Increasing data are available to suggest that physical activity and lifestyle modification in general can benefit erectile function, with effect sizes comparable with established treatment options such as testosterone therapy and phosphodiesterase type 5 inhibitors. Despite this evidence, primary-care physicians are rarely afforded critical information on the underlying mechanisms through which physical activity works as a treatment, severely hampering treatment credibility for both physician and patient. Physical activity is associated with psychological and metabolic adaptations that are compatible with the adaptations required for the treatment of erectile dysfunction (ED). These adaptations include increased expression and activity of nitric oxide synthase, strengthened endothelial function, acute rises in testosterone, decreased stress and anxiety, and improved body image. Use of physical activity as a first-line treatment option for ED is limited, and explicit physical activity guidelines for the treatment of ED are required. Such guidelines should include not only a suggested exercise programme but also guidelines for physician–patient communication that might enhance patient receptivity and therapy continuation. An understanding of how physical activity affects erectile function, as well as its effectiveness in treating ED compared with other established treatments, can benefit urologists and primary-care physicians searching for noninvasive treatment options for men presenting with poor erectile function.
Erectile function is a haemodynamic process governed by multiple regulatory systems; notably endothelial nitric oxide (NO), testosterone and psychological factors.
Physical activity is the most effective way to increase NO and strengthen endothelial function, and can also increase testosterone and positive body image, and decrease stress and anxiety.
Pharmacotherapy is the most common method of treating erectile dysfunction (ED), with testosterone therapy and phosphodiesterase type 5 inhibitors identified as effective treatments.
Physical activity interventions show the largest effect sizes in terms of efficacy for the treatment of ED.
Different exercise modalities — aerobic, resistance, combat training and group sports — have effects on different inputs into erectile function and can, therefore, be used together to maximize the therapeutic benefit.
Regular physical activity should be considered the first-line treatment option for men presenting with poor erectile function.
Subscribe to Journal
Get full journal access for 1 year
only $17.42 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
McCabe, M. P. et al. Definitions of sexual dysfunctions in women and men: a consensus statement from the Fourth International Consultation on Sexual Medicine 2015. J. Sex. Med. 13, 135–143 (2016).
Cheng, J. Y. W., Ng, E. M. L., Chen, R. Y. L. & Ko, J. S. N. Prevalence of erectile dysfunction in Asian populations: a meta-analysis. Int. J. Impot. Res. 19, 229–244 (2007).
Wang, W. et al. Meta-analysis of prevalence of erectile dysfunction in mainland China: evidence based on epidemiological surveys. Sex. Med. 5, e19–e30 (2017).
Mulhall, J. P., Luo, X., Zou, K. H., Stecher, V. & Galaznik, A. Relationship between age and erectile dysfunction diagnosis or treatment using real-world observational data in the USA. Int. J. Clin. Pract. 70, 1012–1018 (2016).
De Tejada, I. S. et al. Pathophysiology of erectile dysfunction. J. Sex. Med. 2, 26–39 (2005).
Andersson, K. E. Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction. Pharmacol. Rev. 63, 811–859 (2011).
Prieto, D. Physiological regulation of penile arteries and veins. Int. J. Impot. Res. 20, 17–29 (2008).
Shamloul, R. & Ghanem, H. Erectile dysfunction. Lancet 381, 153–165 (2013).
Hackett, G. et al. British Society for Sexual Medicine guidelines on the management of erectile dysfunction in men — 2017. J. Sex. Med. 15, 430–457 (2018).
Burnett, A. L. et al. Erectile dysfunction: AUA guideline. J. Urol. 200, 633–641 (2018).
Corona, G. et al. Meta-analysis of results of testosterone therapy on sexual function based on international index of erectile function scores. Eur. Urol. 72, 1000–1011 (2017).
Ponce, O. J. et al. The efficacy and adverse events of testosterone replacement therapy in hypogonadal men: a systematic review and meta-analysis of randomized, placebo-controlled trials. J. Clin. Endocrinol. Metab. 103, 1745–1754 (2018).
Chen, L. et al. Phosphodiesterase 5 inhibitors for the treatment of erectile dysfunction: a trade-off network meta-analysis. Eur. Urol. 68, 674–680 (2015).
Yuan, J. Q. et al. Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur. Urol. 63, 902–912 (2013).
Gong, B. et al. Direct comparison of tadalafil with sildenafil for the treatment of erectile dysfunction: a systematic review and meta-analysis. Int. Urol. Nephrol. 49, 1731–1740 (2017).
