It is estimated that by 2025, approximately 322 million men worldwide will be affected by erectile dysfunction (ED). Despite this, fewer than 25 per cent of men seek treatment. Erectile dysfunction is one of the most common men’s health problems worldwide, affecting approximately 52 per cent of men aged between 40 and 70, according to data from the ‘Massachusetts Male Aging Study’ (Feldman et al., J Urol 1994). In 80 per cent of cases, the cause is vascular; blood cannot fill the corpora cavernosa sufficiently. Psychogenic ED accounts for approximately 20 per cent of cases. Clinically proven treatments include low-intensity shockwave therapy (Li-ESWT), PRP injection (P-Shot) and oral PDE5 inhibitors. The majority of cases can be treated without the need for surgical intervention.

MEDICAL REVIEWER

Dr Doğukan Sökmen, Consultant Urologist

Specialist in Urology and Male Sexual Health – Dr Terziler Exclusive Clinic, Istanbul

Last updated: May 2026

Dr Doğukan Sökmen is a urologist specialising in male sexual dysfunction, vascular-related erectile dysfunction and minimally invasive regenerative treatments. At Dr Terziler Exclusive Clinic, he performs Li-ESWT protocols, intracavernosal treatments and penile prosthesis surgery. He works under the direct supervision of Dr Servet Terziler, a surgeon accredited by the AAACI. The clinic’s focus is on restoring natural erectile function without the need for long-term reliance on medication.

What Exactly Is Erectile Dysfunction?

Erectile dysfunction (ED) is the inability to achieve or maintain a penile erection of sufficient rigidity for satisfactory sexual intercourse for a period of at least three months. Clinically, this condition is classified as primary ED, where the man has never been able to achieve an erection, and secondary ED, where he has lost the erectile capacity he previously possessed.

This condition is also divided into situational ED, which occurs only in specific situations or with specific partners, and persistent ED, which is observed in all sexual encounters. An International Index of Erectile Function (IIEF-5) score below 21 supports the clinical diagnosis of erectile dysfunction.

A healthy erection is underpinned by fully coordinated neurovascular changes. Sexual arousal triggers the brain to send signals via the spinal cord to the pelvic nerve network. These nerve endings release nitric oxide (NO) directly into the smooth muscle cells of the penis.

Nitric oxide triggers the relaxation of the smooth muscles in the cavernous arteries. This relaxation allows for a rapid increase in arterial blood flow to fill the expandable spaces of the corpora cavernosa. The expanding tissue compresses the surrounding venules towards the rigid tunica albuginea sheath.

This venous occlusion traps the blood within the penis, ensuring that the necessary structural rigidity is maintained. A disruption at any stage of this process can lead to erectile dysfunction.

How Common Is Erectile Dysfunction After the Age of 40?

40+ | 1 in 3

One in three men over the age of 40 experiences some degree of erectile dysfunction.

322 Million | Global Projection

Global projections suggest that the total number of men affected will reach 322 million by 2025.

80 per cent | Vascular in Origin

In most cases, the underlying issue is impaired blood flow, endothelial dysfunction or microvascular damage.

Many men experiencing erectile dysfunction at the age of 40 show early-stage endothelial damage. The Massachusetts Male Aging Study provides key prevalence data by age group for modern urology:

Global estimates predict that the total number of affected men will reach 322 million by 2025. This widespread increase highlights the urgent need for accessible clinical interventions targeting the underlying causes, rather than merely managing symptoms temporarily.

The medical landscape in Turkey is characterised by a high prevalence of certain lifestyle risk factors. The smoking rate among adult men stands at approximately 30 per cent. The regionally high prevalence of type 2 diabetes and metabolic syndrome directly accelerates microvascular damage.

These systemic sexual health issues increase the underlying risk of organic ED. This situation makes clinical intervention in Istanbul a locally significant and highly specialised field.

