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Treatment of Erectile Dysfunction in Combination With Arterial Hypertension: Tips And Latest Trends



One of the most important facts about erectile dysfunction (ED) is that men with arterial hypertension are approximately twice as likely to exhibit various violations of potency, the first place among which is erectile dysfunction. In addition, the onset of symptoms of erectile dysfunction can often be noticed earlier than symptoms of cardiovascular diseases, although they are primary in relation to ED. Despite this, the medical community in the management of such patients has traditionally focused mainly on hypertension, underestimating the importance of erectile dysfunction and paying insufficient attention to the treatment of this problem. It is noted that in the case of the development of erectile dysfunction against the background of previously untreated arterial hypertension, the main way to combat potency impairment is to change the way of life, to give up bad habits. If arterial hypertension in a man has already been treated, long-term intake of antihypertensive drugs is recommended to prevent the onset or to alleviate the course of erectile dysfunction. If they do not have the desired effect, oral PDE-5 inhibitors can be considered as therapy, as anti-ED drugs having the least effect on arterial pressure. In most cases of erectile dysfunction, it is of a vascular nature. ED has a huge negative impact not only on the patient himself, but also on his partner. The purpose of this work is to discuss the features of the treatment of ED in patients with arterial hypertension in daily medical practice.
Keywords: Erectile dysfunction, Hypertension, Antihypertensive drugs, Treatment, PDE-5 inhibitors, Cardiovascular risk


Cardiovascular diseases rank first in the world in terms of mortality. At the same time, the majority of deaths due to cardiovascular diseases occur due to arterial hypertension. In 2020, arterial hypertension is registered in approximately 25% of the world’s population [1]. Thus, the risk of developing cardiovascular disease in any person is higher than of any other disease.
Arterial hypertension significantly impairs the quality of life of patients in many of its areas, for example, in sports, but men also begin to suffer from erectile dysfunction. In recent years, the international scientific community has begun to attach importance to the fact that, very often, violations of male sexual function can serve as evidence of a significant cardiovascular risk. The problem, however, is that men are often reluctant to disclose their sexual problems to doctors. Meanwhile, according to rough estimates, more than 150 million men in the world have some degree of erectile dysfunction. Studies have shown that erectile dysfunction in men with hypertension occurs approximately twice as often as in men with normal blood pressure [2].
Arterial hypertension adversely affects the functioning of the arteries of the penis, which are directly responsible for the occurrence of an erection. Under the influence of high blood pressure in the vessels of the penis, signs of atherosclerosis, impaired blood flow, and weakening of the ability to vasodilatation appear [3].
The aim of this work is to highlight the most common problems in the treatment of patients with arterial hypertension and erectile dysfunction and to propose a number of effective ways to solve these problems.

Men with Previously Untreated Hypertension

In men with previously untreated arterial hypertension, in most cases, erectile dysfunction is of a vasculogenic nature. Nevertheless, in the diagnosis of ED, such risk factors as urological disorders, neurological, psychiatric and endocrinological disorders should not be excluded. After the diagnosis of vasculogenic ED has been established, the recommended safest and most appropriate treatment for most patients is to normalize the lifestyle. Despite the traditional underestimation of this method, its effectiveness is quite high. This is due to the fact that the elimination of risk factors for the development of cardiovascular diseases (smoking, obesity, a sedentary lifestyle, alcohol abuse) helps to normalize blood pressure and restore the normal functioning of the vessels of the penis [4, 5].
It is noted that moderate physical activity reduces the risk of ED by about 30%, all other things being equal [6]. At the same time, physical activity has a positive effect on the course of ED, even not in those cases when it is of vascular origin [7]. When erectile dysfunction is combined with metabolic syndrome, a decrease in the caloric intake of the diet has a positive effect on the course of the disease. [8] The indisputable fact is the importance of a balanced diet for obesity-induced ED.
Despite the fact that the recommendations for normalizing the lifestyle are the first that a doctor can resort to, the next stage in the treatment of men with primary identified arterial hypertension and erectile dysfunction is the choice of antihypertensive therapy. The problem with some older generation antihypertensive drugs, such as propranolol, is that they have a negative effect on male sexual function. Meanwhile, many of the newest drugs against high blood pressure either have no effect on potency at all, or even have a positive effect on it, like nebivolol. The beneficial effect of nebivolol on ED is related to its ability to increase nitric oxide production [9]. Another group of first-line antihypertensive drugs that improve the course of erectile dysfunction are angiotensin receptor blockers (ARBs), which promote vasodilation and increase their blood filling [10].

Men with Previously Treated Hypertension

The treatment of erectile dysfunction in patients already receiving antihypertensive medications is complicated by the fact that the doctors need to understand whether ED is caused by hypertension itself, or drugs against it, or it has arisen in an independent way [11]. As a rule, patients with a longer (over 5 years) and severe course of arterial hypertension are more likely to develop erectile dysfunction [12].
An incorrectly selected antihypertensive drug, which causes the development of erectile dysfunction, very often leads to the patient’s refusal of treatment, to a violation of the medication regimen. Thus, the course of both diseases is harmed [13].
To correctly diagnose erectile dysfunction in men receiving treatment for hypertension, it is important to exclude other medications and concomitant diseases. Thus, it is possible to find out whether antihypertensive drugs are the cause of the deterioration of potency. In most cases, the connection between treatment of high blood pressure and the development of erectile dysfunction is observed with b-blockers and diuretics. If switching to other drugs does not help improve erectile dysfunction, it is advisable to consider starting taking specific drugs against erectile dysfunction, primarily PDE-5 inhibitors [14].

