Blood Pressure Medicines and ED (Erectile Dysfunction)

Erectile dysfunction is a common medical condition and so is hypertension. Treatment of hypertension can have effects on sexual and erectile functions. Certain blood pressure medicines have been commonly implicated to cause ED (erectile dysfunction).

ED (erectile dysfunction) is much more common than reported. The prevalence of ED (erectile dysfunction) has been estimated at around 40 to 50% in adult men.

ED is more common in older adults and those with underlying medical conditions such as hypertension and diabetes. Furthermore, antidiabetic and blood pressure-lowering medicines may further worsen the condition.

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Here is a summary and comparison of various studies that evaluated the effect of blood pressure medicine on ED (erectile dysfunction) [Ref]:

Medical Conditions associated with ED (Erectile Dysfunction):

Erectile dysfunction is a common problem with advancing age. Some medical conditions directly cause sexual dysfunction. These include (but are not limited to):

• Primary Hypogonadism
• Secondary hypogonadism
• Hypothyroidism
• Prolactinoma
• Pituitary adenoma
• Spinal Injury and trauma to the penis and sexual organs
• Prostatic and Testicular cancers
• Cushing’s disease and syndrome
• Drugs like Ketoconazole, Finasteride, and Flutamide

Other conditions that can indirectly cause erectile and sexual dysfunction include (but are not limited to):

• Diabetes and Diabetic autonomic neuropathy
• Hypertension
• Cardiovascular diseases
• Stroke
• Peripheral arterial and atherosclerotic diseases
• Depression and anxiety
• Obesity and being overweight (sexual dysfunction can be a cause and effect of obesity)
• Antidepressants and antiallergics

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Blood Pressure Medicines and ED (Erectile Dysfunction):

Blood pressure medicines that are commonly used to treat hypertension are classified as ABCD and Miscellaneous:

• A for ACE Inhibitors and Angiotensin Receptor Blockers
• B for Beta Blockers
• C for Calcium channel Blockers,
• D for Diuretics
• Miscellaneous includes
  • Alpha-blockers
  • Vasodilators
  • Centrally acting drugs

Some blood pressure medicines may have significant effects on male sexual health and erectile function.

Antihypertensive medications that either reduce the levels of plasma testosterone (male sex hormone), increase estrogen (female sex hormone), or cause peripheral vasoconstriction can cause erectile dysfunction.

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The association of blood pressure medicines and ED is like a double-edged sword. The stress associated with ED can result in fluctuations in blood pressure and vice versa.

It is especially a problem in patients with preexisting ED. Initiating treatment with blood pressure medicine that causes ED can worsen the underlying condition.

Aldosterone receptor antagonist and ED:

Aldosterone receptor antagonists include Eplerenone and Spironolactone. Both these drugs inhibit the last part of the RAAS pathway (Renin-angiotensin-aldosterone pathway).

Aldosterone receptors inhibitors are used to treat hypertension, fluid overload, and prevent cardiac hypertrophy and fibrosis. They may also be used to increase the levels of potassium and magnesium.

Spironolactone is a non-specific inhibitor of mineralocorticoid receptors. It also inhibits the testosterone receptors and increases estradiol levels. Thus, it directly results in hypogonadism in males. Hence, it causes erectile dysfunction, breast enlargement in males, and reduces semen quantity.

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Eplerenone is a derivative of spironolactone. It is a specific mineralocorticoid receptor inhibitor. It does not significantly affect the levels of testosterone and estrogen levels in males.

Both Eplerenone and Spironolactone have been studied in men with hypertension. Although both the drugs can cause erectile dysfunction, spironolactone causes a significantly greater degree of erectile dysfunction than eplerenone.

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Diuretics and ED:

Diuretics are also commonly used to treat hypertension especially in the elderly and those with fluid overload. Thiazide diuretics are mainly used to treat hypertension while loop diuretics are used to treat fluid overload.

