AUA2021 Panel Discussion: COVID and Sexual Medicine

By: Mohit Khera MD, MBA, MPH; Alan Shindel MD, MAS; Faysal Yafi, MD, FRCSC; Ranjith Ramasamy, MD; Nelson E. Bennett, Jr., MD, FACS | Posted on: 03 Sep 2021

The Coronavirus Disease 2019 (COVID-19) pandemic started in Wuhan, China at the end of 2019 and in a few months had a significant impact on everyone and nearly everything. Workplace practices, the national and local economy, and personal and public health have been greatly affected. Even the way that health care is delivered has evolved at lightning speed. The global pandemic and resulting quarantine has impacted sexual and reproductive health in various ways. COVID’s impact on hypgonadism, erectile dysfunction (ED), male infertility and delivery of reproductive care (telemedicine) are explored below. A panel discussion, “COVID and Sexual Medicine,” will be presented Sunday, September 12 (10:00 a.m. to 10:20 a.m.) at the American Urological Association’s 2021 Annual Meeting Plenary Program.

COVID-19 and Hypogonadism

There is controversy regarding the relationship between COVID-19 and hypogonadism. Early data suggest that low testosterone levels may increase the risk of developing severe COVID-19 symptoms. Studies demonstrate that men with low testosterone levels who acquire COVID-19 are more likely to be admitted to the intensive care unit and have increased mortality. In addition, testosterone has been shown to play a clear role in modulating the immune response. Several studies have shown that testosterone supplementation may play a role in preventing severe COVID-19 symptoms in those men affected by the virus, and thus testosterone may have a protective role in men who are infected with COVID-19. While there may be an association between low testosterone levels and severity of COVID-19 symptoms, we cannot assume causality. The risk factors for hypogonadism, such as obesity and metabolic syndrome, are the same for those who are more likely to suffer from severe COVID-19 symptoms. Thus, hypogonadism may be indirectly linked to the development of COVID-19.

COVID and Erectile Dysfunction

Epidemiological evidence suggests that ED may be up to 3 times more prevalent in COVID patients versus controls.The established relationship between COVID-19 and endothelial dysfunction suggests a highly plausible mechanism that may explain COVID-19 related ED. Viral particles have been identified near the penile vascular endothelium in the context of severe post-COVID-19 ED. COVID-19 also has a complex relationship with androgens. COVID-19 may involve the testicles and can be associated with tissue changes that may portend risk of potentially long-term testosterone deficiency, another potentially important cause of ED. Several studies have in fact reported on low serum testosterone levels in COVID-19 patients and survivors.

Aside from the physiological aspects of COVID-19 infection, the psychosocial toll of lockdown and economic turmoil associated with the pandemic has most certainly had serious effects on men and their partner’s sexual relationships.Enforced proximity may have variable effects on sexual activity, with many persons reporting improved sexual relationships and or increased sexual activity. An increase in consultations and requests for medical management for ED during the pandemic suggests that the lockdown may also have had a negative effect for some couples and/or brought potentially latent relationship issues to the fore for others.

COVID and Telemedicine

In the past year, the pandemic has had a huge impact on every aspect of our lives, and particularly on health care. Due to the various lockdowns and quarantines that came into effect, it became quite difficult to conduct medicine in the same traditional face-to-face approach we have become accustomed to. This has been particularly true for sexual medicine, due to its mostly nonurgent profile.

The silver lining, however, is that these limitations have led to much needed expedited approvals and relaxed regulations regarding the implementation of telemedicine as an acceptable alternative for patient visits. Through CMS (Centers for Medicare and Medicaid Services) reimbursement of telemedicine, waiving of co-payment and removing technology barriers by relaxing HIPAA (Health Insurance Portability and Accountability Act) restrictions, it became much more facile for both doctors and patients to communicate, which has ultimately improved delivery of health care. As a result, data suggest that telemedicine encounters increased exponentially in the past year.

Another aspect of telemedicine that has also seen a significant surge and uptake amongst patients with sexual complaints is the direct-to-consumer (DTC) approach. This has been spearheaded by a few companies that offer online evaluation and screening, followed by delivery of prescriptions such as PDE5-inhibitors. The DTC approach has been particularly appealing to patients as it allows for easier and faster online access to treatments while circumventing the need for physician visits and the stigma associated with sexual dysfunction.

