Male Health Journal
Men's medicine, explained
Health behind ED

ED and Blood Pressure Meds: Which Ones, If Any, Affect Erections?

By the Male Health Journal editorial staff. Updated .

Summary

  1. A 2022 network meta-analysis of randomized trials found neutral or insignificant effects of the major blood pressure drug classes on erectile function.1
  2. In the double-blind TOMHS trial, chlorthalidone had more early erection problems than placebo (17.1% vs 8.1% at 24 months), but the gap was not significant by 48 months.2
  3. High blood pressure, diabetes and related conditions are themselves established causes of ED.3
  4. PDE5 inhibitors can lower blood pressure further, so the full medication list matters.4,5

Many men blame their blood pressure pill when erections change. The trial data are more mixed, and high blood pressure is itself a cause.

Blood pressure medicine can contribute to erectile dysfunction in some men, but the evidence is weaker than its reputation. A 2022 network meta-analysis of randomized trials found that the major drug classes had neutral or statistically insignificant effects on erectile function.1 High blood pressure itself, and the vascular damage behind it, is a more established cause of ED.3

That does not mean your experience is imagined. Individual men report changes, the NIH lists blood pressure medicines and diuretics among the medicines that can cause ED,3 and the trials below show a few real signals. This article sorts out which ones.

What does the research say about blood pressure drug classes and ED?

The 2022 analysis pooled randomized controlled trials of ACE inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers and thiazide diuretics. It included 25 studies and 7,784 patients in the qualitative review, with 16 studies in the quantitative analysis. No class differed significantly from another or from placebo. The authors also flagged that risk of bias was concerning or high in most studies and that results were inconsistent, so the finding is "no clear harm shown," not "proven harmless."1

Drug class (examples)What the trials found
Thiazide-type diuretics (chlorthalidone)In TOMHS, more men on chlorthalidone reported erection problems at 24 months than on placebo (17.1% vs 8.1%). By 48 months the difference was no longer significant.2
Beta-blockers (acebutolol, metoprolol)Acebutolol was similar to placebo in TOMHS.2 In a small crossover trial, metoprolol lowered IIEF-5 scores in men with ED.6 The network analysis found no significant class effect.1
Vasodilating beta-blocker (nebivolol)Better than non-vasodilating beta-blockers in the network analysis (odds ratio 2.92), but not better than placebo.1
ACE inhibitors (enalapril)Similar to placebo in TOMHS.2
Calcium channel blockers (amlodipine)Similar to placebo in TOMHS.2
Alpha-blockers (doxazosin)Lowest incidence in TOMHS, not significantly different from placebo.2

Is it the pill or the blood pressure?

This is the hard part to untangle. Hypertension damages the lining of blood vessels, and erections depend on those vessels widening and filling. Diabetes, obesity and chronic kidney disease, all common in men with high blood pressure, are also listed by the NIH as causes of ED.3 Our explainer on ED and heart health covers why erection problems can be an early sign of vascular disease.

TOMHS is useful here because it was double-blind and included a placebo group. Among 557 men aged 45 to 69 with stage I diastolic hypertension, new erection problems appeared in 9.5% by 24 months and 14.7% by 48 months, and the incidence in most drug groups looked like placebo. The authors cautioned against routinely blaming erection problems on blood pressure medication.2 All participants in that trial also received lifestyle counseling on weight, sodium, alcohol and activity.2

What about nebivolol and metoprolol?

Nebivolol is a beta-blocker that also increases nitric oxide, the molecule that signals blood vessels in the penis to relax. In a randomized crossover trial of hypertensive men, metoprolol was associated with a drop in IIEF-5 scores across several ED subtypes, while nebivolol was not, and blood pressure control was the same.6 The trial was small and short, with one month on each drug, so it supports a conversation with a prescriber, not a switch on your own. The larger network analysis found nebivolol's advantage only against non-vasodilating beta-blockers, with wide confidence intervals.1

What should you do if ED started after a new blood pressure medicine?

