the U.S., making up over 75% of implants. They use a hidden pump in the scrotum to move fluid into cylinders in the penis, creating a natural-looking and -feeling erection on demand. When deflated, the penis returns to a flaccid state, so appearance is discreet under clothing.
Once considered a “last resort,” prosthesis surgery is now being offered earlier for select patients, particularly those with complex anatomical challenges, severe erectile dysfunction after prostate surgery, Peyronie’s disease, or intolerance to medications. The safety profile has improved significantly over the years, with mechanical reliability often lasting 10–15 years or more.
Dr. Kohler’s team at Mayo Clinic has even developed a novel surgical upgrade called the THALIA technique—short for Tubing, Hitch and Lasso, Intussusception Anchor. This small modification adds a collar to the reservoir tubing, acting like a doorstop to prevent it from migrating into unwanted areas, a rare but potentially serious complication.
Patient and partner satisfaction rates for penile prostheses are among the highest of any ED treatment, often exceeding 80%. The devices are invisible to others, work reliably every time, and can be removed or replaced if needed. For many men, it’s the closest thing to a permanent fix for erectile dysfunction.
Muscle and Sexual Health Are Deeply Connected
Finally, we can’t talk about erectile function without talking about muscle.
Muscle mass and strength are independently associated with better sexual function. In a 2024 study of over 2,500 men, those with normal strength were 62% less likely to report morning erection problems, 63% less likely to experience performance or desire issues, and 66% less likely to have multiple sexual complaints.
In older men, sarcopenia (age-related muscle loss) more than doubled the odds of moderate-to-severe ED. Every increase in muscle strength reduced ED risk by 7%.
A 2025 review that I co-authored in Sexual Medicine Reviews further reinforced this link, showing that skeletal muscle mass and strength predict male sexual health across age groups and comorbidities—even after adjusting for testosterone—highlighting muscle as an independent biomarker of erectile function.
Why does this relationship exist? Muscle tissue is a metabolic powerhouse that helps regulate blood sugar, reduces systemic inflammation, and supports healthy testosterone production. Stronger muscles also improve cardiovascular fitness, ensuring better blood flow to all parts of the body, including the penis. On top of that, resistance training stimulates nitric oxide production, a key chemical messenger that relaxes blood vessels during arousal.
In other words: strong body, strong sex life.
Erectile Health Action Checklist
1. Don’t Ignore ED
- Treat it as a health signal—not just a sexual one
- Talk to your doctor early, especially if you’re under 60
2. Get the Right Labs and Scans
- Ask about a 10-year ASCVD risk score
- If risk is borderline (5–20%), request a Coronary Artery Calcium (CAC) scan
- Consider ceramide testing to uncover hidden heart risk
3. Upgrade Your Lifestyle
- Exercise ≥150 min/week (cardio + strength training)
- Prioritize muscle strength and manage your body weight
- Reduce alcohol, caffeine, and stress
- Sleep 7–9 hours per night—consistently
- Quit smoking
4. Address Stress and Mental Health
- Recognize the role of anxiety, depression, and allostatic load
- Consider therapy or stress-management training if needed
- Remember: performance anxiety is biochemical—not just in your head
5. Understand Your Treatment Options
- Try PDE5 inhibitors (e.g., Viagra, Cialis)—safe for most, with potential heart benefits
- Combine with lifestyle change for better results
- Know that penile implants are effective, discreet, and no longer a “last resort”
6. Watch for Other Urologic Issues
- Get screened for prostate health (PSA + rectal exam if age ≥45 with risk factors)
- Monitor urinary symptoms—nocturia, frequency, urgency
- Never ignore blood in your urine
7. Be Proactive, Not Reactive
- Erectile health is a leading indicator—not a trailing symptom
- Optimizing your sexual health means optimizing your heart, brain, and metabolic health too
Final Thoughts: ED Isn’t Just a Symptom, It’s a Signal
Erectile dysfunction isn’t just about sex. It’s your body waving a red flag. Whether the cause is blocked arteries, chronic stress, low muscle mass, or all of the above, ignoring ED can be a missed opportunity to fix much larger health problems before they get worse.
So if you or someone you love is dealing with erectile issues, don’t brush it off. See a doctor. Get the workup. Start moving more, eating better, sleeping longer, and managing stress. These aren’t just tips for sexual health—they’re the same strategies that prevent heart attacks, diabetes, dementia, and early death.
As Dr. Kohler puts it: the penis is the most sensitive biomarker men have. Pay attention to it.