Overall, while the pandemic seems to be finally (hopefully) abetting in the U.S., one thing is for sure: telemedicine is here to stay, and it is our responsibility as sexual medicine specialists to ensure that it continues to be a part of our clinical armamentarium while being cautious of its limitations and dangers. These include lack of access for some patients who do not have broadband Internet access, concerns regarding long-term insurance coverage and the absence of essential aspects of consultations such as physical examinations.

COVID and Infertility

The COVID-19 pandemic wrought by the novel SARS-CoV-2 virus has struck men with a higher disease morbidity and mortality than women.1-3 The expression of ACE2 and TMPRSS2 receptors in the male genitourinary tract render these organs vulnerable to COVID-19.4,5 Consequently, ED and orchitis can represent outcomes of moderate to severe infection.6 Furthermore, COVID-19 particles have been isolated in penile and testis tissue in both recovered and deceased patients.7,8 Combined with the potential for blood-testis barrier breakdown, this is concerning.9 Fortunately, sexual transmission risk by recovered patients is extremely low (seminal presence of COVID-19 is only during severe, acute infection). However, there is serious risk of both germ cell and Leydig cell depletion after moderate-to-severe infection, affecting spermatogenesis and leading to hypogonadism.10 Early research showed statistically significant impairment of sperm parameters in moderately infected men compared to mildly infected or men without COVID, although all values were in WHO normal ranges.11 Our research demonstrated that sperm parameter impairment was transient likely due to systemic symptoms.12,13 Future research studies need to demonstrate how COVID-19 virus can linger in the organs long after the initial infection, and the mechanism of immune system evasion. We also need to study whether the effects of COVID-19 infection are transient or permanent.

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  2. Mukherjee S and Pahan K: Is COVID-19 Gender-sensitive? J Neuroimmune Pharmacol 2021; 16: 38.
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  4. Sheikhzadeh Hesari F, Hosseinzadeh SS and Asl Monadi Sardroud MA: Review of COVID-19 and male genital tract. Andrologia 2021; 53: e13914.
  5. Wang Z and Xu X: scRNA-seq profiling of human testes reveals the presence of the ACE2 receptor, a target for SARS-CoV-2 infection in spermatogonia, Leydig and Sertoli cells. Cells 2020; 9: 920.
  6. Chen L, Huang X, Yi Z et al: Ultrasound imaging findings of acute testicular infection in patients with coronavirus disease 2019: a single-center-based study in Wuhan, China. J Ultrasound Med 2020; doi: 10.1002/jum.15558.
  7. Kresch E, Achua J, Saltzman R et al: COVID-19 endothelial dysfunction can cause erectile dysfunction: histopathological, immunohistochemical, and ultrastructural study of the human penis. World J Mens Health 2021; 39: 466.
  8. Achua JK, Chu KY, Ibrahim E et al: Histopathology and ultrastructural findings of fatal COVID-19 infections on testis. World J Mens Health 2021; 39: 65.
  9. Gonzalez DC, Khodamoradi K, Pai R et al: A systematic review on the investigation of SARS-CoV-2 in semen. Res Rep Urol 2020; 12: 615.
  10. Ma X, Guan C, Chen R et al: Pathological and molecular examinations of postmortem testis biopsies reveal SARS-CoV-2 infection in the testis and spermatogenesis damage in COVID-19 patients. Cell Mol Immunol 2021; 18: 487.
  11. Holtmann N, Edimiris P, Andree M et al: Assessment of SARS-CoV-2 in human semen-a cohort study. Fertil Steril 2020; 114: 233.
  12. Gacci M, Coppi M, Baldi E et al: Semen impairment and occurrence of SARS-CoV-2 virus in semen after recovery from COVID-19. Hum Reprod 2021; 36: 1520.
  13. Best JC, Kuchakulla M, Khodamoradi K et al: Evaluation of SARS-CoV-2 in human semen and effect on total sperm number: a prospective observational study. World J Mens Health 2021; 39: 489.
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