Exploring the Experiences of Sexual Dysfunction Among Adult Hypertensive Males on Beta-blockers in Karachi: An Exploratory Descriptive Study

Exploring the Experiences of Sexual Dysfunction Among Adult Hypertensive Males on Beta-blockers in Karachi: An Exploratory Descriptive Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Experiences of Sexual Dysfunction Among Adult Hypertensive Males on Beta-blockers in Karachi: An Exploratory Descriptive Study Syed Umar Farooq, Salma Rattani, Zulekha Saleem ., Zainish Hajani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8668544/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Background Hypertension is a major global health issue, and beta-blockers are commonly prescribed for its management. However, these medications are frequently associated with sexual dysfunction, which can severely impact quality of life, emotional well-being, and medication adherence. In conservative societies like Pakistan, sexual health remains a culturally sensitive and rarely discussed topic. This study aimed to explore the lived experiences of sexual dysfunction among adult hypertensive males on beta-blockers in Karachi. Methods An exploratory descriptive qualitative study was conducted at a tertiary cardiac care hospital in Karachi. Ten hypertensive males aged 30–50 years, on beta-blockers for at least six months, were purposively recruited. Semi-structured interviews were conducted in Urdu, audio-recorded, transcribed, and analyzed using reflexive thematic analysis following Braun and Clarke’s framework. Trustworthiness was ensured through Lincoln and Guba’s criteria. Findings Four major themes were extracted: (1) emotional and psychological impact of hypertension diagnosis; (2) sexual dysfunction attributed to beta-blockers; (3) communication barriers about sexual health; and (4) coping strategies, barriers, and recommendations. Participants reported that erectile dysfunction reduced libido, caused emotional distress, non-adherence to medication, and a lack of proactive sexual health counseling. Conclusions Sexual dysfunction is a significant but unaddressed side effect of beta-blocker therapy among hypertensive males in Pakistan. It contributes to emotional distress, relationship strain, and poor medication adherence. Integrating sexual health counseling into routine hypertension care, adopting patient-centered communication, and considering alternative medications with fewer sexual side effects could improve holistic patient outcomes. Hypertension Beta-blockers Sexual dysfunction Erectile dysfunction Men’s health Qualitative research Pakistan Nursing Background Hypertension is a persistent elevation of blood pressure, defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg [ 1 ]. It is one of the most prevalent chronic conditions globally and a leading contributor to cardiovascular disease, stroke, and premature mortality [ 2 , 3 ]. The World Health Organization estimates that over 1.2 billion people live with hypertension, with the burden disproportionately affecting low- and middle-income countries [ 4 ]. In Pakistan, hypertension prevalence is approximately 25%, among the highest in South Asia, and it remains poorly controlled due to low awareness, late diagnosis, and medication non-adherence [ 5 , 6 ]. Beta-blockers are a first-line pharmacological treatment for hypertension, effective in reducing blood pressure and cardiovascular risk [ 7 ]. However, they are also associated with adverse effects, including fatigue, bradycardia, and notably, sexual dysfunction [ 8 , 9 ]. Sexual dysfunction in men encompasses erectile dysfunction (ED), reduced libido, ejaculatory disorders, and overall dissatisfaction with sexual activity [ 10 ]. Among hypertensive patients on beta-blockers, the prevalence of erectile dysfunction is estimated to range from 20% to 50%, varying by drug type, dosage, and patient factors [ 11 , 12 ]. This side effect is not merely a biological concern; it intersects with psychological well-being, self-esteem, marital harmony, and treatment adherence [ 13 , 14 ]. Sexual health is recognized by the World Health Organization as a fundamental aspect of overall health and quality of life [ 15 ]. Yet, in many traditional societies, including Pakistan, discussions about sexuality are constrained by cultural norms, religious values, and social stigma [ 16 , 17 ]. Men may avoid disclosing sexual problems to healthcare providers due to embarrassment, fear of judgment, or assumptions that such issues are a natural part of aging [ 18 , 19 ]. This communication gap can lead to underreporting, delayed intervention, and unnecessary suffering. Furthermore, sexual side effects of antihypertensive medications are a documented reason for non-adherence [ 20 , 21 ]. Patients may intentionally skip doses or discontinue treatment to preserve sexual function, inadvertently increasing their risk of hypertensive complications [ 22 , 23 ]. In Pakistan, where hypertension-related mortality is high, understanding and addressing medication-linked sexual dysfunction is a pressing public health concern. Despite the clinical relevance, there is a scarcity of qualitative research exploring the subjective experiences of hypertensive men regarding sexual dysfunction in the Pakistani context. Prior studies have largely focused on epidemiological data or biomedical perspectives, overlooking the psychosocial and cultural dimensions [ 24 , 25 ]. This exploratory descriptive study aimed to fill that gap by investigating the following research questions: What are the sexual health experiences of adult male hypertensive patients taking beta-blockers? How do these experiences influence their intimate relationships, sexual satisfaction, and overall well-being? What challenges do they face regarding sexual health, and what coping mechanisms do they employ? By centering patient narratives, this study seeks to inform culturally sensitive nursing practices, enhance patient-provider communication, and promote holistic hypertension management that acknowledges and addresses sexual health needs. Methodology Study Design This study employed an exploratory descriptive qualitative design, suitable for investigating under-researched, sensitive phenomena [ 26 ]. The approach allows for rich, detailed descriptions of participants’ lived experiences without imposing rigid theoretical frameworks prematurely [ 27 ]. