Bariatric surgery, which encompasses various procedures aimed at aiding weight loss in severely obese individuals, can potentially have both positive and negative impacts on erectile function in men.

What is “bariatric surgery”?

Bariatric surgery refers to a set of surgical procedures designed to aid weight loss in individuals with severe obesity. These surgeries are typically recommended for people who have been unsuccessful in losing weight through diet and exercise or who have obesity-related health problems that could be improved with weight loss.

Bariatric surgery is typically considered for individuals with a body mass index (BMI) of 40 or higher (severe obesity) or a BMI of 35 or higher with obesity-related health conditions such as type 2 diabetes, hypertension, or obstructive sleep apnea. It is important to note that bariatric surgery is not a quick fix for weight loss and requires significant lifestyle changes, including dietary modifications and regular exercise, to be effective in the long term.

Effects on erectile dysfunction

Bariatric surgery, a highly effective treatment for severe obesity, can significantly impact erectile dysfunction (ED) through several mechanisms:

• Weight Loss: Bariatric surgery induces substantial weight loss, reducing adipose tissue and improving metabolic parameters such as insulin sensitivity and lipid profile. Obesity is a major risk factor for ED, as excessive adiposity can lead to hormonal imbalances, inflammation, and vascular dysfunction, all of which contribute to erectile dysfunction. By promoting weight loss, bariatric surgery can alleviate these adverse effects and improve erectile function.
• Metabolic Changes: Bariatric surgery alters the secretion of various hormones involved in metabolism, including insulin, ghrelin, leptin, and adiponectin. These hormonal changes not only facilitate weight loss but also have direct effects on vascular function and endothelial health, which are crucial for erectile function. Improved insulin sensitivity and reduced inflammation following bariatric surgery can enhance blood flow to the penis, promoting erections.
• Improvement in Comorbidities: Obesity often coexists with comorbid conditions such as diabetes, hypertension, and dyslipidemia, all of which are known to contribute to ED. Bariatric surgery can lead to remission or significant improvement in these comorbidities, further enhancing erectile function. For example, normalization of blood glucose levels and blood pressure can mitigate the vascular damage associated with diabetes and hypertension, thereby improving erectile function.
• Psychological Benefits: Obesity is associated with body image dissatisfaction, depression, and low self-esteem, all of which can adversely affect sexual function and intimacy. Bariatric surgery not only improves physical health but also enhances psychological well-being and quality of life. Reductions in depression and anxiety following weight loss surgery can positively impact sexual confidence and relationship satisfaction, contributing to improved erectile function.
• Endothelial Function: Bariatric surgery has been shown to improve endothelial function, which plays a crucial role in penile erection. Endothelial dysfunction, characterized by impaired nitric oxide bioavailability and increased oxidative stress, is a common feature of obesity-related ED. Bariatric surgery-induced weight loss and metabolic changes can restore endothelial function, promoting vasodilation and enhancing erectile responsiveness.

Impacts on IIEF

The International Index of Erectile Function (IIEF) is a widely used questionnaire designed to assess erectile function and overall sexual satisfaction in men. The effect of bariatric surgery on IIEF scores, which reflect various aspects of erectile function, libido, orgasmic function, and overall satisfaction with sexual activity, has been the subject of investigation in several studies. Here are some key points regarding the effect of bariatric surgery on IIEF scores:

• Improvement in Erectile Function: Numerous studies have reported significant improvements in IIEF scores following bariatric surgery. The weight loss and metabolic changes induced by surgery often lead to enhancements in erectile function, including increased frequency of erections, improved rigidity, and greater satisfaction with sexual intercourse.
• Weight Loss Correlation: The degree of weight loss achieved following bariatric surgery correlates with improvements in IIEF scores. Studies have demonstrated a positive association between the amount of weight lost and the magnitude of improvement in erectile function, suggesting that weight reduction plays a central role in the observed changes in sexual function.
• Resolution of Comorbidities: Bariatric surgery often results in the resolution or improvement of obesity-related comorbidities, such as type 2 diabetes, hypertension, and dyslipidemia, which can have detrimental effects on erectile function. The amelioration of these conditions following surgery contributes to the improvement in IIEF scores and overall sexual health.
• Hormonal Changes: Bariatric surgery can lead to alterations in hormone levels, including testosterone, insulin, leptin, and adiponectin, which may influence erectile function. Improved insulin sensitivity and reductions in inflammation following surgery may contribute to enhanced erectile function, as insulin resistance and chronic inflammation are known to negatively impact sexual health.
• Psychological Factors: Bariatric surgery is often associated with improvements in psychological well-being, body image satisfaction, and self-esteem, which can positively influence sexual function and overall sexual satisfaction. Reductions in depression, anxiety, and stress following surgery may lead to greater sexual confidence and intimacy, reflected in higher IIEF scores.

