High blood pressure and erectile dysfunction (ED) often occur together.
Hypertension, or high blood pressure, is one of the world's most common health conditions but treatment can dramatically decrease mortality.
High Blood Pressure: What is Normal?
Projections for the year 2025 indicate that about 1.56 billion or 29% of adults will have hypertension. In the United States approximately one-third of adults are considered to be hypertensive. The guidelines for high blood pressure by the National Heart, Lung and Blood Institute were modified in 2003. Blood pressures previously considered to be within the "normal" range are now considered to be within the "pre-hypertensive" category. The guidelines do not recommend drug therapy for those with prehypertension unless it is required by another condition, such as diabetes or chronic kidney disease. But people who are prehypertensive and people with normal blood pressures are encouraged to make lifestyle changes including losing excess weight, becoming physically active, limiting alcoholic beverages and following a heart-healthy eating plan. Hypertension is the second most prevalent concurrent disease in men with erectile dysfunction.
Erectile Dysfunction (ED) in Men with High Blood Pressure
Erectile dysfunction in men with high blood pressure occurs either as a result of the side effects of the treatment or as result of the blood pressure being lowered to normal range. It is often necessary to maintain higher perfusion pressures in a hypertensive man in order to maintain the erection.
One consistent theme throughout our discussion of the risk factors and treatments of erectile dysfunction is the importance of modifying the primary behavior (such as obesity, high sodium intake or inactivity). If we don't modify the primary risk factors, the disease process continues and we merely manage the obvious symptoms with medication. Unfortunately, in the United States we tend to treat risk factors separately without recognizing that the risk factors are additive with each other. There are many guidelines and recommendations available to specialists and primary care physicians about the proper blood pressure level and the appropriate therapies, which include life style modification.
Men with ED Tend to Stop Taking Blood Pressure Medicines
Sexual dysfunction is associated both with hypertension and the treatment for hypertension. Hypertensive therapies can impact a man's ability to achieve or maintain an erection. This can be an independent risk factor that can lead to the worsening of a man's already poor erection. Unfortunately when men experience sexual dysfunction as a side effect of anti-hypertensive medications, they typically stop the medication and become non-compliant. It's been estimated that as many as 70% of hypertensive men who have had significant side effects, particularly side effects related to sexual dysfunction, are non-compliant with their medication.
What Caused the Erectile Dysfunction First?
The biggest question regarding hypertension and erectile dysfunction is what caused the erectile dysfunction first: the disease itself, hypertension, or the treatment for the disease. We will review the current literature regarding high blood pressure and endothelial dysfunction. We will also review some of the medications that have been shown to directly affect erections and cause erectile dysfunction.
A simplified analogy of an erection is inflating a tire. In order to maintain a firm tire, it's necessary to pump air into the tire under pressure. More importantly, in order to maintain the erection, it's necessary to maintain that pressure to keep the air in the tire. Erectile dysfunction is merely a disorder of getting blood into the penis, much like getting air into a tire and maintaining the pressure.
The endothelium is the layer of cells that lines the interior surface of the body's blood vessels of the body. In the penis, these cells dilate in response to certain signals generated by both hormones and cellular signals to facilitate an erection. These endothelial cells then relax and allow a seal to be made to prevent blood from leaking out of the penis. Diseases that affect the endothelium such as hypertension, dyslipidemia, metabolic syndrome, or even an atherogenic diet, can prevent the epithelial relaxation that prevents the blood from staying in the penis. We call this condition a venous leak. This is a very simplistic view of the maintenance of an erection but the mechanism is indeed that simple.
Blood Pressure Medications that Cause ED
We will review each of the categories of hypertensive medication and their relevance and effect upon sexual dysfunction.
Thiazide Diuretics and Erections
The mainstay of hypertensive medications includes the thiazide diuretics. These medications are used alone or, more commonly, as a combination pill. Because diuretics are associated with disorders of potassium loss, over time we have used lower and lower doses to decrease blood pressure and decrease potassium loss.
