Erectile Dysfunction

Sleep and Erectile Dysfunction: What’s The Connection?

There is an undeniable relationship between the effects of a lack of sleep on erections, at least at night.

However, our understanding of the relationship between sleep and erectile dysfunction is less clear. 

This is largely due to a lack of research. 

That said, we know that many of the same neurological, biological, and psychological mechanisms which underlie sleep are also involved in erection formation.

Here, we aim to examine what is known, and not known, about the relationship between sleep and erectile dysfunction, including overlaps in the management of both conditions.

What is ED?

Erectile Dysfunction (ED) is a common condition, primarily affecting men over the age of 40. 

We define erectile dysfunction as a constant inability to either get or maintain an erection for sexual performance.

When talking about ED, two leading causes have been identified – physical or psychological. 

Physical ED

The possible causes of physical ED include:

  • Hormonal imbalances
  • Narrowing of blood vessels in the penis
  • Obesity
  • High blood pressure
  • High cholesterol
  • Low testosterone
  • Damage to the penis
  • Substance use (including alcohol) 

A number of illnesses, such as diabetes and insulin resistance, stroke, cardiovascular disease, multiple sclerosis, and Parkinson’s disease have also been associated with ED with a significantly higher prevalence of ED compared to that seen in the general population (Shamloul & Ghanem, 2013). 

Psychological ED

Your mental health and wellbeing can have a significant impact on your erectile function. 

The most common psychological triggers for ED are:

  • Stress
  • Anxiety
  • Depression
  • Guilt
  • Unrealistic sexual expectations

Then, the longer these stressors last, the more vulnerable people become for having low sexual desire, trouble with sexual initiation, achieving an orgasm, and more. 

Is there a relationship between Sleep and ED?

Outside of understanding normal nocturnal erections, does inadequate sleep and sleep loss play a role in ED?

We know that lack of sleep and sleep deprivation can lead to increased irritability, fatigue, and daytime sleepiness, as well as reduced mood (Kahn-Greene et al, 2006; Palagini et al, 2019).

This can have a knock-on effect on our interpersonal relationships, leading to more conflict, promoting psychologically-driven ED (Deliens et al, 2015).

Additionally, many of the illnesses which relate to erectile dysfunction, such as diabetes and cardiovascular disease, also link with sleep deprivation and poor sleep quality.

Testosterone Production And Sleep

Testosterone production is largely sleep-dependent. Your levels rising during sleep and plateau at approximately 90 minutes. Then, they fall when you wake up.

As such, sleep deprivation and insufficient sleep are likely to result in lower overall testosterone production resulting in a more physically-driven form of ED (Andersen & Tufik, 2008).

Obstructive Sleep Apnea

In terms of the relationship between ED and sleep disorder, the most commonly observed association is with Obstructive Sleep Apnea (OSA) (Kellesarian et al, 2018). 

Obstructive Sleep Apnea (OSA) occurs when an individual either partially or fully stops breathing during sleep. 

This is generally caused by the muscles relaxing in the back of the throat, creating an obstruction in the airway. 

This obstruction results in a reduction of oxygen in the blood and the brain having to wake the individual, albeit briefly, in order to start breathing again. 

Symptoms

The symptoms of OSA largely focus on its daytime impact. 

Many individuals do not know they have OSA. The individual often reports being excessively sleepy for no apparent reason, having morning headaches, and being more moody and irritable than usual. 

That said, loud snoring, choking, gasping, or snorting for air, during the night, are the most common nighttime symptoms, although more often reported by concerned bedpartners. 

Effects on Testosterone

Because the individual wakes up to breathe, this impacts sleep quality and its functions, which include the management of the endocrine system and the production of sleep-dependent hormones such as testosterone. 

As testosterone and oxygen are important in getting and maintaining an erection, this is one potential reason for the strong relationship between apnea and ED, although conclusive evidence is lacking. 

An alternative explanation is that severe OSA can result in nerve dysfunction, a potential cause of impotence (Fanfulla et al, 2000). 

This also suggests that OSA can cause ED.

What The Research Says

One study, on over 1,000 men with ED, found 43.8% of them also met the criteria for OSA (Hirshkowitz et al, 1990). 

Conversely, studies of men with OSA have reported prevalence rates of ED between 63-69% (Budweiser et al, 2009; Taken et al, 2016). 

Other Sleep Disorders

With regards to other sleep disorders, a recent study found that although insomnia and ED were common in prostate cancer patients, the two conditions were unrelated (Galvin et al, 2021). 

That said, insomnia symptoms, in addition to androgen deprivation therapy, predicted orgasm difficulty in this population. 

