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ORIGINAL ARTICLE
Year : 2023 | Volume
: 34
| Issue : 1 | Page : 33-38
Does erectile dysfunction develop following COVID-19 infection?
Mustafa Karabiçak1, Hakan Türk2
1 Department of Urology, Batman Training and Research Hospital, Batman, Turkey
2 Department of Urology, Usak University Faculty of Medicine, Usak, Turkey
Correspondence Address:
Mustafa Karabiçak
Department of Urology, Batman Training and Research Hospital, Batman
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_18_22
Purpose: Coronavirus disease 2019 (COVID-19) is a disease that can affect many of our organs, and its effects on the human body are still unknown. In this study, we aimed to find the answer to the question of whether erectile dysfunction (ED) develops in patients who had COVID-19. Materials and Methods: This is a prospective study of 459 patients. Married male patients aged between 25 and 70 years and who were hospitalized and treated for COVID-19 were included in the study. The patients were divided into three groups as mild, moderate, and severe cases, according to the extent of the disease. Each patient was asked to complete the International Index of Erectile Function (IIEF) upon admission and 45th and 90th days after discharge. Admission, 45th and 90th values of IIEF were compared within itself. Results: Statistically significant differences were observed in the IIEF evaluations on admission and 45th and 90th days of the patients in the three groups. IIEF values of three patient groups displayed a decrease on the 45th day with respect to admission, while the 90th day values were higher in comparison to 45th day, although still remained lower than the values of admission. Evaluation of the erectile function values of the patients revealed that IIEF values on admission decreased on 45th and 90th day values. Conclusions: We determined that COVID-19 affected IIEF values in male patients, which might cause ED by reducing erectile function values.
Keywords: COVID-19, erectile dysfunction, IIEF, SARS-CoV-2
The World Health Organization (WHO) designated the coronavirus 2 (SARS-CoV-2) infection outbreak, which began in Wuhan, China, in December 2019, as coronavirus disease 2019 (COVID-19). COVID-19 spread rapidly throughout the world and it was officially declared a pandemic by the WHO in March 2020, due to causing more than 4000 deaths.[1]
When the virus enters the body, it binds to angiotensin-converting enzyme 2 (ACE2), causing the infection to begin in the lungs.[2] ACE2 is also secreted in tissues such as the small intestine, the testicles, the kidneys, the heart, the thyroid, and the blood vessels. This suggests that SARS-CoV-2 may pose a threat to the digestive, urogenital, circulatory, and respiratory systems.[3] Furthermore, recent research has shown that SARS-CoV-2 causes vascular dysfunction, inflammation, and thrombosis in endothelial cells.[4]
The causes of erectile dysfunction (ED) are reclassified as organic, psychogenic, or mixed. Among organic EDs, vasculogenic ED is the most common. Endothelial dysfunction, subclinical inflammation, and androgen deficiency are some of the causes.[5]
People's social life changed as a result of the pandemic, and sexual contact patterns changed as a result of the risk of COVID-19 transmission.[6] Endothelial damage caused by COVID-19, as well as limitations and psychological factors caused by pandemic measures, can all have an impact on people's erectile function. The purpose of this study was to determine whether ED develops in patients who had COVID-19.
MethodsThis is a prospective single-center study. The study included male patients hospitalized with a preliminary diagnosis of COVID-19 between May 2020 and September 2020. Participation in the study was entirely voluntary. The patients were married and ranged in age from 25 to 70 years. All patients had polymerase chain reaction (PCR) positivity or a COVID-19 finding on thorax computed tomography (CT). The current study protocol was reviewed and approved by the Institutional Review Board of Uşak University College of Medicine (approval number: 85-85-12). When they were enrolled, all subjects provided informed consent.
Each patient's age, comorbidities, length of hospital stay, and thoracic CT findings at admission were recorded. According to the severity of COVID-19, the patients were divided into three groups. Patients with uncomplicated positive PCR but normal thorax CT findings were classified as mild cases, whereas patients with bilateral diffuse involvement in thorax CT were classified as severe cases and all other patients as moderate cases.[7]
The clinic doctors asked the patients to fill out a 15-item International Erectile Function Form (IIEF).[8],[9] Patients were asked to fill out the IIEF form based on their sexual orientation before contracting COVID-19. In the severe patient group, it was necessary to wait a few days for the patient's general condition to improve before filling out the IIEF form. Patients whose general condition prevented them from completing the IIEF form were not included in the study. Following discharge, the staff contacted them by phone and had them complete the IIEF on the 45th and 90th days. Patients who could not be reached by phone or who did not engage in sexual activity after discharge were barred from participating in the study. The study excluded seven patients who deteriorated and died in the hospital.
