Liver disease can significantly contribute to erectile dysfunction (ED), with men experiencing chronic hepatic conditions—particularly cirrhosis—reporting ED at rates between 25% and 80%, depending on disease severity. The liver's central role in hormonal metabolism and vascular regulation means that hepatic impairment can disrupt multiple physiological pathways essential for normal sexual function. Hormonal imbalances, including reduced testosterone and elevated oestrogen, alongside vascular changes and medication side effects, create a complex interplay affecting erectile capacity. Understanding this connection is vital for comprehensive patient care, as sexual health profoundly impacts quality of life in men with chronic liver conditions.

Does Liver Disease Cause Erectile Dysfunction?

Liver disease can contribute to erectile dysfunction (ED), though the relationship is complex and multifactorial. Research indicates that men with chronic liver conditions, particularly cirrhosis, experience erectile dysfunction at significantly higher rates than the general population—with prevalence estimates ranging from 25% to 80%, varying considerably with disease severity and stage.

Erectile dysfunction, the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance, can be both a symptom of liver disease and a potential marker of underlying cardiovascular risk.

The liver plays a crucial role in metabolic and hormonal regulation throughout the body. When liver function becomes impaired, several physiological changes occur that can directly and indirectly affect sexual function. These include alterations in hormone metabolism, vascular changes, medication side effects, and psychological factors associated with chronic illness.

Chronic liver diseases most commonly associated with erectile dysfunction include:

• Alcoholic liver disease

• Non-alcoholic fatty liver disease (NAFLD)

• Cirrhosis (regardless of cause)

• Hepatitis C infection

• Haemochromatosis

The severity of erectile dysfunction often correlates with the stage of liver disease. Men with compensated cirrhosis (early-stage) may experience mild symptoms, whilst those with decompensated cirrhosis frequently report more severe sexual dysfunction.

Importantly, certain medications commonly used to treat liver disease and its complications may contribute to erectile problems, including spironolactone, non-selective beta-blockers (such as propranolol), and some antidepressants. Additionally, shared risk factors such as diabetes, cardiovascular disease, obesity, and alcohol consumption can independently cause erectile dysfunction in patients with liver disease.

Whilst there is a well-established clinical association between liver disease and erectile problems, the exact mechanisms remain an area of ongoing research. Understanding this connection is essential for comprehensive patient care, as sexual health significantly impacts quality of life and psychological wellbeing in men with chronic liver conditions.

Hormonal Changes and Erectile Problems in Liver Disease

Hormonal imbalances represent one of the primary mechanisms through which liver disease affects erectile function. The liver is central to sex hormone metabolism, and hepatic dysfunction disrupts this delicate hormonal balance in several ways.

In chronic liver disease, particularly cirrhosis, there is typically an increase in sex hormone-binding globulin (SHBG) production. This protein binds to testosterone in the bloodstream, reducing the amount of free (bioavailable) testosterone—the active form that influences sexual function. Simultaneously, the damaged liver has reduced capacity to metabolise oestrogen, leading to elevated oestrogen levels. This combination of low free testosterone and high oestrogen creates a hormonal environment unfavourable for normal erectile function.

Key hormonal changes in liver disease include:

• Reduced testosterone levels: Both total and free testosterone may decline as liver function deteriorates

• Elevated oestrogen: Impaired hepatic clearance leads to oestrogen accumulation

• Increased prolactin: Hyperprolactinaemia occurs in some patients with cirrhosis, potentially suppressing testosterone

• Altered luteinising hormone (LH): Hormonal feedback mechanisms may be disrupted

These hormonal alterations not only affect erectile function but also contribute to reduced libido, testicular atrophy, gynaecomastia (breast tissue enlargement), and decreased muscle mass. The pattern of hypogonadism in liver disease is often complex, with both testicular dysfunction and hypothalamic-pituitary abnormalities potentially contributing.

Alcoholic liver disease presents additional considerations, as alcohol itself has direct toxic effects on testicular tissue and can suppress testosterone production independently of liver damage. Men with haemochromatosis may experience hypogonadism due to iron deposition in the pituitary gland, affecting hormonal signalling pathways essential for normal sexual function.

Assessment of hormonal status typically includes:

• Morning testosterone measurements (before 11 am) on two separate occasions

• Sex hormone-binding globulin (SHBG) levels, particularly important in cirrhosis where SHBG is often elevated

• Calculation of free or bioavailable testosterone

• Luteinising hormone (LH) and follicle-stimulating hormone (FSH) if testosterone is low

• Prolactin levels to exclude hyperprolactinaemia

• Thyroid function tests and metabolic parameters (HbA1c, lipids)

Managing Erectile Dysfunction with Liver Conditions

Management of erectile dysfunction in men with liver disease requires a careful, individualised approach that considers both the underlying hepatic condition and the safety profile of available treatments. The first-line approach should always address modifiable risk factors and optimise management of the liver disease itself.

