Erectile dysfunction: the non-utilized role of exercise rehabilitation for the most embarrassing forgotten post-COVID complication in men.

For good subjective wellbeing and quality of life (QoL), a good penile erection is an important cornerstone for normal sexual activity in men [1]. Erectile dysfunction (ED), the inability to achieve and/or maintain a penile erection sufficient for successful vaginal intercourse for satisfactory sexual performance or penetration [2], develops psychological disorders that decreases the man’s confidence and his QoL [1]. Recently, according to published literature, many body organs/structures express their post-COVID dysfunctions. ED is one of the most silent/embarrassing residual postCOVID complications in men [3]. At the same time that patients with COVID-19 were 3.3 times more likely to have ED [4], great attention and research are directed toward other post-COVID complications such as dyspnea, limited physical capacity, fatigue, poor sleepiness, etc. The majority of evidence points to COVID-19’s participation in the ED, however, the exact pathophysiology has yet to be thoroughly understood. COVID-19 infection may disrupt male sexual function by causing endothelium damage in erectile tissue, testicular injury, psychological changes [5]. In this domain, the concept of sexual long COVID may raise. Symptoms/complications of long COVID that affect many systems including the respiratory system (dyspnea and pulmonary fibrosis), cardiovascular system (myocarditis and endothelial dysfunction), and endocrine system (thyroid dysfunctions, diabetes, or hypogonadism) may impair erectile function in COVID-19 long haulers [6]. SARS-CoV-2 viral particles have been found in penile and testicular tissue, both in living COVID-19 patients who recovered and in males who died from the COVID condition. SARS-CoV-2 can directly damage cavernosal endothelium, resulting in male sexual dysfunction, as evidenced by the virus’s persistence in penile tissue up to 7 months after infection [7]. Lifestyle changes/interventions [8], including exercise, share the first-line treatment approach for ED with inhibitors of phosphodiesterase type 5 [9]. Despite calls for regular supervised exercise to reduce post-COVID complications (such as dyspnea, reduced physical capacity, mood disturbances, poor sleepiness, muscle weakness, cardiovascular risk, etc.) [10], post-COVID-induced ED is not among them. One of the evidence-based effects of exercise is modifying/correcting endothelial dysfunction [11], the main suspect in the occurrence of ED caused by COVID [12]. Exercise improves circulating levels of nitric oxide (increases vasodilation within penile vessels), hormonal/ chemical compounds that relax penile arterial walls, and free radicals (toxic and destructive substances that contribute to endothelial injury of penile vessels) [13]. Another evidence-based effect of exercise is improving immune system functions. The following are the proposed mechanisms of exercise-improving post-COVID immunity: (a) raising the amount and activity of T-lymphocytes, neutrophils, macrophages, and monocytes, which are crucial ingredients in the body’s defensive system against infectious diseases; (b) raising the level of immunoglobulins, (c) restricting the raise of high circulating levels of C-reactive protein and pro-inflammatory markers [11], and d) lowering anxiety and depression, the other suspect in the occurrence of ED caused by COVID [3] which aids in the rebalancing of T-helper cells (T-helper 1 and 2) [11]. Different exercise intensities (low, moderate, or high), types (aerobic, resistance, or both), and modes (continuous or interval) can be utilized during prescribing an exercise program for ED men. It is important to mention here that the entry of any man into an exercise rehabilitation program must be preceded by a very careful examination of his medical and physical components, which are often affected by the complications of COVID (especially the moderate and severe form). This careful examination will determine the type, intensity, and duration of the rehabilitation program for each ED patient based on simple and important tests, such as cardiopulmonary exercise test. Compared to home training programs, it is worth noting here that supervised exercise programs (programs conducted during the presence of a physiotherapist, physician, or physiologist) are highly recommended [14] for good adherence to sessions and close monitoring of men’s vital signs. At the end of this topic, and in light of the growing interest in the role of exercise in fixing/treating the postCOVID complications across all parts of the body, I do not fail to remind all researchers in sexual rehabilitation to work to find an answer to this forgotten question in their future research: Is there an effect of exercise rehabilitation programs on COVID-induced ED?.