Several recent supports have provided evidence supporting the long-term complications that can be associated with the coronavirus disease 2019 (COVID-19). These long-term effects are often referred to as ‘long COVID.’
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is the virus responsible for COVID-19, invades and damages many organs and systems, including endothelial cells. The primary mode of cellular entry by SARS-CoV-2 is through its interaction with the angiotensin-converting enzyme 2 (ACE2) receptor that is present on the surface of target cells that allow for the internalization of the virus. The involvement of the endothelial cells in erectile function makes COVID-19 a relevant condition for sexual medicine experts and, subsequently, a major reason for concern.
Study: The Sexual Long COVID (SLC): erectile dysfunction as a biomarker of systemic complications for COVID-19 long haulers. Image Credit: VGstockstudio / Shutterstock.com
About the study
In a recent Sexual Medicine Reviews study, the researchers discuss the underlying mechanisms through which COVID-19 can affect erectile function, discussing the epidemiology of long COVID, and suggesting potential treatments wherever possible.
In the current study, the researchers performed an extensive literature search on Scopus, PubMed, and Google Scholar on keywords such as ‘long COVID’, ‘post-acute COVID,’ and ‘erectile dysfunction (ED)’, with the AND/OR Boolean operators. They filtered the results of all the papers published since 2020 and looked into the references of all relevant articles to retrieve additional information. Notably, they included results only in English, French, and Italian.
Epidemiology of long COVID
The symptoms of long COVID have been relatively consistent, although their prevalence varied in different studies that were reviewed in the current study. For example, in one reviewed study performed on more than 500,000 people in the United Kingdom, the observed prevalence rate of long COVID was 37.7% for at least one symptom at 12 weeks.
In another study conducted on 143 hospitalized patients in Italy, the prevalence rate in the post-acute phase was 84.7%. Comparatively, a meta-analysis study pooling data from 15 studies found that 80% of patients showed at least one symptom after two weeks of the disease onset.
Overall, these findings indicate that long COVID might be a systemic and long-lasting condition that occurs in patients with a previous history of SARS-CoV-2 infection. Therefore, independent of the severity of the initial disease, asymptomatic patients and COVID-19 long haulers may also develop ED.
Sexual health complications due to long COVID
There is a bidirectional relationship between COVID-19 and ED. Furthermore, any COVID-induced neurological, respiratory, cardiovascular, or endocrinal complication has the potential to impact sexual health. Several drugs used to treat long COVID, including beta-blockers and diuretics, can also result in ED.
There is evidence that social isolation policies and lockdowns lead to increased rates of depression and anxiety. Several studies have also reported a 15% prevalence of depressive symptoms and a 19% prevalence of post-traumatic stress disorder (PTSD) at three months post-discharge from COVID-19-related hospitalization. Since there is a relationship between sexual and mental health, caring for the sexual health of COVID-19 patients could prove helpful in preventing worsened outcomes for mental health.
One study comparing Chinese long COVID patients and healthy controls found that the prevalence of ED was higher at the first follow-up visit. However, these rates declined significantly after three months at the time of the second visit, thus suggesting that sexual function improved with the patient's psychological status. Importantly, these study results were not conclusive, as the sample size was small of only 30 individuals at the second follow-up visit.
ED is also known to occur in all conditions of impaired oxygen availability. In one meta-analysis study, 44.3% of COVID-19 patients presented with impaired lung function at three months after hospital discharge. Additionally, a high prevalence of residual lung abnormalities and signs of pulmonary fibrosis was reported in 44.1% and 33.9% of patients, respectively, who had previously recovered from COVID-19.
The results of registry studies conducted on over 86,700 patients demonstrated that acute thrombotic events and pulmonary embolism often coincided with more severe endothelial dysfunction. After SARS-CoV-2 infection, viral myocarditis has also been reported in autopsy findings.
To date, researchers have not investigated the long-term endocrine system-related complications in COVID-19 patients as thoroughly as cardiovascular or pulmonary systems. However, there is evidence that ACE2 is expressed in pancreatic β-cells and testicular Sertoli & Leydig cells, both of which are highly relevant cells for the endocrine system. Certain reports have suggested reduced testosterone levels in long COVID patients, thus highlighting the risk of hypogonadism post-infection and other long-term endocrine complications, such as overt diabetes.
Future directions
Erectile function is one of the most reliable measures of a human male's overall health. At present, there is an abundance of evidence confirming the long-term complications of COVID-19; however, sexual health has been directly addressed as a potential side effect of this condition.
Therefore, the researchers of the current study emphasize the need to perform a systematic investigation of the sexual functions of COVID-19 long haulers. More studies should focus on long COVID patients to identify the prevalence and extent of ED, as well as the exact mechanisms underlying this impairment.
Moreover, studies should be undertaken to assess the cardiovascular, respiratory, or neurologic function of sexual long COVID (SLC) patients as compared to those showing no sexual dysfunction. SLC concerns may even motivate young adults to get vaccinated and promote healthy behaviors.
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