Erectile Dysfunction
December 19, 2023
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10 Mins
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4 Things That Don’t Cause Erectile Dysfunction (ED) And 6 Things That Do
Erectile Dysfunction (ED) is a prevalent concern among men, with plenty of myths and misconceptions about its causes circulating on the internet and in old wives' tales. In this article, we aim to dispel myths surrounding ED by highlighting factors that don't cause it and those that do.
Erectile Dysfunction, also known as ED or impotence, is a common condition that affects your ability to get or maintain an erection long or firm enough for sexual intercourse.
A vasectomy is one of the best forms of birth control among men which involves cutting and sealing of vas deferens, a long tube that carries sperms produced from the testes to the urethra. Hence, men won’t be able to ejaculate sperm during orgasm.
You might have heard that vasectomy interferes with your testosterone level to develop erectile dysfunction. However, this is not true. Even after vasectomy, your testicles will continue to produce testosterone as they are connected to your blood supply. A vasectomy might have only minor side effects such as pain, bleeding, or bruising.
A 2015 study 1 revealed that there was no significant difference between the incidence of impotence among men with or without vasectomy. The nerves involved in erection do not get affected and lead to erectile dysfunction or any other sexual problems after undergoing vasectomy. Another 2005 research study 2 also reported that there was no increased risk of erectile dysfunction following the vasectomy procedure.
On the contrary, you will be surprised to know that vasectomy might improve your sexual function.
A 2017 research article 3 reported that vasectomy does not affect the sexual satisfaction of couples negatively. Males after vasectomy had an improvement in sexual satisfaction, while the female’s satisfaction was not reduced due to their partners’ vasectomy.
Similarly, another 2014 research article 4 revealed that vasectomy is a safe operation where females noticed the best improvement of sexual function, erectile function, and sexual satisfaction in their male partners post vasectomy. Hence, 93% of the males and 96% of their female partners would recommend vasectomy.
Blood thinners are medications that are often prescribed by doctors after certain types of surgical procedures, or for patients with cardiovascular diseases. They help to both lower your risk of blood clots forming, as well as prevent existing blood clots from enlarging. This is important because blood clots can hinder the proper flow of blood in the body, putting you at risk of medical emergencies such as strokes or heart attacks.
If you’re taking blood thinners, you may rest assured that these medications will not cause or exacerbate ED symptoms. However, if you noticed that your ED symptoms began showing up around the time you started taking blood thinners, it is likely that your pre-existing medical condition could also be the cause of your ED.
Most patients who take blood thinners are at risk of developing blood clots due to medical conditions such as high blood pressure, diabetes, cancer or cardiovascular disease. Many of these conditions are also risk factors for ED. So, it is likely that your medical condition (and not the blood thinners that you’re taking) is what’s causing your ED.
Bystolic belongs to a class of medications known as beta-blockers. Primarily prescribed to manage hypertension (high blood pressure), it works by blocking certain natural substances in the body, such as adrenaline. By doing so, Bystolic then helps to lower blood pressure, reduce the workload on the heart, and improve blood flow.
A 2017 research study 5 revealed that Bystolic (Nebivolol) has a unique mode of action compared to other beta-blockers. Bystolic possesses vasodilating properties which involve the release of nitric oxide, followed by the dilation of penile blood vessels. Therefore, Bystolic not only does not cause or worsen erectile dysfunction, but actually improves symptoms of ED.
There's a common belief that wearing tight underwear can lead to reduced fertility and erectile dysfunction. This misconception stems from the idea that snug-fitting briefs may increase scrotal temperature, affecting sperm production and causing issues with sexual function.
While tight underwear is unlikely to be the cause of your erectile dysfunction, there is evidence to suggest that tight underwear might be associated with lower sperm count. In a 2018 study6 , researchers found that men who wore loose-fitting underwear or boxers had a higher sperm concentration and total count, as well as lower FSH levels, compared to men who wore tighter underwear.
So if you're looking to have kids, you might want to consider looser underwear.
Studies 7 done across the years have suggested that there is a link between cycling and ED. While more research is needed, there is an observed correlation between the amount (duration) of cycling and the rates of ED.
A large reason why cycling could cause ED in the long run is due to the pudendal nerve entrapment syndrome, whereby sitting for prolonged periods on the saddle can lead to genital numbness. Sitting on a bicycle for long periods places huge pressure on your perineum, the area between the anus and penis. The perineum is packed with blood vessels and nerves that supply oxygen-rich blood and sensation to your penis.
