Can COVID-19 lead to impotence?
For a respiratory disease, COVID-19 causes some peculiar symptoms. It can diminish the senses of smell and taste, leave patients with discolored “COVID toes” or even cause a swollen bumpy “COVID tongue.”
Now scientists are examining a possible link to an altogether unexpected consequence of COVID-19: erectile dysfunction. A connection has been reported in hundreds of papers by scientists in Europe and North America, as well as in Egypt, Turkey, Iran and Thailand.
Estimates of the magnitude of the problem vary wildly. A paper by Dr. Ranjith Ramasamy, director of reproductive urology at the University of Miami’s Desai Sethi Urology Institute, and his colleagues found that the risk of erectile dysfunction increased by 20% after a bout with COVID-19. Other investigators have reported substantially higher increases in that risk.
When patients first started coming to Dr. Ramasamy’s clinic complaining of erection problems, “we dismissed it, thinking it was all psychological or stress-induced,” he said.
But over time, he and other physicians began to see a pattern, he said. “Six months after the initial infection, patients had gotten better overall, but they continued to complain of these problems,” including erectile dysfunction and low sperm counts, said Dr. Ramasamy, who has written several papers on the topic.
At the outset of the pandemic, Dr. Emmanuele Jannini, a professor of endocrinology and medical sexology at the University of Rome Tor Vergata, reported a strong link between erectile dysfunction and COVID-19. When he compared men who had been ill with COVID19 with those who had not, he found that those who had been infected were nearly six times as likely to report impotence as those who had avoided the coronavirus.
“Communicating that the disease can affect your sexual life is a tremendously powerful message,” especially for men who still resist vaccination, Dr. Jannini said. “The evidence is very strong.”
Research from imaging scans and biopsies indicates that the coronavirus can infect tissue within the male genital tract, where it may linger long after the initial infection. Scientists say it is too early to be certain that the link to erectile dysfunction is causal, since so many factors — psychological as well as physiological — play a role in producing and maintaining an erection. The pandemic has led to social isolation and a surge in anxiety and depression, all of which may play a role.
“Men’s erections are more complicated than people think,” said Dr. Justin Dubin, who cowrote a paper about the adverse effect of COVID-19 on men’s health.
“You need good blood flow; you need the nerves to be firing; and you need good hormone levels, specifically testosterone,” he said.
Some researchers speculate that erectile dysfunction may be linked to the well-documented loss of the ability to taste and smell experienced by COVID-19 patients, because these senses play an important role in sexual arousal.
At the very least, men need healthy blood vessels and good blood flow in order to develop and sustain erections. The coronavirus may damage blood vessels and the lining of the vessels, called the endothelium, as it binds to the molecular receptors that are plentiful on endothelial cells.
“Our entire vascular system is connected; it’s not an isolated penis problem,” said Dr. T. Mike Hsieh, director of the men’s health center at University of California, San Diego.
But vascular problems can manifest in the sexual organs first, because the vessels there are so small. (Dr. Jannini calls erectile dysfunction “the canary in the coal mine” for cardiovascular disease.) Erectile dysfunction and cardiovascular disease share risk factors — such as being severely overweight, having metabolic diseases like diabetes, smoking and older age — which also increase the odds of having severe COVID-19.
“The artery for the penis is one-tenth the size of a coronary artery, and when you have a narrower vessel, whether it’s a plumbing problem or a vascular problem, it will show up there first, even before you see it in a larger artery,” Dr. Hsieh said.
Erectile dysfunction can precede a heart attack by about five years, he said, and can be an early signal that there are other underlying risk factors.
“When I see a guy for erectile dysfunction, they don’t just get a Viagra or Cialis prescription,” Dr. Hsieh said. “They get a referral to a primary care colleague or a cardiologist to make sure their cholesterol is in check; their diabetes is under control; to discuss weight management, lifestyle or dietary changes.”