Many men with chronic kidney disease struggle with erectile dysfunction. Here are the reasons why CKD and ED are connected and how men with CKD can improve their sexual health.
Last Updated: 08/30/2023
More than one in seven adults or 37 million people have chronic kidney disease (CKD), according to the Centers for Disease Control and Prevention, and about 12% of men have the disease.1
CKD is a condition where the kidneys are damaged and over time are unable to filter out toxic waste and extra fluid from the blood. This can lead to heart disease, stroke, high blood pressure, and possibly an early death.
People who have only 10%-15% of their kidney function remaining are suffering from kidney failure (also called end-stage renal disease, renal failure, or chronic renal insufficiency). Kidney failure patients must undergo dialysis (otherwise known as renal replacement therapy) to make up for lost renal function.
There are two types of dialysis:
Hemodialysis – This acts like an artificial kidney to filter and detoxify the blood and compensate for renal insufficiency in people with kidney failure. A machine known as a dialyzer is placed outside the body either at home or at a medical facility. A kidney patient’s blood is circulated through the machine, and once blood is filtered it’s then returned to the body.
Peritoneal dialysis – This type of renal replacement therapy filters the blood inside the body of kidney failure patients rather than outside like hemodialysis. In peritoneal dialysis patients, fluid flows into the body through a tube, and the abdominal lining removes the waste from the blood. The fluid and the waste are drained from the body.
Ultimately, CKD patients whose disease is progressing into kidney failure or who are in the later stage of kidney disease can choose to have a kidney transplant.
The two most common risk factors for declining kidney function in adults are diabetes and hypertension. Obesity, coronary artery disease, inherited kidney problems and a family history of CKD, older age, and past damage to the kidneys are also risk factors for renal failure.
Having chronic kidney disease is a strain on the body overall. But it’s also a strain on erectile function. A lot of men with CKD also have erectile dysfunction, the inability to achieve or maintain an erection hard enough for sexual intercourse.
If you have CKD and also have sexual problems you’re not alone. As many as 80% of men with CKD have problems with erectile function, although the prevalence can vary depending on the severity of the kidney disease.
The rate of sexual dysfunction is highest in men with end-stage renal disease compared to other stages of the disease. A review of the medical literature found that 70% of male kidney failure patients undergoing either hemodialysis or peritoneal dialysis had erectile dysfunction.2 Kidney transplant recipients had a much lower rate of ED—59%.
However, the rate of erectile dysfunction in men with kidney disease is high from stage 3 of the disease onward. Kidney failure patients undergoing dialysis also can suffer from other types of sexual problems such as low sexual desire and inability to have an orgasm.3
Sadly, sexual problems in CKD patients stops many male dialysis patients from having sex. According to one survey of both female and male dialysis patients, 63% of dialysis patients don’t have sexual intercourse and half of these patients wished they could have better sexual function.4
Another 19% of the survey respondents had sex two or less times per month and more than half of these patients wished they were able to have sex more often. The survey participants who never had sex were significantly more depressed, had higher anxiety and more physical symptoms, poor quality of life, and were less satisfied with their sexual activity.
Kidney disease is tied to erectile dysfunction for many reasons. Let’s take a look at the reasons why having renal disease could lead to male sexual dysfunction.
Renal insufficiency does a number not only on the kidneys themselves but also on other tissues and organs of the body, including the penis. Often, the sexual dysfunction that occurs in CKD is due to chronic illness that often occurs together with chronic kidney disease.
It’s really common to have diabetes mellitus together with CKD. A review of published studies in CKD patients stage 4 and greater found that having diabetes mellitus with CKD was one of three strongest risk factors for developing erectile dysfunction in kidney disease.5 The other two risk factors in CKD patients were depression and increasing age.5
In a study of men with chronic renal failure who were on hemodialysis, the highest rate of erectile dysfunction was in men whose kidney disease was caused by diabetes.6
Other research found that male hemodialysis patients who had diabetes were twice as likely to have ED compared with non-diabetic men.7 Another study of 81 men with CKD reported that the male diabetic patients were four times more likely to have problems with erectile function compared with non-diabetic men.8
Neuropathy—otherwise known as nerve damage—often happens in patients with CKD, and this can get in the way of healthy erectile function. Healthy nerves are important for sexual function, because the sympathetic nervous system is involved in blood flow to the penis.9
In men with kidney disease who have nerve damage, the smooth muscle of the corpus cavernosum of the penis doesn’t relax. The corpus cavernosum is made up of two columns of spongy erectile tissue that forms most of the penis body. It’s this relaxation of the smooth muscle that allows blood to enter the penis, triggering an erection. Without this healthy flow of blood into the penis, a man can’t achieve or maintain an erection.
A couple of things can cause the nerve damage in CKD that leads to erectile dysfunction. Diabetes is one of the most common causes of nerve damage in CKD patients. The severity of neuropathy in men with type 1 diabetes is linked to erectile dysfunction, but type 2 diabetes can cause nerve damage, too.10
Men with CKD also have uremia, a raised blood level of waste compounds that the kidneys normally help filter out of the body by way of the urine. In uremic patients, uremia in and of itself even without outright diabetes can cause problems with the nervous system that lead to male sexual dysfunction.9
Vascular disease refers to disease that affects the blood vessels. Erectile dysfunction is a sign that a man could have vascular disease since this type of disease reduces the blood supply to the penis.
