Can Bystolic (nebivolol) cause sexual side effects?

Bystolic (Nebivolol) and Sexual Side Effects

Nebivolol is significantly less likely to cause sexual side effects compared to other beta-blockers, and may actually preserve erectile function in hypertensive men due to its unique nitric oxide-mediated vasodilating properties. 1, 2

Key Distinction from Traditional Beta-Blockers

• Traditional beta-blockers commonly cause negative effects on libido and erectile function 1
• Nebivolol differs fundamentally because it has direct vasodilating properties through endothelial nitric oxide release, which is the primary mediator of penile erection 1, 2, 3
• The FDA label for nebivolol lists erectile dysfunction as a postmarketing adverse event, but this occurs at substantially lower rates than with other beta-blockers 4

Clinical Evidence Supporting Nebivolol's Superior Sexual Profile

In head-to-head comparisons, nebivolol consistently demonstrates preservation of erectile function while other beta-blockers cause significant deterioration:

• In a randomized trial of 131 hypertensive men, atenolol decreased satisfactory sexual intercourse episodes from 7.0 to 3.7 per month (p<0.01), while nebivolol maintained sexual activity (6.4 to 6.0 episodes, not significant) 2
• Atenolol combined with chlorthalidone caused even worse outcomes (6.4 to 2.8 episodes per month, p<0.01) 2
• In a crossover trial comparing nebivolol to metoprolol, metoprolol significantly decreased IIEF-5 scores in patients with psychogenic, arteriogenic, and venogenic ED (p<0.001,0.004,0.005 respectively), while nebivolol caused no significant decrease (p=0.201,0.598,0.088) 3
• Metoprolol decreased the IIEF erectile function subscore by 0.92 within 8 weeks, while nebivolol actually improved secondary sexual activity scores 5

Mechanism of Protection

• Nebivolol increases plasma nitric oxide levels (p<0.001), while metoprolol does not (p=0.268) 3
• A positive correlation exists between plasma NO values and IIEF-5 sexual function scores (r=0.284, p=0.026) 3
• The increased nitric oxide release associated with nebivolol counteracts the detrimental effect of beta-blockade on penile erection 2

Clinical Recommendations

When prescribing beta-blockers to men with hypertension, particularly those with existing erectile dysfunction or at risk for developing it:

• Consider nebivolol as the preferred beta-blocker when this drug class is specifically indicated 1, 6
• In patients already on traditional beta-blockers experiencing sexual dysfunction, switching to nebivolol may restore erectile function while maintaining blood pressure control 3, 5
• Both nebivolol and traditional beta-blockers provide equivalent antihypertensive efficacy, so the choice can be based on sexual side effect profile 3, 5

Important Caveats

• While nebivolol is superior to other beta-blockers, it may still cause mild decreases in sexual function in some men without pre-existing ED (p=0.012 in one study, though less than metoprolol's effect) 3
• The FDA label includes erectile dysfunction as a postmarketing adverse event, indicating it can occur, albeit rarely 4
• Sexual function should be assessed before initiating any antihypertensive therapy and monitored during treatment 1
• Erectile dysfunction in hypertensive men may be multifactorial—caused by the hypertension itself, vascular changes, or medications—requiring comprehensive evaluation 1