Outside of these relationships, there is limited research in terms of sleep disorders, including insomnia, and ED. This prevents us from fully understanding the relationship between them. 

Managing ED

The most common treatment strategy for ED is pharmacological. 

Interestingly, sleep problems are not listed as common side-effects of the two most popular drugs for ED (sildenafil citrate or tadalafil). This suggests they do not impact sleep duration or sleep quality. 

Another pharmacological approach has been to increase testosterone via testosterone replacement therapy. But studies show this can negatively impact sleep schedule and sleep habits, and increase the severity of OSA (Cole et al, 2018; Matsumoto et al, 1985). 

Behavioral management strategies for ED include stopping smoking and reducing alcohol consumption levels, eating healthily, increasing exercise, losing weight (if you are overweight), and reducing stress and anxiety. 

These management strategies directly help with ED. And, since they all contribute to good sleep quality, they are likely to help with your sleep problem as well.

Managing Sleep Disorders in ED

For insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment (Qassem et al, 2016; Riemann et al, 2017). 

Studies show CBT-I can improve sleep disturbances in the context of insomnia and result in significant reductions in anxiety and depression. This, therefore, makes it an attractive option in the context of psychologically-driven ED. 

As yet, however, there have been no studies of CBT-I in the context of ED to determine whether this impacts the frequency or severity of ED (Galvin et al, 2021). 

OSA’s main treatment for moderate and severe OSA is Continuous Positive Airway Pressure (CPAP). 

CPAP involves a mask over the nose or mouth (or both). Then, air is gently pumped through the CPAP machine.

In essence, the air creates a splint by which the airway is kept open. This, therefore, allows the individual to breathe throughout the night. 

Numerous studies examine the impact of CPAP on ED. The majority conclude that it significantly reduces or even eliminates ED (Goncalves et al, 2005; Taskin et al, 2010; Yang et al, 2020). 

In one review, combining CPAP with ED treatment (Seftel et al, 2002) resulted in significantly improved Quality of Life ratings in addition to better management of both the ED and the OSA. This, therefore, suggests the superiority of this approach.

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Conclusion

Although there appears to be a relationship between lack of sleep effects and ED, predominately through OSA or stress, there is small research as to why this occurs, with most theorizing testosterone levels being an important determinant. 

Moreover, whether the OSA causes ED or is just a link, is still debatable. 

That said, studies consistently show the management of OSA, using CPAP, can improve ED. This, therefore, suggests that OSA may cause ED in some cases. 

But we need future research in this area, as well as in the relationship between ED and other sleep disorders.

Irrespective, if you experience ED then it may be advisable to seek a sleep medicine specialist alongside an ED specialist.

Next Up

erectile dysfunction diagnosis

Find out 10 Natural Remedies To Improve Erectile Dysfunction In Men.

Sources

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  4. Deliens, G., Stercq, F., Mary, A., Slama, H., Cleeremans, A., Peigneux, P., & Kissine, M. (2015). Impact of acute sleep deprivation on sarcasm detection. PloS one10(11), e0140527. https://pubmed.ncbi.nlm.nih.gov/26535906/
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  6. Galvin, K. T., Garland, S. N., & Wibowo, E. (2021). The Association between Insomnia and Orgasmic Difficulty for Prostate Cancer Patients–Implication to Sex Therapy. Journal of Sex & Marital Therapy47(2), 174-185.
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  8. Hirshkowitz, M., Karacan, I., Arcasoy, M. O., Acik, G., Narter, E. M., & Williams, R. L. (1990). Prevalence of sleep apnea in men with erectile dysfunction. Urology36(3), 232-234. https://pubmed.ncbi.nlm.nih.gov/2392814/
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  10. 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. International journal of impotence research30(3), 129-140. https://pubmed.ncbi.nlm.nih.gov/29795528/
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  12. Palagini, L., Bastien, C. H., Marazziti, D., Ellis, J. G., & Riemann, D. (2019). The key role of insomnia and sleep loss in the dysregulation of multiple systems involved in mood disorders: A proposed model. Journal of sleep research28(6), e12841.
  13. Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine165(2), 125-13
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  18. Taskin, U., Yigit, O., Acioglu, E., Aricigil, M., Toktas, G., & Guzelhan, Y. (2010). Erectile dysfunction in severe sleep apnea patients and response to CPAP. International journal of impotence research22(2), 134-139. https://www.nature.com/articles/ijir20095
  19. Yang, Z., Du, G., Ma, L., Lv, Y., Zhao, Y., & Yau, T. O. (2020). Continuous positive airway pressure therapy in obstructive sleep apnoea patients with erectile dysfunction—A meta‐analysis. The Clinical Respiratory Journal.

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