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

An anonymous letter from “a heterosexual man in [his] 30s” claimed that before having COVID-19 he was “above average” but after suffering erectile dysfunction because of the disease, he had “lost an inch and a half and become decidedly less than average”. 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.

Despite the headlines you might have seen, there’s not overwhelming evidence to support the idea that COVID-19 causes erectile dysfunction. Most of the scientific literature on the topic is opinion, not fact^[3]. 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.

Dr Welliver and urologist Ashley Winter provide the same simplistic explanation for “COVID dick”. They suggest that a lack of stretching of the penis because of erectile dysfunction is probably responsible for it becoming shorter. They liken the situation to shortening of the penis that occurs after men have their prostate glands removed, and both suggest that a particular device for stretching the penis might provide some recovery of length. 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].

Simple explanations are attractive but they’re not always correct. 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].