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological transparency [ 28 ].Semi-structured interviews were conducted in Urdu, audio-recorded, transcribed, and analyzed using reflexive thematic analysis following Braun and Clarke’s framework. Trustworthiness was ensured through Lincoln and Guba’s criteria[ 29 ] Setting The study was conducted at Dr. Ruth K.M. Pfau Civil Hospital Karachi, a large public tertiary care hospital serving a diverse, predominantly low-income population. Participants were recruited from both inpatient cardiac wards and the outpatient cardiology clinic between July 2025 and September 2025. Participants and Sampling Purposive sampling was used to select ten adult male participants who met the following inclusion criteria Diagnosis of hypertension Aged 30–50 years On beta-blocker therapy for at least six months Self-reported experience of sexual dysfunction symptoms Willing to participate and provide informed consent Exclusion criteria included Use of other antihypertensive agents known to cause sexual dysfunction (e.g., thiazide diuretics) History of mental illness Obesity (BMI > 30) Unstable clinical condition (e.g., recent myocardial infarction) Sample size was determined by data saturation, which was achieved after eight interviews; two additional interviews were conducted to confirm redundancy. Ethical Considerations Ethical approval was obtained from the Aga Khan University Ethical Review Committee (ERC-2025-11252-34214). Permission was also secured from the hospital administration. Written informed consent was obtained from all participants after explaining the study’s purpose, procedures, risks, benefits, and confidentiality measures. Participants were assured that refusal would not affect their care. Interviews were conducted in private settings, and data were anonymized using codes (P-1 to P-10). Data Collection Data were collected over three months (July to September 2025) through semi-structured, in-depth interviews conducted in Urdu, the participants’ first language. A semi-structured interview guide was developed based on a review of relevant literature and the biopsychosocial theoretical framework, which posits that health and illness arise from the interplay of biological, psychological, and social factors [ 37 ]. The guide contained open-ended questions and flexible probes to explore key domains: Personal history and experience of hypertension diagnosis and treatment. Perceived changes in sexual function, desire, and satisfaction since starting beta-blockers. Emotional and psychological impact of these changes. Impact on spousal/partner relationships and family life. Communication about sexual health with healthcare providers and intimate partners. Coping strategies employed to manage sexual difficulties. Suggestions for improving care and support. Two pilot interviews were conducted with eligible participants to test the clarity, flow, and cultural appropriateness of the guide. Minor refinements were made to wording and probing techniques based on this feedback; data from pilot interviews were not included in the final analysis. Each main interview lasted between 30 and 50 minutes, with an average duration of 40 minutes. All interviews were audio-recorded with permission. The researcher also maintained field notes during and immediately after each interview to document non-verbal cues, contextual details, and reflective thoughts, thereby enriching the data [ 38 ]. Data Analysis The audio recordings were transcribed verbatim in Urdu by the primary researcher, who is fluent in both Urdu and English. Transcripts were then translated into English for analysis. To ensure conceptual and linguistic accuracy, a backward translation of a sample of transcripts was performed by an independent bilingual expert, and any discrepancies were discussed and resolved [ 39 ]. Data analysis followed the six-phase process of Reflexive Thematic Analysis (RTA) as outlined by Braun and Clarke [ 40 ], which emphasizes the researcher’s active role in interpreting patterns of meaning. The phases were: Familiarization Immersive reading and re-reading of transcripts while listening to audio recordings, accompanied by note-taking of initial ideas. Generating Initial Codes Systematic, line-by-line coding of the dataset to identify features of potential interest. Coding was inductive, allowing themes to emerge from the data. Searching for Themes Collating codes into broader potential themes and gathering all data relevant to each. Reviewing Themes Checking themes against the coded extracts and the entire dataset to ensure they formed a coherent pattern and accurately reflected the data. This involved creating thematic maps and refining themes. Defining and Naming Themes Developing a detailed analysis for each theme, identifying its essence, and selecting an informative name. Producing the Report Weaving together the analytic narrative, selecting vivid, compelling extract examples, and linking analysis to the research questions and relevant literature. Analysis was an iterative, recursive process supported by the use of Microsoft Word and Excel for data organization. Regular peer debriefing sessions were held with the research supervisors to discuss coding decisions, emergent themes, and interpretations, thereby enhancing analytic rigor Ensuring Trustworthiness The study’s trustworthiness its credibility, dependability, confirmability, and transferability was upheld using strategies aligned with Lincoln and Guba’s criteria. Credibility was established through prolonged engagement with the data, member checking (where participants were invited to review their transcript summaries for accuracy), and researcher reflexivity (maintaining a journal to bracket preconceptions). Dependability was promoted via a clear audit trail documenting all methodological decisions and peer review of the analysis process. Confirmability was addressed through triangulation among researchers during analysis and maintaining neutrality by grounding interpretations in the data. Transferability was facilitated by providing thick, contextual descriptions of the participants and setting, enabling readers to judge the applicability of findings to other contexts. Results Participant Characteristics Ten participants aged 30–50 years were included. The majority (60%) had no formal education, and most were engaged in low-income occupations. Duration of hypertension ranged from 1.5 to over 11 years, and beta-blocker use varied from 6 months to several years. Most were on cardio selective beta-blockers such as atenolol or metoprolol. Themes Four major themes and twelve subthemes were identified, reflecting the biopsychosocial complexity of participants’ experiences. Theme 1: Emotional and Psychological Impact of Hypertension This theme captures the distress associated with hypertension diagnosis and the often-delayed recognition of symptoms. Subtheme 1.1: Emotional Distress and Fear Upon Diagnosis Participants described anxiety, fear, and a sense of life disruption upon diagnosis. One participant (P-9) recalled, “I was very nervous when I was first diagnosed with high blood pressure, and it felt like everything was over… I have seen people around me suffer from heart problems and even heart attacks.” Another (P-1) reported physical sensations of danger: “It felt dangerous, and I had this pain all over my body, and my tongue felt like it was twisting.” Subtheme 1.2: Delayed Recognition and Misattribution of Symptoms Many participants initially normalized or misinterpreted hypertensive symptoms. P-10 said, “Headaches happen normally, so it seemed normal to me… I ignored it and considered it work-related.” P-7 attributed his symptoms to psychological stress: “Initially, I assumed these symptoms might be due to tension, but after visiting the doctor, I found out it was high blood pressure.” Theme 2: Sexual Dysfunction Related to Beta-Blockers This theme highlights the physical and emotional consequences of medication-induced sexual changes. Subtheme 2.1: Erectile Dysfunction and Decreased Desire All participants noted a decline in sexual desire and performance after starting beta-blockers. P-6 stated, “I have experienced weakness of the male organ and a lack of sexual desire since using the medicine.” P-10 added, “Since commencing beta blockers, the strength and hardness of my organ have significantly reduced, making it difficult to perform properly.” Subtheme 2.2: Attribution to Medication vs. Age Participants often struggled to discern whether changes were due to medication or aging. P-1 expressed uncertainty: “I am experiencing