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Association between obstructive sleep apnea and erectile dysfunction: a systematic review and meta-analysis


The purpose of the present systematic review and meta-analysis was to assess the association between obstructive sleep apnea (OSA) and erectile dysfunction (ED). To address the focused question, “Is there an association between OSA and ED?” indexed databases were searched up to May 2017 without time or language restrictions using various key words including: obstructive sleep apnea, sleep apnea syndromes, erectile dysfunction, sleep-disordered breathing, snoring, sexual function, and impotence. Review articles, case-reports and case-series, commentaries, letters to the editor, interviews and updates, studies assessing the efficacy of OSA treatment in the improvement of ED, or studies evaluating the efficacy of ED treatment in the improvement of OSA were excluded. Twenty-eight observational studies were included for qualitative synthesis. Overall, 19 studies had a cross-sectional design, 7 studies were case–control, and 2 were cohort studies. The odds ratios (OR) with a 95% confidence interval were calculated from 10 studies. The combined OR was 0.45, with a 95% confidence interval of 0.18–0.71, indicating that in patients without OSA, the risk of ED is significantly lower compared with patients with OSA. The available evidence shows that OSA is associated with a higher risk of ED; however, further well-designed controlled clinical trials and longitudinal prospective studies are needed in this regard.

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  1. 1.

    Duran J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea–hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163:685–9.

  2. 2.

    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Eng J Med. 1993;328:1230–5.

  3. 3.

    Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr., Garcia FA, et al. Screening for obstructive sleep apnea in adults: US preventive services task force recommendation statement. JAMA. 2017;317:407–14.

  4. 4.

    Senaratna CV, Perret JL, Lodge CJ, Lowe AJ, Campbell BE, Matheson MC, et al. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev. 2016;34:70–81.

  5. 5.

    Steinke E, Palm Johansen P, Fridlund B, Brostrom A. Determinants of sexual dysfunction and interventions for patients with obstructive sleep apnoea: a systematic review. Int J Clin Pract. 2016;70:5–19.

  6. 6.

    Vinnikov D, Blanc PD, Alilin A, Zutler M, Holty JC. Fatigue and sleepiness determine respiratory quality of life among veterans evaluated for sleep apnea. Health Qual Life Outcomes. 2017;15:48.

  7. 7.

    Froese CL, Butt A, Mulgrew A, Cheema R, Speirs MA, Gosnell C, et al. Depression and sleep-related symptoms in an adult, indigenous, North American population. J Clin Sleep Med. 2008;4:356–61.

  8. 8.

    NIH Consensus Conference. Impotence. NIH consensus development panel on impotence. JAMA. 1993;270:83–90.

  9. 9.

    Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med. 2007;120:151–7.

  10. 10.

    Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int. 1999;84:50–6.

  11. 11.

    Kellesarian SV, Kellesarian TV, Ros Malignaggi V, Al-Askar M, Ghanem A, Malmstrom H, et al. Association between periodontal disease and erectile dysfunction: a systematic review. Am J Mens Health. 2016;12:338–46.

  12. 12.

    Andersen ML, Santos-Silva R, Bittencourt LR, Tufik S. Prevalence of erectile dysfunction complaints associated with sleep disturbances in Sao Paulo, Brazil: a population-based survey. Sleep Med. 2010;11:1019–24.

  13. 13.

    Bouloukaki I, Papadimitriou V, Sofras F, Mermigkis C, Moniaki V, Siafakas NM, et al. Abnormal cytokine profile in patients with obstructive sleep apnea–hypopnea syndrome and erectile dysfunction. Mediat Inflamm. 2014;2014:568951.

  14. 14.

    Budweiser S, Enderlein S, Jorres RA, Hitzl AP, Wieland WF, Pfeifer M, et al. Sleep apnea is an independent correlate of erectile and sexual dysfunction. J Sex Med. 2009;6:3147–57.

  15. 15.

