Does nebivolol (beta-blocker) improve erectile function in patients with hypertension and endothelial dysfunction?

Does Nebivolol Improve Erectile Function?

Nebivolol does not actively improve pre-existing erectile dysfunction, but it uniquely preserves erectile function compared to other beta-blockers and may prevent beta-blocker-induced erectile dysfunction in hypertensive men. 1

Key Distinction: Preservation vs. Improvement

The evidence demonstrates that nebivolol's benefit lies primarily in avoiding the erectile dysfunction commonly caused by traditional beta-blockers, rather than treating existing ED:

• Nebivolol has direct vasodilating properties through nitric oxide modulation, which distinguishes it from other beta-blockers that typically impair erectile function 1
• The Princeton III Consensus explicitly states that nebivolol "is less likely to cause ED than are other β-blockers" due to these vasodilating properties 1
• A 2025 meta-analysis of randomized controlled trials found significantly higher IIEF-5 scores with nebivolol compared to metoprolol (MD 1.81,95% CI 0.95-2.68, P<0.0001), demonstrating nebivolol reduces the risk of ED occurrence or progression 2

Clinical Evidence for Switching to Nebivolol

When hypertensive patients on traditional beta-blockers develop erectile dysfunction, switching to nebivolol can restore erectile function in many cases:

• In a study of 44 hypertensive men with beta-blocker-induced ED, switching to nebivolol improved erectile function in 69% of patients, with complete normalization in 11 of 20 responders 3
• A crossover trial showed metoprolol significantly decreased IIEF scores by 0.92 within 8 weeks, while nebivolol did not cause this decline and actually improved secondary sexual activity scores 4
• A 2022 prospective randomized trial demonstrated that metoprolol caused significant IIEF-5 score decreases in patients with psychogenic, arteriogenic, and venogenic ED (p<0.001,0.004,0.005 respectively), whereas nebivolol did not (p=0.201,0.598,0.088) 5

Mechanism: Nitric Oxide Pathway

The protective effect is mediated through increased nitric oxide availability, the primary mediator of penile erection:

• Nebivolol increases plasma nitric oxide levels (p<0.001), while metoprolol does not (p=0.268) 5
• A positive correlation exists between plasma NO values and IIEF-5 scores (r=0.284, p=0.026) 5
• This nitric oxide-mediated vasodilation is the same mechanism underlying nebivolol's benefits in heart failure and pulmonary hypertension 1

Clinical Application Algorithm

For hypertensive men requiring beta-blocker therapy:

1. First-line choice: Select nebivolol over traditional beta-blockers (atenolol, metoprolol, bisoprolol) when erectile function is a concern 1, 6

2. For existing beta-blocker users with new-onset ED: Switch from traditional beta-blockers to nebivolol, which preserves blood pressure control while potentially restoring erectile function 3, 5

3. Monitor response: Assess erectile function at 3 months using validated tools like IIEF-5 3, 4

4. If ED persists despite nebivolol: Consider PDE5 inhibitors (sildenafil, tadalafil, vardenafil) as they can be safely coadministered with nebivolol and have additive blood pressure-lowering effects 1, 6

Important Caveats

Nebivolol is not a treatment for erectile dysfunction itself—it is a beta-blocker that avoids causing ED:

• The ACC/AHA guidelines note that traditional beta-blockers and mineralocorticoid receptor antagonists can negatively affect libido and erectile function 1
• If a patient has ED from causes other than beta-blocker therapy (vascular disease, diabetes, psychogenic factors), nebivolol will not reverse these underlying conditions 6, 7
• The evidence base consists primarily of European studies of limited duration (longest 28 weeks), though a 2025 meta-analysis strengthens these findings 8, 2

Alternative Considerations

If nebivolol is not appropriate or available, angiotensin receptor blockers are also less likely to cause ED than diuretics or traditional beta-blockers 1, 6