PDE-5 Inhibitors in Presence of Hypertension

More than twenty years ago, PDE-5 inhibitors revolutionized the treatment of erectile dysfunction. PDE-5 inhibitors act on the mechanism of erection formation, blocking the activity of the enzyme phosphodiesterase type 5, increasing the level of cyclic guanosine monophosphate and causing relaxation of the walls of the penile vessels, which promotes their expansion and increased blood circulation [15]. The traditionally used first-line drug in this category is Sildenafil, however, the more recently developed vardenafil and tadalafil have several advantages over it, in particular, a longer half-life, less dependence of absorption on the amount of food eaten [16, 17]. The relative safety of the use of PDE-5 inhibitors in patients with hypertension has been proven, since in most cases they have only a slight hypotensive effect. Usually, the combination of PDE-5 inhibitors with antihypertensive drugs does not cause any health problems [18]. Nevertheless, taking any means based on organic nitrates is a strict contraindication to taking any PDE-5 inhibitors due to the formation of a strong hypotensive effect [19]. Care must also be taken when combining a-blockers and PDE-5 inhibitors because of the risk of developing dangerously severe hypotension [20]. It is noted that a significant number of patients who are already receiving treatment for erectile dysfunction tend to more closely follow the recommendations of doctors regarding the treatment of hypertension.
In some patients, taking PDE-5 inhibitors improves microcirculation and improves cardiopulmonary load in men with heart failure. This effect is associated with their vasodilating and antiproliferative properties. That is why the primary purpose of PDE5 inhibitors was the treatment of pulmonary arterial hypertension [21].
In addition, tadalafil is used in the treatment of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Efficiency is achieved by normalizing blood circulation in the genitals [22]. This is especially important because the drugs used to treat BPH, mainly a-blockers, often have a detrimental effect on erectile function.

Treatment of Erectile Dysfunction in Hypertensive Patients except PDE-5 Inhibitors

Not all hypertensive patients with erectile dysfunction respond positively to treatment with PDE-5 inhibitors. In such cases, it becomes necessary to resort to second and third line therapy. Second-line therapy involves the use of intracavernous injections, while third-line therapy is mainly represented by surgically implantable penile prostheses. Inflatable or malleable in design, these devices, implanted into the cavernous bodies of the penis, represent a very reliable way to restore sexual function. The infection rate and mechanical failure rates of penile prostheses are extremely low, they are safe and effective. However, many men refuse such a solution to the problem of erectile dysfunction for psychological reasons [23].

Predicting the Occurrence of Cardiovascular Risks

In the last two decades, the appearance of symptoms of erectile dysfunction, especially in men without serious hormonal imbalance and bad habits, very often indicates the risk of cardiovascular diseases. The incidence of erectile dysfunction in men with latent or overt course of coronary artery disease is approximately twice as high as in men without cardiovascular problems [24]. It is noteworthy that in diseases of large coronary arteries, the symptom of a weakened erection begins to appear, as a rule, two to three years before the manifestation of the cardiovascular disease itself [25]. This is due to the fact that often lesions of smaller arteries become evident earlier than lesions of larger arteries, such as coronary arteries [26]. The pathophysiological mechanisms of the onset of erectile dysfunction and atherosclerotic lesions of the cardiovascular system are largely similar, since both conditions are caused by a decrease in the bioavailability of nitric oxide and adhesion of the vascular walls [27]. A review of relevant analyzes and studies confirmed that erectile dysfunction is directly associated with an increased risk of developing cardiovascular diseases and death from them [28]. Such cardiovascular diseases include cerebrovascular events and myocardial infarction. Accordingly, erectile dysfunction, both from a practical and scientific point of view, is a promising tool for identifying the asymptomatic course of cardiovascular diseases [29]. If the patient already suffers from arterial hypertension, against the background of which he developed erectile dysfunction, this is an occasion to pay attention to the state of his cardiovascular system, to conduct a more detailed medical examination by a cardiologist.

Sexual Activity in Hypertension Patients

Recommendations for the treatment of erectile dysfunction and the normalization of sexual activity in men at risk of cardiovascular disease, including those with hypertension, include the need for cardiovascular risk profiling, which falls into three categories: low risk, medium risk, and high risk. Controlled arterial hypertension (low risk) implies free sexual urge and the possibility of treating ED with any means other than b-blockers and diuretics [30]. Uncontrolled hypertension (high risk) implies treating erectile dysfunction and resuming sexual activity only after assessing the state of the cardiovascular system and stabilizing blood pressure.


Today, there is an underestimation of the importance of treating erectile dysfunction in men with hypertension. A comprehensive approach to the treatment of sexual dysfunction in the presence of a risk of cardiovascular events is optimal, including counseling on issues related to sexual activity, the choice of the optimal first-line therapy and support throughout the treatment period. It is important to consider that both hypertension and antihypertensive therapy can be the cause of erectile dysfunction, and antihypertensive therapy should be selected with caution. Lifestyle changes should be the key to ED therapy in men with untreated hypertension.


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