For a respiratory disease, Covid-19 causes 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 a completely unexpected consequence of Covid: erectile dysfunction. A connection has been reported in hundreds of articles by scientists in Europe and North America, as well as Egypt, Turkey, Iran, and Thailand.
Estimates of the magnitude of the problem vary greatly. An article by Dr. Ranjith Ramasamy, director of reproductive urology at the University of Miami Desai Sethi Institute of Urology, and his colleagues found that the risk of erectile dysfunction increased by 20 percent after a bout with Covid. Other researchers have reported substantially larger increases in that risk.
When patients began 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 doctors began to see a pattern, he said. “Six months after the initial infection, patients generally improved but continued to complain of these problems,” including erectile dysfunction and low sperm count, said Dr. Ramasamy, who has written several articles on the subject.
At the beginning of the pandemic, Dr. Emmanuele Jannini, professor of endocrinology and medical sexology at the University of Rome Tor Vergata, reported a strong link between erectile dysfunction and covid. When he compared men who had been sick with covid to those who hadn’t, he found that those who had been infected were nearly six times more likely to report impotence than those who had avoided coronavirus.
“Communicating that the disease can affect your sex life is a tremendously powerful message,” especially for men who are still resistant to vaccination, Dr. Jannini said in an interview. “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 can remain long after initial infection. Scientists say it’s too early to be sure the link to erectile dysfunction is causal, as many factors, both psychological and physiological, play a role in producing and maintaining an erection. The pandemic has led to social isolation and an increase 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 an article on the adverse impact of Covid on men’s health.
“You need good blood flow, you need nerves to fire, and you need good hormone levels, specifically testosterone,” he said. “But you also need to be in a good frame of mind, and you also need to be excited. If any of these things go wrong, you may have trouble getting an erection.”
In that sense, the pandemic is the perfect confluence of converging factors causing erectile dysfunction, said Dr. Joseph Katz, a professor at the Florida College of Dentistry. Dr. Katz stumbled upon the topic of erectile dysfunction while researching the effects of covid on oral health.
Some researchers speculate that erectile dysfunction may be related to the well-documented loss of the ability to taste and smell that Covid patients experience, because these senses play an important role in sexual arousal. “It is through odors that the arousal mechanism in the brain is turned on,” three Italian urologists wrote last year in a letter responding to Dr. Jannini’s article.
At a minimum, men need healthy blood vessels and good blood flow to develop and maintain erections. The coronavirus can damage blood vessels and the lining of the vessels, called the endothelium, as it binds to molecular receptors that are abundant on endothelial cells.
The vessels may not contract or stretch as needed to allow blood flow to the penis. Blood vessel injury can also contribute to more serious complications of covid, such as 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 University of California, San Diego’s Center for Men’s Health.
But vascular problems can first manifest themselves in the sexual organs, because the vessels there are very small. (Dr. Jannini calls erectile dysfunction “the canary in the coal mine” of cardiovascular disease.) Erectile dysfunction and cardiovascular diseases share risk factors, such as severe overweight, metabolic diseases such as diabetes, smoking and advanced age, which also increase the chances of having severe Covid.
“The penile artery is a tenth of 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, before you even see it in a larger vessel. . artery,” said Dr. Hsieh.
Erectile dysfunction can precede a heart attack by about five years, he said, and may be an early sign that there are other underlying risk factors.
“When I see a man for erectile dysfunction, he doesn’t just get a prescription for Viagra or Cialis,” Dr. Hsieh said. “They get a referral to a primary care colleague or a cardiologist to make sure his cholesterol is under control, his diabetes is under control, to talk about weight control, lifestyle or changes in diet”.
Erectile dysfunction can point the way to a better diagnosis of long-term Covid, Dr. Jannini said, or even deteriorating mental health.
“If you have a patient who is a Covid survivor and you want to know if they have Covid for a long time or not, just ask them how they are doing in bed,” said Dr. Jannini. “If you have a normal sex life, the chance that you will have a long and severe covid is very, very low.”
If left untreated, erectile dysfunction can lead to further complications. Cases of Peyronie’s disease, a condition that causes curved and painful erections as a result of a buildup of fibrous scar tissue in the penis, and orchitis, the inflammation of one or both testicles, have developed in men who have had covid, according to published research.
Men who do not have normal erections for several months at a time can develop scar tissue and fibrosis, which makes it difficult to treat erectile dysfunction and can even lead to penile shortening.
Erectile dysfunction can resolve on its own, but Dr. Hsieh encouraged men with symptoms to see their doctors, and sooner rather than later.
“If you have these problems, don’t wait,” he said. “For the most part, we can bring back the sex lives of the guys.”