Specialised ED Screening After the Age of 40

If you notice a decline in the quality of your erections after the age of 40, early clinical screening can help identify underlying vascular problems before they worsen. Please complete our secure diagnostic enquiry form to arrange a specialist medical assessment.

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What Are the Underlying Causes of Erectile Dysfunction and Why Does It Occur?

Erectile dysfunction can develop as a result of chronic medical conditions, psychological stress factors or certain medications disrupting the delicate balance between blood flow and nerve signals required for penile erection.

1. Vascular and Endothelial Factors (80 per cent)

Erectile dysfunction is a warning sign of cardiovascular disease.

Penile arteries (1–2 mm) can develop atherosclerosis 3–5 years before the coronary arteries. Consequently, ED may be an early indicator of cardiac events. (Princeton Consensus III, J Sex Med 2012.) As the penile arteries are much smaller than the coronary arteries, they reveal the build-up of cholesterol plaques at an earlier stage. In patients with vascular erectile dysfunction, arterial blood flow decreases during sexual arousal.

2. Hormonal Imbalances

Low total serum testosterone, i.e. hypogonadism, is directly linked to ED in 25 to 40 per cent of men experiencing erectile dysfunction.

Secondary hormonal causes include high oestradiol levels, thyroid dysfunction and elevated prolactin levels. A comprehensive blood test panel is required to accurately diagnose these complex endocrine disorders.

3. Neurogenic Disorders

Damage to the peripheral nerve pathways prevents arousal signals from being transmitted from the brain to the pelvic organs.

The incidence of ED following prostatectomy varies significantly depending on whether the surgeon performs a nerve-sparing or non-nerve-sparing procedure. Furthermore, diabetes-related peripheral neuropathy can affect between 35 per cent and 50 per cent of men with diabetes. Multiple sclerosis and traumatic spinal cord injuries can also interfere with the transmission of these vital electrical signals.

4. Psychogenic Triggers

Sudden performance anxiety, clinical depression and chronic relationship problems trigger the sympathetic nervous system.

This response leads to the release of adrenaline, which constricts the smooth muscles in the penis and impedes blood flow. Clinical psychologists classify this condition as psychological erectile dysfunction. Treatment for psychological erectile dysfunction focuses on reducing performance anxiety and breaking negative thought patterns. Completely psychogenic ED accounts for approximately 20 per cent of all cases. However, psychological stress is often seen alongside organic vascular causes. Treating only one aspect whilst neglecting the other may lead to suboptimal treatment outcomes.

5. Medication-Induced ED

Some commonly prescribed medicines can directly interfere with the biochemical processes involved in achieving an erection.

Common causes include selective serotonin reuptake inhibitors (SSRIs), beta-blockers, thiazide diuretics and anti-androgens. The use of finasteride has been linked to a controversial condition known as persistent post-finasteride syndrome. Ongoing clinical research continues to investigate these long-term neurosteroid changes without causing undue concern.

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When Does Erectile Dysfunction Become a Medical Issue?

If erection problems persist for three months or longer, a formal clinical assessment is required. The European Association of Urology (EAU) guidelines classify this duration as chronic erectile dysfunction.

Erectile problems lasting less than three months and occurring intermittently are generally situational and may be considered physiologically normal during periods of acute fatigue or temporary emotional stress. However, sudden-onset erectile dysfunction in a man under the age of 40 may be a significant medical warning sign.

This sudden change may often indicate acute vascular disease, early-stage diabetes or serious endocrine disorders. Young patients experiencing a sudden loss of erectile function must undergo a comprehensive and prompt medical assessment. A qualified erectile dysfunction specialist can carry out specific tests to identify these systemic risks at an early stage.

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Diagnosis: What Does an ED Assessment Involve?

At Dr Terziler Exclusive Clinic, a professional erectile dysfunction assessment utilises multidisciplinary diagnostic methods to determine the exact physiological cause of erectile problems.

