Erections in the Time of COVID
Congratulations, you made it! 2020 is finally over. With the first coronavirus vaccines being distributed, we are finally seeing the beginning of the end of this viral pandemic. But we are still in the early stages of understanding the impact that the COVID-19 pandemic may have for years to come.
In addition to causing some pretty serious medical conditions such as blood clots, neurological issues, and long-term damage to the heart, lungs, and kidneys, researchers now believe COVID-19 may have detrimental effects on male sexual and reproductive health. As a sexual health specialist, I am fortunate not to be on the front lines of this pandemic, but will likely be responsible for addressing issues that arise later in those who recover from the virus.
As with many aspects of COVID-19, there are few data points available to indicate who will have long-lasting sexual side effects from their infection and who will not. Some of what we will discuss below is conjecture, and some is information born out of recent scientific publications. What we do know for sure is that the effects of the Coronavirus will continue to surprise us, and that even something seemingly unrelated to the mechanism of disease such as sexual function may be at risk.
We have talked before about the importance of testosterone on male sexual activity and function. In my previous blog, we discussed how testosterone production can be negatively affected by stress. Let’s review:
Chronic stress results in elevated cortisol levels, which in the long term increases your risk of anxiety/depression, heart disease, weight gain, difficulty sleeping, and memory and cognitive dysfunction. Cortisol is also a libido killer. It reduces blood flow to your penis and can decrease the amount of testosterone that your body produces.
2020 has been nothing but one long prolonged and stressful exercise, and all of that stress can most certainly affect your testosterone production. Contracting COVID-19 is taxing on the body as it creates a hyperinflammatory and immunosuppressed state. Specifically, inflammatory cytokines like TNF-α, IL-6 and IL-1β surge (Pederson). These same cytokines have been associated with the clinical progression of sexual dysfunction (Maiorino). And guess what doesn’t function well in these conditions? Testosterone production. One study suggested that men with COVID-19 had a significant deterioration of their serum testosterone levels (Çayan 2020).
A reduction in testosterone, as suggested above, is a sexual function saboteur. Lower testosterone levels often lead to a reduction in energy, decreased libido, and less spontaneous and reliable erections. As if the stress of a global pandemic wasn’t bad enough, now you may have to worry about being able to still get it up!
There’s a lot that goes into making an erection work. First, a man must be interested. That is to say, he must have a certain degree of sexual desire. Then mentally, he must become aroused. This psychological phenomenon is followed by signals released from our nervous system that turn up blood flow to the penis. The penis fills with blood and then, voila!
A lot can go wrong along the way if you become infected with the Coronavirus. After you contract the virus, it begins to replicate and result in an illness that can be detrimental to almost every system in the body. This includes messing with our cardiovascular system and hormonal production, both of which are crucial to erectile function.
The Coronavirus elicits a pretty strong immune response in our bodies, directly impacting the blood vessels in our heart, lungs, and, yes, penis.
Some of the symptoms that arise from this full-fledged attack on our cardiovascular system by the virus are ones you’ve probably heard about already. Blood clots in the lungs have been described, as well as clots leading to “COVID toes” and dead limbs requiring amputation. The penis is no different than any of these other end organs. A healthy erection requires normal, healthy blood flow and if COVID-19 disrupts this, then your erections and sex life will almost assuredly suffer.
The relationship between erections and COVID is convoluted. On the one hand, erectile dysfunction (ED) can result from coronavirus infection (for reasons discussed above). But ED at baseline may also predict which men may have poorer outcomes from COVID-19. Men in poorer health at baseline are at increased risk for erectile dysfunction. We also know that men in poorer health are more likely to have a more severe reaction to COVID-19. ED then can act as a canary in the coal mine and be the harbinger of more significant underlying cardiovascular problems and predict those most at risk for serious COVID-19 infection.
It’s clear that your erections are at particular risk during this pandemic, but not just from the virus itself. Beyond the physical effects of COVID, the psychological toll of the pandemic (from factors like isolation) and recovery for those infected by the virus can cause harm to your erections. Psychological stress is known to suppress libido, and anxiety can be a boner killer.