Schmidt, H. M., Munder, T., Gerger, H., Frühauf, S. & Barth, J. Combination of psychological intervention and phosphodiesterase-5 inhibitors for erectile dysfunction: a narrative review and meta-analysis. J. Sex. Med. 11, 1376–1391 (2014).
Frühauf, S., Gerger, H., Schmidt, H. M., Munder, T. & Barth, J. Efficacy of psychological interventions for sexual dysfunction: a systematic review and meta-analysis. Arch. Sex. Behav. 42, 915–933 (2013).
Melnik, T., Soares, B. G. O. & Nasello, A. G. The effectiveness of psychological interventions for the treatment of erectile dysfunction: systematic review and meta-analysis, including comparisons to sildenafil treatment, intracavernosal injection, and vacuum devices. J. Sex. Med. 5, 2562–2574 (2008).
Man, L. & Li, G. Low-intensity extracorporeal shock wave therapy for erectile dysfunction: a systematic review and meta-analysis. Urology 119, 97–103 (2018).
Allen, M. S. & Walter, E. E. Erectile dysfunction: an umbrella review of meta-analyses of risk-factors, treatment, and prevalence outcomes. J. Sex. Med. 16, 531–541 (2019).
Hallal, P. C. et al. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet 380, 247–257 (2012).
Kyu, H. H. et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ 354, i3857 (2016).
Warburton, D. E. & Bredin, S. S. Health benefits of physical activity: a systematic review of current systematic reviews. Curr. Opin. Cardiol. 32, 541–556 (2017).
Bauman, A., Merom, D., Bull, F. C., Buchner, D. M. & Fiatarone Singh, M. A. Updating the evidence for physical activity: summative reviews of the epidemiological evidence, prevalence, and interventions to promote “active aging”. Gerontologist 56, S268–S280 (2016).
Blondell, S. J., Hammersley-Mather, R. & Veerman, J. L. Does physical activity prevent cognitive decline and dementia? A systematic review and meta-analysis of longitudinal studies. BMC Public Health 14, 510 (2014).
Rebar, A. L. et al. A meta-meta-analysis of the effect of physical activity on depression and anxiety in non-clinical adult populations. Health Psychol. Rev. 9, 366–378 (2015).
Allen, M. S. & Walter, E. E. Health-related lifestyle factors and sexual dysfunction: a meta-analysis of population-based research. J. Sex. Med. 15, 458–475 (2018).
Corona, G. et al. Erectile dysfunction and central obesity: an Italian perspective. Asian J. Androl. 16, 581–591 (2014).
Ning, L. & Yang, L. Hypertension might be a risk factor for erectile dysfunction: a meta-analysis. Andrologia 49, e12644 (2017).
Besiroglu, H., Otunctemur, A. & Ozbek, E. The relationship between metabolic syndrome, its components, and erectile dysfunction: a systematic review and a meta-analysis of observational studies. J. Sex. Med. 12, 1309–1318 (2015).
Vlachopoulos, C. V., Terentes-Printzios, D. G., Ioakeimidis, N. K., Aznaouridis, K. A. & Stefanadis, C. I. Prediction of cardiovascular events and all-cause mortality with erectile dysfunction: a systematic review and meta-analysis of cohort studies. Circ. Cardiovasc. Qual. Outcomes 6, 99–109 (2013).
Dong, J. Y., Zhang, Y. H. & Qin, L. Q. Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies. J. Am. Coll. Cardiol. 58, 1378–1385 (2011).
Fan, Y., Hu, B., Man, C. & Cui, F. Erectile dysfunction and risk of cardiovascular and all-cause mortality in the general population: a meta-analysis of cohort studies. World J. Urol. 36, 1681–1689 (2018).
Kouidrat, Y. et al. High prevalence of erectile dysfunction in diabetes: a systematic review and meta-analysis of 145 studies. Diabet. Med. 34, 1185–1192 (2017).
Guh, D. P. et al. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health 9, 88 (2009).
Wilmot, E. G. et al. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis. Diabetologia 55, 2895–2905 (2012).
Carter, P., Gray, L. J., Troughton, J., Khunti, K. & Davies, M. J. Fruit and vegetable intake and incidence of type 2 diabetes mellitus: systematic review and meta-analysis. BMJ 34, c4229 (2010).
Ioakeimidis, N. & Kostis, J. B. Pharmacologic therapy for erectile dysfunction and its interaction with the cardiovascular system. J. Cardiovasc. Pharmacol. Ther. 19, 53–64 (2014).
Maiorino, M. I., Bellastella, G. & Esposito, K. Lifestyle modifications and erectile dysfunction: what can be expected? Asian J. Androl 17, 5–10 (2015).