During normal erections, the nerve impulses in your brain sends signals to your penis upon sexual arousal. These signals allow the blood vessels in your penis to relax, increasing blood flow through the arteries into the penis, which causes an erection. Long-term cycling and sitting on the saddle causes damage to the pudendal nerve and pudendal artery, thereby restricting blood flow to the penis. Over time, this could lead to genital numbness and eventually ED.
There are currently studies 8 that support this claim. According to a 1997 Norwegian study 9 on 160 men who participated in a long-distance bike tour, it was found that 1 in 5 suffered from genitalia numbness for up to a week after the tour, and 13% developed ED that lasted for over a week.
2. Ethnicity and Genetics
Some studies have shown that certain ethnicities and genetic makeups could increase the risk of developing erectile dysfunction.
Ethnicity
Different ethnic groups have distinct cultural and social practices which influence their diets and lifestyles. In particular, Indians, Malays and Chinese appear to vary in their levels of physical activity and in the types of food they consume.10 This makes Malays and Indians more likely to develop metabolic syndrome (a cluster of conditions including obesity and insulin resistance) than Chinese.
ED is strongly linked to metabolic syndrome11, so it is unsurprising that the lifestyle differences which make Indians and Malays prone to metabolic syndrome also increase their chances of experiencing ED.
Another reason could lie in genetics.
Indians are known to have unusually high rates of vascular disease (blocked blood vessels) and develop conditions like heart disease 5-10 years earlier compared to other ethnic groups.⁷ This can be traced to their genes, according to Indian researchers who discovered that roughly 35% of Indians carry genetic variations that increase their risk of heart disease.12
ED is also a vascular disorder, causing reduced blood flow to the penis. The same genes that increase their risk of vascular disorders may be causing Indians to suffer from ED more often than their Malay or Chinese counterparts.13
Prostatitis is one of the most common urinary and sexual disorders in men across the world. It involves the inflammation of the prostate gland, a small walnut-shaped organ located just below the bladder in men. This gland plays a crucial role in the reproductive system by producing fluid that nourishes and transports sperm.
There are four types of prostatitis:
• Acute bacterial prostatitis
• Chronic or recurrent bacterial prostatitis
• Asymptomatic inflammatory prostatitis
• Chronic prostatitis (nonbacterial) – This is the most common type
Severe prostatitis can directly lead to erectile dysfunction. Milder forms of prostatitis can cause painful ejaculation, interfering with sexual pleasure and reducing sexual desire, ultimately leading to the development of erectile dysfunction.
A 2016 research study 14 reported that chronic prostatitis may impair erectile function through increased endothelial dysfunction and oxidative stress. Another 2020 research study 15 reported that the history of prostatitis is an independent risk factor for developing erectile dysfunction.
Prostatitis can lead to erectile dysfunction in the following ways:
Normally, the penile muscles and endothelial lining (the lining in the blood vessels) should widen to allow the blood to enter the penis region for the purpose of erection
Men with chronic prostatitis are more likely to experience endothelial dysfunction, preventing the penile tissue from filling with blood and impairing erectile function.
Inflammation of the prostate gland causes swelling, which can constrict the nerves, alter nerve signals, and create an imbalance in oxygen and antioxidant agents. As a result, oxidative stress occurs, leading to a chronic reduction in blood flow to the penis, thereby causing difficulty in achieving an erection.
A 2008 study 16 revealed that patients with prostatitis who experience pain and urination problems develop psychological issues such as anxiety, depression, stress, which can affect their erectile function and sexual behaviour.
Vaping involves the use of an electronic cigarette that vaporises nicotine and inhales its vapour. Moreover, they are highly addictive. It is important to note that in Singapore, purchasing, using or owning a vape is illegal and results in fines up to SGD $2000.
Compared to traditional cigarettes, vapes and electronic cigarettes deliver more nicotine. Hence, when you vape a lot, you will experience more sexual complications.
Nicotine is an effective vasoconstrictor (agent that can narrow blood vessels). The use of nicotine and other chemicals in vapes reduces the ability of blood vessels to widen. As they become narrow, it reduces blood flow to the penis. Hence, it becomes more difficult to achieve and maintain erection, and that’s what causes erectile dysfunction.
Nicotine can also disturb hormone regulation in the pituitary gland. Hence, there will be a drop in testosterone level which contributes to the development of erectile dysfunction.
Nitric acid stimulates the lining in the blood vessels (endothelial lining) and muscles of the penis to widen and allow the blood to enter in and get trapped to achieve and maintain an erection. It is believed that vaping causes a reduction in nitric acid secretion as well as problems in this endothelial lining, leading to erectile dysfunction.
