Does COVID-19 cause erectile dysfunction and shrink your penis?

Here we go again.

Last week, an episode of Slate’s How to do it podcast explored the issue of ‘COVID dick’ sparking widespread reports that the virus will make your penis shorter. You’d be forgiven for thinking there was a great penis shrinkage pandemic accompanying the rapid spread of Omicron (as if being 30% more likely to require hospitalisation and 89% more likely to die than females, despite vaccination^[1], is not enough of a burden for men).

Read more: Optimism bias, vaccine hesitancy and the ‘underlying condition’ nobody is talking about

Urologist Charles Welliver, director of Men’s Health at Albany Medical College, tries to “connect the dots” between COVID-19 and penis shrinkage but he comes up… well… a bit short.

It makes sense that COVID-19 could cause erectile dysfunction. Blood vessel function is critical for erectile function, and it is impaired by COVID-19. That’s why the same drugs that are used to treat erectile dysfunction may be useful for treating COVID-19^[2], because of their actions in blood vessels.

The few studies that have assessed sexual function in men after COVID-19 suggest erectile dysfunction is more common than normal, but we need better quality evidence to be sure. It’s probably too early to call it an “epidemic of COVID-19-related erectile dysfunction”³.

Dr Welliver also mentions priapism (a prolonged erection) as a potential consequence of blood clotting disorders that accompany COVID-19. There are six case reports about priapism in COVID-19 patients^[4], so it happens but we don’t know how common it is.

This device, though, has been proven effective only in men aged in their late 50s who have had their prostates removed, or in men with Peyronie’s disease^[5].These are very different groups to a man in his 30s who has had COVID-19.

Read more: Does COVID-19 affect male fertility?

It’s a bit like suggesting that “face masks can make you more attractive”^[6], based on the subjective assessments of 41 female undergraduate psychology students (all but one aged 18-24) from Cardiff University, looking at digitally altered images of 40 men’s faces^[7].

The danger is that simplistic interpretations become dogma and discourage further enquiry. For example, the “artery size hypothesis” is used to explain the association between erectile dysfunction and subsequent cardiovascular events, based simply on the idea that the penile arteries are narrower than the coronaries and are therefore affected earlier in the course of atherosclerosis development^[8].

There is no empirical evidence to support this hypothesis – just the opposite^[9] – but the erroneous explanation persists in the literature^[10].

If “COVID dick” is real, and it really does become an “epidemic”, we will need to understand its pathogenesis to provide optimal treatment. Simplistic explanations and unsupported hypotheses* are unlikely to be enough.

* My own goes like this: COVID-19 increases sympathetic activity^[11]. The penis is maintained in a flaccid state by adrenergic activity of the sympathetic nervous system, acting to maintain tone of the arterial smooth muscle, thereby restricting blood flow in the corpus cavernosum^[12]. I hypothesise that increased sympathetic activity due to COVID-19 increases adrenergic signaling to the arteries supplying the corpus cavernosum, further decreasing blood flow and shortening the penis. A similar cause of penile shortening after prostatectomy has been proposed^[13].

References

_{[1] Hippisley-Cox et al., 2021. Risk prediction of covid-19 related death and hospital admission in adults after covid-19 vaccination: national prospective cohort study. BMJ}

_{[2] Isidori et al., 2021. Targeting the NO‐cGMP‐PDE5 pathway in COVID‐19 infection. The DEDALO project. Andrology}

_{[3] Hsieh., 2021. The Epidemic of COVID-19-Related Erectile Dysfunction: A Scoping Review and Health Care Perspective. Sexual Medicine Reviews}

_{[4] Silverman et al., 2021 Am J Emerg Med: Lamamri et al., 2021 Am J Emerg Med: Lam et al., 2020 Eur J Case Rep Intern Med: Giuliano et al., 2021 Case Rep Urol: Carreño et al., 2021 Urol Int: Addar et al.. 2021 J Surg Case Rep}

_{[5] Toussi et al., 2021. Efficacy of a Novel Penile Traction Device in Improving Penile Length and Erectile Function Post Prostatectomy: Results from a Single-Center Randomized, Controlled Trial. J Urol}

_{[6] https://www.abc.net.au/news/2022-01-18/covid-mask-attractive-study-pandemic-dating/100763642}

_{[7] Hies & Lewis, 2022. Beyond the beauty of occlusion: medical masks increase facial attractiveness more than other face coverings. Cognitive Research: Principles and Implications}

_{[8] Montorsi et al, 2005. The Artery Size Hypothesis: A Macrovascular Link Between Erectile Dysfunction and Coronary Artery Disease. The American Journal of Cardiology}

_{[9] Ponholzer., 2012. Is penile atherosclerosis the link between erectile dysfunction and cardiovascular risk? An autopsy study. International Journal of Impotence Research}

_{[10] Yannas et al., 2021. Erectile Dysfunction Is a Hallmark of Cardiovascular Disease: Unavoidable Matter of Fact or Opportunity to Improve Men’s Health? Journal of Clinical Medicine}

_{[11] Stute et al., 2021. COVID‐19 is getting on our nerves: sympathetic neural activity and haemodynamics in young adults recovering from SARS‐CoV‐2. The Journal of Physiology}

_{[12] Traish et al., 2000. Role of alpha adrenergic receptors in erectile function. International Journal of Impotence Research}

_{[13] Mulhall, 2005. Penile length changes after radical prostatectomy. BJU International}