Medically reviewed by
Dacelin St Martin, MD
Triple board-certified in Sleep Medicine,
Internal Medicine, and Pediatrics.
ED and Sleep Disorders | What’s the Relationship? | Specific Sleep Disorders
Erectile dysfunction and sleep disorders are both critical health problems, and their prevalence has been reported to be higher in the last few years with the COVID-19 outbreak.
Erectile dysfunction (ED) is the inability to create or maintain an erection sufficient for sexual satisfaction. Although it is found at different rates in different populations, one in three men older than 40 has ED on average. The prevalence and severity of ED increase with age. ED is a multifaceted health problem that affects not only the person but also the sexual partner.
One of the diseases in the complex etiology of ED is sleep disorders. The risk of ED is increased 2.1 times in people with sleep disorders compared to people without sleep disorders. This increased risk caused by sleep disorders is greater than the increased risk of having comorbidities such as diabetes, ischemic heart disease, congestive heart failure, and depression.
ED and Sleep Disorders
Spontaneous erections occur during sleep in a healthy adult man. This occurrence is called nocturnal penile tumescence (NPT) and occurs in the REM phase. Each NPT episode lasts around 30 minutes. In a healthy man, the REM-NREM sleep cycle is accompanied by an erection and detumescence cycle. NPT is also responsible for morning erections.
What’s the Relationship?
It’s known that there is a relationship between sleep disorders and erectile dysfunction.
In addition to many sleep problems with different etiologies, there is also a wide range of erectile dysfunction etiology. Therefore, there is a complex relationship with different dimensions more than a simple one-way relationship between these two diseases.
The basic mechanisms underlying this relationship are hormonal, including emotional changes, inflammation, and endothelial dysfunction.
Sleep disorders also cause the formation of atheroma plaques in the arteries. These four mechanisms are very sensitive mechanisms that ensure the proper functioning of many systems in our body. Changes or disruptions in these mechanisms through sleep disorders may cause erectile dysfunction through different processes.
Testosterone is essential to the hormonal mechanisms linking sleep disorders and ED. Testosterone hormone secretion has a circadian rhythm and reaches its maximum level during sleep. Inadequate and poor quality sleep or circadian rhythm disturbances lead to a decrease in testosterone levels. This reaction leads to a decrease in both sexual desire and erection quality.[7, 8]
Specific Sleep Disorders
Obstructive Sleep Apnea and ED
Obstructive sleep apnea (OSA) and ED share similar comorbidities. The prevalence of ED in OSA patients is higher than in the normal population and is reported to range from 40 to 80 percent.[9, 10] Although this has been known for many years, the links between these two diseases are only recently becoming apparent.
Sympathetic nervous system activation occurs during sleep in patients with OSA, thus increasing the levels of norepinephrine in the bloodstream. This situation increases the risk of systemic endothelial dysfunction, hypertension, coronary artery disease, and diabetes mellitus in the long term. These conditions can lead to atherosclerosis, resulting in reduced blood flow to the penile tissues. Eventually, the person has organic erectile dysfunction over time.
Another component that can link OSA to ED is nocturnal hypoxia, the low circulatory oxygen that occurs during sleep at night. This situation may impair endothelial functions in penile vessels and all vessels, thus leading to erectile dysfunction.
In conclusion, we can say that the main reasons for the increased risk of ED in OSA patients are increased sympathetic tone, endothelial dysfunction, a reduction in nitric oxide (NO) bioavailability, and hypoxia.
With the treatment of OSA, erectile functions were found to improve. CPAP, phosphodiesterase type 5 inhibitors, and surgical treatment options have promising results regarding erectile function in patients with OSA. On the other hand, it is seen that the most effective treatment in this regard is CPAP for now.
Insomnia and ED
It’s known that abnormal sleep duration is associated with many cardiovascular diseases. In particular, shortened sleep increases the risk of hypertension and coronary heart disease. [13,14]
Shortened sleep increases the risk of organic ED development through mechanisms similar to the OSA process. Even if the total sleep time is normal in insomnia patients, the autonomic nervous system and hormonal balance are affected since the circadian rhythm is frequently disrupted. Again, this can result in decreased erectile function.
Circadian Rhythm and ED
It’s no longer a mystery that our body has a circadian rhythm in harmony with its environment and that disturbances in this rhythm can lead to significant health problems. All the neural, vascular, and hormonal processes involved in the erection process oscillate with the circadian rhythm.
It has been shown that erectile function is significantly impaired in people with shift work sleep disorder.
On the Flipside
Half of the men newly diagnosed with ED have OSA or insomnia. Therefore, it is essential not only to evaluate erectile function in patients with sleep disorders but also to evaluate patients for sleep problems in urology clinics.
Sleep disorders can cause erectile dysfunction through different mechanisms. While sleep problems are quite common, many can be avoided or effectively treated. Therefore, effective treatment of sleep disorders, especially sleep apnea syndrome, will improve erectile function. In addition, sleep assessment should be included in the clinical management process of erectile dysfunction patients.
