COMMENTARY

6 Meds That Can Mess With Your Patient's Sex Life

Henry Rosevear, MD

Disclosures

January 19, 2021

All too often, our patients do not take the drugs we prescribe. Studies have consistently shown that 25% of prescriptions are not filled and 50% of prescriptions for chronic conditions are not taken as directed.

While numerous factors play into those decisions, the most common reason I hear from patients in my urology clinic for not taking a prescription is the negative sexual side effects of a drug. With that in mind, it is important to understand how certain common classes of medications can negatively affect a patient's sexual health. Here are six classes of drugs that patients commonly skip because of sexual side effects.

Antihypertensives

We assume that a patient's cardiovascular health would be more important to them than their ability to achieve and maintain an erection, but in the real world that is not always the case.

An erection is a vascular event. Hence, anything that interferes with the body's ability to produce blood flow to the penis results in erectile dysfunction. This is why antihypertensives (eg, spironolactone or any thiazide) are notorious for negatively affecting the ability to achieve an erection. To make the problem worse, during sexual stimulation, a person's heart rate increases; thus, beta-blockers such as metoprolol, which are designed to limit increases in heart rate, are some of the worst offenders in this category.

Alpha-Blockers

I prescribe alpha-blockers on a daily basis as first-line therapy for treating prostatic obstruction. They are cheap, generic, and work really well. Unfortunately, they have the potential to negatively affect a man's sex life in two specific ways.

First, the early-generation drugs (eg, terazosin and prazosin) are also antihypertensive medications and thus have the same problem as all antihypertensives: they decrease blood flow to the penis and therefore worsen erectile dysfunction.

The second side effect, common even in the later generations of alpha-blockers (like tamsulosin or silodosin), is retrograde ejaculation.

Let's be blunt: For some men, sex without ejaculation isn't worth having. Alpha-blockers relax muscles in the bladder neck, allowing the ejaculate to go into the bladder instead of out of the penis. This side effect is very patient- and drug-specific, so changing the alpha-blocker will not always solve the problem.

SSRIs

Selective serotonin reuptake inhibitors (SSRIs) are one of the numerous medication classes used to treat depression. SSRIs like fluoxetine, paroxetine, sertraline, citalopram, and escitalopram all have a sexual side effect that can be very bothersome to both men and women: delayed ejaculation or delayed orgasm.

This side effect is so common that low-dose paroxetine is my preferred treatment for men who come to my clinic with premature ejaculation.

Other Antidepressants

Almost all antidepressants — whether tricyclic antidepressants (amitriptyline, doxepin, imipramine, and nortriptyline), monoamine oxidase inhibitors (phenelzine and tranylcypromine), or antipsychotic medications (thioridazine, thiothixene, and haloperidol) — can negatively affect libido. Some of these medications, such as citalopram, may dramatically lower sperm count or even cause azoospermia.

In no way am I suggesting that depression go untreated because of these side effects, but patients should be counseled about the side effects of these medications so that they and their loved ones understand what to expect.

Advanced Prostate Cancer Drugs

Until a few years ago, treatment options for patients with advanced prostate cancer were limited to chemical castration. Today there are a number of great options for these patients that dramatically increase both their quantity and quality of life.

Unfortunately, it does not matter if the patient is on first-generation hormone therapy (leuprolide) or one of the later-generation drugs (darolutamide, enzalutamide, apalutamide, or abiraterone); all of these dramatically reduce libido by decreasing the level of testosterone. Because the underlying cancer is hormone sensitive, there is no good way to increase serum testosterone levels without potentially worsening the patient's cancer.

PDE5 Inhibitors

Yes, I realize that the PDE5 inhibitors (sildenafil, tadalafil, vardenafil, and avanafil) are used to help men achieve erections, so it may seem odd to include these agents in a discussion of meds that can mess with a patient's sex life.

But these drugs, like all drugs, have side effects. Headaches, nasal congestion, facial flushing, and heartburn can happen while taking these drugs and can ruin the mood. Advise your patients to avoid food before taking these medications, avoid alcohol, stay hydrated, and use over-the-counter drugs such as acetaminophen or ibuprofen to help counter any of these other side effects and keep the moment going.

Henry Rosevear, MD, is a private-practice urologist based in Colorado Springs, Colorado. He comes from a long line of doctors, but before entering medicine he served in the US Navy as an officer onboard the USS Pittsburgh, a fast-attack submarine based out of New London, Connecticut. During his time in the Navy, he served in two deployments to the Persian Gulf, including combat experience as part of Operation Iraqi Freedom.

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