Gupta, B. P. et al. The effect of lifestyle modification and cardiovascular risk factor reduction on erectile dysfunction: a systematic review and meta-analysis. Arch. Intern. Med. 171, 1797–1803 (2011).
Maiorino, M. I. et al. Effects of Mediterranean diet on sexual function in people with newly diagnosed type 2 diabetes: the MÈDITA trial. J. Diabetes Complicat. 30, 1519–1524 (2016).
Esfahani, S. B. & Pal, S. Obesity, mental health, and sexual dysfunction: a critical review. Health Psychol. Open 5, 2055102918786867 (2018).
Moran, L. J. et al. Long-term effects of a randomised controlled trial comparing high protein or high carbohydrate weight loss diets on testosterone, SHBG, erectile and urinary function in overweight and obese men. PLOS ONE 11, e0161297 (2016).
Silva, A. B., Sousa, N., Azevedo, L. F. & Martins, C. Physical activity and exercise for erectile dysfunction: systematic review and meta-analysis. Br. J. Sports Med. 51, 1419–1424 (2017).
Gerbild, H., Larsen, C. M., Graugaard, C. & Josefsson, K. A. Physical activity to improve erectile function: a systematic review of intervention studies. Sex. Med. 6, 75–89 (2018).
Maio, G., Saraeb, S. & Marchiori, A. Physical activity and PDE5 inhibitors in the treatment of erectile dysfunction: results of a randomized controlled study. J. Sex. Med. 7, 2201–2208 (2010).
La Vignera, S., Condorelli, R., Vicari, E., D’agata, R. & Calogero, A. Aerobic physical activity improves endothelial function in the middle-aged patients with erectile dysfunction. Aging Male 14, 265–272 (2011).
Khoo, J. et al. Comparing effects of low-and high-volume moderate-intensity exercise on sexual function and testosterone in obese men. J. Sex. Med. 10, 1823–1832 (2013).
Esposito, K. et al. Effects of intensive lifestyle changes on erectile dysfunction in men. J. Sex. Med. 6, 243–250 (2009).
Kalka, D. et al. Association between physical exercise and quality of erection in men with ischaemic heart disease and erectile dysfunction subjected to physical training. Kardiol. Pol. 71, 573–580 (2013).
Kalka, D. et al. Effect of endurance cardiovascular training intensity on erectile dysfunction severity in men with ischemic heart disease. Am. J. Mens. Health 9, 360–369 (2015).
Kalka, D. et al. Heart rate recovery, cardiac rehabilitation and erectile dysfunction in males with ischaemic heart disease. Anatol. J. Cardiol. 16, 256–263 (2016).
Lamina, S., Okoye, C. G. & Dagogo, T. T. Therapeutic effect of an interval exercise training program in the management of erectile dysfunction in hypertensive patients. J. Clin. Hypertens. 11, 125–129 (2009).
Maresca, L. et al. Exercise training improves erectile dysfunction (ED) in patients with metabolic syndrome on phosphodiesterase-5 (PDE-5) inhibitors. Monaldi Arch. Chest Dis. 80, 177–183 (2013).
Begot, I. et al. A home-based walking program improves erectile dysfunction in men with an acute myocardial infarction. Am. J. Cardiol. 115, 571–575 (2015).
Gillespie, L. D. et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst. Rev. 9, CD007146 (2012).
Andersson, K. E. & Wagner, G. Physiology of penile erection. Physiol. Rev. 75, 191–236 (1995).
Burnett, A. L., Lowenstein, C. J., Bredt, D. S., Chang, T. S. & Snyder, S. H. Nitric oxide: a physiologic mediator of penile erection. Science 257, 401–403 (1992).
Hawley, J. A., Hargreaves, M., Joyner, M. J. & Zierath, J. R. Integrative biology of exercise. Cell 159, 738–749 (2014).
Neufer, P. D. et al. Understanding the cellular and molecular mechanisms of physical activity-induced health benefits. Cell Metab. 22, 4–11 (2015).
Calvert, J. W. & Lefer, D. J. Role of β-adrenergic receptors and nitric oxide signaling in exercise-mediated cardioprotection. Physiology 28, 216–224 (2013).
Akita, Y. et al. Exercise-induced activation of cardiac sympathetic nerve triggers cardioprotection via redox-sensitive activation of eNOS and upregulation of iNOS. Am. J. Physiol. Heart Circ. Physiol. 292, H2051–H2059 (2007).