Lifestyle modifications form the foundation of management:

• Alcohol cessation: Essential for alcoholic liver disease and beneficial for all liver conditions

• Weight management: Particularly important in non-alcoholic fatty liver disease

• Glycaemic control: Optimising diabetes management if present

• Cardiovascular risk reduction: Addressing hypertension, hyperlipidaemia, and smoking

• Regular physical activity: Improves vascular health and metabolic function

Medication review is important, as some drugs commonly used in liver disease may contribute to erectile dysfunction, including spironolactone, non-selective beta-blockers, and certain antidepressants. Where possible, alternatives may be considered in consultation with your liver specialist.

Phosphodiesterase-5 (PDE5) inhibitors—including sildenafil, tadalafil, vardenafil and avanafil—are the first-line medical treatments for erectile dysfunction. These medications work by enhancing nitric oxide-mediated vasodilation in penile tissue, facilitating erections in response to sexual stimulation.

PDE5 inhibitors have specific considerations in liver disease:

• Sildenafil: Use with caution in liver impairment; consider a reduced starting dose of 25mg

• Tadalafil: As-needed use not recommended in severe hepatic impairment; avoid daily dosing in significant liver disease

• Vardenafil and avanafil: Contraindicated in severe hepatic impairment (Child-Pugh C)

Important safety information: PDE5 inhibitors are absolutely contraindicated with nitrate medications and riociguat due to dangerous blood pressure drops. They should be used with caution alongside alpha-blockers. In decompensated cirrhosis, there is increased risk of hypotension—specialist advice is recommended before starting treatment.

Hormone replacement therapy may be considered in men with documented hypogonadism, though this requires specialist endocrinology input. Testosterone replacement must be approached cautiously in liver disease and is contraindicated in prostate cancer and male breast cancer. Regular monitoring of haematocrit, PSA and liver function is essential.

Alternative and adjunctive treatments include:

• Vacuum erection devices (mechanical, non-pharmacological option)

• Intracavernosal injections (specialist-supervised; caution with bleeding disorders or anticoagulation)

• Psychological counselling and sex therapy

• Treatment of underlying depression or anxiety

Note that pharmacy-supplied sildenafil (Viagra Connect) may not be appropriate for men with liver disease—consult your GP or pharmacist first.

Any treatment plan should be developed in consultation with both hepatology and urology or sexual health specialists to ensure safety and appropriateness given the individual's liver function status.

When to Seek Medical Advice for Sexual Health Concerns

Men experiencing erectile dysfunction in the context of liver disease should not hesitate to seek medical advice, as sexual health is an important component of overall wellbeing and quality of life. Unfortunately, many patients feel embarrassed discussing these concerns, but healthcare professionals recognise sexual dysfunction as a common and legitimate medical issue deserving appropriate attention.

You should contact your GP or specialist if:

• You experience persistent or worsening erectile difficulties

• Sexual problems are affecting your relationship or psychological wellbeing

• You notice other symptoms alongside erectile dysfunction (reduced libido, fatigue, mood changes)

• You are considering over-the-counter or online treatments without medical supervision

• You experience side effects from any treatments you are using

It is particularly important to seek prompt medical attention if erectile dysfunction appears suddenly or is accompanied by other concerning symptoms. Whilst erectile problems in liver disease are often related to the underlying condition, they can occasionally signal disease progression or the development of complications requiring medical assessment.

Seek urgent medical advice if you experience:

• Painful, prolonged erections lasting more than four hours (priapism)—a medical emergency

• Call 999 if you experience sudden onset of erectile dysfunction with chest pain or severe breathlessness

• Signs of worsening liver function (jaundice, confusion, abdominal swelling, bleeding)

• Severe depression or thoughts of self-harm related to sexual health concerns

• If unsure about urgency, contact NHS 111 for guidance

Your GP can provide initial assessment, review your medications (including beta-blockers, spironolactone, and antidepressants that may contribute to erectile problems), and arrange appropriate investigations. Initial tests typically include fasting glucose/HbA1c, lipids, blood pressure assessment, morning testosterone (repeated if low), SHBG, and liver function tests. Depending on findings and the complexity of your situation, referral to hepatology, endocrinology, or urology services may be appropriate.

NICE guidance emphasises patient-centred care, and discussing sexual health concerns is an integral part of managing chronic conditions. Healthcare professionals can provide evidence-based information about treatment options suitable for your specific circumstances, ensuring that any interventions are safe given your liver function status.

If you experience side effects from any medication, report them through the MHRA Yellow Card scheme, which helps monitor medicine safety.

Remember that effective treatments are available, and addressing erectile dysfunction can significantly improve quality of life for men living with liver disease.

Frequently Asked Questions