severe sexual difficulties… but I am unsure whether it is due to my age or medication.” In contrast, P-10 was more definitive: “I don’t believe it’s due to age; I firmly believe these changes are caused by medications.” Subtheme 2.3: Emotional Consequences of Sexual Changes Sexual dysfunction led to significant emotional distress, including diminished self-worth, frustration, and anxiety. P-10 shared, “When a man cannot perform, he starts feeling useless, and I also feel hopeless, anxious.” P-7 felt embarrassed after his partner commented on his weakness, leading to emotional distress. Theme 3: Communication Barriers About Sexual Health This theme reveals the silence surrounding sexual health in clinical and personal contexts. Subtheme 3.1: Barriers to Communication Participants cited shame, cultural stigma, and fear of judgment as reasons for not discussing sexual issues. P-5 said, “I have not disclosed these issues to my doctor just because I feel shy talking about them.” P-9 explained, “As a man, it is not suitable to discuss these issues. It is considered unacceptable… it feels like a matter of humiliation.” Subtheme 3.2: Healthcare Providers’ Gap in Counseling Most participants reported never receiving information about sexual side effects. P-7 stated, “I was not counselled at the time of starting beta blockers regarding potential sexual side effects.” Only one participant (P-8) recalled proactive counseling, which helped him mentally prepare. Subtheme 3.3: Patient Suggestions for Improving Communication Participants recommended that healthcare providers initiate conversations about sexual health in a respectful, confidential manner. P-6 suggested providers should “talk about sexual side effects and suggest supportive treatments.” P-4 emphasized the need for a “respectful environment where patients can discuss sensitive topics comfortably.” Theme 4: Coping Strategies, Barriers, and Recommendations This theme encapsulates how participants managed their condition and their advice for others. Subtheme 4.1: Lifestyle Modifications and Inner Resilience Many adopted exercise, dietary changes, and spiritual practices. P-2 noted, “The most effective strategy for me is exercise, which has proven a crucial improvement.” P-4 found solace in prayer: “Be at peace and pray five times a day, stay strong, and remember Allah.” Subtheme 4.2: Use of Alternative and Traditional Medicine Some sought help from traditional healers (hakims) when conventional care felt inadequate. P-9 reported, “I felt some improvement after use of a 15-day herbal course from a hakim.” However, cost was a barrier for others. Subtheme 4.3: Non-Adherence to Beta-Blocker Therapy Non-adherence was a common, deliberate response to sexual side effects. P-7 admitted, “After experiencing disturbance and weakness in sexual activity, I began to take it on and off, only when needed.” Psychosocial stressors like unemployment also contributed. Subtheme 4.4: Recommendations for Other Patients Participants advised open communication with doctors, requesting alternative medications, and prioritizing holistic health. P-8 urged, “Individuals should maintain regular communication with doctors because proper guidance can help manage side effects effectively.” Discussion This study provides an in-depth understanding of how hypertensive men in Karachi experience sexual dysfunction linked to beta-blocker use. The findings align with existing literature on the high prevalence of erectile dysfunction among beta-blocker users [ 30 , 31 ] and the emotional burden it carries [ 32 , 33 ]. However, this research uniquely highlights the cultural and communicative barriers that exacerbate the problem in the Pakistani context. The emotional distress following a hypertension diagnosis reflects the psychological impact of chronic illness, consistent with studies showing anxiety and fear are common upon diagnosis [ 34 , 35 ]. The misattribution of symptoms underscores low health literacy and normalization of hypertension signs, which delays care-seeking [ 36 , 37 ]. Sexual dysfunction emerged as a central concern, with participants describing both physiological changes (erectile weakness, low libido) and psychological consequences (shame, hopelessness). The confusion between medication effects and aging mirrors findings by Manolis et al. [ 38 ], who noted that such ambiguity can prevent men from seeking timely help. Communication barriers rooted in cultural stigma are a critical finding. In Pakistan, masculinity norms discourage open discussion of sexual problems, leading to silence and isolation [ 39 , 40 ]. The lack of proactive counseling from healthcare providers echoes global reports of clinicians’ discomfort in addressing sexual health [ 41 , 42 ]. This gap is particularly significant in nursing, where holistic, patient-centered care is emphasized. Coping strategies such as lifestyle changes, spiritual practices, and use of traditional healers reflect culturally embedded resilience mechanisms [ 43 , 44 ]. However, non-adherence as a coping response highlights a dangerous trade-off between sexual function and cardiovascular health, consistent with international studies linking sexual side effects to poor adherence [ 45 , 46 ]. Implications for Nursing Practice Nurses are well-positioned to bridge the communication gap regarding sexual health. Integrating sexual health assessments into routine hypertension follow-ups, using culturally sensitive language, and providing education about medication side effects can empower patients. Training programs for nurses on sexual health counseling, perhaps using models like PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy), could enhance clinical practice [ 47 , 48 ]. Policy and Education Healthcare institutions should develop guidelines for discussing sexual side effects of antihypertensive drugs. Pre-service and in-service training for physicians and nurses should include modules on sexual health communication. Pharmacological considerations, such as preferential use of beta-blockers with lower sexual side effect profiles (e.g., nebivolol), could be incorporated into treatment protocols where appropriate [ 49 , 50 ]. Strengths and Limitations A key strength is the focus on an under-researched population using a rigorous qualitative approach. However, the study is limited by its single-center setting, small sample size, and lack of perspectives from healthcare providers and partners. Future research could employ mixed methods, include larger and more diverse samples, and explore interventions to improve sexual health communication in clinical settings. Conclusions This study demonstrates that sexual dysfunction is a significant, multifaceted issue for hypertensive men on beta-blockers in Karachi. It affects biological, psychological, and social dimensions of health, contributing to emotional distress, relationship strain, and medication non-adherence. The cultural silence surrounding sexual health exacerbates these challenges. There is an urgent need for healthcare providers, especially nurses, to adopt a proactive, sensitive, and holistic approach to sexual health in hypertension management. By doing so, they can improve adherence, quality of life, and overall health outcomes for this patient population. Abbreviations ACC American College of Cardiology AHA American Heart Association AKU Aga Khan University BPS Biopsychosocial ED Erectile Dysfunction EDQ Exploratory Descriptive Qualitative ERC Ethical Review Committee HTN Hypertension