Jungersten, L., Ambring, A., Wall, B. & Wennmalm, A. Both physical fitness and acute exercise regulate nitric oxide formation in healthy humans. J. Appl. Physiol. 82, 760–764 (1997).
Förstermann, U. & Sessa, W. C. Nitric oxide synthases: regulation and function. Eur. Heart J. 33, 829–837 (2011).
Anderson, T. J. Assessment and treatment of endothelial dysfunction in humans. J. Am. Coll. Cardiol. 34, 631–638 (1999).
Moyna, N. M. & Thompson, P. D. The effect of physical activity on endothelial function in man. Acta Physiol. Scand. 180, 113–123 (2004).
Esposito, K. et al. Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA 292, 1440–1446 (2004).
Woodman, C. R., Muller, J. M., Laughlin, M. H. & Price, E. M. Induction of nitric oxide synthase mRNA in coronary resistance arteries isolated from exercise-trained pigs. Am. J. Physiol. Heart Circ. Physiol. 273, H2575–H2579 (1997).
Green, D. J., Maiorana, A., O’Driscoll, G. & Taylor, R. Effect of exercise training on endothelium-derived nitric oxide function in humans. J. Physiol. 561, 1–25 (2004).
Hambrecht, R. et al. Regular physical activity improves endothelial function in patients with coronary artery disease by increasing phosphorylation of endothelial nitric oxide synthase. Circulation 107, 3152–3158 (2003).
Travison, T. G. et al. Harmonized reference ranges for circulating testosterone levels in men of four cohort studies in the United States and Europe. J. Clin. Endocrinol. Metab. 102, 1161–1173 (2017).
Isidori, A. M. et al. A critical analysis of the role of testosterone in erectile function: from pathophysiology to treatment—a systematic review. Eur. Urol. 65, 99–112 (2014).
Elkhoury, F. F., Rambhatla, A., Mills, J. N. & Rajfer, J. Cardiovascular health, erectile dysfunction, and testosterone replacement: controversies and correlations. Urology 110, 1–8 (2017).
Lugg, J. A., Ng, C. H., Rajfer, J. A. & Gonzalez-Cadavid, N. E. Cavernosal nerve stimulation in the rat reverses castration-induced decrease in penile NOS activity. Am. J. Physiol. 271, E354–E361 (1996).
Travison, T. G., Araujo, A. B., Kupelian, V., O’Donnell, A. B. & McKinlay, J. B. The relative contributions of aging, health, and lifestyle factors to serum testosterone decline in men. J. Clin. Endocrinol. Metab. 92, 549–555 (2006).
Svartberg, J. et al. The associations of age, lifestyle factors and chronic disease with testosterone in men: the Tromso Study. Eur. J. Endocrinol. 149, 145–152 (2003).
Corona, G. et al. Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis. Eur. J. Endocrinol. 168, 829–843 (2013).
MacDonald, A. A., Herbison, G. P., Showell, M. & Farquhar, C. M. The impact of body mass index on semen parameters and reproductive hormones in human males: a systematic review with meta-analysis. Hum. Reprod. Update 16, 293–311 (2009).
Rossow, L. M., Fukuda, D. H., Fahs, C. A., Loenneke, J. P. & Stout, J. R. Natural bodybuilding competition preparation and recovery: a 12-month case study. Int. J. Sport Physiol. 8, 582–592 (2013).
Hooper, D. R. et al. Endocrinological roles for testosterone in resistance exercise responses and adaptations. Sports Med. 47, 1709–1720 (2017).
Slimani, M. et al. Hormonal responses to striking combat sports competition: a systematic review and meta-analysis. Biol. Sport 35, 121–136 (2018).
Geniole, S. N., Bird, B. M., Ruddick, E. L. & Carré, J. M. Effects of competition outcome on testosterone concentrations in humans: an updated meta-analysis. Horm. Behav. 92, 37–50 (2017).
Salvador, A. & Costa, R. Coping with competition: neuroendocrine responses and cognitive variables. Neurosci. Biobehav. Rev. 33, 160–170 (2009).
Wood, R. I. & Stanton, S. J. Testosterone and sport: current perspectives. Horm. Behav. 61, 147–155 (2012).
Ronay, R. & Hippel, W. V. The presence of an attractive woman elevates testosterone and physical risk taking in young men. Soc. Psychol. Personal. Sci. 1, 57–64 (2010).
Gonzalez-Bono, E., Salvador, A., Ricarte, J., Serrano, M. A. & Arnedo, M. Testosterone and attribution of successful competition. Aggress. Behav. 26, 235–240 (2000).
