When N., a 23-year-old man from western Massachusetts, got sick with Covid, he knew he might be in for a tough time. He ultimately had to quit his job because he was so ill.
What he did not expect was that the virus would affect his sexual health, depriving him of the ability to get and maintain an erection, and bringing multiple diagnoses and treatments, none of them effective.
“Peeing is off, erections are off, ejaculation is off. Just none of it is right,” N. told ClearHealthCosts. “And [the doctors] have zero idea what’s going on.”
As we learn more about Covid, we discover the numerous and unexpected ways in which the virus can affect the body. One such area is the effect of Covid on sexual and reproductive health, a topic that is only somewhat clinically acknowledged, and not widely discussed.
In September 2020, ClearHealthCosts reported on this topic after speaking with numerous women who shared stories of bizarre reproductive health symptoms after they became ill with Covid.
The women, who varied widely in age, background, and location, reported symptoms that included changes in menstrual cycles and sex drive, the appearance of illness and pain that correlate with times of menses, changes in severity of pre-existing conditions, and even the return of menstrual-associated symptoms and menses in post-menopausal women.
Far fewer men shared their experiences. But there have been a number of reports, both anecdotal and clinical, of men around the world experiencing sexual health challenges, particularly erectile dysfunction (ED) and pain following Covid infection.
Early in the pandemic, ClearHealthCosts noted booming site traffic on posts about Viagra sales and birth control pills, and a decline in traffic on a post on abortion costs.
“Some physicians attribute the record numbers of men experiencing impotence to psychological stress and increased alcohol consumption during quarantine,” ClearHealthCosts wrote. “However, there are some indications that the virus itself may be affecting male reproductive health.”
At 23, he had a severe case of Covid
N., who spoke on the condition that we use only his first initial, got sick with what he believes to be Covid last August.
Around a month later, he began experiencing a plethora of symptoms, including what he described as “crushing fatigue,” loss of coordination, shortness of breath, dizziness, joint pain, tachycardia and bradycardia. The symptoms became so severe that N. was forced to quit his job, he said in a telephone interview.
A specialist diagnosed him with Chronic Fatigue Syndrome (CFS), but the symptoms did not quite add up. After doing some research and talking to other people, N. became certain that he was suffering from “long Covid,” the lingering and debilitating illness that develops in some people following a Covid infection.
N.’s symptoms have persisted to this day, close to a year later, which is often the case in people with long Covid.
About two months ago, N. said he began experiencing some concerning sexual health issues, which he believes are related to long Covid.
Sexual dysfunction
While on a trip to the store, N. said, something “didn’t feel right,” and he experienced some difficulty urinating. Unable to do anything about it at the time, N. put the issue to the side.
“I remember that night, showering, and things were really off,” N. said. “[My genitals were] kind of shrunken and tender and it almost seemed like there was some sort of weird inflammation going on. It scared me bad. And then I was like, alright, well let’s see if I can get it up. I masturbated and…I couldn’t. Then I was like oh no, something’s really wrong.”
N. had never had issues with maintaining an erection before, but doctors at the ER told him that he was experiencing run-of-the mill erectile dysfunction, and that the pain and shrinkage were all in his head.
“The thing that baffled me was that they were like, ‘we don’t think it’s appropriate to go see a urologist based on what you’re presenting,’” N. told ClearHealthCosts. “[They said] ‘you should just go and check in with your primary care doctor, but we’ll give you the urologist’s number, just in case.’ And I’m like, okay, so it wasn’t enough to dismiss me and just say it was all in my head, but now you’re telling me that I’m overreacting to a point that my primary care doctor can just handle this? I did both. I went to my primary care and I called the urologist in this area.”
Still more symptoms
Around that time, N. said he began experiencing symptoms that resembled those of a urinary tract infection (UTI), including pain and pressure in the bladder area and burning during urination. N. said he has not been sexually active since becoming ill, so sexually transmitted infections were off the table as potential explanations.
N.’s primary care physician told him that he did not have a UTI, but that he might be experiencing “the male equivalent of a yeast infection.” When medication for that failed to alleviate his symptoms, N. saw a urologist.
The urologist suggested that N. might have an enlarged prostate. They also diagnosed him with balanitis, an inflammation of the foreskin and head of the penis, and recommended circumcision. N. said he was concerned that the doctors seemed to have no interest in examining what might be the root cause of his symptoms, particularly since he had never experienced any such issues before.
The urologist gave N. cream for the balanitis and prescribed Flomax for the enlarged prostate. N. said he used the cream, but did not use the Flomax, as his research showed it might be dangerous in combination with some of his long Covid symptoms.
Painful ejaculation, decreased sex drive
N. said that the cream did not help and his symptoms worsened. Ejaculation also became painful. He went back to his primary care doctor. They prescribed him doxycycline. N. said his symptoms improved for about a week, then became much worse. He also developed discoloration around the head of his penis, a new symptom.