These drugs have an effect on the normal erection and when a man has a temporal association of erectile dysfunction with the onset of treatment for hypertension it's reasonable to change the medications. If a man says, "I had great erections but when I started a thiazide diuretic, my erections became bad", we recommend changing the medication. The man who says, "I've been on the thiazide diuretic for twenty years and I've slowly lost my erections" requires a different medication to treat the erectile dysfunction and not just a different diuretic. This specific discussion should be undertaken between a patient and the health professional who prescribed the anti-hypertensive medication.
Beta Blockers and Erections
Beta blockers are another class of medications that are commonly used alone or in combination with other therapies for men with hypertension. Unfortunately, beta blockers have a significant association with erectile dysfunction. For this reason, if men complain that their erections were adequate but decreased dramatically when they started a beta blocker, it is time for a discussion for the health professional who prescribed the medication.
Potassium Sparing Diuretics and Erections
Some of the less commonly used medications include a class of diuretics that are known as the potassium sparing diuretics. These drugs are commonly used for hypertension in men with some degree of renal insufficiency and can have a side effect of erectile dysfunction because of effects on the hormonal status of the patient. The potassium sparing diuretics can also cause painful breast tenderness which can be quite significant for men.
Alpha Blockers and Erections
The class of medications called alpha blockers includes drugs such as prazosin, terazosin and doxazosin. These classic alpha blockers are used for hypertension and more commonly have been used to treat men for the symptoms related to an enlarged prostate. These drugs have not been shown to affect the erection in an adverse way. However, they have been shown to decrease a man's ability to ejaculate, a condition called retrograde ejaculation, because of a unique action on the bladder neck. Retrograde ejaculation is the reason some men do not like to take alpha blockers. They are usually not primary therapy for the man with the new diagnosis of hypertension but are more commonly used in combination therapy. A newer class of alpha blockers formulated specifically for prostate disease does not tend to have as many cardiovascular side effects.
Calcium Channel Blockers and Erectile Dysfunction
Another class of medications used in blood pressure management is the calcium channel blockers. These are very common medications that have not been shown to have a dramatic effect on erectile function. They are commonly used alone and are also included in "step therapy" which is used in patients who have difficult-to-treat high blood pressure requiring multiple medications.
Angiotensin Receptor Blockers and ED
Perhaps the best medication available to treat high blood pressure in men with erectile dysfunction is the angiotensin receptor blockers or ARBs. This class of compounds includes drugs such as valsartan. This medication is one of the few that does not adversely affect erections. Angiotensin receptor blockers are probably the number one choice for use in men who have erection problems related to hypertensive therapy.
ACE Inhibitors and ED
Another class of anti-hypertensive medication that is particularly useful in men with erectile dysfunction are the angiotensin converting enzyme (ACE) inhibitors. These inhibitors are indicated in the treatment of high blood pressure either alone or in combination.
Side Effects of Blood Pressure Medicines
It has been well documented that the side effects of anti-hypertensive therapy are the most significant and common reason that patients stop medications for hypertension. Sexual dysfunction is certainly one of the potential side effects of medications used to treat hypertension. It's important to highlight the fact that a patient should never stop a medication because of side effects without consulting his physician so that an appropriate change may be made.
Hypertension remains a significant risk factor for general health and should not be ignored. Erectile dysfunction may be a very early warning sign for hypertension and for cardiovascular disease. It is not uncommon for the medications used to treat hypertension to result in or exacerbate erectile dysfunction. It will be many years before we know whether the hypertension causes the erectile dysfunction or whether the medications used to treat the hypertension cause erectile dysfunction. However, we do know that men with erectile dysfunction are twice as likely to have hypertension as men without erectile dysfunction. We suspect the answers related to hypertension and erectile dysfunction will be complex and will probably involve a number of factors that are not even known at this point.
References: See Bibliography
Posted August 2008
Updated August 2009