1. IIEF-5 Questionnaire

Patients complete the validated International Index of Erectile Function (IIEF-5) questionnaire to measure the frequency of erections and the ability to maintain an erection in the recent past.

2. Comprehensive Blood Panel

Laboratory technicians measure serum levels of total testosterone, luteinising hormone (LH), follicle-stimulating hormone (FSH), prolactin and thyroid-stimulating hormone (TSH) to assess the endocrine system.

3. Metabolic and Diabetes Screening

The medical team measures HbA1c and fasting blood glucose levels to identify hidden insulin resistance or the risk of active peripheral neuropathy.

4. Penile Biphasic Doppler Ultrasound

This specialised imaging test is recognised as the clinical gold standard for the diagnosis of vascular-related ED.

A peak systolic velocity (PSV) measured below 25 cm/s confirms arterial insufficiency.

5. Cardiovascular Risk Assessment

Doctors apply the Princeton Consensus III guidelines to assess a patient’s cardiac safety for specific treatments.

Find Out More About ED Diagnosis

If you would like further information about our comprehensive blood tests or ultrasound assessments, please contact our clinical coordinators.

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What Are the Treatment Options for Erectile Dysfunction?

Modern urology offers a progressive range of treatments, extending from short-acting oral medications to advanced non-surgical regenerative protocols and permanent surgical implants. Patients seeking to address erectile dysfunction can choose from a range of evidence-based clinical options. The most appropriate treatment depends on the underlying cause of vascular or nerve damage.

PDE5 | Oral PDE5 Inhibitors (First-Line Treatment)

Commonly used oral phosphodiesterase type 5 (PDE5) inhibitors include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra).

These medicines inhibit the PDE5 enzyme to prevent the breakdown of cyclic guanosine monophosphate (cGMP) in penile tissue. This effect prolongs smooth muscle relaxation and increases blood flow during sexual arousal.

These medicines may be effective in 60 to 70 per cent of men with mild to moderate erectile dysfunction. However, oral PDE5 inhibitors do not directly treat the underlying cause of vascular disease. They merely manage the symptoms temporarily and require the man to take the medication before each sexual encounter.

Low-cost generic options are now widely available worldwide. The main limitation of this first-line treatment is that it may fail in approximately 30–35 per cent of men with severe organic vascular ED. In men with severely blocked penile arteries or nerve damage, sufficient nitric oxide production may not occur for these medicines to be effective.

WAVE | Low-Intensity Extracorporeal Shock Wave Therapy (Li-ESWT)

Low-intensity extracorporeal shock wave therapy involves the direct application of acoustic waves to the penile shaft and the crural regions.

These mechanical waves travel through the skin, creating controlled micro-stress at the cellular level. This stress activates specific cellular signalling pathways that trigger the release of vascular endothelial growth factors.

Low-intensity shock wave therapy is one of the non-surgical treatments for erectile dysfunction shown in randomised controlled trials to stimulate angiogenesis in penile vascular tissue. During the treatment process, the formation of new microcapillaries within the corpus cavernosum tissue may be promoted. This process aims to increase the penis’s blood flow capacity.

A standard clinical protocol may consist of 6 to 12 short outpatient sessions. The procedure generally does not require local anaesthesia and, for most patients, does not necessitate a lengthy recovery period before returning to daily life.

PRP | P-Shot (Platelet-Rich Plasma)

In the Platelet-Rich Plasma (PRP) treatment, known as the P-Shot, plasma containing platelets and growth factors derived from the patient’s own blood is applied to the penile tissues.

The medical team draws a small amount of blood from the patient and processes it in a specialised medical centrifuge. This process enables the separation of platelets containing high levels of regenerative proteins.

These proteins include Platelet-Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF) and Transforming Growth Factor-beta (TGF-beta). Clinical studies have reported that improvements in IIEF-5 scores may be observed six months after treatment. (Levy et al., J Sex Med 2021.)