A recent 2021 study in the American Journal of Preventive Medicine 17 reported that healthy males aged between 20 to 65 with no past history of cardiovascular disease who vaped nicotine every day were greater than twice as likely to suffer from erectile dysfunction when compared to non-smokers.
Sertraline is a prescription medicine that is available as the brand-name drug Zoloft. It is an antidepressant medication belonging to a group of drugs called selective serotonin reuptake inhibitors (SSRIs), which are some of the most commonly prescribed and highly effective antidepressants available.
Zoloft is used to treat depression, panic attacks, social anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and premenstrual dysphoric disorder. The drug works by increasing the amount of serotonin (a natural substance in the brain), to help to restore mental health balance.
If you’ve been prescribed Zoloft, it is important to know that sexual side effects can occur as a result of its consumption. The most common of these side effects include a decreased sex drive (libido), difficulty or inability to reach orgasm, and erectile dysfunction (ED). However, the exact prevalence rate of such sexual side effects are not known. Some studies reported up to 80% of SSRI-induced sexual side effects 18 while past reports found that SSRI-associated sexual and erectile dysfunction occur at rates of 40% to 70%.19 Hence, issues such as ED are not a guaranteed occurrence after the consumption of Zoloft but some men do experience these side effects.
There are numerous theories that account for how SSRIs result in these side effects, but in general, an increase in serotonin can diminish one’s sexual function. Some studies 20 suggest that an increase in serotonin may affect hormones and neurotransmitters such as testosterone, which affects sexual arousal, and dopamine, which helps achieve orgasm. Another theory 21 suggests that SSRIs may inhibit nitrous oxide, which is needed for the muscles in the penis to relax, allowing blood to flow into the penis to maintain an erection.
However, the occurrence and severity of ED caused by Zoloft varies from person to person. For some, the side effects of Zoloft may also decrease over time as the body adjusts to the medication, but for others, the effects may continue to stay.
Xanax is a depressant that slows down the central nervous system, affecting nerve impulses throughout the body. This suppression can cause a decrease in libido (sexual drive), making it more difficult to get or maintain an erection.
In general, many medications have been associated with ED, such as medications used to treat hypertension, depression, and other psychiatric disorders. In fact, about 25% of ED cases 22 are related to medication side effects. In particular, the use of benzodiazepines was reported 23 to have a number of adverse reactions, including changes in libido, dystonia (the uncontrollable contraction of muscles), loss of coordination and fatigue.
Currently, scientific research regarding the relationship between Xanax and ED remains minimal and overall inconclusive. However, in a placebo-controlled clinical trial 24 of Xanax, 7% of patients given Xanax experienced sexual dysfunction compared to 4% of patients who were given a placebo treatment. ED is just one example of the numerous forms of sexual dysfunction. Sexual dysfunctions include a wide range of conditions that cause a hindrance in either a person’s ability to respond to sexual stimuli or to experience sexual pleasure.
The results of a study of 32 patients 25 who received Xanax treatment for several weeks supported the contention that Xanax may be associated with a decline in sexual functioning. The majority of patients in the study experienced adverse sexual side effects such as decreased libido. A number of patients also reported erectile difficulties, ejaculatory inhibition, or orgasmic dysfunction.
Generally, there have also been a few studies reporting an association of benzodiazepines with ED. For example, the Massachusetts Male Aging Study (MMAS) 26, a longitudinal study that occurred from 1987 to 1997, found that the use of benzodiazepines was positively associated with ED. Similarly, the 2013 Boston Area Community Health (BACH) Survey 27 of 2,301 men aged 30 to 79 found that the use of benzodiazepines had a two-to-three-fold increase in the odds of ED occurring.
However, further studies are needed to determine whether the association between Xanax and sexual dysfunctions are independent of underlying health conditions, and to further explore the relationship between benzodiazepines like Xanax and ED.
Lisinopril belongs to a class of medications known as angiotensin-converting enzyme (ACE) inhibitors and is one of the first-line treatments for hypertension, as well as cardiovascular heart problems like heart failure.
Individuals with hypertension have certain types of vasoconstrictive hormones in their body. These hormones constrict blood vessels, increasing blood pressure. Lisinopril works by reducing these hormones, thus relaxing the blood vessels and reducing overall blood pressure. Doing so makes it easier for blood to flow throughout the body.
