Hydrochlorothiazide And Erectile Dysfunction: What You Need To Know

Erectile dysfunction is a common condition experienced by at least 18 million men¹ in the US, with the proportion increasing with age. It becomes more prevalent as men get older² and when comorbidities are present. 

A major contributing factor to age-related erectile dysfunction is that medication use also increases as people age. 

What is hydrochlorothiazide?

Hydrochlorothiazide³ is a thiazide diuretic (water pill) prescribed to treat high blood pressure (hypertension). Water pills work by increasing urination, which helps remove excess water and salt build-up and lowers blood pressure. 

Hydrochlorothiazide is a prescription-only medicine. It may be given in a capsule or tablet form and is usually taken daily in the morning with food. Daily doses range from 12.5 to 50 mg,⁴ depending on their application.

Common brand names of hydrochlorothiazide include:

• Aquazide H

• Hydrocot

• Microzide

• Zide

Hydrochlorothiazide is also prescribed to treat edema.

This is common in people with congestive heart failure, scarring of the liver (cirrhosis), kidney disorders, and people who take steroids or estrogen. Hydrochlorothiazide helps reduce swelling brought on by the edema.

How does hydrochlorothiazide work?

By removing excess salt and water from the body, hydrochlorothiazide helps decrease blood pressure and reduce swelling. Long-term use can also affect the vascular system. It helps widen blood vessels further to lower blood pressure.

Hydrochlorothiazide is often used with other medications,  such as beta and alpha-blockers, to help treat blood pressure.

Side effects of taking hydrochlorothiazide

Hydrochlorothiazide is an effective diuretic that can help many patients maintain healthy blood pressure. However, it has both mild and severe side effects that should be kept in mind.

Mild side effects of hydrochlorothiazide include:

• Nausea

• Vomiting

• Dizziness

• Low blood pressure

• Muscle spasms

• Diarrhea

• Erectile dysfunction

Furthermore, hydrochlorothiazide can lower one’s blood pressure too much, causing hypotension (low blood pressure). It is also linked to orthostatic hypotension, which is the sudden drop in blood pressure when moving from a seated or lying position to a standing. This movement might make a person feel light-headed and dizzy and, in some cases, can cause them to faint. 

Muscle spasms are a common side effect seen in patients taking diuretics. This can be due to electrolyte imbalances from increased urination and salt removal from the body. 

To alleviate muscle spasms, hydrochlorothiazide is sometimes taken with a potassium supplement to help prevent potassium loss and maintain electrolyte balance. 

 More severe side effects include:

• Hives

• Difficulty breathing

• Swelling in the face, lips, tongue, or throat

• Fever

• Chills

• Electrolyte imbalances

• Sore throat

• Burning eyes

• Skin pain

• Skin rashes, blistering, and peeling

• Lightheadedness

• Vision loss

• Pale skin

• Unusual bleeding from the mouth or rectum

Hydrochlorothiazide may also interact with other medications. 

You should inform your doctor of any other prescription or over-the-counter medications and vitamins you are taking if they prescribe hydrochlorothiazide.

Hypertension and erectile dysfunction

Hypertension or high blood pressure commonly affects over 50% of men⁵ over 18.

Men with high blood pressure are more likely to develop erectile dysfunction, with over 70% of hypertensive men⁶ experiencing some form of the condition. High blood pressure affects general blood flow throughout the body, including the penis. 

Some erectile dysfunction drugs are known as PDE-5 inhibitors. Although these are generally an excellent choice for erectile dysfunction, up to 30% of patients⁷ taking these drugs report unsatisfactory results. 

This may be because PDE-5 relies on nitrous oxide production, which is inhibited in hypertensive patients due to an increase in reactive oxygen species. 

Healthy and controlled blood flow is essential in getting and maintaining an erection. To fully understand how hypertension affects the penis, let’s look at how an erection occurs and how poor blood flow can prevent it from sticking around. 

The flaccid penis 

Within the penis is a sponge-like tissue called the corpora cavernosa. This is filled with smooth muscle blood vessels that contain little blood when you are not aroused.

The tumescent penis 

When sexually aroused, the nervous system relaxes the muscles and widens the blood vessels inside the corpora cavernosa. This lets more blood into the penis, causing it to swell.

The erect penis 

As blood flows into the corpora cavernosa, the blood vessels become compressed by expanding smooth muscle, trapping the blood in the penis. The pressure of the trapped blood causes the penis to become firm and allows for sexual intercourse.

High blood pressure is associated with an increase in the release of vasoconstrictors such as angiotensin II, endothelin I, and aldosterone. 

The continual release of these hormones can damage endothelial linings of the blood vessels in the corpus cavernosal. It causes them to stay contracted and prevents blood from flowing into the corpora cavernosa. 

How common is erectile dysfunction with hydrochlorothiazide?

Erectile dysfunction is more common in men with hypertension. Someone taking medications such as diuretics like hydrochlorothiazide may already be at a higher risk for erectile dysfunction. 

It’s still unknown whether erectile dysfunction is more common in hypertensive men due to hypertension, antihypertensive treatments, or other medications. 

