What is the safest method for masturbation in an individual with pre-existing heart disease or erectile dysfunction?

Safest Masturbation Method for Individuals with Heart Disease or Erectile Dysfunction

Masturbation is the safest sexual activity for individuals with cardiovascular disease, requiring less than 3 METs of energy expenditure and representing the lowest cardiac risk category among all sexual activities. 1

Energy Requirements and Cardiac Safety

• Masturbation poses minimal cardiac stress, requiring significantly less energy than sexual intercourse (which ranges from 3.7 METs preorgasm to 5 METs during orgasm) 2
• The American Heart Association and European Society of Cardiology classify non-coital sexual activities, including masturbation, as the lowest-risk option for cardiac patients 1
• Sexual activity is generally safe for patients who can achieve 5 METs during exercise testing without angina, dyspnea, ischemic changes, or arrhythmias 3

Risk Stratification Before Resuming Sexual Activity

Low-risk patients (successfully revascularized, controlled hypertension, mild valvular disease, or heart failure NYHA class I-II) can safely engage in masturbation without additional cardiac evaluation 1

Intermediate-risk patients (mild-to-moderate stable angina, recent MI, or heart failure NYHA class III) require exercise stress testing to confirm they can achieve 3-5 METs without ischemia before any sexual activity 1

High-risk patients (unstable angina, uncontrolled hypertension, or very recent MI) must defer all sexual activity until their condition is stabilized and optimally managed 1

Practical Safety Recommendations

• Be well-rested before engaging in sexual activity to minimize cardiac strain 1
• Stop immediately if experiencing chest pain, shortness of breath, rapid or irregular heart rate, or dizziness 3, 1
• If prescribed nitroglycerin, it can be taken before sexual activity if chest pain typically occurs, but seek emergency care for unrelieved chest pain 3
• Patients using supplemental oxygen should continue using it during sexual activity 3

Managing Erectile Dysfunction During Masturbation

Phosphodiesterase-5 inhibitors (such as tadalafil or sildenafil) are safe and effective for achieving erections during masturbation in cardiac patients, provided they are not taking nitrates. 1, 4

• PDE5 inhibitors are contraindicated with any nitrate use due to life-threatening hypotensive risk—at least 48 hours must elapse after the last PDE5 inhibitor dose before nitrate administration 4
• These medications are also contraindicated with guanylate cyclase stimulators like riociguat 4
• Tadalafil has demonstrated clinically meaningful improvements in erectile function across multiple trials, with success rates of 54-77% for achieving erections suitable for sexual activity 4
• PDE5 inhibitors have been shown to be safe in patients with ischemic heart disease and hypertension when properly selected 5, 6

Alternative Approaches for Erectile Dysfunction

• Topical anesthetics (lidocaine/prilocaine cream) can be applied 20-30 minutes before sexual activity, though avoid prolonged application (30-45 minutes) as this causes excessive penile numbness and loss of erection 7
• If erectile dysfunction coexists with premature ejaculation, treat the erectile dysfunction first, as premature ejaculation may improve when erectile function is restored 7

Special Considerations for Heart Failure Patients

• Adjust timing of diuretic medications to avoid frequent urination interfering with sexual activity 3
• Use comfortable positioning to minimize physical exertion 3
• Patients who cannot complete a 6-minute walk test or expend 3-5 METs may not tolerate the exertion required for sexual activity and should discuss this with their physician 3

Patients with Implantable Cardioverter-Defibrillators (ICDs)

• Sexual activity including masturbation is generally safe if moderate physical activity does not precipitate arrhythmias 3, 1
• Approximately 13% of patients receive an ICD shock during sexual activity, but this will not harm the patient and should not deter appropriate sexual activity 3
• It is reasonable to return to sexual activity after ICD implantation for both primary and secondary prevention patients 3

Important Caveats

• Unusual or awkward masturbatory practices (such as prone masturbation or excessive pressure techniques) can contribute to sexual dysfunction and should be assessed during sexual history taking 8
• ED in otherwise asymptomatic men may be a marker for underlying coronary artery disease and warrants cardiovascular risk screening 5, 9
• Regular exercise is associated with decreased risk of sexual activity-triggered myocardial infarction and should be encouraged 3