Erectile Dysfunction Tied To Concussion In Former NFL Players

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Former pro football players who reported experiencing more concussion symptoms during their careers were also more likely to report erectile dysfunction and low testosterone levels years later, survey results showed.

Ex-National Football League (NFL) athletes in the highest quartile of self-reported concussion symptoms during their playing days had 72% greater odds of suffering erectile dysfunction later (adjusted OR 1.72, 95% CI 1.30-2.27) compared with those in the lowest quartile, according to Rachel Grashow, PhD, of the Harvard T.H. Chan School of Public Health in Boston, and co-authors in JAMA Neurology.

Similarly, odds of having low testosterone levels were more than doubled in the highest versus lowest quartile of past concussion symptoms (adjusted OR 2.39, 95% CI 1.79-3.19). Participants were judged to have had erectile dysfunction or low testosterone if, on the survey, they indicated that healthcare professionals had recommended treatment for the condition.

Findings in general suggested a dose response between concussion symptoms during players' careers and subsequent erectile dysfunction and low testosterone.

This is the first large study to look at sexual health in a nonclinical population with a high prevalence of repeated injuries, the researchers noted. "It's important because it connects the dots between the two types of studies that are currently published on this topic," Grashow told MedPage Today.

"On the one hand, you have small studies in men who are at risk of repeated head injuries -- boxers and military personnel -- that show pituitary hormone dysfunction like low testosterone and growth hormone deficiency," she explained. "On the other hand, there is only one large study -- using national health insurance data in Taiwan -- that showed an increase in erectile dysfunction in civilian men who received only a single head injury that was severe enough to send them to a doctor or clinic."

Before this study, "we did not know that there was a dose-response relationship between concussion symptoms and odds of reporting erectile dysfunction or low testosterone," Grashow continued. "We also did not know that even a relatively small number of head hits was linked to an increased risk of low testosterone."

Smaller studies have suggested that head trauma in men may be tied to low testosterone and sexual dysfunction possibly through hypopituitarism secondary to ischemic injury and pituitary axonal tract damage. Athletes in contact sports may especially be at risk for pituitary insufficiencies or erectile dysfunction because of the high number of head traumas they receive during their careers.

"It's been known for a few decades that acute brain injury is associated with declines in testosterone levels, but most studies suggest that over a period of months, this likely resolves," said Adrian Sandra Dobs, MD, MHS, a subspecialist in male hormones at the Johns Hopkins University School of Medicine, who was not involved with the NFL study.

"This publication documents that some men with concussions likely have reduced serum testosterone levels, and that this may persist for several years," Dobs told MedPage Today.

In their study, Grashow and co-authors sent electronic and postal mail surveys to former NFL players from 2015 to 2017, asking about past football exposures, demographic factors, and current health conditions.

The researchers calculated concussion symptom scores by summing how frequently former players reported symptoms such as loss of consciousness, disorientation, nausea, memory problems, and dizziness when football-related head injury occurred. They used players' self-reported information about recommendations or prescriptions for low testosterone or erectile dysfunction medication as indicators of testosterone insufficiency and erectile dysfunction. They adjusted for age and race in their analysis and controlled for health factors like hypertension, sleep apnea, prescription pain medication, obesity, high cholesterol, diabetes, previous use of performance-enhancing drugs, and history of prostate or testicular cancer.

In total, 3,409 former NFL players responded to the survey; their mean age was 52.5 and they had played a mean of 6.8 seasons. The overall prevalence of low testosterone and erectile dysfunction indicators were 18.3% and 22.7%, respectively.

Besides head injury, two of the biggest drivers of testosterone levels and erectile function were sleep apnea and use of prescription pain medication. Odds of reporting low testosterone or erectile dysfunction were also elevated for known risk factors including diabetes and mood disorders.

"Unfortunately, the authors did not actually have serum testosterone levels, but rather used indirect measures of the serum hormone, such as erectile dysfunction," Dobs pointed out. "Further research is needed to document if serum testosterone levels are truly low, and if so, how long does this persist and after what kinds of head trauma," she added.

The research has several other limitations, the investigators noted. Concussion data were collected retrospectively and may be subject to recall bias. The concussion symptom scale has not been validated, and whether low testosterone and erectile dysfunction preceded football exposure is unknown. Illicit drug use was also not assessed and may have influenced results, they added.

"We also feel this study is important because it gets the message to former players that if they are suffering from erectile dysfunction, it may be directly connected to their playing history, not some sort of personal failure," Grashow said. "We hope that any man with erectile dysfunction speaks to his physician, both because this condition is treatable, but also because it can be a sign of systemic illness like cardiovascular disease."

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