In most cases, hypertension can be controlled using medication. However, men often don’t keep up with their hypertension therapies to avoid the common side effect of erectile dysfunction. 

Drug-related erectile dysfunction⁸ has been reported in numerous studies and may make up a considerable proportion of patients with erectile dysfunction. When medications are stopped or alternatives are given, the condition is at least somewhat reversed. 

Thiazide diuretics and certain types of beta-blockers are classes of antihypertensive drugs most commonly associated with erectile dysfunction. Thiazides at higher doses (above 50 mg) can contribute to erectile dysfunction. 

Lowering the dose to 12.5 mg may help alleviate symptoms, but a doctor should always be consulted before changing medication doses. 

Does hydrochlorothiazide cause erectile dysfunction?

One study⁹ found that thiazide diuretics can cause a reduction of zinc levels in blood serum. In the study, men who experienced sexual dysfunction after taking hydrochlorothiazide were given a zinc supplement treatment. Some saw a marked improvement in their ability to obtain and maintain erections. 

Zinc is an essential mineral for male sexual health. The majority of zinc in a man’s body is found within the prostate. A zinc deficiency¹⁰ is a common sign in men with benign prostatic hyperplasia (BPH), a condition associated with a high incidence of erectile dysfunction. 

Hydrochlorothiazide is often taken in combination with a beta-blocker. A beta-blocker–thiazide diuretic therapy is a combination of antihypertensive drugs that lower blood pressure by removing excess water and salt from the body and slowing the heart rate. They work synergistically to alleviate hypertension. 

When taken in combination with a beta-blocker, the diuretic (such as hydrochlorothiazide) usually has fewer side effects while also boosting the blood pressure-lowering the effects of the beta-blockers. Diuretics are also helpful if the person with high blood pressure has edema.  

How do beta-blockers affect erectile dysfunction?

Beta-blockers reduce hypertension by slowing the pulse, lowering blood pressure, and reducing the output of the heart. They are a common medication for hypertensive individuals and may be taken as a combination pill.

Beta-blockers may contribute to erectile dysfunction by blocking beta 2 receptors, leading to constriction of penile blood vessels and disrupting blood flow into the penis, thus preventing the man from achieving an erection. 

No clear consensus exists on whether beta-blockers can cause erectile dysfunction. This is partly due to the lack of properly controlled studies on hypertensive males who are otherwise healthy. 

In addition, a “nocebo effect” seems to be associated with certain beta-blockers, where men who are told erectile dysfunction is a common side effect are more likely to experience it than those who are not informed. 

It’s hypothesized that beta-blockers contribute to erectile dysfunction by reducing general blood pressure and, in turn, decreasing penile blood flow.

A study¹¹ of nondiabetic hypertensive men found that the beta-blockers atenolol, bisoprolol, and carvedilol reduced penile vascular blood flow after 8 to 12 weeks of treatment. 

However, not all beta-blockers seem to have the same effect on erectile dysfunction. Studies suggest that nebivolol, a new generation of beta-blocker, doesn’t affect penile vascular blood flow in hypertensive males. Nebivolol releases nitrous oxide, the most common vasodilator, which may improve penile blood flow. 

Blood pressure medications that don’t cause erectile dysfunction

Not all blood pressure medications affect sexual function. These include:

Angiotensin-converting enzyme (ACE) inhibitors  

Examples of ACE inhibitors are Capoten, Lotensin, Prinivil, and Zestril. These medications induce vasodilation and increase blood flow. They work by lessening the effects of angiotensin-converting enzymes in the body, which narrow blood vessels and increase blood pressure.

Alpha-blockers 

Alpha-blockers, such as Cardura, help lower blood pressure by reducing artery resistance and relaxing muscular tone in vascular walls. 

Calcium channel blockers 

Calcium channel blockers, like Amlodipine, Diltiazem, and Verapamil, block calcium activity, helping lower blood pressure. 

Angiotensin receptor blockers (ARBs) 

ARBs limit the effects of angiotensin 2, a hormone that restricts blood vessels (increases blood pressure). 

Hydrochlorothiazide and drugs for erectile dysfunction

Some medications used to treat erectile dysfunction aren’t recommended for patients with severe cardiovascular disease and high blood pressure. Hydrochlorothiazide can also interact with sildenafil (Viagra). 

It’s generally safe to take PDE-5 inhibitors such as sildenafil with hydrochlorothiazide. However, if hydrochlorothiazide is taken in combination with an alpha-blocker, care should be taken.

The lowdown

Erectile dysfunction is more common in hypertensive males; however, it’s still unclear whether this is due to high blood pressure or antihypertensive medications. 

Numerous studies have suggested that hypertensive medications such as beta-blockers can have physiological effects on penile tissue aside from general effects on blood flow throughout the body. Recent research has shown that new variations of beta-blockers may not have the same effect on erectile dysfunction. 

Many alternative medications are available, such as ACE inhibitors and alpha-blockers, that can help lower blood pressure and are not known to commonly cause erectile dysfunction. 

If you are taking hypertensive medication and notice symptoms of erectile dysfunction, consult your doctor to see if alternatives are available that may alleviate symptoms.