The 5 a-reductase inhibitors, which inhibit conversion of testosterone to dihydrotestosterone, are used for miscellaneous clinical applications, including the treatment of benign prostatic hyperplasia and male pattern hair loss, and for possible reduction of the risk of prostate cancer. Erectile dysfunction has been associated with 5 a-reductase inhibitors. Overall, reports in the literature suggest rates of erectile dysfunction to be between 0.8%-33% in men using these medications. However, randomized controlled studies report the rates of erectile dysfunction to be between 0.8%-15.8%. The possible risk association is that these medications impact androgen function, which is understood to contribute to normal erectile physiology. The 5 a-reductase inhibitors result in a drop in median serum dihydrotestosterone levels by 60%-93% within 2 years, but there is no major change in testosterone levels. In this review, we surveyed studies on erectile dysfunction in patients treated with 5 areductase inhibitors and critically examined the evidence that associates 5 a-reductase inhibitors and erectile dysfunction. We conclude that 5 a-reductase inhibitors do not lead to erectile dysfunction to a significant degree, and we support the position that dihydrotestosterone is less relevant than testosterone in erectile function.J Androl 2008;29:514-523T he 5 a-reductase inhibitors (5ARIs) have been successfully used for more than 20 years for treatments of benign prostatic hyperplasia (BPH) and male pattern hair loss, and lately they have been evaluated for reduction in prostate cancer risk. Presently available orally administered 5ARIs, finasteride and dutasteride, inhibit 5 a-reductase, an enzyme that catalyzes the irreversible reduction of testosterone (T) to dihydrotestosterone (DHT), with NADPH as the hydrogen donor (Russell and Wilson, 1994). There are 2 isoenzyme forms (types I and II). Type I is located predominantly in the skin, in both hair follicles and sebaceous glands, as well as in the liver, prostate, and kidney and is responsible for approximately one-third of circulating DHT (Thiboutot et al, 1995). Type II is found in the prostate, seminal vesicles, epididymis, hair follicles, and liver, and is responsible for the remaining two-thirds of circulating DHT (Thigpen et al, 1993a;Gisleskog et al, 1998). Finasteride inhibits type II, while dutasteride is an inhibitor of both types and may decrease circulating DHT to a greater extent than finasteride (Clark et al, 2004).The sex steroidal influence in the physiology of the erectile response has been an issue of controversy for many years. Points of view have ranged from thought that the androgens offer an unneeded role in physiological mechanisms of penile erection (Handelsman and Zajac, 2004) to the view that these hormones critically influence structural and functional circumstances required for the erectile response (Gooren and Saad, 2006;Traish and Guay, 2006).We are able to treat patients for prostatic or hair diseases by decreasing their DHT levels. D...