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
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 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 COVID-19 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, 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 co-wrote 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. “But you also need to be in a good state of mind, and
you also need to be aroused. If any of these things go wrong, you may have an
issue getting an erection.”
In that sense, the pandemic is the perfect
confluence of converging factors for causing erectile dysfunction, said Dr
Joseph Katz, a professor at Florida College of Dentistry. Katz stumbled on the
issue of erectile dysfunction while investigating COVID-19’s effects on oral
health.
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. “It is through smells that the arousal
mechanism in the brain is ignited,” three Italian urologists wrote last year in
a letter responding to Jannini’s paper.
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.
The vessels may not constrict and stretch
as needed to allow for blood flow to the penis. Injury to the blood vessels may
also contribute to more serious complications of COVID-19, like heart attacks,
strokes and abnormal clotting.
“Our entire vascular system is connected;
it’s not an isolated penis problem,” said Dr T Mike Hsieh, director of the
men’s health centre at University of California, San Diego.
But vascular problems can manifest in the
sexual organs first, because the vessels there are so small. (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,” 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,” 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.”
Erectile dysfunction may point the way to
better diagnosis of long COVID-19, Jannini said, or even deteriorating mental
health.
“If you have a patient who survived COVID,
and you want to know if he has long COVID or not, just ask him how it’s going
in bed,” Jannini said. “If he’s having a normal sex life, the possibility of
him having serious long COVID is very, very low.”
Left untreated, erectile dysfunction can
lead to further complications. Cases of Peyronie’s disease, a condition that
causes curved, painful erections as a result of fibrous scar tissue built up in
the penis, and orchitis, the inflammation of one or both testicles, have
developed in men who have had COVID-19, according to published research.
Men who do not have normal erections for
several months at a time may develop scar tissue and fibrosis, which makes
erectile dysfunction harder to treat and may even lead to shortening of the
penis.
Erectile dysfunction can resolve on its
own, but Hsieh encouraged men with symptoms to see their physicians, and sooner
rather than later.
“If you’re having these problems, do not
wait,” he said. “For the most part, we can get the guys’ sex lives back.”
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