Erectile dysfunction (ED) is the consistent inability to attain or maintain an erection firm enough for satisfactory sexual performance. Research has established a clear association between COVID-19 infection and the development or worsening of erectile difficulties. The SARS-CoV-2 virus contributes to ED through physical mechanisms that compromise vascular and hormonal function. Understanding these underlying causes is the first step in developing an effective treatment strategy for men experiencing this complication. A comprehensive approach, starting with diagnosis and moving through a structured treatment ladder, can help restore erectile function.
The Biological Link Between COVID-19 and Erectile Dysfunction
The primary mechanism linking COVID-19 to new or persistent ED involves damage to the lining of blood vessels, known as endothelial dysfunction. The SARS-CoV-2 virus can directly infect endothelial cells, including those within the corpus cavernosum. This infection triggers a widespread inflammatory response, which further damages the vascular system. Such damage impairs the body’s ability to produce nitric oxide, a molecule required for the smooth muscle relaxation that allows blood flow into the penis.
The resulting vasculitis and microvascular injury lead to vascular ED, where penile blood vessels cannot expand sufficiently to achieve or maintain rigidity. Furthermore, the testes, which express the ACE2 receptor used by the virus, can also be targeted by the infection. This direct effect may result in a temporary or persistent reduction in testosterone levels. Low testosterone contributes to ED by reducing libido and negatively affecting erection quality.
Clinical Assessment and Ruling Out Other Factors
Before initiating treatment for ED following a COVID-19 infection, a thorough medical evaluation is necessary to confirm the diagnosis and rule out other contributing factors. A healthcare provider will take a detailed medical history, focusing on the timing of ED onset relative to the infection and the severity of the viral illness. The provider will also conduct a physical examination and may use validated questionnaires, such as the International Index of Erectile Function (IIEF-5), to objectively measure the condition’s severity.
Laboratory tests are essential for identifying common underlying conditions that share risk factors with post-COVID ED. A morning serum total testosterone level is measured to assess for hormonal deficiencies. Fasting glucose or hemoglobin A1c (HbA1c) tests screen for undiagnosed or poorly controlled diabetes, a major contributor to vascular ED. A complete fasting lipid panel is also obtained because ED is often an early indicator of underlying cardiovascular disease.
First-Line Pharmacological and Device Therapies
The initial and most effective treatment involves oral medications known as phosphodiesterase type 5 (PDE5) inhibitors, including sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra). These drugs work by selectively blocking the PDE5 enzyme, which breaks down cyclic guanosine monophosphate (cGMP). By preventing cGMP degradation, these inhibitors increase the effect of nitric oxide, promoting smooth muscle relaxation and enhancing blood flow to the corpus cavernosum.
The differences between these medications relate primarily to their duration of action and side effect profiles. Sildenafil has a shorter half-life, while tadalafil offers a longer window of effectiveness, sometimes lasting up to 36 hours. Common side effects are usually mild, including headache, facial flushing, and dyspepsia. A serious concern is the absolute contraindication of taking PDE5 inhibitors with nitrate medications, as this combination can cause a dangerous drop in blood pressure.
For men who do not respond adequately to oral medications, Vacuum Erection Devices (VEDs) are considered a viable first-line device therapy. A VED consists of a cylinder, a pump to create a vacuum, and a tension ring. The negative pressure draws blood into the penile tissue, and the tension ring is slid down to the base of the penis to maintain the erection. VEDs are a non-pharmacological, non-invasive option that can be highly effective for achieving rigidity.
Advanced and Regenerative Treatment Options
If first-line therapies are unsuccessful, second-line treatments are necessary, especially if vascular damage from post-COVID inflammation is significant. Intracavernosal injections (ICI) involve the patient self-injecting a vasoactive medication, most commonly alprostadil, directly into the side of the penis. This method bypasses the need for neural or endothelial signaling, causing the smooth muscle to relax and the arteries to dilate, resulting in a predictable and firm erection.
The primary risk of ICI is priapism, a prolonged erection lasting more than four hours, which requires immediate medical attention to prevent permanent tissue damage. An alternative is the use of intraurethral suppositories, such as MUSE, which deliver alprostadil via a small pellet inserted into the urethral opening. Both ICI and suppositories offer a high success rate for men who have not responded to oral medication.
Beyond these established options, emerging treatments focus on tissue repair, which addresses the vascular nature of post-COVID ED. Low-intensity shockwave therapy (Li-SWT) uses acoustic waves to stimulate the formation of new blood vessels (neoangiogenesis) and regenerate penile tissue. Platelet-Rich Plasma (PRP) therapy involves injecting a concentration of a patient’s own platelets, which contain growth factors, into the penile tissue to stimulate healing.
While these regenerative therapies show promise in clinical studies, current medical guidelines categorize them as experimental or investigational. They are not yet approved for routine ED treatment due to a lack of standardized protocols and long-term data. For cases of severe ED that do not respond to non-surgical intervention, the most definitive treatment is the surgical placement of a penile implant, which provides a reliable, on-demand solution.