  • Do not stop the medication on your own. Uncontrolled blood pressure raises the risk of heart attack and stroke, and the trials above do not show that stopping fixes ED in everyone.
  • Note the timing. ED that began within weeks of a start or dose change is more suggestive than ED that built up over years.
  • Ask about alternatives. A prescriber can consider a different dose or class, particularly if you are on a thiazide diuretic or a non-vasodilating beta-blocker.
  • Get the wider picture checked. Blood sugar, cholesterol, testosterone, sleep, alcohol and stress all feed into ED.3

Can you take an ED medication with blood pressure pills?

Often, with supervision. PDE5 inhibitors lower blood pressure slightly. In the sildenafil label, giving 100 mg with amlodipine to hypertensive patients produced an average additional supine reduction of 8 mmHg systolic and 7 mmHg diastolic.4 The labels advise caution and a low starting dose with alpha-blockers, and nitrates are never to be combined with these drugs.4,5 The full list is in our guide to ED medication interactions. Whether an ED drug is appropriate is a decision for the clinician who knows your blood pressure regimen.

Limits of the evidence

Most trials of antihypertensives were not designed to measure erectile function, relied on interviews or questionnaires, and ran for months, not years. The TOMHS data are from the 1990s and tested older drugs at doses that may differ from current practice. The metoprolol and nebivolol trial was small. Any one man's response can differ from the average.

Talk to a clinician. This article explains the evidence; it cannot tell you what is right for you. A licensed clinician who knows your health history and medications can.
Important safety information. PDE5 inhibitors (sildenafil, tadalafil, vardenafil) must not be taken with nitrates in any form, including nitroglycerin, or with guanylate cyclase stimulators such as riociguat, and need caution with alpha-blockers.4 The most common side effects are headache and flushing.4 An erection lasting more than four hours needs emergency care, and sudden loss of vision or hearing means stopping and getting medical help right away.5 Only a licensed clinician who knows your health history and medications should decide whether these are safe for you.

Questions readers ask

Which blood pressure medication is least likely to cause ED?

No class has been shown to cause ED clearly in pooled randomized trials. Nebivolol did better than non-vasodilating beta-blockers in one analysis, and doxazosin had the lowest incidence in the TOMHS trial, but neither was significantly different from placebo. A prescriber chooses based on your whole health picture.

Can lisinopril cause erectile dysfunction?

ACE inhibitors such as enalapril looked similar to placebo in the TOMHS trial, and the network meta-analysis found no significant effect on erectile function. Some men still report changes, so mention any new symptom to your prescriber.

Does amlodipine cause ED?

In TOMHS, amlodipine's rate of erection problems was similar to placebo. Amlodipine does add to the blood-pressure-lowering effect of sildenafil, so tell your prescriber if you plan to use both.

Can I stop my blood pressure medicine to see if ED improves?

Not on your own. Stopping can leave blood pressure uncontrolled. Ask your prescriber about changing the dose or drug.

Is ED caused by the medication or by high blood pressure?

It can be either or both. Hypertension and related conditions such as diabetes damage blood vessels, and some blood pressure drugs may add to it. A clinician can help sort out which is more likely.

Further reading

Part of our guide: ED and Your Health: The Heart, Blood Pressure, Diabetes and Age

References

  1. Farmakis IT, et al. Effects of major antihypertensive drug classes on erectile function: a network meta-analysis. Cardiovasc Drugs Ther. 2022. PubMed.
  2. Grimm RH Jr, et al. Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women (TOMHS). Hypertension. 1997. PubMed.
  3. National Institute of Diabetes and Digestive and Kidney Diseases. Erectile Dysfunction (ED). National Institutes of Health.
  4. Pfizer. VIAGRA (sildenafil citrate) prescribing information. DailyMed, U.S. National Library of Medicine.
  5. Eli Lilly. CIALIS (tadalafil) prescribing information. DailyMed, U.S. National Library of Medicine.
  6. Gungor G, et al. Nebivolol protects erectile functions compared to metoprolol in hypertensive men: a prospective, randomized, cross-over clinical trial. Eur J Intern Med. 2022. PubMed.