- Erectile dysfunction is a significant health problem affecting millions of men and their partners globally.
- Having sleep disorders increases the risk of ED by 2.1 times.
- The main mechanisms that link sleep disorders and ED are increased sympathetic tone, endothelial dysfunction, and a reduction in nitric oxide (NO) bioavailability.
- The two most common sleep disorders that can lead to erectile dysfunction are OSA and insomnia.
- Most of the OSA treatment options significantly improve erectile function.
- Circadian rhythm-related sleep problems also impair erectile function.
- Andersen, M. L., & Tufik, S. (2022). The Association Between Sleep Disturbances and Erectile Dysfunction During the COVID-19 Pandemic. Sex Med Rev,10(2), 263-270. https://doi.org/10.1016/j.sxmr.2021.12.001
- Chew, K. K., Earle, C. M., Stuckey, B. G., Jamrozik, K., & Keogh, E. J. (2000). Erectile dysfunction in general medicine practice: prevalence and clinical correlates. Int J Impot Res,12(1), 41-45. https://doi.org/10.1038/sj.ijir.3900457
- Lin, H. H., Ho, F. M., Chen, Y. F., Tseng, C. M., Ho, C. C., & Chung, W. S. (2015). Increased risk of erectile dysfunction among patients with sleep disorders: a nationwide population-based cohort study. Int J Clin Pract,69(8), 846-852. https://doi.org/10.1111/ijcp.12629
- Jankowski, J. T., Seftel, A. D., & Strohl, K. P. (2008). Erectile dysfunction and sleep related disorders. J Urol,179(3), 837-841. https://doi.org/10.1016/j.juro.2007.10.024
- Konstantinovsky, A., Tamir, S., Katz, G., Tzischinsky, O., Kuchersky, N., Blum, N., & Blum, A. (2019). Erectile Dysfunction, Sleep Disorders, and Endothelial Function. Isr Med Assoc J,21(6), 408-411. https://www.ncbi.nlm.nih.gov/pubmed/31280511
- Libby, P., Ridker, P. M., & Maseri, A. (2002). Inflammation and atherosclerosis. Circulation,105(9), 1135-1143. https://doi.org/10.1161/hc0902.104353
- Andersen, M. L., & Tufik, S. (2008). The effects of testosterone on sleep and sleep-disordered breathing in men: its bidirectional interaction with erectile function. Sleep Med Rev,12(5), 365-379. https://doi.org/10.1016/j.smrv.2007.12.003
- Burschtin, O., & Wang, J. (2016). Testosterone Deficiency and Sleep Apnea. Urol Clin North Am,43(2), 233-237. https://doi.org/10.1016/j.ucl.2016.01.012
- Campos-Juanatey, F., Fernandez-Barriales, M., Gonzalez, M., & Portillo-Martin, J. A. (2017). Effects of obstructive sleep apnea and its treatment over the erectile function: a systematic review. Asian J Androl,19(3), 303-310. https://doi.org/10.4103/1008-682X.170440
- Kellesarian, S. V., Malignaggi, V. R., Feng, C., & Javed, F. (2018). Association between obstructive sleep apnea and erectile dysfunction: a systematic review and meta-analysis. Int J Impot Res,30(3), 129-140. https://doi.org/10.1038/s41443-018-0017-7
- Gu, Y., Wu, C., Qin, F., & Yuan, J. (2022). Erectile Dysfunction and Obstructive Sleep Apnea: A Review. Front Psychiatry,13, 766639. https://doi.org/10.3389/fpsyt.2022.766639
- Kalejaiye, O., Raheem, A. A., Moubasher, A., Capece, M., McNeillis, S., Muneer, A., Christopher, A. N., Garaffa, G., & Ralph, D. J. (2017). Sleep disorders in patients with erectile dysfunction. BJU Int,120(6), 855-860. https://doi.org/10.1111/bju.13961
- Han, B., Chen, W. Z., Li, Y. C., Chen, J., & Zeng, Z. Q. (2020). Sleep and hypertension. Sleep Breath,24(1), 351-356. https://doi.org/10.1007/s11325-019-01907-2
- Cappuccio, F. P., Cooper, D., D’Elia, L., Strazzullo, P., & Miller, M. A. (2011). Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J,32(12), 1484-1492. https://doi.org/10.1093/eurheartj/ehr007
- Rodriguez, K. M., Kohn, T. P., Kohn, J. R., Sigalos, J. T., Kirby, E. W., Pickett, S. M., Pastuszak, A. W., & Lipshultz, L. I. (2020). Shift Work Sleep Disorder and Night Shift Work Significantly Impair Erectile Function. J Sex Med,17(9), 1687-1693. https://doi.org/10.1016/j.jsxm.2020.06.009