    Bozorgmehri S, Fink HA, Parimi N, Canales B, Ensrud KE, Ancoli-Israel S, et al. Association of sleep-disordered breathing with erectile dysfunction in community dwelling older men. J Urol. 2017;197:776–82.

  16. 16.

    Chediak AD, Acevedo-Crespo JC, Seiden DJ, Kim HH, Kiel MH. Nightly variability in the indices of sleep-disordered breathing in men being evaluated for impotence with consecutive night polysomnograms. Sleep. 1996;19:589–92.

  17. 17.

    Chen CM, Tsai MJ, Wei PJ, Su YC, Yang CJ, Wu MN, et al. Erectile dysfunction in patients with sleep apnea—a nationwide population-based study. PLoS ONE. 2015;10:e0132510.

  18. 18.

    Chen KF, Liang SJ, Lin CL, Liao WC, Kao CH. Sleep disorders increase risk of subsequent erectile dysfunction in individuals without sleep apnea: a nationwide population-base cohort study. Sleep Med. 2016;17:64–68.

  19. 19.

    Fanfulla F, Malaguti S, Montagna T, Salvini S, Bruschi C, Crotti P, et al. Erectile dysfunction in men with obstructive sleep apnea: an early sign of nerve involvement. Sleep. 2000;23:775–81.

  20. 20.

    Giner MA, Rovira E, Julve R, Salvador MI, Naval E, Puertas FJ, et al. Factors related with the presence of erectile dysfunction in patients with obstructive sleep apnea. Med Clin. 2012;139:243–8.

  21. 21.

    Gürbüz C, Okur HK, Demir S, Ordu S, Caşkurlu T. Pure obstructive sleep apnea syndrome and erectile dysfunction. Balkan Med J. 2011;28:435–9.

  22. 22.

    Heruti R, Shochat T, Tekes-Manova D, Ashkenazi I, Justo D. Association between erectile dysfunction and sleep disorders measured by self-assessment questionnaires in adult men. J Sex Med. 2005;2:543–50.

  23. 23.

    Hanak V, Jacobson DJ, McGree ME, Sauver JS, Lieber MM, Olson EJ, et al. Snoring as a risk factor for sexual dysfunction in community men. J Sex Med. 2008;5:898–908.

  24. 24.

    Hirshkowitz M, Karacan I, Arcasoy MO, Acik G, Narter EM, Williams RL. Prevalence of sleep apnea in men with erectile dysfunction. Urology. 1990;36:232–4.

  25. 25.

    Hirshkowitz M, Karacan I, Gurakar A, Williams RL. Hypertension, erectile dysfunction, and occult sleep apnea. Sleep. 1989;12:223–32.

  26. 26.

    Jeon YJ, Yoon DW, Han DH, Won TB, Kim DY, Shin HW. Low quality of life and depressive symptoms as an independent risk factor for erectile dysfunction in patients with obstructive sleep apnea. J Sex Med. 2015;12:2168–77.

  27. 27.

    Margel D, Cohen M, Livne PM, Pillar G. Severe, but not mild, obstructive sleep apnea syndrome is associated with erectile dysfunction. Urology. 2004;63:545–9.

  28. 28.

    Popp R, Kleemann Y, Burger M, Pfeifer M, Arzt M, Budweiser S. Impaired vigilance is associated with erectile dysfunction in patients with sleep apnea. J Sex Med. 2015;12:405–15.

  29. 29.

    Petersen M, Kristensen E, Berg S, Midgren B. Sexual function in male patients with obstructive sleep apnoea. Clin Respir J. 2010;4:186–91.

  30. 30.

    Pressman MR, DiPhillipo MA, Kendrick JI, Conroy K, Fry JM. Problems in the interpretation of nocturnal penile tumescence studies: disruption of sleep by occult sleep disorders. J Urol. 1986;136:595–8.

  31. 31.

    Chung SD, Hung SH, Lin HC, Tsai MC, Kao LT. Obstructive sleep apnea and urological co-morbidities in males: a population-based study. Sleep Breath. 2016;20:1203–8.