Having chronic kidney disease at the same time as vascular disease only makes things worse since CKD leads to calcification of the blood vessels, which worsens blood flow and reduces blood supply.11
End-stage renal disease speeds up atherosclerosis (the hardening of arteries and blood vessels). This can lead to sexual dysfunction by blocking blood flow in large vessels.12 A lot of men with chronic renal failure (78% in one study) have blockages in their corpus cavernosum artery, leading to erectile dysfunction.13 These men also have vascular problems in other areas of the penis.
Obesity is a risk factor for CKD and for sexual dysfunction. Obesity causes a number of problems in the kidneys including inflammation and structural changes.14
Obesity also causes other changes throughout the body that affect the kidney, including the buildup of fat and cholesterol and promoting insulin resistance, a process where the body starts to ignore the blood-sugar-lowering effects of insulin.
Erectile dysfunction happens more often in obese and overweight men compared to men who are normal weight.15 Belly fat in particular leads to inflammation and to damage to the lining of blood vessels, decreasing blood supply to the penis. Obesity also leads to a drop in testosterone levels, which impacts libido and erectile function.
Chronic kidney disease increases the risk of cardiovascular disease, which is also linked to erectile dysfunction.16
A common factor between cardiovascular disease and erectile dysfunction is that the blood vessel lining becomes damaged, reducing blood supply throughout the body and to the penis. Scientists call this endothelial dysfunction. It’s caused by the cells lining the blood vessels not producing enough of a chemical called nitric oxide, which widens the blood vessels to improve blood flow.
Endothelial dysfunction is also common in chronic kidney disease, so it’s not surprising that CKD patients often have problems with erectile function.17
A lot of the coexisting conditions that CKD patients have—like diabetes, high cholesterol, and hypertension—are also known to cause cardiovascular disease. This is another way in which chronic kidney disease is linked to sexual dysfunction.
High blood pressure, which causes endothelial dysfunction in penile vessels, is a risk factor for erectile dysfunction. Many people with CKD (70%-95%) have hypertension, but it’s not known for sure whether the high blood pressure itself causes impaired erectile function or if it’s the result of antihypertensive drugs prescribed to these patients.18
High cholesterol is common in men who have erectile dysfunction. Having a build up of lipids affects the lining of the blood vessels and the smooth muscle cells of the corpus cavernosum of the penis and can lead to impaired blood flow.
Some research suggests high cholesterol is an independent risk factor for erectile dysfunction, including a study of 2,869 men, which found that high cholesterol was independently and significantly linked to ED.19
People with chronic kidney disease are twice as likely to have anemia as people who don’t have kidney disease, and as kidney disease progresses toward kidney failure, the rate of anemia rises.9
CKD patients often don’t make enough of a hormone called erythropoietin, which is responsible for triggering the production of red blood cells. In several studies, treating dialysis patients with recombinant human erythropoietin led to improved sexual function.16
CKD patients with anemia have a reduced ability to deliver oxygen to tissues, including the corpus cavernosa of the penis. This drop in oxygen may lead to a decline in nitric oxide production and worse erectile function.
Another reason why kidney disease patients are more vulnerable to sexual dysfunction could be because they often have changes in hormones linked to sexual function.16 Doctors sometimes refer to these hormonal problems as endocrine abnormalities since testosterone is secreted from the testes, which is part of the endocrine system.
Chronic renal disease patients usually have reduced total and free testosterone levels. An estimated 40%-60% of hemodialysis patients have testosterone deficiency.9
Healthy levels of this hormone are associated with sexual desire and erectile function, and testosterone production is needed to make nitric oxide, a chemical that is critical for erections and sexual function.
Low testosterone levels in patients with chronic kidney disease can lead to structural changes in the penis.16 Low testosterone levels can result in replacement of the smooth muscle in the corpus cavernosa with collagen fibers. This in turn leads to blocked blood vessels and fibrosis (stiffening of the penile tissue), resulting in sexual problems.
Men with chronic kidney disease also often have high levels of a hormone known as prolactin. High levels of this hormone are associated with low libido and sexual dysfunction. High prolactin also can lower plasma testosterone levels, which further interferes with sexual function and quality of life.
Many CKD patients take medications that could cause sexual dysfunction. A number of drugs used to treat hypertension are some of the biggest offenders.
Blood pressure drugs like beta blockers are linked to erectile dysfunction in part because they reduce testosterone levels. Taking thiazide diuretics can lead to difficulty in achieving and maintaining an erection, as well as problems ejaculating. The diuretic drug spironolactone can cause low libido and erectile dysfunction.
On the other hand, calcium antagonists, angiotensin converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers have a lower risk of sexual dysfunction.