QOL Quality of Life SRH Sexual and Reproductive Health WHO World Health Organization Declarations Ethics approval and consent to participate: Approved by Aga Khan University Ethical Review Committee (ERC-2025-11252-34214). Written informed consent obtained from all participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Funding: No external funding received. Author Contribution SUF: Conceptualization, methodology, data collection, analysis, writing and original draft. SR: Supervision, validation, writing review & editing. ZS: Supervision, methodology, writing review & editing. ZH: Supervision, resources, writing review & editing. All authors approved the final manuscript. Acknowledgements: We thank the participants for their trust and time, and the staff of Dr. Ruth K.M. Pfau Civil Hospital Karachi for their support. Authors' statement : This manuscript is based on the original thesis work of the first author. No generative AI was used in the writing of the manuscript; only the free version of Grammarly was employed for grammar correction Authors' information : SUF is an MSc Nursing scholar and registered nurse with cardiac care experience. SR is an Associate Professor at AKU School of Nursing and Midwifery. ZS is a Senior Instructor at the same institution. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8668544","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582640939,"identity":"019064bd-c83a-49f8-8bab-c47872dc507f","order_by":0,"name":"Syed Umar Farooq","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYNACGzDJ+OADkGRjJ0pLGphkNpwB0sJMghY2aR6wTgKK5WdkJ36uSLDL52dv3iBt82ubPB8zA+OHjzm4tRjcyN0seSYh2XJmz7EC49y+24ZtzAzMkjO34dEikbtBsvEHs4HBjRyD5Nye24xALWzMvHi0yM/I3fyzIaEerOWwZc9te4JaGG7kbpNsSDgM0mLYzPDjdiJBLQZn3m6zbEg4biDZc6yYsbfhdnIbM2MzXr/It+duvtmQUG0ADLHtP378uW07v7354IeP+ByGbCMDYxuIZmwgTj1YC8MfohWPglEwCkbBCAIADMdQZYNiAfEAAAAASUVORK5CYII=","orcid":"","institution":"Aga Khan University","correspondingAuthor":true,"prefix":"","firstName":"Syed","middleName":"Umar","lastName":"Farooq","suffix":""},{"id":582640940,"identity":"305c843f-695e-40f5-9996-70c6c6454252","order_by":1,"name":"Salma Rattani","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Salma","middleName":"","lastName":"Rattani","suffix":""},{"id":582640941,"identity":"a4df57e6-fff9-47ab-bac7-688f84c8b0a6","order_by":2,"name":"Zulekha Saleem .","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Zulekha","middleName":"Saleem","lastName":".","suffix":""},{"id":582640943,"identity":"64b0a700-b8b4-4b61-9f8c-d67daef39d81","order_by":3,"name":"Zainish Hajani","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zainish","middleName":"","lastName":"Hajani","suffix":""}],"badges":[],"createdAt":"2026-01-22 10:39:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8668544/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8668544/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101475927,"identity":"80c0e43c-8c41-40b8-a4a9-f17473661f03","added_by":"auto","created_at":"2026-01-30 06:57:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1113796,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8668544/v1/c37534e5-323b-4606-9122-9660803166f2.pdf"},{"id":101475861,"identity":"82bde1f5-afc9-4f84-a023-05fb87918b97","added_by":"auto","created_at":"2026-01-30 06:56:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19194,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixI.docx","url":"https://assets-eu.researchsquare.com/files/rs-8668544/v1/1a0a14c827e078489a1b2d7d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExploring the Experiences of Sexual Dysfunction Among Adult Hypertensive Males on Beta-blockers in Karachi: An Exploratory Descriptive Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHypertension is a persistent elevation of blood pressure, defined as systolic blood pressure\u0026thinsp;\u0026ge;\u0026thinsp;140 mmHg and/or diastolic blood pressure\u0026thinsp;\u0026ge;\u0026thinsp;90 mmHg [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is one of the most prevalent chronic conditions globally and a leading contributor to cardiovascular disease, stroke, and premature mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The World Health Organization estimates that over 1.2\u0026nbsp;billion people live with hypertension, with the burden disproportionately affecting low- and middle-income countries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Pakistan, hypertension prevalence is approximately 25%, among the highest in South Asia, and it remains poorly controlled due to low awareness, late diagnosis, and medication non-adherence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeta-blockers are a first-line pharmacological treatment for hypertension, effective in reducing blood pressure and cardiovascular risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, they are also associated with adverse effects, including fatigue, bradycardia, and notably, sexual dysfunction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Sexual dysfunction in men encompasses erectile dysfunction (ED), reduced libido, ejaculatory disorders, and overall dissatisfaction with sexual activity [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among hypertensive patients on beta-blockers, the prevalence of erectile dysfunction is estimated to range from 20% to 50%, varying by drug type, dosage, and patient factors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This side effect is not merely a biological concern; it intersects with psychological well-being, self-esteem, marital harmony, and treatment adherence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual health is recognized by the World Health Organization as a fundamental aspect of overall health and quality of life [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Yet, in many traditional societies, including Pakistan, discussions about sexuality are constrained by cultural norms, religious values, and social stigma [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Men may avoid disclosing sexual problems to healthcare providers due to embarrassment, fear of judgment, or assumptions that such issues are a natural part of aging [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This communication gap can lead to underreporting, delayed intervention, and unnecessary suffering.\u003c/p\u003e \u003cp\u003eFurthermore, sexual side effects of antihypertensive medications are a documented reason for non-adherence [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Patients may intentionally skip doses or discontinue treatment to preserve sexual function, inadvertently increasing their risk of hypertensive complications [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In Pakistan, where hypertension-related mortality is high, understanding and addressing medication-linked sexual dysfunction is a pressing public health concern.\u003c/p\u003e \u003cp\u003eDespite the clinical relevance, there is a scarcity of qualitative research exploring the subjective experiences of hypertensive men regarding sexual dysfunction in the Pakistani context. Prior studies have largely focused on epidemiological data or biomedical perspectives, overlooking the psychosocial and cultural dimensions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This exploratory descriptive study aimed to fill that gap by investigating the following research questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the sexual health experiences of adult male hypertensive patients taking beta-blockers?