This may be especially true for those whose recovery is more complicated. These so-called “long-haulers” are people who have technically recovered from their infection but continue to experience persistent symptoms or side effects from COVID-19. Prolonged recovery can lead to a protracted period of psychological distress and may put long-haulers at increased risk for ED.
It’s hard to remember that COVID-19 has only been around a short time. There is still so much to be learned. For instance, we don’t know if men who develop ED as a result of coronavirus infection will one day regain normal erectile function. Like with other COVID-related conditions affecting our neurological and cardiovascular symptoms, there hasn’t been enough time passed for us to gather the necessary research to determine how long patients can expect ED to last.
There’s already plenty of reasons why you should do everything you can to avoid getting COVID-19, but now you can add erectile dysfunction to the list.
Another area of concern regarding the potentially lasting effects of COVID-19 infection is fertility. There have been reports of testicular damage caused by Coronavirus. This is thought to be due to the high expression of the ACE2 receptor, which the Coronavirus binds onto to enter our cells, in the testicle. This plethora of ACE2 may indicate that testicular involvement in COVID-19 occurs early after infection. In one study, examinations of testicular tissue from men who succumbed to COVID-19 revealed a reduction in testosterone-producing cells high in ACE2 along with swelling and inflammation (Yang). Because sperm-producing cells in the testicle also have an abundance of ACE2, one might assume similar effects on reproductive function from COVID-19 infection. Even sperm cells themselves have ACE2 receptor, which may explain why COVID-19 has been identified in semen (Li). Because the virus has been found in semen, issues surrounding sperm cryopreservation are essential to consider, especially for those men who may require assisted reproductive technology in the future.
The real effect of COVID-19 on fertility remains debatable. As with erections, we don’t know yet because so little time has passed. However, our knowledge of the virus thus far gives reason enough to suspect that male sexual and reproductive health could be negatively affected in men who survive COVID-19. Because ED can be a surrogate marker for cardiovascular and overall health, it could also be a valuable way to assess potential long-term health complications in survivors.
The effects of this pandemic will be with us for a while. As life slowly returns to normal, we will face unanswered questions about how our sexual and reproductive function may be impacted.
Given its effects on bodily systems important to male sexual function, men who survive COVID-19 infection may be dealing with the sexual aftermath for some time. I never thought I would play a significant part in this pandemic, but it is clear now that as a sexual health expert, I will need to be there to help put people’s lives back together once this is all over. Prioritizing sexual and reproductive health, along with practicing safe sex, is so vital to restoring one’s quality of life, and I am honored to step into that role.
Sansone, A., Mollaioli, D., Ciocca, G., Limoncin, E., Colonnello, E., Vena, W., & Jannini, E. A. (2020). Addressing male sexual and reproductive health in the wake of COVID-19 outbreak. Journal of endocrinological investigation, 1–9. Advance online publication. https://doi.org/10.1007/s40618-020-01350-1
Pedersen SF, Ho YC. SARS-CoV-2: a storm is raging. J Clin Invest. 2020;130(5):2202–2205. doi: 10.1172/JCI137647.
Maiorino MI, Bellastella G, Giugliano D, Esposito K. From inflammation to sexual dysfunctions: a journey through diabetes, obesity, and metabolic syndrome. J Endocrinol Invest. 2018;41(11):1249–1258. doi: 10.1007/s40618-018-0872-6.
Çayan S, Uğuz M, Saylam B, Akbay E. Effect of serum total testosterone and its relationship with other laboratory parameters on the prognosis of coronavirus disease 2019 (COVID-19) in SARS-CoV-2 infected male patients: a cohort study. Aging Male. 2020 Sep 3:1-11. doi: 10.1080/13685538.2020.1807930. Epub ahead of print. PMID: 32883151.
Yang M, Chen S, Huang B, Zhong JM, Su H, Chen YJ, et al. Pathological findings in the testes of COVID-19 patients: clinical implications. Eur Urol Focus. 2020 doi: 10.1016/j.euf.2020.05.009.
Li D, Jin M, Bao P, Zhao W, Zhang S. Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019. JAMA Netw Open. 2020;3(5):e208292. doi:10.1001/jamanetworkopen.2020.8292