Erectile dysfunction (ED), defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance, is a common condition among aging men and has gained recognition as an early indicator of underlying cardiovascular pathology. Epidemiological data suggest that ED affects nearly 40% of men in their forties and up to 70% of those in their seventies, with the prevalence rising significantly among individuals with chronic health conditions such as hypertension, diabetes mellitus, and atherosclerosis [1].

Hypertension, one of the most widespread non-communicable diseases globally, is a well-established risk factor for both cardiovascular disease and ED. The mechanisms linking hypertension to erectile dysfunction include endothelial dysfunction, impaired nitric oxide bioavailability, arterial stiffness, and vascular remodeling, all of which contribute to reduced penile perfusion and impaired erectile capacity [2]. Moreover, long-term management of hypertension through pharmacological means may independently influence sexual function.

Antihypertensive medications, while critical for cardiovascular protection, have varying impacts on erectile function. Beta-blockers and thiazide diuretics, for instance, have been historically associated with higher rates of ED, likely due to their influence on central sympathetic inhibition and peripheral vascular resistance [3]. On the other hand, certain antihypertensive agents such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers appear to have a more neutral or even favorable effect on erectile function, owing to their vascular protective properties [4].

Despite the growing awareness of these drug-related sexual side effects, many patients remain uninformed, and healthcare providers may not routinely consider the impact of antihypertensive therapy on sexual health during treatment planning. This oversight is particularly significant in patients with multiple comorbidities, where polypharmacy further compounds the risk of ED [5].

This study aims to evaluate the prevalence and severity of erectile dysfunction among hypertensive men receiving different classes of antihypertensive therapy, and to investigate potential associations between specific drug classes and ED severity.

Study Design and Setting

This was a hospital-based, cross-sectional observational study conducted in the Department of General Medicine at Government Medical College, Ramagundam, Telangana. The study was carried out over a period of twelve months, from August 2023 to July 2024.

Study Population

The study population consisted of male hypertensive patients aged between 40 and 70 years attending the outpatient and inpatient services of the General Medicine department during the study period.

Inclusion Criteria

Male patients aged 40 to 70 years

Diagnosed with essential hypertension (as per JNC 8 guidelines)

On antihypertensive medication for at least 6 months

Provided informed written consent to participate in the study

Exclusion Criteria

Known cases of primary erectile dysfunction prior to the onset of hypertension

Patients with major psychiatric illness or neurological disorders

History of pelvic surgery, trauma, or endocrine disorders affecting sexual function

Patients currently on medications known to affect erectile function other than antihypertensives (e.g., antidepressants, antipsychotics)

Unwilling or unable to complete the IIEF-5 questionnaire

Sample Size

A total of 100 participants who met the inclusion criteria were selected using consecutive sampling technique.

Data Collection Procedure

After obtaining ethical clearance from the Institutional Ethics Committee and formal permission from the college authorities, eligible participants were approached during their routine visits to the hospital. Written informed consent was obtained. Data were collected using a structured interview schedule that included:

Sociodemographic details

Medical and medication history

Duration and type of antihypertensive therapy

Comorbid conditions (e.g., diabetes, dyslipidemia)

Erectile dysfunction was assessed using the International Index of Erectile Function-5 (IIEF-5) questionnaire, a validated tool widely used for clinical and research assessment of male sexual function. Scores range from 5 to 25, with lower scores indicating greater severity of dysfunction.

Classification of Erectile Dysfunction (based on IIEF-5 score)

22–25: No ED, 17–21: Mild ED, 12–16: Mild-to-moderate ED, 8–11: Moderate ED, 5–7: Severe ED

Data Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 25.0. Descriptive statistics such as mean, standard deviation, frequency, and percentage were used to summarize demographic and clinical data. The chi-square test was employed to assess the association between antihypertensive drug class and severity of erectile dysfunction. Pearson’s correlation coefficient was used to determine the relationship between duration of hypertension and ED severity. A p-value of <0.05 was considered statistically significant.

Ethical Considerations

Ethical clearance was obtained from the Institutional Ethics Committee of Government Medical College, Ramagundam prior to the commencement of the study. Confidentiality of participants was maintained throughout, and participation was entirely voluntary.

Participant Characteristics

A total of 100 hypertensive male participants aged 40–70 years were included in the study. The mean age of the cohort was 58.4 ± 7.2 years. Of these, 65% were aged 55 years or older. Comorbidities were prevalent, with 30% having type 2 diabetes mellitus, 24% with dyslipidemia, and 18% reporting a history of smoking.