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do these experiences influence their intimate relationships, sexual satisfaction, and overall well-being?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat challenges do they face regarding sexual health, and what coping mechanisms do they employ?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eBy centering patient narratives, this study seeks to inform culturally sensitive nursing practices, enhance patient-provider communication, and promote holistic hypertension management that acknowledges and addresses sexual health needs.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed an exploratory descriptive qualitative design, suitable for investigating under-researched, sensitive phenomena [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The approach allows for rich, detailed descriptions of participants\u0026rsquo; lived experiences without imposing rigid theoretical frameworks prematurely [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological transparency [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].Semi-structured interviews were conducted in Urdu, audio-recorded, transcribed, and analyzed using reflexive thematic analysis following Braun and Clarke\u0026rsquo;s framework. Trustworthiness was ensured through Lincoln and Guba\u0026rsquo;s criteria[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted at Dr. Ruth K.M. Pfau Civil Hospital Karachi, a large public tertiary care hospital serving a diverse, predominantly low-income population. Participants were recruited from both inpatient cardiac wards and the outpatient cardiology clinic between July 2025 and September 2025.\u003c/p\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was used to select ten adult male participants who met the following \u003cb\u003einclusion criteria\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDiagnosis of hypertension\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAged 30\u0026ndash;50 years\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOn beta-blocker therapy for at least six months\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSelf-reported experience of sexual dysfunction symptoms\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWilling to participate and provide informed consent\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria included\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUse of other antihypertensive agents known to cause sexual dysfunction (e.g., thiazide diuretics)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHistory of mental illness\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eObesity (BMI\u0026thinsp;\u0026gt;\u0026thinsp;30)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUnstable clinical condition (e.g., recent myocardial infarction)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSample size was determined by data saturation, which was achieved after eight interviews; two additional interviews were conducted to confirm redundancy.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the Aga Khan University Ethical Review Committee (ERC-2025-11252-34214). Permission was also secured from the hospital administration. Written informed consent was obtained from all participants after explaining the study\u0026rsquo;s purpose, procedures, risks, benefits, and confidentiality measures. Participants were assured that refusal would not affect their care. Interviews were conducted in private settings, and data were anonymized using codes (P-1 to P-10).\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData were collected over three months (July to September 2025) through semi-structured, in-depth interviews conducted in Urdu, the participants\u0026rsquo; first language. A semi-structured interview guide was developed based on a review of relevant literature and the biopsychosocial theoretical framework, which posits that health and illness arise from the interplay of biological, psychological, and social factors [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The guide contained open-ended questions and flexible probes to explore key domains:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePersonal history and experience of hypertension diagnosis and treatment.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerceived changes in sexual function, desire, and satisfaction since starting beta-blockers.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEmotional and psychological impact of these changes.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eImpact on spousal/partner relationships and family life.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCommunication about sexual health with healthcare providers and intimate partners.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCoping strategies employed to manage sexual difficulties.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSuggestions for improving care and support.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTwo pilot interviews were conducted with eligible participants to test the clarity, flow, and cultural appropriateness of the guide. Minor refinements were made to wording and probing techniques based on this feedback; data from pilot interviews were not included in the final analysis. Each main interview lasted between 30 and 50 minutes, with an average duration of 40 minutes. All interviews were audio-recorded with permission. The researcher also maintained field notes during and immediately after each interview to document non-verbal cues, contextual details, and reflective thoughts, thereby enriching the data [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe audio recordings were transcribed verbatim in Urdu by the primary researcher, who is fluent in both Urdu and English. Transcripts were then translated into English for analysis. To ensure conceptual and linguistic accuracy, a backward translation of a sample of transcripts was performed by an independent bilingual expert, and any discrepancies were discussed and resolved [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Data analysis followed the six-phase process of Reflexive Thematic Analysis (RTA) as outlined by Braun and Clarke [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], which emphasizes the researcher\u0026rsquo;s active role in interpreting patterns of meaning. The phases were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFamiliarization\u003c/b\u003e Immersive reading and re-reading of transcripts while listening to audio recordings, accompanied by note-taking of initial ideas.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGenerating Initial Codes\u003c/b\u003e Systematic, line-by-line coding of the dataset to identify features of potential interest. Coding was inductive, allowing themes to emerge from the data.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSearching for Themes\u003c/b\u003e Collating codes into broader potential themes and gathering all data relevant to each.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eReviewing Themes\u003c/b\u003e Checking themes against the coded extracts and the entire dataset to ensure they formed a coherent pattern and accurately reflected the data. This involved creating thematic maps and refining themes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDefining and Naming Themes\u003c/b\u003e Developing a detailed analysis for each theme, identifying its essence, and selecting an informative name.