Thiazide diuretic, Chlorthalidone, has been found to cause significant erectile dysfunction compared to placebo and other comparator drugs in the TOMHS study (Treatment of Mild Hypertension Study). The results of the study are given here:

It is not clear why diuretics, especially thiazide diuretics, cause erectile dysfunction. However, certain mechanisms that might influence the effect of catecholamines on the vascular endothelium and the role of nitric oxide might be responsible.

Beta-Blockers and ED:

Beta-blockers are not commonly prescribed to lower blood pressure. However, in patients with palpitations, coronary artery disease, migraine, and anxiety, beta-blockers are preferred.

Different classes of beta-blockers are used to treat hypertension. Beta-blockers have been associated with erectile dysfunction. The mechanism by which beta-blockers cause erectile dysfunction is primarily attributed to their effect on the peripheral blood vessels.

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Some non-selective beta-blockers may directly cause vasoconstriction because of the unopposed alpha-adrenergic receptors activation.

Other mechanisms that are especially associated with the use of metoprolol, atenolol, pindolol, and propranolol are their effect on sex hormones. These beta-blockers reduce the levels of testosterone and follicle-stimulating hormones.

In one study by Cordero et al, the incidence of erectile dysfunction with the use of various beta-blockers is as follows [Ref]:

The results of the above-mentioned study are in contrast to other studies where Nebivolol is associated with significantly less ED compared to other beta-blockers.

Nebivolol is associated with the release of nitric oxide. Nitric oxide is a potent vasodilator. It results in vasodilation of the penile blood vessels and may improve erectile dysfunction.

Calcium Channel Blockers and ED:

Calcium channel blockers have not been properly evaluated in patients with erectile dysfunction. A few studies have been published with mixed results. One study found amlodipine or enalapril to have a positive effect on erectile dysfunction. Furthermore, there was no significant difference between patients treated with amlodipine or enalapril [Ref].

Another study evaluated the relative risk of ED with calcium channel blockers vs other blood pressure medicines as: [Ref]

However, the latest studies have not found any significant association of ED with the use of calcium channel blockers [Ref].

ACE-Inhibitors and ED:

Data is limited to clearly make any inference whether ACE-Inhibitors might result in or improve the symptoms of erectile dysfunction.

ACE-Inhibitors are thought to have beneficial effects and at least they do not worsen the symptoms of ED. The mechanisms underlying their beneficial effects are related to the vasodilatory effects of ACE Inhibitors. ACE Inhibitors also enhance the release of nitric oxide and prevent tissue and vascular endothelial remodeling in the long run.

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ARBs and ED:

Angiotensin II receptor blockers are also thought to have a beneficial effect on the symptoms of erectile dysfunction. In animal studies, it was seen that the levels of intracavernosal angiotensin peaked at the time erection was lost.

In drug-induced erection in animal studies, the injection of angiotensin resulted in penile detumescence. On the other hand, erection was restored when losartan was injected intracavernosal.

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In Conclusion:

Sexual dysfunction in men, primarily erectile dysfunction, is a common condition. The association of ED with the use of spironolactone and diuretics seems stronger than other blood pressure-lowering medicines. Calcium channel blockers, ACE Inhibitors, and Angiotensin Receptor Blockers have either a neutral effect or might improve the symptoms of ED.

Tips and Caution:

Apart from switching the antihypertensive medicine, it is also advisable to add a phosphodiesterase inhibitor such as Sildenafil, Verdenafil, or tadalafil in patients with refractory erectile dysfunction.

It is important to avoid nitrates and phosphodiesterase combination because of the severe hypotension associated with these drugs when given in combination.

In some cases, nitrates should be withheld and restarted 24 hours after sildenafil or vardenafil. Nitrates may be restarted after 48 hours if tadalafil is used because of its longer duration of action.

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One must also be cautious when using Nebivolol in patients using nitrates since both drugs enhance the release of nitric oxide and may result in serious side effects in patients with cardiovascular diseases.

Here is a summary and comparison of various studies that evaluated the effect of blood pressure medicine on ED (erectile dysfunction) [Ref]:

Can you now answer: What blood pressure medications do not cause erectile dysfunction?