Generally speaking, erectile dysfunction is an extremely rare side effect of Lisinopril, affecting only less than 1% of users. As mentioned earlier, Lisinopril belongs to a class of drugs known as ACE inhibitors, which are among the cardiovascular medications that are least likely to cause ED 28 .
That said, while uncommon, it’s still possible to experience ED as a temporary side effect. According to some research studies 29, Lisinopril can temporarily cause sexual side effects, especially during the first few months of treatment.
On the flipside, some argue that Lisinopril can actually improve erectile function instead. This is because Lisinopril works by increasing blood flow throughout the body, which is similar to how phosphodiesterase type 5 (PDE-5) ED medications work. Furthermore, as hypertension can result in ED, a medication like Lisinopril can actually help in improving ED instead.
Ultimately, Lisinopril can potentially cause sexual side effects like ED, but these side effects are temporary and extremely rare. In fact, Lisinopril could also potentially reduce the effects of ED instead.
Myths and Misconceptions About Erectile Dysfunction
Despite ED being a prevalent issue affecting many men worldwide, many myths and misconceptions about this condition persist.
Let's debunk some of them:
While it is true that older men are more likely to experience erectile dysfunction, erectile dysfunction doesn’t discriminate against age and men of any age can still be affected. In a study 30 done by the New England Research Institute, researchers found that erectile dysfunction prevailed at a rate of 52%. The study also found that by the age of 40, 40% of their participants had experienced some degree of erectile dysfunction.
While this might sound worrying, a study conducted by John Hopkins University found that only 4% of men in their 50s and 17% of men in their 60s were completely unable to achieve an erection. This means that while you might experience erectile dysfunction issues as you age, it is unlikely that you will experience complete erectile dysfunction and that your issues can be treated.
As we mentioned earlier, studies have shown a correlation between the prevalence of erectile dysfunction and the ages at which men experience them. However, aging is not the sole cause of erectile dysfunction and that there are a range of factors that can cause men of any age to experience erectile dysfunction. Here are the most common factors that have been linked to erectile dysfunction:
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Studies have shown that psychological factors play a huge role in the development of erectile dysfunction and that psychological conditions like stress, depression and anxiety increase the risk of erectile dysfunction. Erectile dysfunction that is directly linked to psychological issues is also called “psychological impotence”.
Medical conditions that affect blood circulation, blood pressure and hormone balances can increase the risk of erectile dysfunction. Diseases like heart disease and type 2 diabetes were found to be the most common factors that were linked to erectile dysfunction.
Medical treatments like chemotherapy and radiation can increase your risk of developing erectile dysfunction. Surgical treatments like prostate surgery can also increase the risk of you developing erectile dysfunction.
If you are overweight or obese, you are at risk of developing several chronic health issues which in turn, can increase the risk of you being affected by erectile dysfunction. Obesity can also hinder blood flow which can contribute to the development of erectile dysfunction.
Smoking can unsurprisingly negatively affect your body and your health. Smoking can damage your blood vessels which impedes blood circulation and affects your ability to get and hold an erection. Similarly, overconsumption of alcohol can also negatively affect both your health and sexual health. Too much alcohol in your system can diminish your sex drive, prevent you from getting and maintaining an erection and prevent you from orgasming.
It is important not to shrug off erectile dysfunction as an “older man’s problem” or something that is the result of aging as erectile dysfunction can affect men of all ages and can be brought on by a host of factors; some of which can be prevented by practicing a healthier lifestyle.
In a study 31 done by the Harvard School of Public Health, researchers found that there was a correlation between erectile dysfunction and factors like alcohol intake, smoking habits, and physical activity. The study found that men who exercised regularly were 30% less likely to develop erectile dysfunction than men who did not exercise. Men that lived healthier lifestyles and did not experience any chronic disease were less likely to experience erectile dysfunction than men who were overweight, drank, smoked and lived sedentary lives.
While experiencing erectile dysfunction in of itself isn’t life threatening, it could be indicative of a larger underlying health issue that could be concerning if left undiagnosed and untreated.
Of all the potential root causes of erectile dysfunction, heart disease is the most concerning. Heart disease refers to several health conditions that are characterised by cardiovascular problems like arrhythmia, anatomical defect or atherosclerosis. In a study 32 done by the Vienna Medical School, researchers found that atherosclerosis was the most likely factor to cause erectile dysfunction, of all the stated cardiovascular problems.
