Thiazide diuretics erectile dysfunction with

Erectile dysfunction (ED), the inability to achieve or maintain a penile erection sufficient to permit satisfactory sexual intercourse, is estimated to affect over 100 million men worldwide, with a prevalence of 39% in those of 40 years. Its numerous causes include cardiovascular disease, diabetes mellitus and other endocrine disorders, alcohol and substance abuse, and psychological factors (14%). While the evidence is not conclusive, drug therapy is thought to underlie 25% of cases, notably from antidepressants (SSRI and tricyclic), phenothiazines, cypro-terone acetate, fibrates, levodopa, histamine H -receptor blockers, phenytoin, carbamazepine, allopurinol, indomethacin, and possibly adrenoceptor blockers and thiazide diuretics. 

The adverse effects of thiazide and thiazide-like diuretics on male sexual function include reduced libido, erectile dysfunction, and difficulty in ejaculating. The exact incidence of sexual dysfunction in patients taking diuretics is poorly documented, perhaps because of the personal nature of the problem and the reluctance of patients and/or physicians to discuss it. However, these abnormalities have been reported with incidence rates of 3-32%. The true incidence of sexual dysfunction probably lies closer to the lower end of this range (119). In a meta-analysis of 13 randomized, placebo-controlled trials conducted over a mean of 4 years the NNH (number needed to harm) for erectile impotence with thiazide diuretics in hypertension was 20 and the relative risk was 5.0 (120). 

Erectile impotence is particularly common in men with diabetes (16), who are likely to have difficulties because of autonomic dysfunction. It is unclear whether younger men and women are similarly affected and whether nor-motensive men have fewer such problems (124). Most investigations of the effects of diuretics on sexual function have been characterized by poor study design (125) the majority had no placebo control and relied on comparisons with baseline. The best studies have suggested an increase in erectile dysfunction in thiazides users compared with placebo. Bearing in mind all the confounding factors, it can be concluded that diuretics will sometimes cause impotence, but that in the population as a whole the effect is slight compared with other causes (SEDA-11, 197) (SEDA-11,198). 

ADVERSE EFFECTS AND PRECAUTIONS Adverse effects of diuretics see Chapter 28) determine tolerance and adherence. Erectile dysfunction is a troublesome adverse effect of thiazide diuretics physicians should inquire specifically regarding its occurrence. Albeit uncommon, gout may be a consequence of the hyperuricemia induced by these diuretics. Either of these adverse effects is reason to consider alternative therapies. Hydrochlorothiazide may cause rapidly developing, severe hyponatremia in some patients. Thiazides inhibit renal Ca " excretion, occasionally leading to hypercalcemia although generally mUd, this can be more severe in patients subject to hypercalcemia, such as those with primary hyperparathyroidism. The thiazide-induced decreased Ca excretion may be used therapeutically in patients with osteoporosis or hypercalciuiia. 

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