Other drugs commonly used in CKD patients that could cause erectile dysfunction include tricyclic antidepressants, the heartburn drugs cimetidine and metoclopramide, and benzodiazepines (tranquilizers).18
Psychological factors that impact CKD patients include depression, which reduces sexual desire and can lead to decreased libido. An estimated 20%-30% of hemodialysis patients suffer from clinical depression.20
A study of chronic kidney disease patients stages 4 or 5 found that 25% had major depression and another 20% had minor depression.9 In one study of patients with CKD, symptoms of depression were strongly linked to an increased risk of developing erectile dysfunction.21
Male dialysis patients often feel a sense of helplessness, because they’re worried about complications or being hospitalized, and these fears do nothing to promote healthy sexual function.
A lot of men with kidney disease also have body image issues. Many men with chronic kidney failure developed their kidney disease when they were younger and the disease interfered with normal physical development and led to short stature.
In addition, kidney disease treatment affects aspects of appearance. Men can be sensitive about scars from various procedures or kidney transplantation, and hemodialysis or peritoneal dialysis catheters stick out from the skin.
During dialysis, a surgically created connection between an artery and vein—called an arteriovenous (AV) fistula—is created to make dialysis easier. An AV is visible in dialysis patients if the forearms are exposed. Peritoneal dialysis can also cause the abdomen to distend.
Renal replacement can lead to weight gain, causing renal transplant recipients who once had a normal body mass index to become obese after kidney transplantation. Drugs used to suppress the immune system in kidney transplant recipients also can change their physical appearance. For example, the drug ciclosporin can cause excessive hair growth.
Any of these changes to physical appearance can affect a man’s body image and lead to sexual dysfunction. A study of young adults (both males and females) ages 16-30 years with chronic renal failure found that either kidney disease itself or its treatment caused intimate relationships to suffer.22
Male kidney patients can work with their doctor to treat sexual dysfunction. Here are some of the ways men with kidney problems can improve sexual function and quality of life:
Male kidney patients can talk to their healthcare provider about using oral sildenafil and other phosphodiesterase-5 (PDE5) inhibitors used to treat ED.
Three randomized controlled trials in CKD patients compared PDE5 inhibitors with a placebo.9 Two of the studies looked at renal transplant patients while the other investigated PDE5 inhibitor use in hemodialysis patients. In the male kidney patients taking PDE5 inhibitors, the studies found a consistent improvement in the International Index of Erectile Function (IIEF).
In men with testosterone deficiency, testosterone therapy improves erectile function and quality of life. According to one study of 261 men with low testosterone levels, testosterone therapy led to a 71% improvement in erectile function within three months.23 Many patients went from having severe ED to no erectile dysfunction at all.
An analysis of 14 studies that included a total of 2,298 men observed that testosterone therapy improved sexual function compared to the placebo.24 The therapy was more effective in men with a lower testosterone level at the start of the study.
Another study included 28 male chronic dialysis patients, 46 men with chronic kidney disease, stages II - IV, who had not gone on dialysis yet, and 35 controls without kidney disease.25 The study authors administered testosterone replacement therapy by intramuscular injections every three weeks in subjects with testosterone deficiency (15 men on hemodialysis and in 14 of the predialysis CKD patients).
In both groups of CKD patients given testosterone replacement, the intensity of clinical symptoms of low testosterone gradually decreased. In addition, erectile function, as measured by the IIEF-5 (International Index of Erectile Function) questionnaire, also improved after 3, 6, and 12 months of TRT in the men on dialysis and the predialysis kidney disease patients.
Zinc deficiency may account for the reason why male patients with CKD don’t produce enough testosterone. One study found that giving zinc supplements to 10 male hemodialysis patients led to an increase in serum testosterone compared to the placebo group.26
In this randomized, controlled trial, oral zinc therapy also improved sexual function, libido, and frequency of intercourse, which didn’t happen in the placebo group. Zinc lowered levels of serum luteinizing hormone and follicle stimulating hormone, higher levels of which could lead to sexual dysfunction.
In some cases, people who have anemia related to CKD are resistant to recombinant human erythropoietin treatment, so administering this hormone to these renal patients doesn’t always get rid of the anemia. Replenishing zinc levels may improve the anemia by making the body less resistant to erythropoietin.27
Chronic kidney disease, especially in male renal failure patients, is linked to sexual dysfunction. Research has found that 75% of male end-stage renal disease patients undergoing either hemodialysis or peritoneal dialysis had erectile dysfunction. Kidney transplant recipients had a much lower rate of ED—59%.
A number of factors can cause sexual dysfunction in chronic kidney disease. These include coexisting conditions like cardiovascular disease, diabetes, high blood pressure, nerve pain, high cholesterol, obesity, and anemia. Other reasons why CKD patients develop ED include medications, low testosterone, depression, and a poor body image.
Oral sildenafil and other erectile dysfunction medications are safe and effective for male patients with CKD. Studies have found a consistent improvement in the International Index of Erectile Function (IIEF) in kidney transplantation patients and hemodialysis patients who were taking oral sildenafil and other ED medications.
PDE5 inhibitors, testosterone replacement therapy, zinc supplementation, and treating anemia and other coexisting conditions can improve erectile dysfunction in CKD patients and their quality of life.