  32. 32.

    Santos T, Drummond M, Botelho F. Erectile dysfunction in obstructive sleep apnea syndrome—prevalence and determinants. Rev Port Pneumol. 2012;18:64–71.

  33. 33.

    Schiavi RC, Mandeli J, Schreiner-Engel P, Chambers A. Aging, sleep disorders, and male sexual function. Biol Psychiatry. 1991;30:15–24.

  34. 34.

    Seftel AD, Strohl KP, Loye TL, Bayard D, Kress J, Netzer NC. Erectile dysfunction and symptoms of sleep disorders. Sleep. 2002;25:643–7.

  35. 35.

    Shin HW, Rha YC, Han DH, Chung S, Yoon IY, Rhee CS, et al. Erectile dysfunction and disease-specific quality of life in patients with obstructive sleep apnea. Int J Impot Res. 2008;20:549–53.

  36. 36.

    Stannek T, Hurny C, Schoch OD, Bucher T, Munzer T. Factors affecting self-reported sexuality in men with obstructive sleep apnea syndrome. J Sex Med. 2009;6:3415–24.

  37. 37.

    Szymanski FM, Filipiak KJ, Hrynkiewicz-Szymanska A, Grabowski M, Dabrowska-Kugacka A, Opolski G. The high risk of obstructive sleep apnea--an independent risk factor of erectile dysfunction in ST-segment elevation myocardial infarction patients. J Sex Med. 2011;8:1434–8.

  38. 38.

    Taken K, Ekin S, Arisoy A, Gunes M, Donmez MI. Erectile dysfunction is a marker for obstructive sleep apnea. Aging Male. 2016;19:102–5.

  39. 39.

    Teloken PE, Smith EB, Lodowsky C, Freedom T, Mulhall JP. Defining association between sleep apnea syndrome and erectile dysfunction. Urology. 2006;67:1033–7.

  40. 40.

    Guilleminault C, Eldridge FL, Tilkian A, Simmons FB, Dement WC. Sleep apnea syndrome due to upper airway obstruction: a review of 25 cases. Arch Intern Med. 1977;137:296–300.

  41. 41.

    Hoekema A, Stel AL, Stegenga B, van der Hoeven JH, Wijkstra PJ, van Driel MF, et al. Sexual function and obstructive sleep apnea–hypopnea: a randomized clinical trial evaluating the effects of oral-appliance and continuous positive airway pressure therapy. J Sex Med. 2007;4:1153–62.

  42. 42.

    Zhang T, Li J, Yang P. Oral-appliance for erectile dysfunction induced by obstructive sleep apnea–hypopnea syndrome. Zhonghua nan ke xue. 2014;20:510–3.

  43. 43.

    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

  44. 44.

    Roberts C. Modelling patterns of agreement for nominal scales. Stat Med. 2008;27:810–30.

  45. 45.

    Zeng X, Zhang Y, Kwong JS, Zhang C, Li S, Sun F, et al. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta-analysis, and clinical practice guideline: a systematic review. J Evid-Based Med. 2015;8:2–10.

  46. 46.

    Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available from:

  47. 47.

    Chinn S. A simple method for converting an odds ratio to effect size for use in meta-analysis. Stat Med. 2000;19:3127–31.

  48. 48.

    Zias N, Bezwada V, Gilman S, Chroneou A. Obstructive sleep apnea and erectile dysfunction: still a neglected risk factor? Sleep Breath. 2009;13:3–10.

  49. 49.

    Kilic K, Aktan B, Sedat-Sakat M, Kiziltunc A, Yoruk O. Vascular endothelial dysfunction caused by oxidative stress is a predictor factor for complications of obstructive sleep apnea syndrome. West Indian Med J. 2016;50:23–27.

  50. 50.

    Zhang D, Luo J, Qiao Y, Xiao Y, Huang R, Zhong X. Measurement of exhaled nitric oxide concentration in patients with obstructive sleep apnea: A meta-analysis. Medicine. 2017;96:e6429.

