Chronic kidney disease is prevalent and encountered by millions of people globally. Its incidence is continuously rising, affecting the quality of life. Disturbance of sexual function is common in men with long-standing kidney disorders, as both these conditions share common causes, such as hormonal and vascular abnormalities. Besides, they both are affected by coexisting conditions such as hypertension, cardiovascular disease, and diabetes mellitus.

However, sexual dysfunction remains under-diagnosed and under-treated in most of these patients due to lack of awareness.

So, if you are diagnosed with chronic kidney disease and notice any change in the frequency or duration of your erection, talk to your doctor. They will work with you to manage the condition and help you get back your healthy sex life.

Prevalence of ED in CKD Patients (Chronic Kidney Disease)

Erectile dysfunction is a common disorder in men with chronic kidney disease. Going by the numbers, ED is seen in approximately 80% of the CKD patients

The Process of Erection

Before we move ahead to the causes, let us first understand the process of erection. The shaft of the penis is surrounded by two chambers and contains the urethra in the centre. The surrounding tissues of the chambers include smooth muscle fibre, small blood vessels, and empty spaces. 

Erection is a complex process and needs signals from the nerve endings in the penis or brain to prompt the blood vessels to dilate and smooth muscles of the chambers to relax. This causes the empty spaces to fill with blood.

The pressure of blood flow causes the sheath to press on veins, which drain blood out of the penis. The pressure thus traps the blood inside the penis. With more flow of blood, the penis stiffens and expands, resulting in an erection.

When arousal ends, smooth muscles contract, relieving pressure off the veins, and the penis returns to the original flaccid state.

Causes of ED in CKD Patients

Chronic kidney disease and ED share common causative factors. 

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Some causes include:

Hormonal Abnormalities

Long-term kidney disorders are associated with impaired sperm production, which is an important cause of infertility.

Besides, testes develop faulty hormonal functions. 

Usually, luteinizing hormone (LH) binds to the receptors on Leydig cells (a type of cells in testes) to produce and secrete testosterone. But in patients with kidney disorders, these Leydig cells do not respond to LH the way they should, which is the primary cause of low testosterone levels.

As we have seen earlier, normal testosterone is essential for the healthy functioning of the penis and libido. Low testosterone levels result in the loss of smooth muscles in the penis, making it difficult to get an erection.

Moreover, high prolactin level is seen in men with chronic kidney diseases. Researchers believe that abnormal prolactin levels are secondary to hyperprolactinemia and low zinc levels in long-standing kidney disease patients. High prolactin levels, in turn, lowers testosterone levels and sexual desire, resulting in ED.

Endothelial Dysfunction

Various studies have shown that chronic kidney diseases are a risk factor for cardiovascular diseases. 

Endothelial dysfunction, an indicator of heart disease, is also seen in patients with kidney problems.

Moreover, endothelial dysfunction causes reduced production of nitric oxide (NO). As NO helps the blood vessels relax, its deficiency results in narrow blood vessels that carry less blood to the penis, increasing the risk of erectile dysfunction. 

Besides, chronic kidney disease patients suffer from various metabolic disorders, such as hyperlipidemia, hypertension, and diabetes These metabolic conditions also result in endothelial dysfunction and are thus risk factors for ED.

Disturbance in Autonomic Nervous Systems

Autonomic neuropathy, a condition where one or more nerves are affected, is commonly seen in people with end-stage kidney disorders. When it involves the nerve supplying the penis, autonomic neuropathy can cause ED.

Besides, diabetes is also a common factor for autonomic neuropathy. As diabetes is a common association with kidney diseases, it could be the cause of ED

Anemia & Erythropoietin Deficiency

Erythropoietin (Epo) is widely used to manage anemia in kidney disease patients. Studies have shown that Epo improves erectile function in men undergoing dialysis. While the mechanism of how Epo improves erection is unknown, studies have shown that it normalizes the increased prolactin level, which is a cause of ED. Besides, Epo is also seen to improve testosterone levels.

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A study on rats suggested Epo improved the functioning of the nerves, including those supplying the penis. The study also showed that Epo helped in the regeneration of damaged nerves.