The combined use of Li-ESWT and P-Shot injections aims to create a synergistic effect in erectile tissue. Whilst acoustic shock waves help to support the vascular structure, PRP provides growth factors that support the cellular healing process.

RESET Performance Protocol

Dr Doğukan Sökmen administers this combined treatment at Dr Terziler Exclusive Clinic as part of the specialised RESET Performance Protocol.

TRT | Testosterone Replacement Therapy

Testosterone Replacement Therapy may only be medically considered in cases where repeated laboratory blood tests show serum testosterone levels below 300 ng/dL and where there are clear symptoms of hypogonadism.

TRT may help to correct low libido, improve daily energy levels and increase nitric oxide synthase expression in pelvic tissues.

Testosterone replacement therapy does not, on its own, treat severe vascular-related erectile dysfunction. If the penile arteries are physically blocked due to plaque, optimising hormone levels may not, on its own, restore structural rigidity. Doctors may consider combining TRT with PDE5 inhibitors or shockwave therapy to achieve an additional therapeutic effect.

Clinical administration methods include regular intramuscular injections, daily topical gels or long-acting transdermal patches. For long-term safety, haematocrit levels and prostate-specific antigen (PSA) values should be monitored regularly in patients receiving TRT.

VED | Vacuum Erection Device

A vacuum erection device is a non-surgical mechanical device designed to draw blood into the penis using negative pressure.

The patient places a transparent plastic cylinder over the flaccid penis and uses a manual or motorised pump to extract the air. This vacuum creates a pressure difference that allows blood to fill the cavernous spaces.

Once sufficient rigidity is achieved, the patient places a flexible silicone constriction ring at the base of the penis to retain the blood. When used correctly, this mechanical system can be effective in 80 to 90 per cent of users.

Clinical data support the use of vacuum devices in early penile rehabilitation following radical prostatectomy. Mechanical tension may help to prevent tissue fibrosis and preserve penile length whilst nerves are healing. The most suitable vacuum device for erectile dysfunction should be fitted with certified safety valves to prevent tissue damage.

IMPL | Penile Prosthesis (Surgical Option)

Penile prosthesis surgery is one of the final treatment options considered when all conservative and non-surgical treatments have failed to provide sufficient rigidity.

In this procedure, penile prostheses—consisting of semi-rigid rods or fluid-filled inflatable systems—are surgically implanted into the damaged corpora cavernosa.

Long-term clinical data show high patient satisfaction rates ranging from 92% to 98% for modern three-piece inflatable devices. In Turkey, the cost of penile prosthesis surgery can range from 5,000 to 12,000 euros, depending on the type of implant used and the complexity of the procedure. As this procedure permanently alters the erectile tissues of the penis, it is generally considered when other treatment options have failed.

What Is the Latest Treatment for ED?

The field of clinical research in regenerative medicine focuses on cellular regeneration.

Patients seeking the latest treatment for ED may wish to consider modern non-surgical alternatives. The RESET Protocol, which combines low-intensity shockwave therapy with platelet-rich plasma (PRP) derived from the patient’s own blood, is one of the approaches currently being investigated in clinical practice.

Among the treatments currently under development are Stromal Vascular Fraction (SVF) stem cell therapy, which utilises cells derived from adipose tissue, and experimental gene therapies aimed at directly targeting the expression of endothelial nitric oxide synthase (eNOS).

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How Much Does Erectile Dysfunction Surgery Cost, and Is It Worth It?

The cost of erectile dysfunction surgery can vary significantly depending on geographical location and the type of prosthesis chosen.

In the US, the cost of a penile prosthesis procedure can range from 15,000 to 20,000 dollars.

The same surgical procedure, performed in Turkey using similar medical implants, can cost between 5,000 and 12,000 euros. Regional differences in the cost of erectile dysfunction surgery can be attributed to lower hospital operating costs in Istanbul.

In men who respond to conservative treatments, surgery may not be medically necessary. Surgical intervention may be considered in cases where options such as first-line medication, Li-ESWT and appropriate PRP treatments have failed.