Antihypertensive Medication Distribution

Participants were grouped based on their primary antihypertensive medication regimen. Beta-blockers were the most commonly prescribed class (25%), followed by diuretics (20%), ACE inhibitors (18%), calcium channel blockers (17%), ARBs (15%), and combination therapy (5%). The detailed distribution is presented in Table 1.

Table 1: Distribution of Participants by Antihypertensive Medication Class

Figure 1. Distribution of Participants by Antihypertensive Medication Class

Prevalence and Severity of Erectile Dysfunction

Erectile dysfunction (ED) was assessed using the International Index of Erectile Function-5 (IIEF-5) questionnaire. Among the study population, 62% (n = 62) were found to have some degree of ED. The severity of ED was categorized as mild in 21% of cases, moderate in 26%, and severe in 15%.

Patients receiving beta-blockers and diuretics had a higher frequency of moderate-to-severe ED compared to those on ACE inhibitors, ARBs, or calcium channel blockers. These findings are summarized in Table 2.

 Table 2: Severity of Erectile Dysfunction by Antihypertensive Class

Figure 2.Severity of Erectile Dysfunction by Antihypertensive Class

Statistical Associations

A chi-square test was performed to evaluate the association between the class of antihypertensive medication and ED severity. The analysis revealed a statistically significant association (χ² = 14.72, p = 0.023), indicating that medication type influences the severity of erectile dysfunction.

Further subgroup analyses demonstrated that ED prevalence was significantly higher among patients with diabetes mellitus (p = 0.01). Moreover, participants aged ≥60 years exhibited a greater severity of ED compared to their younger counterparts (p = 0.03). Duration of hypertension also showed a positive correlation with ED severity (Pearson’s r = 0.42, p < 0.001).

This study examined the prevalence and severity of erectile dysfunction (ED) in hypertensive men receiving long-term antihypertensive therapy, with particular attention to the influence of specific antihypertensive drug classes. ED was reported by 62% of participants, with moderate-to-severe ED affecting 41%. These findings are consistent with previous reports that document a high prevalence of ED among hypertensive men, reflecting a shared pathophysiological basis involving endothelial dysfunction and vascular impairment [6, 7].

A statistically significant association was found between the type of antihypertensive medication and the severity of ED (p = 0.023). Beta-blockers and diuretics were associated with notably higher rates of moderate-to-severe ED (68% and 60%, respectively), whereas ACE inhibitors, ARBs, and calcium channel blockers were associated with lower rates of ED. This observation supports the conclusions of earlier studies suggesting that non-selective beta-blockers and thiazide diuretics can negatively affect erectile function by reducing penile blood flow, suppressing testosterone levels, and influencing central neurovascular regulation [6, 7, 8].

Conversely, drugs acting on the renin-angiotensin system—such as ACE inhibitors and ARBs—may have protective effects on erectile function by improving endothelial health and enhancing nitric oxide bioavailability [8, 10]. Several studies have reinforced this therapeutic advantage, indicating that such agents may offer not only cardiovascular protection but also preservation of sexual health [9, 10].

The current findings also demonstrate that increasing age and longer duration of hypertension are significantly associated with worsening erectile function (p = 0.03 and r = 0.42, p < 0.001, respectively). These associations are biologically plausible, as aging and chronic hypertension contribute to structural and functional vascular damage, autonomic dysfunction, and decreased penile perfusion, all of which impair erectile capacity [9].

Moreover, the presence of diabetes mellitus was found to significantly exacerbate ED severity (p = 0.01). This is consistent with earlier research that identifies diabetes as a key modifier of ED due to its compounded effects on vascular, neurologic, and hormonal pathways [11, 12]. Polypharmacy in patients with multiple comorbidities may further amplify the risk of drug-related sexual dysfunction [12].

Given these findings, it is imperative for healthcare providers to consider the potential impact of antihypertensive agents on sexual health during therapeutic decision-making. Substituting beta-blockers or diuretics with agents known to have neutral or beneficial effects—such as ARBs or calcium channel blockers—may be warranted when clinically feasible. A proposed management algorithm by Doumas and colleagues emphasizes the value of individualized therapy that balances hemodynamic goals with quality-of-life considerations, including sexual function [6].

Limitations

This study had certain limitations. As a cross-sectional observational study, causal relationships could not be firmly established. Self-reported erectile function assessments may have introduced response bias due to social stigma or underreporting. Furthermore, factors such as serum testosterone levels, psychosocial status, and partner-related variables were not evaluated, which could have further enriched the analysis.