Statistical analysis
The Kolmogorov–Smirnov test was used to determine whether the data conformed to a normal distribution. The Kruskal–Wallis test was used for in-group evaluations of mild, moderate, and severe COVID cases, and the Bonferroni-corrected Mann–Whitney U test was used for post hoc evaluations. As a post hoc analysis, features that were not normally distributed repetitively were examined using a Friedman test and pairwise signed-ranks test. For numerical variables, Median Quartile 1 and Quartile 3 were provided as descriptive statistics, while number and percentage values were provided for categorical variables. For statistical analysis, the SPSS Windows version 23.0 (Armonk, NY, USA, IBM Corp.) package program was used, and P < 0.05 was considered statistically significant.
ResultsFollowing the application of exclusion criteria, 459 patients were accepted into the study. Fifty-eight patients were classified as mild, 256 as moderate, and 145 as severe. The mean age of the patients was 51.85 ± 12.04 years. There were 67 patients with hypertension, 70 with diabetes mellitus, 18 with coronary artery disease, and 37 with chronic obstructive pulmonary disease. The mean hospitalization period of the patients was 7.53 ± 3.38 days. [Table 1] displays demographic information about the patients.
There were statistically significant differences in the evaluations of IIEF filled in on admission, as well as on the 45th and 90th days (P < 0.001). The post hoc test revealed that IIEF values at the time of admission decreased statistically significantly on the 45th and 90th days (P < 0.05). When we looked at the subgroup IIEF values, we found that patients' erectile function and sexual and general satisfaction were statistically significantly different on admission, as well as on 45th and 90th days (P < 0.001). The post hoc test revealed statistically significant decreases in erectile function and sexual and general satisfaction on the 45th and 90th days following admission (P < 0.05). There were also statistically significant differences in patients' orgasmic function with libido values on the 45th and 90th days after admission (P < 0.001). In the post hoc test, patients' orgasmic function and libido values were decreased statistically significantly on the 90th day after admission (P < 0.05) [Table 2].
Table 2: Changes in international index of erectile function and subgroup international index of erectile function values between admission, 45th day, and 90th dayExcept for general satisfaction values, statistically significant differences were observed in the IIEF values of admission, 45th day, and 90th day, as well as in the subgroup values for mild cases [Table 3].
Table 3: Changes in international index of erectile function and subgroup international index of erectile function values of mild cases between admission, 45th day, and 90th dayExcept for libido, the IIEF values and subgroup values in moderate cases showed statistically significant differences between admission, 45th day, and 90th day [Table 4].
Table 4: Changes in international index of erectile function and subgroup international index of erectile function values of moderate cases between admission, 45th day, and 90th dayThere were statistically significant differences in the IIEF and subgroup IIEF values on admission, 45th day, and 90th day for severe cases [Table 5].
Table 5: Changes in international index of erectile function values of severe cases between admission, 45th day, and 90th dayWhen we examined IIEF values in all three patient groups, we found a decrease in 45th day values compared to admission, while 90th day values were higher compared to 45th day, but remained lower than admission values [Figure 1].
Figure 1: IIEF variation by COVID-19 severity in patients. IIEF: International Index of Erectile FunctionWhen we examined the erectile function of the patients in all three groups, we found that the values obtained on admission decreased on the 45th day and that the 45th and 90th day values were compatible [Figure 2].
Figure 2: Erectile function data with respect to COVID-19 severity in patients Discussion There are currently insufficient data on the effects of COVID-19 on sexual behavior and erectile function. In a study of young men and women conducted in China, 25% had decreased libido, 37% had decreased frequency of sexual intercourse, and 35% had decreased satisfaction with sexual intercourse.[10] We found a decrease in libido, sexual satisfaction, and orgasmic function values in our study as well. COVID-19 was found to cause a 22% decrease in libido and a 41% decrease in the frequency of sexual intercourse in another survey study conducted in China.[11] Similarly, in our study, we discovered low libido levels. We observed that total IIEF and subgroup IIEF values, including erectile function, orgasmic function, libido, sexual and general satisfaction, decreased on the 45th and 90th days, which was consistent with previous research.
When we looked at the patients in groups, we noticed that the total IIEF and subgroup IIEF values of all three groups were significantly lower on the 45th and 90th days. COVID-19 was found to increase the rates of depression and anxiety, in the general population and those who had COVID-19.[12],[13] Depression and anxiety have been shown to interfere with the erection mechanism by inhibiting the nervous system's spinal erection center.[14] Furthermore, the stress caused by being isolated at home, as well as the increasing economic concerns during this period, has a significant impact on sexual life.[6] On the other hand, it is unknown whether COVID-19 is sexually transmitted, but the possibility of transmitting COVID-19 through physical contact and kissing may deter healthy sexual intercourse.[15] Sexual activity and mental and psychological health are inextricably linked. In a study conducted in Turkey with 148 men comparing pre- and postpandemic periods, statistically significant decreases in erectile function, orgasmic function, and sexual and general satisfaction values were found in the postpandemic period, as well as a nonstatistically significant decrease in libido.[16] These findings are consistent with our research. Furthermore, no significant libido difference was found in our study's moderate patient group. We attribute this to the increased time spent at home as a result of pandemic isolation. In the postpandemic period, there was a statistically significant decline in erectile function values, according to a study conducted in China.[17] In an Italian study using an online survey, men's libido and frequency of sexual intercourse were found to be lower during the pandemic period compared to the prepandemic period.[18] The studies' samples were drawn from the general population. The pandemic's impact on sexual life was based on restrictions, as well as depression and anxiety during this period. Our study is consistent with these previous studies; however, COVID-19 patients were also included in our study.