In contrast, non-surgical options such as the RESET Performance Protocol may be more cost-effective. Such non-surgical approaches can help avoid the permanent structural changes and surgical risks associated with open surgery.

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Can Erectile Dysfunction Be Treated?

Erectile dysfunction can be significantly improved if treatment targets the underlying physical cause rather than merely masking the symptoms. The success of treatment depends largely on the specific cause of the condition and its structural stage.

1. Early and Moderate Vascular-Origin ED

Low-intensity shockwave therapy has been associated with lasting improvements in approximately 50–60 per cent of men at the 12-month follow-up in some clinical trials. These patients may regain their natural erectile function, and their need for medication prior to sexual intercourse may decrease.

2. Advanced Fibrotic ED

Long-term diabetes or severe tissue scarring can significantly hinder the restoration of vascular structure. Whilst improvement may be achieved in these cases using combined regenerative protocols, it may be more difficult to achieve lasting results with a single treatment alone.

3. Purely Psychogenic ED

This condition is highly treatable. A combination of Cognitive Behavioural Therapy (CBT) with short-term, low-dose PDE5 inhibitor support can help break the cycle of performance anxiety and re-establish normal neural processes.

Modern multidisciplinary urological care can help many men achieve sustainable, medication-free recovery. Clinically speaking, ‘recovery’ is no longer a binary outcome assessed simply as ‘yes’ or ‘no’. It can be an outcome achievable through targeted treatment.

ED and Relationships

Erectile dysfunction is an interpersonal health issue that can directly affect the psychological well-being of both partners. Sixty per cent of partners of men experiencing ED report a decrease in sexual satisfaction and an increase in relationship conflicts. (Fisher et al., J Sex Marital Ther 2005)

Many couples may worry about whether the man will be able to sexually satisfy his partner when he has erectile dysfunction. Partner support can help reduce the man’s performance anxiety, thereby improving his response to medical approaches such as Li-ESWT or medication.

This situation can often lead to communication problems, emotional distancing and, for the partner, feelings of unnecessary rejection or inadequacy. Evidence suggests that couples who tackle erectile dysfunction together can achieve better outcomes during their treatment.

You can address your medical and relationship needs in complete confidence. You can arrange a confidential consultation to begin a structured and collaborative treatment process.

Start Your Confidential Treatment Process

You can address your medical and relationship needs in complete confidentiality. You can arrange a confidential consultation to begin a structured and collaborative treatment process.

Arrange a Confidential Consultation

Why Choose Istanbul for ED Treatment?

Istanbul stands out as an international healthcare destination for its advanced regenerative medicine and urology practices. The city is home to numerous healthcare institutions with international accreditation that uphold rigorous operational standards.

Dr Terziler Exclusive Clinic offers a modern, privacy-focused clinical environment utilising advanced medical technologies. The clinic holds AAACI accreditation, and its medical specialists actively participate in international urology congresses to keep abreast of the latest clinical developments.

40 per cent

Choosing Istanbul can offer a cost advantage of between 40 per cent and 60 per cent compared to private clinics in the United Kingdom or the United States for similar non-surgical regenerative protocols. Furthermore, comprehensive international patient packages can be arranged.

Plan

Packages can offer the initial diagnostic blood panel, penile ultrasound imaging, a personalised treatment protocol and a structured post-treatment follow-up process, all within a single plan.

Plan Your ED Treatment Visit to Istanbul

Our international patient coordination team can provide support at various stages of your visit, including appointment scheduling, translation services and clinic transfers. To begin planning your treatment, you can submit a contact request via our secure web form.

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Frequently Asked Questions About ED

What is erectile dysfunction?

Erectile dysfunction is the inability to achieve or maintain a penile erection firm enough for satisfactory sexual intercourse. For this condition to be considered in a formal clinical assessment, it generally needs to have persisted for three months or longer. The underlying cause is usually related to a disruption in the vascular, nervous or hormonal mechanisms that control blood flow to the penis.

