Obstructive sleep apnea as an underrecognized contributor to erectile dysfunction: Implications for urologic screening and integrated management

Obstructive sleep apnea (OSA) and erectile dysfunction (ED) are highly prevalent disorders that frequently coexist and share overlapping vascular, autonomic, endocrine, inflammatory, metabolic, neurocognitive, and psychological mechanisms. Despite growing recognition of this relationship, OSA remains underrecognized in many urologic settings. This narrative review examines the relationship between OSA and ED, emphasizing shared pathophysiologic mechanisms and their implications for screening and integrated clinical management. A structured search of PubMed and PsycINFO was conducted using terms related to OSA, ED, sleep-disordered breathing, endothelial dysfunction, intermittent hypoxia, rapid eye movement sleep, continuous positive airway pressure, testosterone, and sexual dysfunction. Priority was given to systematic reviews, meta-analyses, randomized trials, and clinically relevant observational studies published through early 2025. Current evidence indicates that OSA contributes to ED through multiple interacting mechanisms, including endothelial dysfunction, impaired nitric oxide signaling, chronic intermittent hypoxia, sympathetic nervous system hyperactivation, inflammation, metabolic dysregulation, hormonal alterations, disrupted sleep architecture, and psychological distress. Men presenting with ED frequently demonstrate an increased risk of undiagnosed OSA, particularly in the presence of obesity, hypertension, diabetes mellitus, excessive daytime sleepiness, loud snoring, or treatment-resistant sexual dysfunction. Continuous positive airway pressure therapy, weight reduction, and comprehensive cardiometabolic management may improve erectile function in selected patients, although treatment response varies. Recognition of ED as a potential clinical marker of OSA provides an opportunity for earlier diagnosis, multidisciplinary intervention, and improved sexual, cardiovascular, metabolic, and quality-of-life outcomes.