He saw his primary care physician yet again, and they prescribed Diflucan, a medication for yeast infections. This did nothing.
N. said he has also been experiencing decreased sex drive, but he is not certain if this is a specific symptom, or if it is being caused by reactive depression to his situation. He is currently waiting to see a urology specialist at Mass General in Boston.
Sex drive and ability to perform
John Price, a 42-year-old man from Kansas City, Mo., tested positive for Covid in March of last year. Since then, he said, he has experienced symptoms of long Covid, including brain fog, fatigue, tachycardia and more. In November he had what he believed might be another case of Covid.
Since he first became ill in March 2020, Price told ClearHealthCosts in a phone interview, both his desire to have sex and his ability to perform sexually have been non-existent. He has not been able to maintain an erection.
Price said that he believes there may be many other men experiencing sexual health issues related to Covid, but that people are simply not talking about it.
“Our society doesn’t allow men to talk about reproductive health issues that they have, without it becoming a joke and making a mockery out of it,” Price said. “The only way that we’re going to change things so that men can start speaking openly about their more, shall we say, sensitive health issues is if we continue to battle — and I hate this term, but it fits — toxic masculinity, where a man is not a man unless they ‘man up, tough it out and deal with it themselves.’”
Existing ED correlated with higher risk of severe Covid
This March, a study was carried out by researchers at the Department of Systems Medicine at the University of Rome Tor Vergata in Rome. The study, partially entitled “Mask Up to Keep It Up,” was one of the first to examine the relationship between erectile dysfunction (ED) and Covid-19.
The researchers found that the prevalence of erectile dysfunction was significantly higher in men who had a reported diagnosis of coronavirus.
The reason for this, researchers believe, is twofold, and is due to endothelial dysfunction, an impairment of the layer of cells lining blood vessels in the body, which typically regulate exchanges between the bloodstream and surrounding tissues.
Endothelial dysfunction, which causes erectile dysfunction, can increase the risk of severe Covid in those who already have it, and can also arise as a result of Covid.
Studies have shown that vascular endothelial cells can be infected by the coronavirus, and widespread endothelial injury and inflammation has been found in individuals with advanced cases of Covid.
Endothelial dysfunction is also a common feature of the key comorbidities that increase risk for severe illness when infected with Covid.
Other high risks of serious Covid
Because erectile dysfunction is “a clinical marker and predictor of non-communicable chronic diseases, particularly cardiovascular” (illness known to increase risk of severe Covid infection), individuals with erectile dysfunction are thus more likely to have one of these non-communicable diseases, which could potentially give them a higher risk of contracting Covid-19, or a more severe case of Covid.
“It has been very clearly demonstrated that non-communicable diseases — like oncological diseases, pulmonary diseases, metabolic diseases, and cardiovascular diseases — these four non-communicable diseases are altogether the main risk factor for having Covid,” Dr. Emmanuelle A. Jannini, full professor of endocrinology, andrology and sexual medicine at the Department of Systems Medicine at the University of Rome Tor Vergata, told ClearHealthCosts in a video interview.
“It’s one of the reasons why young people usually are not subjected to COVID-19, because they usually do not have these non-communicable diseases as are present in the middle and late age… What we demonstrated is that, in fact, since those non-communicable diseases are, indeed, the risk factor for erectile dysfunction, they’re also a risk factor for Covid. So, erectile dysfunction is, let’s say, the best biomarker of Covid in some ways.”
Lifestyle factors
Lifestyle and depression, Dr. Jannini said, are also important factors influencing likelihood to experience erectile dysfunction as well as susceptibility to Covid.
“It is much more easy to get Covid, to have pneumonia, to have severe Covid, if you are obese, if you are drinking too much alcohol, if you are not moving enough,” Dr. Jannini said. “All those things are tremendously related to the lifestyle. So, the lifestyle at the end of the story, is in the center of all the things. It is producing erectile dysfunction, it is producing non-communicable diseases, it is producing Covid. Or better, it is producing the risk of Covid. Of course, Covid is coming from a virus, but the risk of Covid is definitely very much related to the lifestyle.”
Endothelial dysfunction, Dr. Jannini said, can also affect women’s reproductive health, specifically in their ability to create lubrication and become aroused. However, he said, the effect is not as readily apparent as erectile dysfunction is in men.
“The same mistakes in [lifestyle] affect the ability to lubricate, the ability to get aroused…and so, they should also provoke the same risk of Covid,” Dr. Jannini told ClearHealthCosts. “But the problem, scientifically speaking, is that complaints about, say, 25 to 30% reduction in lubrication is not the same as a patient of the same age with 25 or 30% reduction in erection. In other words, a man with a 30% reduction in erection is impotent, is almost unable to have sex. A girl having a 25, 30, even 40% reduction in lubrication, she does not feel anything. It is a symptom which is not relevant to them. It is relevant actually, but that the subject is not perceiving it as a problem.”