Atherosclerosis occurs when artery walls are thickened by the accumulation of cholesterol and other fatty substances (also known as, “plaque”), which then narrows the artery’s opening and inhibits both the flow and the amount of blood going through the arteries. Besides preventing you from getting and maintaining an erection, conditions like atherosclerosis that hinders blood pressure and circulation can lead to serious health issues such as stroke, heart attack and even death.
Besides heart disease, another health condition that could potentially cause erectile dysfunction is type 2 diabetes. Diabetes occurs when your body is unable to regulate the blood sugar levels as insulin production is impaired. Eventually, the high blood sugar levels in the body will damage the circulatory, immune and nervous systems.
If you experience chronic erectile dysfunction, it is important that you consult your doctor sooner rather than later. Your doctor will be able to determine the root cause of your erectile dysfunction, and whether it is caused by psychological factors or a bigger underlying health issue.
You might think that the only and best way to treat erectile dysfunction is to take erectile dysfunction drugs like sildenafil (also known by the brand name Viagra) or other similar medication. While it is true that these prescription medications can help you get and maintain an erection with a success rate as high as 70%, it is not the be-all-end- all way to treat erectile dysfunction.
There are instances where erectile dysfunction medication might not work at all for some men, or even might cause side effects like headaches, facial flushing, muscles aches, congestions and back pain.
If you are experiencing erectile dysfunction, it is advisable that you consult a doctor. Here at Noah, our doctors are best equipped with the knowledge to help you ascertain the root cause of your ED. They will be able to advise you on the best treatment suited for you, and can also prescribe you the right medication should you need it.
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1 Barone, M, Achola, J, Glob. libr. women's med., (ISSN: 1756-2228) 2015; DOI 10.3843/GLOWM.10409 Long-Term Risks of Vasectomy
2 Bertero E, Hallak J, Gromatzky C, Lucon AM, Arap S. Assessment of sexual function in patients undergoing vasectomy using the international index of erectile function. Int Braz J Urol. 2005 Sep-Oct;31(5):452-8. doi: 10.1590/s1677-55382005000500006. PMID: 16255791.
3 Engl T, Hallmen S, Beecken WD, Rubenwolf P, Gerharz EW, Vallo S. Impact of vasectomy on the sexual satisfaction of couples: experience from a specialized clinic. Cent European J Urol. 2017;70(3):275-279. doi: 10.5173/ceju.2017.1294. Epub 2017 Jun 23. PMID: 29104791; PMCID: PMC5656365.
4 Mohamad Al-Ali B, Shamloul R, Ramsauer J, Bella AJ, Scrinzi U, Treu T, Jungwirth A. The effect of vasectomy on the sexual life of couples. J Sex Med. 2014 Sep;11(9):2239-42. doi: 10.1111/jsm.12567. Epub 2014 May 12. PMID: 24820516.
5 Sharp RP, Gales BJ. Nebivolol versus other beta blockers in patients with hypertension and erectile dysfunction. Ther Adv Urol. 2017 Feb;9(2):59-63. doi: 10.1177/1756287216685027. Epub 2017 Jan 6. PMID: 28203288; PMCID: PMC5298412.
6 Mínguez-Alarcón, Lidia et al. “Type of underwear worn and markers of testicular function among men attending a fertility center.” Human reproduction (Oxford, England) vol. 33,9 (2018): 1749-1756. doi:10.1093/humrep/dey259
7 8 Sommer, Frank et al. “Bicycle riding and erectile dysfunction: a review.” The journal of sexual medicine vol. 7,7 (2010): 2346-58. doi:10.1111/j.1743-6109.2009.01664.x
9 Andersen, K V, and G Bovim. “Impotence and nerve entrapment in long distance amateur cyclists.” Acta neurologica Scandinavica vol. 95,4 (1997): 233-40. doi:10.1111/j.1600-0404.1997.tb00104.x
10 Tan AKG, Dunn RA, Yen ST. Ethnic Disparities in Metabolic Syndrome in Malaysia: An Analysis by Risk Factors. Metab Syndr Relat Disord. 2011;9(6): 441–451. doi: 10.1089/met.2011.0031. Accessed September 12, 2021.
11 Tan WS, Ng CJ, Khoo EM, et al. The triad of erectile dysfunction, testosterone deficiency syndrome and metabolic syndrome: findings from a multi-ethnic Asian men study (The Subang Men’s Health Study). Aging Male. 2011;14(4): 231-236, doi: 10.3109/13685538.2011.597463. Accessed September 12, 2021.
12 Subramanian L, Khan AA, Allu PKR, et al. A haplotype variant of the human chromogranin A gene ( CHGA) promoter increases CHGA expression and the risk for cardiometabolic disorders. J Biol Chem. 2017;292(34): 13970-13985. doi: 10.1074/jbc.M117.778134. Accessed September 12, 2021.
