Aerobic Exercise: Randomized Controlled Trial Data Suggest Qualified Benefits for Erectile Dysfunction

Erectile dysfunction (ED) refers to the difficulty in achieving and maintaining a degree of penile erection that suffices for satisfactory sexual activity. ED is not all or none; the degree of erection achieved and maintained, the experience of what is sufficient and satisfactory, and even the nature and context of the sexual activity associated with ED qualify how ED is perceived by the individual and partner. ED is therefore commonly quantified rather than categorized in research, such as by using the 15-item International Index of Erectile Function (IIEF) scale, or the 5- or 6-item IIEF erectile function domain (IIEF-EF-5 or IIEF-EF-6).^1,2

ED is multifactorial, with risk factors including older age, obesity, stress, anxiety, substance use disorders, major mental illness, medical and especially endocrine and cardiovascular disorders, use of certain medications, prostate surgery, and others. Accordingly, the prevalence of ED is nuanced, varying widely not only with how ED is defined but also with the population and subpopulation studied. As examples, in a nationally representative sample of 1822 US men aged 18–87 years, the overall prevalence of ED was 24.2%. The prevalence was 17.9% in men aged 18–24 years and 52.2% in those aged >75 years.³ In meta-analyses of epidemiological studies of subpopulations, ED was present in 43% of men who survived cancer,⁴ 44% of men with schizophrenia,⁵ 53% of men with diabetes,⁶ 74% of men with diabetes and depressive symptoms,⁷ and 76% of men with chronic kidney disease.⁸

ED negatively impacts psychosocial well-being,⁹ is associated with poorer quality of life,¹⁰ and predictably decreases marital satisfaction.¹¹ Among many treatments available for ED, phosphodiesterase-5 inhibitor drugs, especially sildenafil, provide strong evidence for immediate and consistent, though transient, benefit.^12,13 Given that many lifestyle diseases are risk factors for ED and that physical exercise reduces the risk of or results in improvements in lifestyle diseases,^14,15 it is reasonable to examine whether physical exercise benefits ED. A recent meta-analysis on the subject is examined in the rest of this article.

Aerobic Exercise and Erectile Function

Khera et al¹⁶ described a systematic review and meta analysis of randomized controlled trials (RCTs) that examined the effect of aerobic exercise on erectile function. The authors identified 11 relevant RCTs (pooled N = 1,147 men) through electronic searches, manual searches, and searches of reference lists. RCTs that qualified for inclusion compared aerobic exercise interventions (pooled N = 636) with nonexercising control conditions (pooled N = 511).

These 11 RCTs had been conducted in North America (2 studies), South America (2 studies), Africa (1 study), and Europe (6 studies) and were published between 2004 and 2021. All RCTs had been conducted in subjects with medical and/or surgical conditions that included overweight, obesity, diabetes mellitus, hypertension, metabolic syndrome, androgen deficiency, cardiovascular surgery, and prostate surgery. Sample sizes ranged from a low of 20 to a high of 372 (median, 60). The mean age of the men in the studies ranged from 39 to 69 years (median, 59 years).

In these RCTs, the exercise intervention was supervised or unsupervised, was individually tailored or conducted in groups, and involved walking, treadmill use, cycling, and other activities, across 2–24 months (median, 6 months). Exercise sessions were commonly 30–60 min in duration at a frequency of 3–5 sessions/wk. Exercise intervention was commonly combined with advice for dieting and weight loss. Control conditions included waitlist, lifestyle advice, usual activity, and usual care.

Important findings from the meta-analysis¹⁶ are presented in Table 1. In summary, aerobic exercise was significantly superior to nonexercising control conditions, with greater improvement in erectile functioning observed in subjects with greater baseline impairment in erectile functioning.

Comments and Observations

There are 2 downsides of the findings of this meta analysis.¹⁶ One is that it is impossible to blind subjects to the nature of the active intervention; besides exercise, this limitation applies to meditation, yoga, psychedelic therapies, many somatic therapies, and psychotherapies, as well. So, placebo effects may at least partly drive the measured benefits of the active intervention. On the positive side, such findings may more accurately reflect what might be observed in real-world practice where treatment is unblinded. The findings will therefore have merit only if the benefits are shown to be sustained.

The other and more important downside is that the magnitude of benefit was modest and of limited clinical significance. The smallest improvement in the IIEF-EF that could be considered clinically important is 2, 5, and 7 points for mild, moderate, and severe ED.¹⁷ In the meta analysis by Khera et al,¹⁶ the required threshold for improvement with aerobic exercise was met only for subjects with mild ED (Table 1).

The meta-analysis¹⁶ suggests the thought that aerobic exercise as a sustained lifestyle change, rather than as a short-term intervention, may result in sustained improvements in men with ED; this is a possibility worth examining in follow-up studies.

Parting Notes

ED associated with aging, obesity, diabetes mellitus, cardiovascular disorders, and many other states evolves across time, and aerobic exercise as a lifestyle behavior may reduce the evolution of ED to the extent that it reduces stress, anxiety, depression, weight gain, hemoglobin A_1c levels, atherosclerotic changes, and other predispositions to ED. Such a protective effect of moderate to high levels of physical activity (against ED) has long been known and was demonstrated in a meta analysis published almost 2 decades ago.¹⁸

Physical exercise improves sexual functioning in women, as well.^19,20 The manifold health benefits of exercise^14,15 therefore recommend regular exercise as a lifestyle behavior for the primary and secondary prevention of a wide range of physical and mental health conditions in both men and women, and not only for the improvement of sexual functioning.

It goes without saying that lifestyle guidance to prevent or treat ED, and other physical and mental health disorders should not be limited to exercise alone. Ample research is available to support roles for healthy diet, maintenance of ideal body weight, adherence to recommended medical treatments, avoidance of smoking, drinking, and illicit substance use, and others.

Article Information

Published Online: July 29, 2024. https://doi.org/10.4088/JCP.24f15480
© 2024 Physicians Postgraduate Press, Inc.
To Cite: Andrade C. Aerobic exercise: randomized controlled trial data suggest qualified benefits for erectile dysfunction. J Clin Psychiatry. 2024;85(3):24f15480.
Author Affiliation: Department of Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India (candrade@psychiatrist.com).

Each month in his online column, Dr Andrade considers theoretical and practical ideas in clinical psychopharmacology with a view to update the knowledge and skills of medical practitioners who treat patients with psychiatric conditions.
Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore, India (candrade@psychiatrist.com).
Financial disclosure and more about Dr Andrade.