Archivio Italiano di Urologia e Andrologia 2016; 88, 4270

ORIGINAL PAPER

Are erectile functions affected by AB0 blood group?

Erdal Benli 1, Abdullah Çırakoğlu 1, Ercan Öğreden 2, Selamettin Demir 3, Yasemin Kaya 4, 
Mustafa İbas 5, Ali Ayyıldız 6, Ahmet Yüce 1

1 Department of Urology, Ordu University, Faculty of Medicine, Ordu, Turkey; 
2 Department of Urology, Giresun University, Faculty of Medicine, Giresun, Turkey; 
3 Clinic of Urology, Istanbul Hospital, Van, Turkey; 
4 Department of Internal Medicine, Ordu University, Faculty of Medicine, Ordu, Turkey; 
5 Intern, Necmettin Erbakan University, Faculty of Medicine, Konya, Turkey;    
6 Clinic of Urology, Ankara Training Research Hospital, Ankara, Turkey.

Aim: The aim of this study was to investi-
gate whether there is a relationship

between erectile dysfunction (ED), thought to be a vascular
disease, and AB0 blood group.
Material and Method: The study included 350 people abiding
by the study criteria who applied to our clinic from April
2012-April 2015. The patients were divided into two groups
including those with ED (Group 1) and those without (Group
2). Age, blood group, IIEF-5 score and presence of additional
diseases were recorded. Erectile functions were analyzed
according to blood group.
Results: There was no difference between the mean age of 111
patients with ED and that of 239 patients without ED included
in the study (p = 0.284). There was no difference between
patients in the two groups in terms of smoking, alcohol use,
hypertension and diabetes (p > 0.05). Among patients in the
ED group, the mean IIEF-5 score according to blood group
was 19.8 ± 5.04 in the 0 blood group, 16.5 ± 5.2 in the A
blood group, 17.2 ± 5.3 in the B blood group and 13.3 ± 3.02
in the AB blood group. The IIEF-5 scores of individuals in the
0 blood group were significantly high compared to individuals
in other blood groups (p = 0.004). Logistic regression analysis
found that compared to the 0 blood group, the erectile dys-
function risk was 3.9 times greater for the A blood group, 3.5
times greater for the B blood group and 4.7 times greater for
the AB blood group (p = 0.001) (Table 3).
Conclusion: The risk of erectile dysfunction was significantly
increased for individuals in the A, B and AB blood groups
compared to individuals in the 0 blood group.

KEY WORDS: AB0 blood group; Erectile dysfunction; 
Vascular disease.

Submitted 6 May 2016; Accepted 31 May 2016

Summary

No conflict of interest declared.

factors such as aging, hypertension, diabetes, smoking,
central obesity and dyslipidemia increasing the risk of ath-
erosclerotic coronary artery disease (CAD) are also impor-
tant risk factors for ED. For both CAD and ED, early indi-
cators of the common vascular disease of atherosclerosis
may occur in erectile tissue (2, 3). 
The relationship between AB0 blood groups and some dis-
eases was first reported by Alexzender for the first time in
1921 (4). Later studies have reported a close relationship
between vascular diseases like coronary artery disease and
thrombosis, and also a variety of cancers such as pancre-
atic and bladder cancer (5, 6). According with the demon-
strated correlation with many vascular diseases, the corre-
lation between AB0 blood groups and another vascular
disorder such as ED has not been investigated. In this
study we aimed to investigate whether there was a corre-
lation between AB0 blood groups and erectile dysfunction. 

MATERIALS AND METHODS
The data belonging to 972 patients applying to our clin-
ic from April 2012 to April 2015 were retrospectively
investigated. The study included 350 patients with age,
blood group, IEFF-5 score and presence of additional
diseases recorded. Permission was obtained from the
local ethics committee of Ordu University (decision no.
2015/1). The exclusion criteria for the study included
congestive heart failure, hyperprolactinemia, hypogo-
nadism, renal function disorders, peripheral or auto-
nomic neuropathy, psychiatric problems and treatment
for sexual function disorders. Patients were divided into
two groups; those requiring treatment due to lack of or
to unsustained erections (ED group) and those with
problem-free sexual relations (control group). 
The erectile functions of patients were determined using
the International Index of Erectile Function-5 (IIEF-5).
Each question on this from is scored from 1 to 5. If the
patient could not fill out the form, help was given by the
same person. The total IIEF-5 score is calculated by
adding the scores (from 1-5) given to 5 questions.
According to total points sexual function was defined as
normal (22-25), mild (17-21), moderate (12-16) and
severe dysfunction (1-11). 