Impacts on testosterone levels

The effect of bariatric surgery on testosterone levels is multifaceted and can vary depending on several factors, including the type of surgery, pre-existing hormonal imbalances, and individual patient characteristics. Here are some key points regarding this topic:

• Weight Loss: Bariatric surgery often leads to significant weight loss, which can have a positive impact on testosterone levels. Obesity is associated with lower levels of testosterone due to increased conversion of testosterone to estrogen in adipose tissue and suppression of hypothalamic-pituitary-gonadal (HPG) axis activity. Weight loss following bariatric surgery can reverse these effects, leading to an increase in testosterone levels.
• Hormonal Changes: Bariatric surgery can result in alterations in various hormones involved in the regulation of testosterone production. For example, improvements in insulin sensitivity and reductions in inflammation following surgery may lead to normalization of HPG axis function, resulting in increased testosterone synthesis. Additionally, changes in levels of adipokines, such as leptin and adiponectin, may also influence testosterone levels.
• Type of Surgery: Different types of bariatric procedures may have varying effects on testosterone levels. For instance, procedures that involve malabsorption, such as Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD-DS), may lead to more pronounced improvements in hormonal profiles compared to restrictive procedures like sleeve gastrectomy. This difference is partly attributed to the rapid transit of nutrients and changes in gut hormone secretion following malabsorptive procedures.
• Resolution of Comorbidities: Bariatric surgery often results in remission or improvement of obesity-related comorbidities, such as type 2 diabetes and obstructive sleep apnea, which are known to negatively impact testosterone levels. By addressing these comorbidities, bariatric surgery may indirectly contribute to the restoration of testosterone levels.
• Individual Variability: While many patients experience an increase in testosterone levels following bariatric surgery, individual responses can vary. Factors such as age, baseline testosterone levels, presence of hypogonadism, and adherence to post-operative lifestyle changes can influence the magnitude of the hormonal response to surgery.

Long term results

Several studies have examined the long-term effects of bariatric surgery on erectile dysfunction (ED), shedding light on the sustained benefits of weight loss surgery for sexual health. Here are some key findings from long-term studies:

• Weight Loss Maintenance: Long-term studies have shown that many individuals maintain significant weight loss following bariatric surgery over several years. This sustained weight loss is associated with continued improvements in metabolic parameters and obesity-related comorbidities, which can contribute to the long-term alleviation of ED.
• Improvements in Erectile Function: Research indicates that improvements in erectile function following bariatric surgery can be maintained over the long term. Studies have reported sustained enhancements in parameters such as erectile rigidity, frequency of erections, and overall sexual satisfaction, reflecting the lasting benefits of weight loss and metabolic changes induced by surgery.
• Resolution of Comorbidities: Longitudinal studies have demonstrated the continued remission or improvement of obesity-related comorbidities, such as type 2 diabetes, hypertension, and dyslipidemia, following bariatric surgery. The long-term resolution of these conditions contributes to the maintenance of erectile function and overall sexual health.
• Psychological Well-being: Long-term studies have highlighted the enduring improvements in psychological well-being, body image satisfaction, and quality of life following bariatric surgery. Reductions in depression, anxiety, and stress contribute to greater sexual confidence and intimacy, supporting long-term improvements in sexual function.
• Hormonal Changes: Research suggests that hormonal changes induced by bariatric surgery, including alterations in testosterone levels, can be sustained over the long term. Maintenance of hormonal balance may contribute to the ongoing improvements in erectile function observed in individuals undergoing weight loss surgery.

Summary

The effect of bariatric surgery on erectile dysfunction (ED) is notable, with numerous studies indicating significant improvements in sexual function following surgery. Bariatric procedures lead to substantial weight loss and metabolic changes, addressing key factors contributing to ED such as obesity, insulin resistance, and inflammation. Additionally, resolution of obesity-related comorbidities and improvements in psychological well-being contribute to enhanced sexual confidence and intimacy. While the exact mechanisms underlying these improvements require further study, bariatric surgery emerges as a promising intervention for obese individuals seeking to alleviate ED and improve overall sexual health and quality of life.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE