Risk for Erectile Dysfunction Sixfold Higher in Men With COVID-19

Becky McCall

April 06, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

COVID-19 increases the risk of developing erectile dysfunction (ED) by nearly sixfold, according to data from the first study to investigate the association between ED and COVID-19 in young men in a real-life setting.

The preliminary data also indicated that ED is a marker of increased susceptibility to SARS-CoV-2 infection. Men with ED are more than five times more likely to have COVID-19 (odds ratio [OR] = 5.27).

For men with a history of COVID-19, the OR of developing ED was 5.66. The strength of the association remained after adjusting for factors considered to affect ED.

The study, which was led by Emmanuele A. Jannini, MD, professor of endocrinology and medical sexology, University of Rome Tor Vergata, Rome, Italy, was published on 20 March in Andrology.

"Mask Up to Keep It Up"

ED can be both a short-term and a long-term complication of COVID-19, he suggests.

"When offered, men should have the COVID vaccination. It also gives a whole new meaning to wearing the mask ― mask up to keep it up," says Jannini. "It could possibly have the added benefit of preventing sexual dysfunction."

He points out that older age, diabetes, high body mass index (BMI), and smoking increase the risk of contracting COVID-19.

"These are the same as risk factors for ED. Results of our study agree with the pathophysiological mechanisms linking ED, endothelial dysfunction, and COVID-19. Basically, endothelial dysfunction is common in both conditions [COVID-10 and ED].

"We would like to find some sort of biomarker of endothelial dysfunction post COVID, because it seems that there are many sequelae that coexist for a long time after infection," added Jannini. "Asking a patient if they have ED after COVID might provide a measure of systemic wellness."

Allan Pacey, MD, professor of andrology at the University of Sheffield, Sheffield, United Kingdom, welcomed the research, noting, "This seems to be a well-conducted study. However, at the moment, the relationship is just a correlation, and it might be that some of the comorbidities that increased the men's chances of getting a significant COVID-19 infection may have also independently increased their chances of erectile dysfunction.

"But the authors offer a plausible mechanism by which COVID-19 may impact directly on erectile function," agrees Pacey. However, "There’s more work to be done," he said. "I'd also argue it's a good reason for men to wear a mask, practice social distancing, and take the vaccine when it's offered to them."

Urologist John Mulhall, MD, from Memorial Sloan Kettering Cancer Center, New York City, remarked, "It was a highly preliminary study, but the data are suggestive of a potential link between COVID-19 infection and ED.

"However, it raises enough questions such that further large, more long-term analyses are required to define causation. Future studies assessing testosterone levels and erectile hemodynamics will be needed to provide definite evidence of a causative link," he stressed.

Erectile Problems a "Hallmark" of Systemic Endothelial Dysfunction

Prior research has suggested that asymptomatic COVID-19 could be associated with subclinical microvascular involvement with long-term cardiovascular effects.

"Indeed, COVID-19 is by all means an endothelial disease, in which systemic manifestations...can potentially be due to alterations in the endothelial thrombotic/fibrinolytic balance," emphasized Jannini. "In addition, endothelial cells express many of the cofactors used by SARS-CoV-2 to invade host cells.

"Erectile dysfunction has often been considered a hallmark of endothelial dysfunction, and as such, a potential association between ED and COVID-19 has also been postulated and underpinned the investigation in this study," he explained.

The study was predicated on the fact that ED is often considered a clinical marker of impaired overall health status, which often features cardiovascular events at an early age. It aimed to investigate the bidirectional relationship between COVID-19 and ED. It asked whether ED could be a risk factor for contracting COVID-19 and whether having COVID-19 predisposes to developing ED.

"This would possibly suggest that men with ED, due to the underlying conditions which impair erectile response, could also be more susceptible to contracting COVID-19," said Jannini.

Data were drawn from the Sex@COVID online survey, which was conducted from April 7 to May 4, 2020, in Italy. The survey included 6821 participants aged 18 years or older (4177 women; 2,644 men; mean age, 32.83 ± 11.24 years). Participants were stratified on the basis of marital status and sexual activity during lockdown. From these participants, 985 sexually active men were identified, among whom 25 (2.54%) reported having tested positive for COVID-19. These persons were matched with 75 COVID-19-negative men using propensity score matching in a 1:3 ratio.

The researchers used standardized psychometric tools to measure the effects of lockdown and social distancing on the intrapsychic, relational, and sexual health of the participants.

Erectile function was measured with the International Index of Erectile Function or the Sexual Health Inventory for Men, which are often used in clinical settings. In light of the two-way interaction between sexual activity and psychological well-being, results were adjusted for any influence of anxiety and depression, which were measured with recognized scales for use in patients with a history of COVID-19.

Results showed that the prevalence of ED was significantly higher among men who self-reported a history of COVID-19 compared to a matching COVID-negative population (28% vs 9.33%; P = .027).

After adjusting for variables that are considered to have a bearing on the development of ED, such as psychological status, age, and BMI, the OR for developing ED after having had COVID-19 was 5.66 (95% CI, 1.50 – 24.01).

Similarly, after adjusting for age and BMI, men with ED were more likely to have COVID‐19 (OR, 5.27; 95% CI, 1.49 – 20.09).

The authors note that persons who experience "a sudden onset or worsening of ED might also consider precautionary quarantine or nasopharyngeal swab, as COVID‐19 might act as a potential initiating trigger for the onset of erectile impairment, or an aggravating factor for its progression to more severe forms."

Similarly, patients who have ED "should consider their erectile impairment as a sign of possible underlying conditions that could increase the likelihood of suffering from COVID‐19," they write.

Mulhall highlighted several limitations of the study, including its retrospective nature, recall bias associated with the use of online questionnaires, and the inclusion of COVID‐19 diagnoses that were based on the response to the survey rather than on testing with nasopharyngeal swabs. In addition, comorbidity data were incomplete, and there was no indication of duration after COVID-19 infection, the severity of COVID-19, or the severity of ED.

The authors have disclosed no relevant financial relationships. Pacey is chairman of the advisory committee of the UK National External Quality Assurance Schemes in Andrology, editor-in-chief of Human Fertility, trustee of the Progress Educational Trust, and trustee of the British Fertility Society (all unpaid). Mulhall has disclosed no relevant financial relationships.

Andrology. Published online March 20, 2021. Full text

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