Antihypertension and Erectile Dysfunction

• One of five cases of erectile dysfunction is due to adverse drug events.
• Antihypertensive drugs represent one of the most implicated classes.
• Older antihypertensive drugs (central-acting, β blockers, diuretics) have traditionally been considered to cause erectile dysfunction, while the newer ones (calcium antagonists, angiotensin-converting enzyme [ACE] inhibitors, and angiotensin receptor blockers [ARBs]) have either neutral effects or may even be beneficial with respect to sexual function
• Epidemiologic data suggest that a sedentary lifestyle represents a risk factor for erectile dysfunction; thus, it seems logical to assume that lifestyle modification will be of benefit. However, only minimal data are available to support this assumption

Angiotensin Receptor Blockers

• although available data indicate that ARBs may benefit erectile function, large randomized studies are needed to confirm these findings.

ACE Inhibitors

• although available data are not quantitatively and qualitatively adequate, ACE inhibitors have neutral effects on erectile function in hypertensive patients.
• This statement, if confirmed by appropriate studies, suggests that ACE inhibitors are inferior to ARBs with respect to erectile function, possibly due to incomplete blockade of angiotensin II production

Calcium Antagonist

• Existing data regarding the effect of calcium antagonists on erectile function are far from conclusive. Experimental data indicate that calcium antagonists do not exert the beneficial effects of ARBs on penile structure

Beta Blockers

• β blockers have been considered a major cause of erectile dysfunction.
• Previous studies indicate that erectile dysfunction is dose-dependent and more prevalent with older-generation β blockers (propranolol) than with newer ones (celiprolol and carvedilol), with atenolol standing in between

Diuretics

• Vast majority of available data points to a negative effect of diuretics on erectile function

Recommendations

• Several lines of evidence indicate that drugs used in the treatment of hypertension can indeed deteriorate sexual function, but this effect appears mainly with older generation drugs (beta blockers, diuretics) while newer agents (nebivolol, angiotensin receptor blockers) might even improve sexual function. 
• Life-style modification seems to benefit sexual function and should be advised in all hypertensive patients with sexual dysfunction. 
• PDE-5 inhibitors have offered new perspectives in the management of erectile dysfunction,
  they are effective and safe in hypertensive patients, but their use should follow appropriate consultation.

References:

1. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-6175.2005.05285.x/full#f1
2. http://www.medscape.com/viewarticle/445181_2
3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108714/
4. https://www.nps.org.au/australian-prescriber/articles/drug-induced-sexual-dysfunction-in-men-and-women