Sexual Dysfunction in Patients with Hypertension: Implications for Therapy

Carlos M. Ferrario, MD, Pavel Levy, MD

In This Article

Sexual Dysfunction -- Association With Antihypertensive Agents and the Dysmetabolic Syndrome of High Blood Pressure

Sexual dysfunction is a frequently encountered problem in patients with hypertension and may occur either as a side effect of some types of antihypertensive medications or as a component of the dysmetabolic syndrome of high blood pressure.[6,14] In hypertensive males, sexual dysfunction may present in a variety of ways, including a decreased incidence of sexual activity, difficulty attaining or maintaining an erection, and problems in ejaculating.[9] For the most part, sexual problems have been reported to occur more frequently in patients receiving antihypertensive medication than in those with either untreated hypertension or in normotension (Figure 1 and Table I ).[9,11,15,16,17,18] However, as discussed below, this finding is not universal.[18] In the Treatment of Mild Hypertension Study (TOMHS),[19] a placebo-controlled trial, there was no difference in the incidence of sexual dysfunction among several antihypertensive agents when compared to placebo at 4 years. At 1 year, however, a greater incidence was noted with a diuretic than with other drugs.[19]

Male patients who had received prior antihypertensive therapy had a higher incidence of distress over sexual symptoms than those who had not received antihypertensive therapy. The sexual symptoms distress index, consisting of a series of four items commonly associated with male sexual distress, was assessed on a 5-point scale as part of a self-administered questionnaire. The study focused specifically on distress over symptoms of sexual dysfunction rather than an overall assessment of quality of life.

The concept of hypertension as a dysmetabolic syndrome has brought to the forefront the frequent association of high blood pressure with dyslipidemia, insulin resistance, coagulation disorders, and peripheral vascular disease.[20] The anatomic and hemodynamic characteristics of the penile circulation make the process of penile tumescence inextricably linked to blood pressure, perfusion pressure, and vascular compliance. In this context, Toblli et al.[21] reported that cavernous-tissue vascular fibrosis was present in rats with spontaneous hypertension and that the degree of vascular sclerosis in the rat penis was highly correlated with the level of arterial pressure. These intriguing observations suggest a vasculogenic mechanism of erectile dysfunction in hypertensive subjects, since peripheral arterial disease has begun to be recognized as an early consequence or direct contributor to high blood pressure.

In keeping with the new animal studies, the recent findings of Llisteri and colleagues[11] demonstrate that erectile dysfunction in hypertensive patients aged 30-65 years was associated with medications that had not been usually considered to impair sexual function. Thus, hypertension-related erectile dysfunction may be a consequence of a reduction in penile perfusion pressure associated with the decrease in systemic arterial pressure induced by antihypertensive medications in the presence of an already decreased penile vascular compliance. Under this scenario, erectile dysfunction may represent a previously unrecognized early symptom of peripheral vascular disease.