Covid may directly attack the male sex organs
Prior studies have noted that the Covid virus can act directly on the testes, another factor contributing to the development of erectile dysfunction and other reproductive health issues in men who have been infected with Covid.
There have been several official reports of men developing testicular pain after becoming ill with Covid, including a Harvard Medical School case report of a 42-year-old man who experienced severe testicular and abdominal pain as his first symptoms of Covid, and a similar case report of another such patient by researchers at the University of Modena and Reggio Emilia in Italy.
A study published this May in the World Journal of Men’s Health reported that researchers found coronavirus particles in penile tissue samples taken from two male Covid patients who both became impotent after infection. The samples were taken 6-8 months after initial infection, indicating that the virus may linger in the penis, long after initial infection.
The study also revealed evidence of endothelial dysfunction in the penises of Covid patients, further confirming Dr. Jannini’s earlier findings.
“COVID-19 can enter the endothelial cells and affect many organs, including the penis,” said senior researcher Dr. Ranjith Ramasamy, director of the reproductive urology program at the University of Miami’s Miller School of Medicine. “In our pilot study, we found that men who previously did not complain of erectile dysfunction developed pretty severe erectile dysfunction after the onset of COVID-19 infection… We found that the virus affects the blood vessels that supply the penis, causing erectile dysfunction.The blood vessels themselves malfunction and are not able to provide enough blood to enter the penis for an erection.”
The researchers compared the damage in the patients’ penises to damage seen in other organs in Covid patients, including the lungs, kidneys, and brain. “We think the penis also could be affected in a similar way,” Dr. Ramasamy told WebMD. “We don’t think this is a temporary effect. We think this could be permanent… [Our findings] suggest that men who develop COVID-19 infection should be aware that erectile dysfunction could be an adverse effect of the virus, and they should go to a physician if they develop ED symptoms.”
SARS-CoV-2, the virus responsible for Covid, is thought to enter into host cells by binding to a type of protein called angiotensin-converting enzyme 2 (ACE-2). Studies have previously found that “the organ involvements of SARS correlated with organ expression of ACE-2.” This means that any cells expressing ACE-2 may be susceptible to SARS-CoV-2 infection.
Researchers have also noted that receptors for this enzyme are quite abundant in the testes, suggesting a potential vulnerability of the male gonads to Covid infection.
Last spring, a study carried out by researchers in Wuhan, China, examined the sex hormone profiles of men with Covid in comparison to healthy, age-matched individuals. The researchers determined significant differences between the two groups, specifically that “serum luteinizing hormone (LH) levels were elevated and the ratio of testosterone (T) to LH and the ratio of follicle stimulating hormone (FSH) to LH were dramatically decreased in males with Covid-19.”
“This study,” the researchers wrote, “provides the first evidence about the alteration of sex-related hormones under Covid-19…[and should alert] more attention to gonadal function evaluation among patients recovered from SARSCoV-2 infection, especially in reproductive-aged men.”
Covid correlated with development of erectile dysfunction
There are thus multiple contributing factors to the potential for men with Covid to develop erectile dysfunction, Dr. Jannini said. In addition to endothelial dysfunction and Covid’s ability to act directly on the testes and reduce testosterone levels, Covid can induce pneumonia, which reduces blood-oxygen concentration, another main contributor to erectile dysfunction.
“So, you have a vascular reason, respiratory reason, endocrine reason; effects on the endothelium, lung and testes,” Dr. Jannini said. “But there is a fourth reason, which is very, very important, and that is depression coming after the severe disease. Even if you are very happy because you survived, you may have lost a lot of things. And also, unfortunately, many of [the survivors] are not completely healthy. After the virus, many of them have some lasting problems. Respiratory problems, bad feeling, etc. And all those things are of course impacting the mood and producing a kind of reactive depression. The reactive depression is indeed one major cause of erectile dysfunction.”
A fifth potential reason, Dr. Jannini said, could perhaps be Covid’s ability to destroy, at least temporarily, scent receptors in the nose, causing ansomnia, the loss of smell, one of the hallmark symptoms of the virus.
It has been demonstrated, Dr. Jannini told ClearHealthCosts, that the human sexual response is in a very small way related to odors and the ability to sense pheromones. Thus, a loss of sense of smell due to the virus could perhaps affect sexual response, such as the ability to get an erection, in some way.
Dr. Jannini said that this connection has not yet been formally studied, but that it is something he hopes to look into in the future. Another future project of his is a study of the effect of Covid infection on orgasm intensity.
The physical effects for someone like N. have been profound. But that’s not all.
“It’s just…being a guy, there’s that whole piece of it,” N. said. “Like, it is, unfortunately, a very large symbol of manhood. At least even just internally, like my ego and my pride. And then also being 23 and having all these issues, you know, like, I don’t know what’s going to happen, if it’s going to get better. Is it going to not get better?
“And dating and intimacy, how’s that going to work? And then, you know, I do want to have kids someday.”