Moreover, Epo also has anti-apoptotic and proangiogenic activities, which may help restore erectile functions.

Researchers believe that erythropoietin improves erectile functioning through its receptors on vascular endothelial cells and nerves rather than on red blood cells, along with improvement in anemia.

Vitamin D Deficiency

While there is a lack of conclusive data, studies have shown that a decline in parathyroid hormone caused by the treatment with vitamin D3 was associated with recovery of the erectile functions in patients undergoing dialysis.

It is also seen that parathyroid hormone administration increased prolactin levels, which is a risk factor for erectile dysfunction.

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Depression

Almost 20%-30% of patients undergoing dialysis have depression. Several studies have proven that depression is an independent risk factor for erectile dysfunction.

Read more about depression and ED here.

Zinc Deficiency

Researchers believe that zinc supplementation improves erectile function, which is correlated with an increase in testosterone levels.

However, some studies have also shown adverse effects of zinc supplementation of ED.

It is thus recommended to consult a doctor before starting to take zinc supplements.

Drugs

Many medicines used to manage long-standing kidney diseases are also seen to cause ED.

Some common ones include:

  • Diuretics
  • Beta-blockers
  • Agonists for α-2 adrenergic receptors
  • Tricyclic antidepressants
  • Cimetidine
  • Metoclopramide

Read more about medication that cause ED here.

Treatment

Oral prescription medicine and testosterone therapy is the ideal treatment for men with ED and CKD.

Prescription Medicines

Usually, the doctor’s first choice is oral pills called PDE5 inhibitors. These medicines do not influence your sexual desire but increase blood flow to the penis and help get an erection when you are sexually aroused. 

Some common medicines used to manage ED include Viagra, Levitra, Cialis, Staxyn

Of note, men whose blood pressure levels are not under control and are on alpha-blockers should not take these medicines.

You should also avoid these medicines if you:

  • Take nitrate drugs
  • Have liver or kidney diseases
  • Have an eye disorder known as retinitis pigmentosa
  • Had a stroke or heart attack in the past six months

However, do not worry, even if pills are not an option for you. There are other treatment options, as well.

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Testosterone Therapy

Testosterone is the primary sex hormone in men and plays a vital role in overall health. As testosterone levels are often low in kidney disorders, doctors may prescribe testosterone. 

Besides, prescription medicines are most effective when used along with testosterone therapy if the hormone levels are less.

However, the therapy comes with risks. Testosterone is seen to increase the risk of stroke or heart attack. The Food and Drug Administration (FDA) advises testosterone in men who have lower testosterone levels due to an underlying health condition.

Moreover, if you are on testosterone, your doctor will monitor you. They will also get your testosterone levels checked, both before and during the treatment. If your testosterone levels are higher than normal, your doctor may advise a lower dose or stop it completely.

Some common side effects of testosterone are:

  • Male breasts
  • Swelling due to fluid retention
  • Sleep apnea
  • Acne
  • Prostate growth
  • Moodiness

Testosterone for ED is available in many forms, including transdermal gel, transdermal cream, nasal gel, transdermal solution, transdermal patch, oral tablet, oral capsule, pellet implant, solution for intramuscular injection, and topical gel

Effects of Treatments on Erectile Function

Various treatment options are available for chronic kidney disease patients. The ideal treatment option depends on your age, creatinine levels, kidney functioning, and presence or absence of other health conditions.

It is seen that dialysis therapy is not associated with improved sexual functions. But various studies have shown that renal transplantation may improve erectile function. The renal transplant was also associated with an improvement in sperm motility and testosterone levels. 

While chances of reversing erectile function are higher in patients who received renal transplants than those on dialysis, ED is still prevalent in kidney transplant recipients. In such cases, preventing cardiovascular diseases is crucial to maintain erectile function.

Final Thoughts

Erectile dysfunction is a common association in kidney disease patients. The cause for the same is multifactorial, including metabolic, hormonal, psychological, and nutritional factors.

Oral prescription medicines and testosterone therapy are useful for CKD patients. Besides, renal transplantation may reverse erectile dysfunction, especially in young patients.

Lastly, ED is an indicator of cardiovascular disease. It is thus recommended to consult a doctor if you notice any change in your erection.

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