  51. 51.

    Monica FZ, Bian K, Murad F. The endothelium-dependent nitric oxide-cGMP pathway. Adv Pharmacol. 2016;77:1–27.

  52. 52.

    Kato M, Roberts-Thomson P, Phillips BG, Haynes WG, Winnicki M, Accurso V, et al. Impairment of endothelium-dependent vasodilation of resistance vessels in patients with obstructive sleep apnea. Circulation. 2000;102:2607–10.

  53. 53.

    Ritchie R, Sullivan M. Endothelins & erectile dysfunction. Pharmacol Res. 2011;63:496–501.

  54. 54.

    Pelliccione F, D’Angeli A, Filipponi S, Falone S, Necozione S, Barbonetti A, et al. Serum from patients with erectile dysfunction inhibits circulating angiogenic cells from healthy men: relationship with cardiovascular risk, endothelial damage and circulating angiogenic modulators. Int J Androl. 2012;35:645–52.

  55. 55.

    Zhang XH, Melman A, Disanto ME. Update on corpus cavernosum smooth muscle contractile pathways in erectile function: a role for testosterone? J Sex Med. 2011;8:1865–79.

  56. 56.

    Burschtin O, Wang J. Testosterone deficiency and sleep apnea. Sleep Med Clin. 2016;11:525–9.

  57. 57.

    Luboshitzky R, Lavie L, Shen-Orr Z, Lavie P. Pituitary-gonadal function in men with obstructive sleep apnea. The effect of continuous positive airways pressure treatment. Neuro Endocrinol Lett. 2003;24:463–7.

  58. 58.

    Ziegler MG, Milic M. Sympathetic nerves and hypertension in stress, sleep apnea, and caregiving. Curr Opin Nephrol Hypertens. 2017;26:26–30.

  59. 59.

    Schroder CM, O’Hara R. Depression and obstructive sleep apnea (OSA). Ann Gen Psychiatry. 2005;4:13.

  60. 60.

    Ramanathan R, Mulhall J, Rao S, Leung R, Martinez Salamanca JI, Mandhani A, et al. Predictive correlation between the International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM): implications for calculating a derived SHIM for clinical use. J Sex Med. 2007;4:1336–44.

  61. 61.

    Diehm N, Borm AK, Keo HH, Wyler S. Interdisciplinary options for diagnosis and treatment of organic erectile dysfunction. Swiss Med Wkly. 2015;145:w14268.

  62. 62.

    Rynja S, Bosch R, Kok E, Wouters G, de Kort L. IIEF-15: unsuitable for assessing erectile function of young men? J Sex Med. 2010;7:2825–30.

  63. 63.

    Chen B, Lu YN, Han YF, Huang XY, Hu K, Wang YX, et al. IIEF-5 cannot be used as a tool for differential diagnosis of vasculogenic erectile dysfunction. Zhonghua Nan Ke Xue. 2007;13:118–21.

  64. 64.

    Senaratna CV, English DR, Currier D, Perret JL, Lowe A, Lodge C, et al. Sleep apnoea in Australian men: disease burden, co-morbidities, and correlates from the Australian longitudinal study on male health. BMC Public Health. 2016;16:1029.

  65. 65.

    Chaudhary RK, Shamsi BH, Chen HM, Tan T, Tang KF, Xing JP. Risk factors for erectile dysfunction in patients with cardiovascular disease. J Int Med Res. 2016;44:718–27.

  66. 66.

    Kellesarian SV, Malmstrom H, Abduljabbar T, Vohra F, Kellesarian TV, Javed F, et al. Low testosterone levels in body fluids are associated with chronic periodontitis. Am J Men’s Health. 2017;11:443–53.

  67. 67.

    Woods CE, Usher K, Maguire GP. Obstructive sleep apnoea in adult indigenous populations in high-income countries: an integrative review. Sleep Breath. 2015;19:45–53.

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Correspondence to S. V. Kellesarian.

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