The Association of Obstructive Sleep Apnea and Erectile Dysfunction

Christopher J. Lettieri, MD


July 30, 2013

Editor's Note: Obstructive sleep apnea (OSA) is associated with numerous comorbid conditions. In many, a causative relationship has either been well established or strongly associated. As the knowledge of sleep-disordered breathing and its consequences continues to grow, so does the list of associated or consequential conditions. The following is part 3 of a 5-part series exploring more recently identified consequences of OSA.


Erectile dysfunction (ED) is common in patients with OSA. Sleep apnea induces hormonal alterations, deviations in neural regulation, endothelial dysfunction, and changes in microvascular perfusion that can cause or contribute to the development of ED.

The association of ED and OSA, and the causative nature of OSA in the development of ED, continue to be better defined, and there have been numerous recent publications exploring these relationships. Men with OSA experience more sexual dysfunction and sexual dissatisfaction when compared with age-matched controls.[1,2] Not only is there a high incidence of ED among patients with OSA, but the 2 conditions together also tend to cause further detriments in both mood and quality of life than either condition alone.[3]

Several studies have found that the prevalence of ED is high among patients with OSA. A study by Seftel and colleagues[4] found that 40% of OSA patients had ED. Similarly, Santos and colleagues[5] determined a prevalence of ED among 62 men with newly diagnosed OSA. Using the 5-item version of the International Index Erectile Function (IIEF) questionnaire, the authors identified ED in 64.4% of the cohort. Dombrowsky and colleagues[6] conducted a prospective analysis of 92 men who were nondiabetic and under the age of 60 years with newly diagnosed OSA to determine the prevalence of ED and decreased libido. Among the cohort, the mean age was 45.8 ± 8.2 years, and the mean apnea-hypopnea index (AHI) was 38.2 ± 27.6 events/hour. At baseline, ED was present in 45.6%, and 27.2% had diminished libido.

It seems that the reciprocal of this association is also true. While ED is common among those with OSA, OSA is also common in men presenting with ED. Hirshkowitz and colleagues[7] assessed patients with ED for evidence of sleep disordered breathing. They found that 91.3% men with ED also had OSA.

Overlapping Risk Factors

While there appears to be a direct link between OSA and the development of ED, the common overlapping features and shared risk factors make it somewhat difficult to establish a clear causal relationship. Both conditions are associated with advanced age, hypertension, and diabetes, which may confound the true relationship between OSA and ED. As such, some debate exists about whether OSA is a primary cause of ED or whether the two merely coexist due to similar shared comorbid causative factors.

This was, in part, explored in a prospective, cross-sectional analysis by Budweiser and colleagues,[1] who examined the prevalence of ED among patients with suspected OSA who had risk factors for ED. The authors further attempted to evaluate the relationship between sexual dysfunction and several polysomnographic variables. Erectile and sexual function were assessed using the 15-item IIEF questionnaire. Among 401 men referred for polysomnography for clinically suspected sleep disordered breathing, OSA was diagnosed in 92%. ED was present in 69% of patients with OSA, compared with only 34% of those without OSA (P < .001). In a multivariate stepwise regression analysis including known risk factors for ED (age, obesity, coronary heart disease, peripheral vascular disease, hypertension, diabetes, prior prostate surgery, and beta-blocker therapy) and polysomnographic measures (AHI and mean nocturnal oxygen saturation), the authors found that OSA was an independent risk factor for ED. While age, vascular disease, prostate surgery, and hypertension were confirmed as risk factors for ED, they did not abolish the independent association with OSA. By logistic regression analysis, the mean nocturnal oxygen saturation was independently associated with ED (P = .012). Similarly, Santos and colleagues[5] identified OSA, age (odds ratio [OR], 1.226; 95% confidence interval [CI], 1.062-1.415), and diabetes (OR, 31.205; 95% CI, 1.222-796.557) as independent risk factors for ED.


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