We’re all familiar with the common symptoms of COVID-19: fever, shortness of breath, fatigue, and loss of smell or taste. But the impact of the illness doesn’t end there. On December 4, infectious disease expert Dena Grayson, MD, told Chicago TV station NBCLX that one of the potential complications of the virus is erectile dysfunction (ED).
“We now know that people can have long-term health effects from this virus, neurologic complications, and now, for men who are watching this—there is some real concern here that men could have long-term issues of erectile dysfunction from this virus, because we know that it causes issues in the vasculature,” Dr. Grayson said. She added that “this is something that is of real concern.”
Some research suggests a connection between the coronavirus and ED. A study published in the Journal of Endocrinological Investigation in July examined the effects of COVID-19 on men’s sexual and reproductive health and found a correlation between coronavirus survivors and ED. “Our research shows that ED is a perfect biomarker of general physical and psychological health,” study author Emmanuele A. Jannini, MD, professor of endocrinology and medical sexology in the department of systems medicine at the University of Rome Tor Vergata, tells Health.
We still don’t know, exactly. But experts agree that different factors could lead to the potential onset of ED in the aftermath of COVID-19.
One factor could be the effects of inflammation. “In many people, the damage to the body that occurs with COVID-19 isn’t from the virus itself but from the body’s response to the virus; COVID-19 triggers a state of ‘hyperinflammation,'” Mike Bohl, MD, MPH, from digital men’s health clinic Roman, tells Health. Hyperinflammation can cause small blood clots to form as well as inflammation of the endothelium, the lining of the blood vessels. “This endothelial dysfunction, plus the presence of blood clots, ultimately disrupts blood flow—and blood flow is of the utmost importance when it comes to getting an erection,” Dr. Bohl explains.
COVID-19 can also worsen an already existing heart condition, such as heart inflammation or an irregular heartbeat. Plus, many of the medications used to treat heart conditions—like beta-blockers—can cause erectile dysfunction as a side effect. “So there are potentially two things going on here: The COVID-19 virus and inflammatory molecules damaging the blood vessels, and medications causing side effects,” Dr. Bohl says.
Dr. Jannini highlights another study he co-authored, which was published in the Journal of Sexual Medicine in October. The researchers performed anxiety and depression tests on 7,000 Italian study subjects—who weren’t sick with COVID-19—during lockdown. The results showed that very “full and satisfactory sexual activity” served both as a preventive and curative measure for mental health issues during lockdown, supporting the argument that sexual activity is closely linked to mental health.
“Being in the right mindset is an important part of engaging in sexual activity and achieving an erection,” Dr. Bohl says. “Stress, anxiety, and depression have always been potential causes of erectile dysfunction.” As rates of those go up due to the pandemic, rates of erectile dysfunction may rise as well, he adds.
Because ED is usually a symptom of an underlying health issue, men with poor health may be more likely to develop ED and also to experience COVID-19-related complications. “The same people who are at major risk for COVID-19 complications are exactly the same people who have risk factors for ED, such as diabetes, cancer, respiratory problems, and cardiovascular disease,” Dr. Jannini says. “The virus hits these patients hard and is expected to exacerbate equal dysfunction after recovery.”
“Erectile dysfunction is a complex physiologic and psychologic disorder,” Jesse N. Mills, MD, associate clinical professor of urology and director of The Men’s Clinic at UCLA, tells Health. “A man has to have good nerve function, hormone (testosterone) levels, adequate blood flow, and a willing mind to have normal erections. COVID-19 causes severe physiologic and psychologic stress, which leads to lower testosterone levels and increased stress hormone release.”
Dr. Bohl points out that for the vast majority of patients, COVID-19 manifests as a respiratory illness, which includes difficulty breathing, coughing, and shortness of breath. “For those who become more severely ill, these issues can make it difficult to get enough oxygen into the bloodstream,” he says. “And when this happens, it can be harder to get an erection as well—oxygen is required to make nitric oxide, an important molecule in the sequence of steps required to achieve an erection.”
Dr. Mills points out another “even more concerning” hypothesis—that long term COVID-19 complications can lead to fibrosis of the erectile tissue. “Testosterone levels should bounce back when the acute infection subsides, and one would hope stress levels decline as well,” he says. “But if COVID-19 infection leads to fibrosis of the penile tissue, that’s a more difficult and less reversible condition to treat.”
There’s also evidence to suggest that SARS-CoV-2, the full name of the virus that causes COVID-19, has an impact on the testes. “SARS-CoV-2 enters cells with the help of a protein called ACE2—and ACE2 is prevalent in the testes,” Dr. Bohl says. Because this is where the majority of testosterone is made in men, COVID-19 may therefore cause a decrease in the amount of testosterone in the body.
“This is significant for two reasons,” says Dr. Bohl. “First, low testosterone itself can contribute to erectile dysfunction. And second, testosterone normally helps suppress inflammation in the body. But with lower testosterone, inflammation may not be as suppressed anymore. Therefore, the damage caused to blood vessels by pro-inflammatory molecules may be worsened because testosterone levels are decreased.”
More data is needed
Though a number of factors may explain why COVID-19 could cause ED, experts assert that much more research needs to be done. “Drugs like sildenafil (Viagra) were used in clinical trials in China to mitigate the pulmonary damage [caused by COVID-19], so it will be interesting to see if men that took the drug will have a lower rate of erectile dysfunction than men that did not take the drug,” Dr. Mills says.
Of course, if you have ED, that doesn’t mean you have—or have had—COVID-19. “Erectile dysfunction is actually pretty common, more common than people think,” Dr. Bohl says. “Estimates vary widely, but the Massachusetts Male Aging Study suggested that 52% of men between the ages of 40 and 70 experience some degree of erectile dysfunction.” If you or your partner is dealing with it, scheduling a checkup with a doctor is the first step to take to address the cause.