DOI: 10.4081/aiua.2016.4.270

INTRODUCTION
Erectile dysfunction (ED) is defined as either continuous
or repeated lack of erection, or lack of sustained erection,
necessary for satisfying sexual relations (1). The penis
includes a very rich and specialized vascular system. The
complete endothelium furnishing this vascular system
plays an important role in erectile tissue function.
Disruption of the complete endothelial may cause devel-
opment of atherosclerotic vein diseases, in addition to
affecting erectile functions. Studies have shown that risk

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271Archivio Italiano di Urologia e Andrologia 2016; 88, 4

AB0 blood types and erectile dysfunction

RESULTS
The mean age of all patients included in the study was
62.34 ± 8.51 (41-84) years. The mean age of the 111
patients in the ED group was 63.05 ± 8.5 (41-84) years,
while the mean age of patients in the control group with-
out ED complaints was 62 ± 8.5 (43-84) years. There
was no difference between the groups in terms of age
(p = 0.284). 
Apart from cardiac disease, there was no difference
between patients in the ED group and those in the non-ED
group in terms of demographic characteristics (Table 1). 
The distribution of individuals with erectile dysfunction
in terms of blood groups is shown in Table 2. 
The mean IIEF-5 score of patients in the ED group
according to blood group was found as 19.8 ± 5.04 for 0
blood group, 16.5 ± 5.2 for A blood group, 17.2 ± 5.3
for B blood group and 13.3 ± 3.02 for AB blood group.
The mean IIEF-5 score for individuals with the 0 blood
group was identified to be significantly high compared to
other blood groups (p = 0.004). 
The presence of ED was found in 15.7% of patients with
0 blood group, in 41.6% of patients with A blood group,
in 39.3% of patients with B blood group and in 46.7% of
patients with AB blood group (p < 0.001). Logistic
regression analysis showed that compared to the 0 blood
group the risk of erectile dysfunction was 3.9 times
increased for A blood group, 3.5 times increased for B
blood group and 4.7 times increased for AB blood group
(p = 0.001) (Table 3). 

Statistical analysis
Descriptive statistics for continuous variables are given as
mean, standard deviation, minimum and maximum val-
ues, while for categorical variables these are given as
number and percentage. To determine whether there was
a difference in ED presence for continuous variables, the
Student t test was performed. To determine the correla-
tion between categorical variables, the chi-square test
was used. Additionally to determine the possible risk fac-
tors affecting erectile dysfunction, multiple logistic
regression analysis was performed. For calculations the
level of statistical significance was taken as 5% and cal-
culations used the SPSS (ver. 13) statistical package pro-
gram. 

DISCUSSION
The results of our study found a relationship between ED
and AB0 blood groups and ED was identified to have
increased incidence in A, B and AB blood groups com-
pared to 0 blood group. The clearly increased ED risk in
the AB blood group may be related to the synergic effect
caused by the presence of A and B antigens together. The
increased risk identified in the study using multivariate
analysis shows the ED risk is independent of promoting
factors such as alcohol, smoking and hypertension. 
The penis, with a very rich vein network, is one of the
richest organs in terms of endothelium per unit area (7).
Healthy endothelium releases material with antifibri-
nolytic and anticoagulant properties, as well as strong
vasodilatator materials like NO. Disruption of the com-
pleteness of the endothelium disrupts these functions
and synthesis of vasoconstrictor materials like throm-
boxane A2, endotelin, and angiotensin 2 increases.
Additionally loss of the permeability and antithrombo-
cyte properties of endothelium is proposed to trigger the
atherosclerotic process (8). As a result, studies related to
atherosclerotic vascular diseases have frequently used
measurements of endothelial functions. Diseases that
form a risk for vascular disease, like hypertension,
hypercholesterolemia, diabetes and obesity, affect the
endothelin in the vein walls, by affecting homeostasis
function (9). As a result the process beginning with
endothelial disruption is reported to show itself in a vari-
ety of diseases such as angina, stroke and CAD where tis-
sue perfusion is disrupted (9, 10). The degree of
endothelial dysfunction is related to the severity of these
diseases experienced by the patient (11). 
Endothelial dysfunction is shown to be an effective factor
in the development of ED (12). This effect is thought to be
due to effects on the vein elasticity of erectile tissue and on
the release of endothelial factors like NO released by
endothelium (13, 14). A study by Davignon et al. proposed

