Research Keeps Finding Ties Between COVID-19 and Erectile Dysfunction

It might be helpful to start with a quick review of how erections work—and how they occasionally don't work. From there, it's possible to look at why it's feasible COVID could be implicated in ED.

For a man to get an erection, a series of interlocking systems must function in concert.

First, sensory and mental stimulation begin the process of arousal. This sends nerve signals that trigger the release of hormones, which tell the muscles of both corpora cavernosa in the penis to relax and allow blood to flow in.

Simultaneously, veins that normally allow the blood to flow out of the penis close and trap it. A thin sheath of membrane called the tunica albuginea that surrounds the internal structures of the penis also helps to trap the blood, resulting in an erection.

On a fundamental level, the systems involved include:

• Mental and physical stimulation
• Nerve signaling
• Hormonal release
• Blood flow

Given this list, along with what we know about how COVID-19 affects the body and mind, it's not a big leap to suggest the virus could have an effect on erectile function.

"Any systemic infection that causes an inflammatory response, like COVID or many other illnesses, can disrupt the homeostasis and affect your erections," said Neel Parekh, M.D., a men's fertility and sexual health specialist with Cleveland Clinic. "That's not surprising. Definitely, the more serious illnesses that require hospitalization, that's probably more likely to affect erections."

During the initial uncertain days of the COVID-19 outbreak, a small study came out that suggested men who contracted COVID were six times more likely to develop ED.

There were some issues with the study, somewhat amusingly titled, "Mask Up to Keep It Up." One criticism was that it used a very small sample; another was that the researchers showed a correlation but not necessarily a causal link between COVID-19 and ED.

Nonetheless, the importance of combating pandemic misinformation—including rumors that the vaccine, not the disease itself, causes ED—prompted a group of urologists to work with actor Tim Meadows to create a pro-vaccination public service announcement based on the research.

"So this study that showed you were six times more likely to develop ED, was that a great study? No. It was not a great study," said Amy Pearlman, M.D., the director of men's health at the Carver College of Medicine at University of Iowa Health Care, who appeared in the PSA. "The research is not great, but still, it's an important message. And, ultimately, anything that affects blood vessel function, overall wellness, hormones, and causes fevers and sickness, that will affect testosterone and erectile function.

Indeed, ongoing analysis appears to support the study's conclusions. More recent research from October 2022 found a high prevalence of ED in the study participants three months after COVID recovery. However, researchers suggested that two factors already known to be linked to ED predicted whether it would persist in these men: being older than 40 and having experienced major depression during their COVID infection.

Other research on long-haul COVID, while far from conclusive, appears to suggest a connection to ED, too. An April 2022 comprehensive review of all the relevant literature suggested many other symptoms of long-haul COVID could be linked to the increased prevalence of ED. These symptoms include neuropsychiatric issues such as:

• Brain fog
• Fatigue
• Anxiety
• Depression
• Sensory dysfunction

In addition, cardiovascular and respiratory symptoms persist, such as pulmonary fibrosis, myocarditis, endothelial dysfunction and more.

"You also have to take into account all the new medications these [long-haul COVID] patients are put on to treat clotting issues and other secondary medical issues," Parekh said. "And then there's the mental component, the psychological component to it, too. Depression can also affect it."

A much larger study pulled data for 66 million patients in 42 healthcare systems around the U.S. Researchers adjusted for age, race, body mass index (BMI) and any history of comorbidities, such as diabetes, high blood pressure and heart disease. They eliminated men who had previously been diagnosed with ED. In the end, a COVID-19 diagnosis was associated with a higher likelihood of developing ED.

And the evidence of a connection continues to emerge. Yet another review—this one a scoping review that examined data from 60 previous studies—concurred with others. Researchers found compelling evidence suggesting COVID-19 has a biological impact on erectile function, as well as a mental health impact.

Perhaps most concerning, one very small study found evidence that damaged endothelial cells in penis tissue collected from men who had previously been infected with COVID were correlated with the presence of COVID-19 cells. Researchers said this suggests the virus may continue to be present in the penis tissue long after the initial infection.

Research on COVID-19 and, specifically, the long-haul version is definitely a field in its infancy. However, seeing study after study suggest a link between the virus and ED is compelling, even if they can't explain exactly how all the connections work between COVID-19, ED and other health issues. What the research points to at the moment is that the best approach is to avoid getting infected in the first place.