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProducing the Report\u003c/b\u003e Weaving together the analytic narrative, selecting vivid, compelling extract examples, and linking analysis to the research questions and relevant literature.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAnalysis was an iterative, recursive process supported by the use of Microsoft Word and Excel for data organization. Regular peer debriefing sessions were held with the research supervisors to discuss coding decisions, emergent themes, and interpretations, thereby enhancing analytic rigor\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnsuring Trustworthiness\u003c/h3\u003e\n\u003cp\u003eThe study\u0026rsquo;s trustworthiness its credibility, dependability, confirmability, and transferability was upheld using strategies aligned with Lincoln and Guba\u0026rsquo;s criteria.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCredibility\u003c/b\u003e was established through prolonged engagement with the data, member checking (where participants were invited to review their transcript summaries for accuracy), and researcher reflexivity (maintaining a journal to bracket preconceptions).\u003c/p\u003e \u003cp\u003e\u003cb\u003eDependability\u003c/b\u003e was promoted via a clear audit trail documenting all methodological decisions and peer review of the analysis process.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConfirmability\u003c/b\u003e was addressed through triangulation among researchers during analysis and maintaining neutrality by grounding interpretations in the data.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTransferability\u003c/b\u003e was facilitated by providing thick, contextual descriptions of the participants and setting, enabling readers to judge the applicability of findings to other contexts.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eTen participants aged 30\u0026ndash;50 years were included. The majority (60%) had no formal education, and most were engaged in low-income occupations. Duration of hypertension ranged from 1.5 to over 11 years, and beta-blocker use varied from 6 months to several years. Most were on cardio selective beta-blockers such as atenolol or metoprolol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThemes\u003c/h2\u003e \u003cp\u003eFour major themes and twelve subthemes were identified, reflecting the biopsychosocial complexity of participants\u0026rsquo; experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Emotional and Psychological Impact of Hypertension\u003c/h2\u003e \u003cp\u003eThis theme captures the distress associated with hypertension diagnosis and the often-delayed recognition of symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1.1: Emotional Distress and Fear Upon Diagnosis\u003c/h2\u003e \u003cp\u003eParticipants described anxiety, fear, and a sense of life disruption upon diagnosis. One participant (P-9) recalled, \u003cem\u003e\u0026ldquo;I was very nervous when I was first diagnosed with high blood pressure, and it felt like everything was over\u0026hellip; I have seen people around me suffer from heart problems and even heart attacks.\u0026rdquo;\u003c/em\u003e Another (P-1) reported physical sensations of danger: \u003cem\u003e\u0026ldquo;It felt dangerous, and I had this pain all over my body, and my tongue felt like it was twisting.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1.2: Delayed Recognition and Misattribution of Symptoms\u003c/h2\u003e \u003cp\u003eMany participants initially normalized or misinterpreted hypertensive symptoms. P-10 said, \u003cem\u003e\u0026ldquo;Headaches happen normally, so it seemed normal to me\u0026hellip; I ignored it and considered it work-related.\u0026rdquo;\u003c/em\u003e P-7 attributed his symptoms to psychological stress: \u003cem\u003e\u0026ldquo;Initially, I assumed these symptoms might be due to tension, but after visiting the doctor, I found out it was high blood pressure.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Sexual Dysfunction Related to Beta-Blockers\u003c/h2\u003e \u003cp\u003eThis theme highlights the physical and emotional consequences of medication-induced sexual changes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2.1: Erectile Dysfunction and Decreased Desire\u003c/h2\u003e \u003cp\u003eAll participants noted a decline in sexual desire and performance after starting beta-blockers. P-6 stated, \u003cem\u003e\u0026ldquo;I have experienced weakness of the male organ and a lack of sexual desire since using the medicine.\u0026rdquo;\u003c/em\u003e P-10 added, \u003cem\u003e\u0026ldquo;Since commencing beta blockers, the strength and hardness of my organ have significantly reduced, making it difficult to perform properly.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2.2: Attribution to Medication vs. Age\u003c/h2\u003e \u003cp\u003eParticipants often struggled to discern whether changes were due to medication or aging. P-1 expressed uncertainty: \u003cem\u003e\u0026ldquo;I am experiencing severe sexual difficulties\u0026hellip; but I am unsure whether it is due to my age or medication.\u0026rdquo;\u003c/em\u003e In contrast, P-10 was more definitive: \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t believe it\u0026rsquo;s due to age; I firmly believe these changes are caused by medications.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2.3: Emotional Consequences of Sexual Changes\u003c/h2\u003e \u003cp\u003eSexual dysfunction led to significant emotional distress, including diminished self-worth, frustration, and anxiety. P-10 shared, \u003cem\u003e\u0026ldquo;When a man cannot perform, he starts feeling useless, and I also feel hopeless, anxious.\u0026rdquo;\u003c/em\u003e P-7 felt embarrassed after his partner commented on his weakness, leading to emotional distress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Communication Barriers About Sexual Health\u003c/h2\u003e \u003cp\u003eThis theme reveals the silence surrounding sexual health in clinical and personal contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3.1: Barriers to Communication\u003c/h2\u003e \u003cp\u003eParticipants cited shame, cultural stigma, and fear of judgment as reasons for not discussing sexual issues. P-5 said, \u003cem\u003e\u0026ldquo;I have not disclosed these issues to my doctor just because I feel shy talking about them.\u0026rdquo;\u003c/em\u003e P-9 explained, \u003cem\u003e\u0026ldquo;As a man, it is not suitable to discuss these issues. It is considered unacceptable\u0026hellip; it feels like a matter of humiliation.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 3.2: Healthcare Providers\u0026rsquo; Gap in Counseling\u003c/h2\u003e \u003cp\u003eMost participants reported never receiving information about sexual side effects. P-7 stated, \u003cem\u003e\u0026ldquo;I was not counselled at the time of starting beta blockers regarding potential sexual side effects.\u0026rdquo;\u003c/em\u003e Only one participant (P-8) recalled proactive counseling, which helped him mentally prepare.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3.3: Patient Suggestions for Improving Communication\u003c/h2\u003e \u003cp\u003e Participants recommended that healthcare providers initiate conversations about sexual health in a respectful, confidential manner. P-6 suggested providers should \u003cem\u003e\u0026ldquo;talk about sexual side effects and suggest supportive treatments.