Table 1. 
Demographic characteristics of participants in the research.

Characteristics ED n (%) P-value
(Present/absent) Present Absent

Alcohol Present 9 (33.7) 18 (66.7) 0.832
Absent 101 (31.6) 219 (68.4)

Smoking Present 38 (33) 77 (67) 0.728
Absent 73 (31.2) 161 (68.8)

Diabetes Present 26 (37.7) 43 (62.3) 0.289
Absent 84 (31) 187 (69)

Hypertension Present 37 (33.3) 74 (66.7) 0.711
Absent 73 (31.1) 162 (68.9)

Cardiac disease Present 29 (43.9) 37 (56.1) 0.27
Absent 82 (73.9) 202 (84.5)

Table 2. 
Distribution of blood groups in ED.

Blood group Erectile dysfunction n (%)
Present Absent

0 blood group 21 (18.9%) 113 (47.3)
A blood group 52 (46.8) 73 (30.5)
B blood group 24 (21.6) 37 (15.5)
AB blood group 14 (12.6) 16 (6.7)

Table 3. 
Results of logistic regression analysis.

Odds ratio (OR) 95.0% C.I. P-value
Lower Upper

Age 1.009 .979 1.040 0.556
A blood group 3.949 2.143 7.279 0.001
B blood group 3.504 1.712 7.173 0.001
AB blood group 4.742 1.960 11.473 0.001
OR: Odds ratio; CI: Confidence interval. For blood group 0 is the reference category. 

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that one of the earliest indicators of atherosclerosis is
changes in NO activity (15). Thus, ED is thought to occur
as a part of the systemic vascular disease of atherosclerosis
(16). Many studies on this topic have shown a close rela-
tionship between ED and vascular diseases. In fact, some
studies have proposed ED is the first symptom of systemic
vascular disease. Montorsi et al. in a study reported that
problems related to ED began 3 years before the occur-
rence of coronary artery disease, while Ponholzer et al.
reported such problems began 10 years before stroke (17,
18). While explaining the reasons for this, the researchers
used the artery diameter hypothesis. According to this
hypothesis, as the size of penile arteries (1-2 mm) is small
compared to coronary arteries (3-4 mm), the same level of
atherosclerotic/endothelial damage causes greater reduc-
tion in perfusion in erectile tissue compared to coronary or
other veins (19). As a result ED may occur in erectile tissue
as the first indicator of systemic atherosclerosis (20, 21).
Researchers have proposed that erectile tissue may be a
sensitive indicator of systemic atherosclerotic diseases (7). 
The reason for the relationship between AB0 blood
groups and ED identified in our study may be related to
endothelial dysfunction and related atherosclerosis occur-
ring in erectile tissue. Many studies supporting this
hypothesis have shown a relationship between athero-
sclerotic vascular diseases and AB0 blood groups (1).
Atherosclerotic vascular diseases like myocardial infarct,
peripheral vascular diseases, intermittent claudication,
and venous thromboembolism are reported to be encoun-
tered more frequently in the non-0 blood groups com-
pared to the 0 blood group (22, 23). A study by
Carpenggiani et al. investigated the blood groups of 4901
patients undergoing coronary angiography due to athero-
sclerotic CAD and reported that atherosclerotic coronary
disease was most frequently observed in non-0 blood
groups (24). This conclusion may explain our results.
Probably blood groups cause atherosclerotic results or
endothelial dysfunction leading to development of ED. 
The reason for the relationship between AB0 blood
groups and atherosclerotic vascular diseases is not fully
known. The genetic nature of the AB0 blood groups may
affect this. There are many hypotheses to explain this sit-
uation. One of these is the ATP-binding cassette 2
(ABCA2) gene known to be important for cholesterol
balance and carried in the 9q34 locus of chromosome 9
together with AB0 blood groups (25, 26). The study by
Carpeggiani et al. identified a significant relationship
between non-0 blood group and hypercholesterolemia
and family history (24). In human and animal models,
hypercholesterolemia is shown to disrupt smooth muscle
relaxation linked to endothelium, enzyme activity of
endothelial nitric oxide synthesis (eNOS) and penile
angiogenesis resulting in ED (16, 27). Another hypothe-
sis is related to adhesion molecules such as sICAM-1
(high soluble intercellular adhesion molecule-1), sP-
selectin (soluble P-selectin) and sE-selectin (soluble E-
selectin) which affect AB0 blood groups and are thought
to cause endothelial disruption (28). 
Another opinion gaining great interest is related to blood
groups affecting von Willebrand factor (vWF) and factor 8
levels causing development of atherosclerosis (29). These
factors, known as adhesion molecules, are reported to be

