A new meta-analysis suggests that worsening sleep-disordered breathing may lead to decreased erectile function, highlighting why men with symptoms of ED and OSA would benefit from a more detailed sleep assessment.
Research: Association between obstructive sleep apnea and erectile dysfunction: A systematic review and meta-analysis. Image credit: Rawpixel.com / Shutterstock
In a recent study published in International Journal of Impotence ResearchA group of researchers assessed the association between obstructive sleep apnea (OSA) severity and erectile dysfunction (ED) using validated measures of sleep apnea severity and erectile function.
background
Up to 1 billion people worldwide may be affected by OSA. OSA is a common sleep disorder that can significantly reduce quality of life and increase the risk of cardiovascular disease and other chronic health conditions.
ED is also a widespread disease that affects millions of men and is often associated with metabolic and vascular disorders. Increasing evidence indicates that these conditions share common biological pathways, including intermittent hypoxia, vascular dysfunction, inflammation, and decreased nitric oxide (NO) availability. However, the relationship between increasing OSA severity and worsening of ED remains poorly quantified. Further research is needed to more precisely define this association.
About research
The researchers conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered the protocol with the International Prospective Register of Systematic Reviews (PROSPERO).
Researchers selected studies according to predefined population, exposure, comparator, outcome, and study design (PECOS) criteria. This included an English-language study in adults 18 years and older diagnosed with OSA that reported an association between sleep apnea severity and ED. Randomized controlled trials, cohort studies, cross-sectional studies, and case-control studies published in English were included, while reviews, editorials, conference abstracts, and non-English studies were excluded.
A systematic search of PubMed, Embase, and Scopus found 458 records published from January 2000 to February 10, 2025. After titles, abstracts, and full texts were reviewed, eight observational studies were finally selected based on eligibility criteria.
All studies included in the final analysis were observational and consisted of prospective cohort and cross-sectional designs. Erectile function was assessed using validated International Index of Erectile Function (IIEF) questionnaires, including the International Index of Erectile Function-5 (IIEF-5), IIEF-15, and the International Index of Erectile Function (IIEF-EF) erectile function domain.
OSA severity was measured using apnea-hypopnea index (AHI) and minimum oxygen saturation. Because there was considerable heterogeneity between studies, statistical analyzes were performed using R software with a random-effects model. Risk of bias and certainty of evidence were assessed using the Risk of Bias in Nonrandomized Exposure Studies (ROBINS-E) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) frameworks.
Research results
Eight observational studies were included in the final analysis. Seven studies involving 594 participants evaluated whether AHI correlated with erectile function. Six of these studies showed that increased AHI was associated with decreased IIEF scores, and erectile function worsened as sleep apnea became more severe.
The results of the pooled analysis showed a statistically significant moderate negative correlation. Pooled Fisher’s Z = -0.43. 95% confidence interval (CI): -0.66 to -0.19. One study reported a small positive correlation, but the result was not statistically significant. Sensitivity analysis excluding one study reduced heterogeneity while maintaining a significant negative association (pooled Fisher’s Z = -0.33; 95% CI: -0.49 to -0.17).
Three studies involving 513 participants assessed minimum oxygen saturation during sleep. Pooled analysis showed a statistically significant positive correlation between higher minimum oxygen saturation and better erectile function (pooled Fisher’s Z = 0.36; 95% CI: 0.04 to 0.69). Despite considerable statistical heterogeneity in both analyses, these findings consistently suggest that more severe sleep-disordered breathing and greater oxygen deprivation are associated with poorer erectile function. This result supported the association between OSA severity and decreased erectile function.
Secondary analyzes demonstrated that ED is prevalent in men with OSA, with prevalence reported to be between 59.3% and 69.0% across four studies. Another study showed that the prevalence of ED in men with OSA was significantly higher than in the group without OSA. Additionally, the analysis showed that age was consistently reported as an important factor in OSA severity and ED prevalence. Evidence about how OSA affects hormone levels and mental health has been inconsistent. Some studies have shown that men with OSA have lower testosterone, while others have found no association, and studies on depression and anxiety have had conflicting results.
Three studies evaluated continuous positive airway pressure (CPAP) therapy. One study showed that after 3 months of treatment, IIEF-5 scores improved significantly in patients with mild to moderate and severe OSA. Another study showed that ED completely resolved in 42.6% of patients after treatment. This was supported by a significant increase in erectile function scores in the same study. A third study found that IIEF-15 scores increased within 1 year of treatment. However, this review points out that these treatment results should be interpreted with caution as they are based on a limited number of primarily observational studies with relatively short follow-up periods and uncontrolled or non-randomized designs.
conclusion
The results showed that higher OSA severity was consistently associated with poorer erectile function. Higher AHI values were associated with lower IIEF scores and higher minimum oxygen saturation with better erectile function. This review highlighted that many men with OSA suffer from ED and found that CPAP treatment was associated with improved erectile function in affected patients.
While these findings highlight the importance of considering OSA screening in men presenting with ED, especially when sleep-disordered breathing symptoms and risk factors are present, they acknowledge that additional well-designed prospective studies are needed to strengthen the available evidence. Because the evidence is observational, heterogeneous, and rated as low certainty, this review cannot establish causality or define a specific OSA severity threshold at which erectile function declines.
Reference magazines:
- Pan, K. H., Tong, K. S., Munir, A., and Al-Najjar, H. M. (2026). Association between obstructive sleep apnea syndrome and erectile dysfunction: A systematic review and meta-analysis. International Journal of Impotence Research. Doi: 10.1038/s41443-026-01315-7, https://www.nature.com/articles/s41443-026-01315-7
