The Association of Obstructive Sleep Apnea and Erectile Dysfunction

Christopher J. Lettieri, MD


July 30, 2013

Pathophysiology: Sexual Dysfunction in OSA

The pathophysiology of sexual dysfunction in OSA is likely multifactorial and affected by several disease-related factors, including obesity, sleep fragmentation, hypoxia and intermittent desaturations, and alterations in vascularity. Intermittent hypoxic events and sleep fragmentation limit spontaneous nocturnal erections, which have been linked to daytime erectile function.[8] OSA produces endothelial dysfunction and sympathetic activation, which leads to hypertension and microvascular disease, both of which are established risk factors for ED. Androgen deficiency, which is also commonly identified in patients with untreated OSA, may further mediate ED in these patients.[9,10]

Of the various physiologic derangements resulting from sleep disordered breathing, it appears that the oxygenation nadir has the greatest association with the development of ED among patients with OSA. As mentioned, Budweiser and colleagues[1] found that the mean nocturnal oxygen saturation was independently associated with ED. Similarly, Shin and colleagues[2] compared 32 patients with OSA vs 27 normal controls. The authors found that 19/32 (59.3%) patients with OSA also had ED, compared with only 8/27 (29.6%) controls (P = .012). The authors did not observe a correlation between ED and the AHI but did find a correlation with the oxygen desaturation nadir (r = 0.338, P = .009). The authors determined that an SpO2 nadir threshold of 77% was associated with a positive predictive value for ED of 88.9%.

Effect of Treatment

Treatment of OSA with continuous positive airway pressure (CPAP), oral appliance therapy, and uvulopalatopharyngoplasty have all been demonstrated to improve erectile function.[6,11,12,13,14,15,16] Karacan and colleagues[11] noted a 40% reported improvement in ED following CPAP therapy. Similarly, among 40 patients with severe sleep apnea randomly assigned to CPAP or antidepressants, Taskin and colleagues[12] found that after 1 month of regular CPAP use, IIEF scores significantly improved from 15.7 ± 5.1 to 19.1 ± 3.9. In this study, all participants reported improved erection status. Similar to prior reports, the authors noted a strong correlation with ED and the overnight SpO2 nadir.

Budweiser and colleagues[13] investigated the long-term effect of OSA on sexual function. Ninety-one men with OSA and moderate to severe ED were stratified according to regular use of CPAP. They found that CPAP users experienced an improvement in overall sexual function compared with patients who did not use CPAP (P = .014).

In a prospective cohort, Dombrowsky and colleagues[6] assessed the impact of CPAP on sexual function and desire at baseline and after 6 months of therapy. They found that CPAP therapy improved sexual function and satisfaction in both those with and without ED, with greater improvements from baseline in those with established ED. Regular use of CPAP was associated with an 88.3% improvement in the Functional Outcomes of Sleep Questionnaire sexual domain and a 71.7% improvement in IIEF function. While CPAP improved both sexual function and desire, it did not resolve ED in all patients. Normalization of IIEF function occurred in 41.2% of those with ED.

A meta-analysis assessing the effectiveness of sildenafil vs CPAP for patients with ED and OSA found that sildenafil was superior to CPAP in terms of the percentage of successful intercourse attempts (OR, 3.24; 95% CI, 2.37-4.43), erectile function scores [weighted mean difference, 3.57; 95% CI, 1.68-5.45), and satisfaction levels of the patients and their partners (OR, 3.56; 95% CI, 1.27-9.98).[16] However, it should be noted that CPAP did result in improved measures of sexual function, and this meta-analysis was limited to only 2 randomized controlled trials, 70 patients, and a limited (12 weeks) treatment period.


ED and decreased libido are common in men with OSA and may be underrecognized as patients may not voluntarily report the problem or understand this association. CPAP therapy has been shown to improve both sexual function and satisfaction in the majority of patients, regardless of baseline erectile function. Like other forms of OSA-related end-organ dysfunction, ED improves but may not resolve despite adequate treatment.


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