The IIEF values in all three patient groups decreased on the 45th day compared to admission, but increased again on the 90th day compared to the 45th day, though still below the initial values at admission. We interpreted this increase on the 90th day as patients' efforts to adapt to existing conditions and normalize as the pandemic process progressed. Similarly, all three groups' erectile function values noted on admission decreased on the 45th day, and the 45th and 90th day values were found to be compatible. In contrast to IIEF values, the fact that erectile function values remained low on the 90th day prompted us to wonder whether the erection mechanisms in these patients were affected by COVID-19. Recent research has shown that ED is associated with endothelial dysfunction. Erectile function necessitates vascular integrity.[19] COVID-19-related vascular damage can affect the vascular bed of the penis, leading to ED.[4],[20] As it is known, when SARS-CoV-2 enters the body, it binds to ACE2. Leydig cells also secrete this enzyme. As a result, testicular damage may occur as a result of COVID-19 in patients, and subsequently, hypogonadism may develop due to decreased rate of testosterone luteinizing hormone and may lead to ED.[21] Hormonal evaluations such as testosterone and luteinizing hormone were not performed in our study because patients participating in the study were provided with telephone communication.
Thrombotic events occur frequently in COVID-19 disease. Thrombotic events were found to occur at a rate of 31% in a study where 184 patients.[22] Other than microvascular thrombosis studies reported macrovascular thrombosis. Small fibrin thrombi were found in both damaged and intact lung parenchyma, as well as superficial dermal vessels.[23] In a postmortem study of 12 patients who died as a result of COVID-19, deep vein thrombosis was found in 7 of them. Again in the same study, thrombosis was found in the prostatic venous plexus in 6 of 9 male patients.[24] In our study, we discovered a decrease in the patients' erectile functions. Based on the evidence, this could be one of the causes of post-COVID-19 ED.
In a case series of 214 patients with COVID-19 published in China, neurological complications, in addition to systemic symptoms, were observed in 36.4% of the patients. Among the most common neurological findings were headache, dizziness, impaired consciousness, encephalitis, encephalopathy, cerebrovascular disease, peripheral nervous system damage, and neuromuscular disorders.[25] Several mechanisms have been proposed to explain the neural damage that may occur as a result of COVID-19. One of these, and the most prominent, is the ACE2 receptor-mediated mechanism. ACE2 receptor, which enables SARS-CoV-2 to infect human cells, is found in the nasal mucosa, lung parenchyma, lymphoid tissue, gastrointestinal tract, urinary tract, reproductive organs, vascular endothelium, and brain. Having said that, SARS-CoV-2 was thought to have achieved neural invasion by isolating a similar virus in the brain tissue via genomic sequencing from CSF obtained from patients diagnosed with encephalitis and in postmortem studies.[26] Furthermore, the presence of COVID-19 cases in the literature presenting with peripheral facial paralysis and Guillain–Barré syndrome suggests that the virus affects peripheral nerves.[27],[28] Although it has not been confirmed, we believe that SARS-CoV-2 may cause ED by affecting the cavernous nerves.
In the current study, we discovered that the severe patient group had lower IIEF and subgroup values than the other two groups. Elderly, diabetic, obese patients, and those with cardiac disease are candidates for having COVID-19 as a severe case and are liable to facing serious complications. Severe patient group is also at a high risk of ED.[19],[29] We hypothesized that the patients in the severe case group of our study were in this higher risk group and that the additional stress caused by COVID-19 caused sexual complaints to appear or preexisting complaints to worsen. We attribute the lower IIEF and subgroup values of the severe patient group in comparison to the other two groups to the aforementioned reasons.
Our study's limitations are the small number of patients and the short follow-up period. We do not know whether the ED situations are temporary or permanent because we do not have a patient follow-up for more than 90 days. However, we believe that our study is important because, to the best of our knowledge, there are no studies in the literature that investigate the relationship between COVID-19 and IIEF.
ConclusionsWe discovered that COVID-19 affected IIEF values in male patients and may cause ED by lowering erectile function values. Larger patient groups and longer follow-up periods in further studies may provide more accurate results.
Acknowledgments
The authors acknowledge that the final manuscript has been prepared and submitted with their approval. The authors thank all hospital staff for their support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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