\u0026rdquo;\u003c/em\u003e P-4 emphasized the need for a \u003cem\u003e\u0026ldquo;respectful environment where patients can discuss sensitive topics comfortably.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eTheme 4: Coping Strategies, Barriers, and Recommendations\u003c/h2\u003e \u003cp\u003eThis theme encapsulates how participants managed their condition and their advice for others.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 4.1: Lifestyle Modifications and Inner Resilience\u003c/h2\u003e \u003cp\u003eMany adopted exercise, dietary changes, and spiritual practices. P-2 noted, \u003cem\u003e\u0026ldquo;The most effective strategy for me is exercise, which has proven a crucial improvement.\u0026rdquo;\u003c/em\u003e P-4 found solace in prayer: \u003cem\u003e\u0026ldquo;Be at peace and pray five times a day, stay strong, and remember Allah.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtheme 4.2: Use of Alternative and Traditional\u003c/b\u003e \u003cem\u003eMedicine\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSome sought help from traditional healers (hakims) when conventional care felt inadequate. P-9 reported, \u0026ldquo;I felt some improvement after use of a 15-day herbal course from a hakim.\u0026rdquo; However, cost was a barrier for others.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 4.3: Non-Adherence to Beta-Blocker Therapy\u003c/h2\u003e \u003cp\u003eNon-adherence was a common, deliberate response to sexual side effects. P-7 admitted, \u003cem\u003e\u0026ldquo;After experiencing disturbance and weakness in sexual activity, I began to take it on and off, only when needed.\u0026rdquo;\u003c/em\u003e Psychosocial stressors like unemployment also contributed.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 4.4: Recommendations for Other Patients\u003c/h2\u003e \u003cp\u003eParticipants advised open communication with doctors, requesting alternative medications, and prioritizing holistic health. P-8 urged, \u003cem\u003e\u0026ldquo;Individuals should maintain regular communication with doctors because proper guidance can help manage side effects effectively.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides an in-depth understanding of how hypertensive men in Karachi experience sexual dysfunction linked to beta-blocker use. The findings align with existing literature on the high prevalence of erectile dysfunction among beta-blocker users [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and the emotional burden it carries [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, this research uniquely highlights the cultural and communicative barriers that exacerbate the problem in the Pakistani context.\u003c/p\u003e \u003cp\u003eThe emotional distress following a hypertension diagnosis reflects the psychological impact of chronic illness, consistent with studies showing anxiety and fear are common upon diagnosis [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The misattribution of symptoms underscores low health literacy and normalization of hypertension signs, which delays care-seeking [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual dysfunction emerged as a central concern, with participants describing both physiological changes (erectile weakness, low libido) and psychological consequences (shame, hopelessness). The confusion between medication effects and aging mirrors findings by Manolis et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], who noted that such ambiguity can prevent men from seeking timely help.\u003c/p\u003e \u003cp\u003eCommunication barriers rooted in cultural stigma are a critical finding. In Pakistan, masculinity norms discourage open discussion of sexual problems, leading to silence and isolation [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The lack of proactive counseling from healthcare providers echoes global reports of clinicians\u0026rsquo; discomfort in addressing sexual health [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This gap is particularly significant in nursing, where holistic, patient-centered care is emphasized.\u003c/p\u003e \u003cp\u003eCoping strategies such as lifestyle changes, spiritual practices, and use of traditional healers reflect culturally embedded resilience mechanisms [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, non-adherence as a coping response highlights a dangerous trade-off between sexual function and cardiovascular health, consistent with international studies linking sexual side effects to poor adherence [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eImplications for Nursing Practice\u003c/h3\u003e\n\u003cp\u003eNurses are well-positioned to bridge the communication gap regarding sexual health. Integrating sexual health assessments into routine hypertension follow-ups, using culturally sensitive language, and providing education about medication side effects can empower patients. Training programs for nurses on sexual health counseling, perhaps using models like PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy), could enhance clinical practice [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003ePolicy and Education\u003c/h2\u003e \u003cp\u003e Healthcare institutions should develop guidelines for discussing sexual side effects of antihypertensive drugs. Pre-service and in-service training for physicians and nurses should include modules on sexual health communication. Pharmacological considerations, such as preferential use of beta-blockers with lower sexual side effect profiles (e.g., nebivolol), could be incorporated into treatment protocols where appropriate [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA key strength is the focus on an under-researched population using a rigorous qualitative approach. However, the study is limited by its single-center setting, small sample size, and lack of perspectives from healthcare providers and partners. Future research could employ mixed methods, include larger and more diverse samples, and explore interventions to improve sexual health communication in clinical settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that sexual dysfunction is a significant, multifaceted issue for hypertensive men on beta-blockers in Karachi. It affects biological, psychological, and social dimensions of health, contributing to emotional distress, relationship strain, and medication non-adherence. The cultural silence surrounding sexual health exacerbates these challenges. There is an urgent need for healthcare providers, especially nurses, to adopt a proactive, sensitive, and holistic approach to sexual health in hypertension management. By doing so, they can improve adherence, quality of life, and overall health outcomes for this patient population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican College of Cardiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Heart Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAKU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAga Khan University\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBiopsychosocial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eErectile Dysfunction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEDQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExploratory Descriptive Qualitative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEthical Review Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHTN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual and Reproductive Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e Approved by Aga Khan University Ethical Review Committee (ERC-2025-11252-34214). Written informed consent obtained from all participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo external funding received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSUF: Conceptualization, methodology, data collection, analysis, writing and original draft. SR: Supervision, validation, writing review \u0026amp; editing. ZS: Supervision, methodology, writing review \u0026amp; editing. ZH: Supervision, resources, writing review \u0026amp; editing. All authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eWe thank the participants for their trust and time, and the staff of Dr. Ruth K.M. Pfau Civil Hospital Karachi for their support.