Zhaohui Liu, Guiting Lin, Xiang-Hu Meng
With global population aging, erectile dysfunction is becoming increasingly prevalent among middle-aged and older men, who frequently present with cardiometabolic comorbidities, such as hypertension and diabetes mellitus. Although these conditions are well-established risk factors for erectile dysfunction, their long-term pharmacological management may exert heterogeneous and adverse effects on erectile function, complicating clinical decision-making. This review synthesizes current evidence on the shared pathophysiological mechanisms linking erectile dysfunction with hypertension and diabetes mellitus, including endothelial dysfunction, oxidative stress, vascular remodeling, metabolic dysregulation, and neurovascular impairment. This review also critically evaluates the effects of commonly prescribed antihypertensive and antidiabetic drug classes on erectile function, highlighting both their beneficial and detrimental profiles. By integrating mechanistic insights with clinical evidence, this review highlights medication-associated sexual dysfunction in aging men. It emphasizes its recognition and management in clinical practice. The goal is to guide individualized treatment strategies that control cardiometabolic disease while preserving sexual health and quality of life.