Association between red blood cell distribution width-to-albumin ratio with erectile dysfunction in US men: Insights from national cross-sectional study in NHANES 2001 to 2004

Erectile dysfunction (ED) is closely linked to inflammation, which impairs penile vascular architecture. The red blood cell distribution width-to-albumin ratio (RAR), a novel marker of inflammation and nutritional status gaining wide attention, has not yet been studied in relation to ED. This study aimed to investigate the relationship between RAR and ED among American men, which addresses this knowledge gap. This study utilized publicly available data from NHANES, focusing on adult males who completed the ED questionnaire and RAR measurements. Multivariable logistic regression models were employed to examine the association between RAR and ED, adjusting for potential covariates. Subgroup and sensitivity analyses were performed to validate the robustness of the findings. Additionally, Receiver operating characteristic analysis was conducted to evaluate the predictive performance of both combined and individual indicators for ED. A total of 3550 eligible participants were included in this study, among whom 986 reported ED. In fully adjusted models, higher RAR levels were statistically associated with a greater prevalence of ED (odds ratio [OR]: 3.41, 95% confidence interval [CI]: 2.14–5.44; P  < .001). Participants in the highest RAR quartile exhibited higher odds of ED compared with those in the lowest quartile (OR: 2.74, 95% CI: 1.76–4.27; P  = .002). Sensitivity analyses using alternative ED definitions yielded consistent associations, with RAR remaining positively associated with both general ED (OR: 2.58, 95% CI: 1.64–4.07) and severe ED (OR: 3.41, 95% CI: 1.97–5.93). Receiver operating characteristic analyses indicated modest statistical discrimination for RAR (areas under the curve: 0.685, 95% CI: 0.666–0.704), which should be interpreted descriptively rather than as evidence of clinical prediction. Higher RAR values were statistically associated with ED in this nationally representative sample of U.S. men. Although these findings support an epidemiologic link between inflammation-related biomarkers and ED, the modest discriminative performance and cross-sectional design limit clinical interpretation. Longitudinal studies are needed to clarify the temporal relevance of this association.