effective on thrombocyte leukocyte interaction, adhesion
of thrombocytes to veins, migration of leukocytes into
veins and development of atheroma plaque; in short on
the development of atherosclerosis (30, 31). Studies have
identified higher vWF and F8 levels in individuals with A
and B blood groups compared to 0 blood group (32, 33). 
The study by Sarode et al. reported that A and B blood
groups were effective on adhesive activity of vWF (34).
Again a study by Ray et al. on acute coronary syndrome
and a study by Convay et al. on thromboemboli and
stroke diseases reported a close relationship between
AB0 blood group and vWF (35, 36). 
In short there are many studies in the literature showing
the close relationship between AB0 blood groups and
atherosclerotic vascular diseases (37). In fact a study by
Kaya et al. reported that AB0 blood groups may be relat-
ed to the complications of atherosclerosis, in addition to
the development of atherosclerosis (38). 
In our study, A, B and AB blood groups were found to be
related to the risk of a person experiencing erectile dys-
function. As mentioned in many studies above, due to
the relationship shown between vascular diseases and
AB0 blood groups, the relationship with ED thought to
be a vascular disease is not surprising. We consider that
this effect progresses through endothelial dysfunction
and atherosclerotic processes. We consider that endothe-
lial damage affects synthesis of a variety of materials like
NO known to play an important role in erections, dis-
rupts the effect of endothelium on vascular tonus, nar-
rows the venous lumens due to atherosclerosis and final-
ly affects blood flow to erectile tissue. 
There are some limitations to this study. These include its
retrospective nature, reflecting results from a single center
and that laboratory results from patients including lipid
profile, serum F8 and vWF level were not examined.

CONCLUSION
This study found a close relationship between A, B and AB
blood groups and ED. We believe this correlation is due to
effect of the complicated process resulting in endothelial
dysfunction, similar to the correlation previously reported
for blood groups and atherosclerotic events. In spite of the
limitations of the study, we believe this study is very impor-
tant in being the first study to show the relationship
between AB0 blood groups and ED. This may be important
in terms of taking preventive precautions related to athero-
sclerotic vein diseases known to be related to ED.

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Correspondence
Erdal Benli, MD (Corresponding Author) 
drerdalbenli@gmail.com

Abdullah Çırakoğlu, MD 
dr_cirakoglu@yahoo.com

Ahmet Yüce, MD 
ahmetyuce7@gmail.com
Department of Urology, Ordu University, Faculty of Medicine, Ordu, Turkey

Ercan Öğreden, MD 
9isik061@mynet.com
Department of Urology, Giresun University, Faculty of Medicine, Giresun,
Turkey

Selamettin Demir, MD 
drselami1978@hotmail.com
Clinic of Urology, Istanbul Hospital, Van, Turkey

Mustafa İbas, MD 
ibasmustafa91@hotmail.com
Intern, Necmettin Erbakan University, Faculty of Medicine, Konya, Turkey

Ali Ayyıldız, MD 
urology52@gmail.com
Clinic of Urology, Ankara Training Research Hospital, Ankara, Turkey

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