This study highlights a significant association between certain classes of antihypertensive medications and the prevalence of erectile dysfunction (ED) in middle-aged and elderly men. Beta-blockers and diuretics were associated with higher rates of moderate-to-severe ED, while ACE inhibitors, ARBs, and calcium channel blockers showed a comparatively lower impact. Age, duration of hypertension, and diabetes mellitus were also key contributors to increased ED severity. These findings underscore the importance of considering sexual health when prescribing antihypertensives. Patient education, routine screening for ED, and individualized therapy may enhance both blood pressure control and quality of life. Clinicians should adopt a holistic approach to long-term hypertension management.

1. Cordero A, Bertomeu-Martínez V, Mazón P, Fácila L, González-Juanatey JR. Erectile dysfunction may improve by blood pressure control in patients with high-risk hypertension. Postgrad Med. 2010 Nov;122(6):51-6. doi: 10.3810/pgm.2010.11.2223. PMID: 21084782.
2. Hernández-Cerda J, Bertomeu-González V, Zuazola P, Cordero A. Understanding Erectile Dysfunction in Hypertensive Patients: The Need for Good Patient Management. Vasc Health Risk Manag. 2020 Jun 12;16:231-239. doi: 10.2147/VHRM.S223331. PMID: 32606719; PMCID: PMC7297457.
3. Agostini JV, Tinetti ME, Han L, Peduzzi P, Foody JM, Concato J. Association between antihypertensive medication use and non-cardiovascular outcomes in older men. J Gen Intern Med. 2007 Dec;22(12):1661-7. doi: 10.1007/s11606-007-0388-9. Epub 2007 Sep 25. PMID: 17899299; PMCID: PMC2219823.
4. Chrysant SG. Antihypertensive therapy causes erectile dysfunction. Curr Opin Cardiol. 2015 Jul;30(4):383-90. doi: 10.1097/HCO.0000000000000189. PMID: 26049386.
5. Zaman Huri H, Lian Choo T, Sulaiman CZ, Mark R, Abdul Razack AH. Oral drug treatments in patients with erectile dysfunction and multiple comorbidities: a retrospective observational study. BMJ Open. 2014 Jul 7;4(7):e005381. doi: 10.1136/bmjopen-2014-005381. PMID: 25001396; PMCID: PMC4091539.
6. Doumas M, Douma S. The effect of antihypertensive drugs on erectile function: a proposed management algorithm. J Clin Hypertens (Greenwich). 2006 May;8(5):359-64. doi: 10.1111/j.1524-6175.2005.05285.x. PMID: 16687945; PMCID: PMC8109585.
7. Akinyede AA, Nwaiwu O, Fasipe OJ, Olusanya A, Olayemi SO, Akande B. A prospective study of the effect of antihypertensive medications on the sexual functions of hypertensive adult male patients. Future Sci OA. 2020 Jun 2;6(6):FSO479. doi: 10.2144/fsoa-2020-0030. PMID: 32670607; PMCID: PMC7351083.
8. Viigimaa M, Vlachopoulos C, Lazaridis A, Doumas M. Management of erectile dysfunction in hypertension: Tips and tricks. World J Cardiol. 2014 Sep 26;6(9):908-15. doi: 10.4330/wjc.v6.i9.908. PMID: 25276292; PMCID: PMC4176800.
9. Gareri P, Castagna A, Francomano D, Cerminara G, De Fazio P. Erectile dysfunction in the elderly: an old widespread issue with novel treatment perspectives. Int J Endocrinol. 2014;2014:878670. doi: 10.1155/2014/878670. Epub 2014 Mar 17. PMID: 24744785; PMCID: PMC3976909.
10. Lou IX, Chen J, Ali K, Chen Q. Relationship Between Hypertension, Antihypertensive Drugs and Sexual Dysfunction in Men and Women: A Literature Review. Vasc Health Risk Manag. 2023 Nov 3;19:691-705. doi: 10.2147/VHRM.S439334. PMID: 37941540; PMCID: PMC10629452.
11. Zhao C, Feng JL, Deng S, Wang XP, Fu YJ, Wang B, Li HS, Meng FC, Wang JS, Wang X. Genetically predicted hypertension, antihypertensive drugs, and risk of erectile dysfunction: a Mendelian randomization study. Front Cardiovasc Med. 2023 Jun 9;10:1157467. doi: 10.3389/fcvm.2023.1157467. PMID: 37363097; PMCID: PMC10289031.
12. Huri HZ, Ling CF, Razack AH. Drug-related problems in patients with erectile dysfunctions and multiple comorbidities. Ther Clin Risk Manag. 2017 Mar 31;13:407-419. doi: 10.2147/TCRM.S118010. PMID: 28408836; PMCID: PMC5384729.