What causes erectile dysfunction in men over the age of 40?

Organic vascular diseases are one of the common causes of erectile dysfunction in men over the age of 40. Over time, atherosclerosis can restrict blood flow in the small arteries of the penis. Other common causes include type 2 diabetes, low testosterone levels, chronic stress and the side effects of certain blood pressure or antidepressant medications.

Can erectile dysfunction be permanently treated?

Significant improvement can be achieved depending on the cause of erectile dysfunction and the stage of the condition. In vascular-related ED, low-intensity shockwave therapy can help to support vascular structure. Psychogenic causes, on the other hand, can be treated with appropriate psychological therapy and, where necessary, medication.

What is the latest treatment for erectile dysfunction?

One of the approaches currently being investigated in clinical practice is the combination of low-intensity shockwave therapy with autologous platelet-rich plasma injections. Known as the RESET Protocol, this non-surgical approach aims to support the healing of vascular tissue by combining tissue stimulation via acoustic waves with local growth factors. Advanced stem cell therapies, meanwhile, are still being evaluated within the scope of clinical trials.

How much does treatment for erectile dysfunction cost?

The total cost varies depending on whether non-surgical regenerative protocols or surgical treatment is required. In Turkey, non-surgical treatments such as shockwave therapy and PRP may offer cost advantages compared to Western Europe. In Istanbul, the cost of penile prosthesis surgery can range from approximately 5,000 to 12,000 euros, depending on the type of implant and the scope of the procedure.

Does shockwave therapy work for erectile dysfunction?

Low-intensity shockwave therapy is one of the treatment options being evaluated, particularly for men with vascular-related erectile dysfunction. Various randomised controlled trials have shown that acoustic waves may promote blood vessel formation in the cavernous tissue. The treatment may improve erectile rigidity in some patients and reduce the need for medication.

Can a specialist in erectile dysfunction help if medication isn’t working?

Yes. When oral medication does not produce satisfactory results, a specialist doctor can assess different treatment options depending on the underlying cause. Vascular blockages or nerve damage may limit the effectiveness of medication. A specialist in erectile dysfunction may consider alternatives such as low-intensity shockwave therapy, autologous P-Shot injections, appropriate intracavernosal medication, or, where necessary, surgical penile prostheses.

Sources

Prevalence and Cardiovascular Risk

Feldman et al. (1994) – Massachusetts Male Aging Study – prevalence of erectile dysfunction in men aged 40–70.

Ayta et al. (1999) – Projected global increase in erectile dysfunction between 1995 and 2025. BJU Int.

Princeton Consensus III (2012) – Miner et al. – Assessment of ED as a marker of cardiovascular risk. J Sex Med.

Hormones and Regenerative Therapy

Isidori et al. (2005) – The effects of testosterone on male sexual function. Eur Urol.

Clavijo et al. (2017) – Extracorporeal shock wave therapy for ED – a meta-analysis of 14 randomised controlled trials. J Sex Med.

Levy et al. (2021) – PRP (P-Shot) for erectile dysfunction – IIEF results at 6 months. J Sex Med.

Surgery, Partner Outcomes and Guidelines

Rajpurkar and Dhabuwala (2003) – Penile implant satisfaction rates of 92–98 per cent. J Urol.

Fisher et al. (2005) – Partners’ experience of erectile dysfunction. J Sex Marital Ther.

EAU Guidelines – Male Sexual Dysfunction (2023) – European Association of Urology – Diagnostic and treatment framework.

NIH / NIDDK – Erectile Dysfunction – National Institute of Diabetes and Digestive and Kidney Diseases.

About Dr Terziler Clinic

Located in Istanbul, Dr Terziler Exclusive Clinic is a premium healthcare clinic with AAACI accreditation, serving international patients in the fields of men’s sexual health, longevity, regenerative urology and advanced aesthetic treatments.