13 Subramanian L, Khan AA, Allu PKR, et al. A haplotype variant of the human chromogranin A gene ( CHGA) promoter increases CHGA expression and the risk for cardiometabolic disorders. J Biol Chem. 2017;292(34): 13970-13985. doi: 10.1074/jbc.M117.778134. Accessed September 12, 2021.
14 Hu, Y et al. “Chronic prostatitis/chronic pelvic pain syndrome impairs erectile function through increased endothelial dysfunction, oxidative stress, apoptosis, and corporal fibrosis in a rat model.” Andrology vol. 4,6 (2016): 1209-1216. doi:10.1111/andr.12273
15 Ma, Chengquan et al. “History of Prostatitis Is an Independent Risk Factor for Erectile Dysfunction: A Cross-Sectional Study.” BioMed research international vol. 2020 8964673. 17 Oct. 2020, doi:10.1155/2020/8964673
16 S. Aubin, R. E. Berger, J. R. Heiman, and M. A. Ciol, “Original research—sexual pain disorders: the association between sexual function, pain, and psychological adaptation of men diagnosed with chronic pelvic pain syndrome type III,” The Journal of Sexual Medicine, vol. 5, no. 3, pp. 657–667, 2008
17 Omar El-Shahawy, Tanmik Shah, Olufunmilayo H. Obisesan, et al. Association of E-Cigarettes with Erectile Dysfunction: The Population Assessment of Tobacco and Health Study, American Journal of Preventive Medicine (ISSN 0749-3797) 2021: 62(1): 26-38.
18 21 Atmaca, Murad. “Selective Serotonin Reuptake Inhibitor-Induced Sexual Dysfunction: Current Management Perspectives.” Neuropsychiatric disease and treatment vol. 16 1043-1050. 20 Apr. 2020, doi:10.2147/NDT.S185757
19 Nurnberg, H. George *; Duttagupta, Sandeep2. Economic Analysis of Sildenafil Citrate (Viagra®) Add-on to Treat Erectile Dysfunction Associated With Selective Serotonin Reuptake Inhibitor Use. American Journal of Therapeutics 11(1):p 9-12, January 2004.
20 Jing, Elizabeth, and Kristyn Straw-Wilson. “Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review.” The mental health clinician vol. 6,4 191-196. 29 Jun. 2016, doi:10.9740/mhc.2016.07.191
22Miller, T.A., 2000. Diagnostic Evaluation of Erectile Dysfunction. American Family Physician, 61(1), pp. 95-104.
23 24 Cunha, J. P., 2021. Side effects of Xanax (alprazolam), warnings, uses. RxList. Retrieved December 27, 2021.
25 Lydiard, R.B. et.al., 1987. Sexual side effects of alprazolam. American Journal of Psychiatry, 144(2), pp. 254b-255.
26 Derby, C.A. et.al., 2001. Drug Therapy and Prevalence of Erectile Dysfunction in the Massachusetts Male Aging Study Cohort. American College of Clinical Pharmacy, 21(6) pp. 676-683.
27 Kupelian, Varant et al. “Common prescription medication use and erectile dysfunction: results from the Boston Area Community Health (BACH) survey.” BJU international vol. 112,8 (2013): 1178-87. doi:10.1111/bju.12231
28 Sooriyamoorthy T, Leslie SW. Erectile Dysfunction. [Updated 2023 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
29 Roberto Fogari, Annalisa Zoppi, Luca Corradi, Amedeo Mugellini, Luigi Poletti, Paola Lusardi, Sexual Function in Hypertensive Males Treated with Lisinopril or Atenolol: A Cross-Over Study, American Journal of Hypertension, Volume 11, Issue 10, October 1998, Pages 1244–1247
30 Feldman, H A et al. “Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study.” The Journal of urology vol. 151,1 (1994): 54-61. doi:10.1016/s0022-5347(17)34871-1
31 Bacon, Constance G et al. “Sexual function in men older than 50 years of age: results from the health professionals follow-up study.” Annals of internal medicine vol. 139,3 (2003): 161-8. doi:10.7326/0003-4819-139-3-200308050-00005
32 Ponholzer, A et al. “Is penile atherosclerosis the link between erectile dysfunction and cardiovascular risk? An autopsy study.” International journal of impotence research vol. 24,4 (2012): 137-40. doi:10.1038/ijir.2012.3