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAuthors' statement\u003c/b\u003e: This manuscript is based on the original thesis work of the first author. No generative AI was used in the writing of the manuscript; only the free version of Grammarly was employed for grammar correction\u003c/p\u003e \u003cp\u003e\u003cb\u003eAuthors' information\u003c/b\u003e: SUF is an MSc Nursing scholar and registered nurse with cardiac care experience. SR is an Associate Professor at AKU School of Nursing and Midwifery. ZS is a Senior Instructor at the same institution. ZH is a Senior Head Nurse at Aga Khan University Hospital.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are available from corresponding author upon reasonable request, subject to ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO, Hypertension. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/hypertension\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/hypertension\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnwer F, Malik AA. Hypertension Research in Pakistan: A Scientometric Analysis. Cureus. 2024;16(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenjamin EJ, et al. Heart disease and stroke statistics\u0026mdash;2019 update. 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J Am Heart Assoc. 2022;11(17):e026582.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkinyede AA, et al. Effect of antihypertensive medications on sexual function. Future Sci OA. 2020;6(6):FSO479.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaafarpour M, et al. Sexual counseling based on PLISSIT model in postmenopausal women. Climacteric. 2025;28(1):74\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMecugni D, et al. Sexual competence in nursing education. Healthcare. 2021;9(2):166.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorona G, et al. Anti-hypertensive medications and erectile dysfunction: focus on β-blockers. Endocrine. 2025;87(1):11\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViigimaa M, et al. Update on arterial hypertension and erectile dysfunction. J Hypertens. 2020;38(7):1220\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Beta-blockers, Sexual dysfunction, Erectile dysfunction, Men’s health, Qualitative research, Pakistan, Nursing","lastPublishedDoi":"10.21203/rs.3.rs-8668544/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8668544/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHypertension is a major global health issue, and beta-blockers are commonly prescribed for its management. However, these medications are frequently associated with sexual dysfunction, which can severely impact quality of life, emotional well-being, and medication adherence. In conservative societies like Pakistan, sexual health remains a culturally sensitive and rarely discussed topic. This study aimed to explore the lived experiences of sexual dysfunction among adult hypertensive males on beta-blockers in Karachi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e An exploratory descriptive qualitative study was conducted at a tertiary cardiac care hospital in Karachi. Ten hypertensive males aged 30\u0026ndash;50 years, on beta-blockers for at least six months, were purposively recruited. Semi-structured interviews were conducted in Urdu, audio-recorded, transcribed, and analyzed using reflexive thematic analysis following Braun and Clarke\u0026rsquo;s framework. Trustworthiness was ensured through Lincoln and Guba\u0026rsquo;s criteria.\u003c/p\u003e\u003ch2\u003eFindings\u003c/h2\u003e \u003cp\u003eFour major themes were extracted: (1) emotional and psychological impact of hypertension diagnosis; (2) sexual dysfunction attributed to beta-blockers; (3) communication barriers about sexual health; and (4) coping strategies, barriers, and recommendations. Participants reported that erectile dysfunction reduced libido, caused emotional distress, non-adherence to medication, and a lack of proactive sexual health counseling.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSexual dysfunction is a significant but unaddressed side effect of beta-blocker therapy among hypertensive males in Pakistan. It contributes to emotional distress, relationship strain, and poor medication adherence. Integrating sexual health counseling into routine hypertension care, adopting patient-centered communication, and considering alternative medications with fewer sexual side effects could improve holistic patient outcomes.\u003c/p\u003e","manuscriptTitle":"Exploring the Experiences of Sexual Dysfunction Among Adult Hypertensive Males on Beta-blockers in Karachi: An Exploratory Descriptive Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 06:54:26","doi":"10.21203/rs.3.rs-8668544/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-19T19:50:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-08T12:48:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T09:03:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-03T04:52:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265057452736185883798735940880279987847","date":"2026-03-01T22:45:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316713393138264856854051631772822962805","date":"2026-03-01T09:26:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-28T11:17:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T07:54:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194181270630171534795894500747954283454","date":"2026-02-25T01:18:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323291539042970747664459167802025357536","date":"2026-02-20T04:23:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T10:04:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322563612567566765899409745634704166706","date":"2026-02-18T08:11:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235922880274125761346091275404042086077","date":"2026-02-18T07:55:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267175621505738788997360972867743817262","date":"2026-02-18T04:25:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T17:27:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T17:49:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-24T10:56:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-24T10:54:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2026-01-22T10:08:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4469204-7dd2-4351-b740-0531b43ea6a6","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T17:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 06:54:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8668544","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8668544","identity":"rs-8668544","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}