Carré, J. M. No place like home: testosterone responses to victory depend on game location. Am. J. Hum. Biol. 21, 392–394 (2009).
Allen, M. S. & Jones, M. V. The “home advantage” in athletic competitions. Curr. Dir. Psychol. Sci. 23, 48–53 (2014).
Ahtiainen, J. P. et al. Effects of resistance training on testosterone metabolism in younger and older men. Exp. Gerontol. 69, 148–158 (2015).
Ponholzer, A. et al. Prevalence and risk factors for erectile dysfunction in 2869 men using a validated questionnaire. Eur. Urol. 47, 80–86 (2005).
Liu, Q. et al. Erectile dysfunction and depression: a systematic review and meta-analysis. J. Sex. Med. 15, 1073–1082 (2018).
Hedon, F. Anxiety and erectile dysfunction: a global approach to ED enhances results and quality of life. Int. J. Impot. Res. 15, S16–S19 (2003).
Schuch, F. B. et al. Physical activity and incident depression: a meta-analysis of prospective cohort studies. Am. J. Psychiatry 175, 631–648 (2018).
Allen, M. S., Walter, E. E. & Swann, C. Sedentary behaviour and risk of anxiety: a systematic review and meta-analysis. J. Affect. Disord. 242, 5–13 (2019).
De Moor, M. H., Boomsma, D. I., Stubbe, J. H., Willemsen, G. & de Geus, E. J. Testing causality in the association between regular exercise and symptoms of anxiety and depression. Arch. Gen. Psychiatry 65, 897–905 (2008).
Stubbs, B. et al. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: a meta-analysis. Psychiatry Res. 249, 102–108 (2017).
Rosenbaum, S. et al. Physical activity in the treatment of post-traumatic stress disorder: a systematic review and meta-analysis. Psychiatry Res. 230, 130–136 (2015).
Steptoe, A. & Kivimäki, M. Stress and cardiovascular disease. Nat. Rev. Cardiol. 9, 360–370 (2012).
Brotman, D. J., Golden, S. H. & Wittstein, I. S. The cardiovascular toll of stress. Lancet 370, 1089–1100 (2007).
Black, P. H. The inflammatory response is an integral part of the stress response: implications for atherosclerosis, insulin resistance, type II diabetes and metabolic syndrome X. Brain Behav. Immun. 17, 350–364 (2003).
Kobori, Y. et al. The relationship of serum and salivary cortisol levels to male sexual dysfunction as measured by the international index of erectile function. Int. J. Impot. Res. 21, 207–212 (2009).
Brumby, S. et al. The effect of physical activity on psychological distress, cortisol and obesity: results of the farming fit intervention program. BMC Public Health 13, 1018 (2013).
Reed, J. & Buck, S. The effect of regular aerobic exercise on positive-activated affect: a meta-analysis. Psychol. Sport Exerc. 10, 581–594 (2009).
Ekkekakis, P., Parfitt, G. & Petruzzello, S. J. The pleasure and displeasure people feel when they exercise at different intensities. Sports Med. 41, 641–671 (2011).
Alderman, B. L., Arent, S. M., Landers, D. M. & Rogers, T. J. Aerobic exercise intensity and time of stressor administration influence cardiovascular responses to psychological stress. Psychophysiology 44, 759–766 (2007).
Goldfarb, A. H. & Jamurtas, A. Z. β-Endorphin response to exercise. Sports Med. 24, 8–16 (1997).
Chaouloff, F. Effects of acute physical exercise on central serotonergic systems. Med. Sci. Sport Exerc. 29, 58–62 (1997).
Landers, D. M., Arent, S. M. in Handbook of Sport Psychology (eds Tenenbaum, G. & Eklund, R. C.) 3rd edn 469–491 (Wiley, 2007).
Fabbri, A. et al. Endorphins in male impotence: evidence for naltrexone stimulation of erectile activity in patient therapy. Psychoneuroendocrinology 14, 103–111 (1989).
Bala, A., Nguyen, H. M. & Hellstrom, W. J. Post-SSRI sexual dysfunction: a literature review. Sex. Med. Rev. 6, 29–34 (2018).
Woertman, L. & Van den Brink, F. Body image and female sexual functioning and behavior: a review. J. Sex. Res. 49, 184–211 (2012).
Stanton, A. M., Handy, A. B. & Meston, C. M. The effects of exercise on sexual function in women. Sex. Med. Rev. 6, 548–557 (2018).
Barlow, D. H. Causes of sexual dysfunction: the role of anxiety and cognitive interference. J. Consult. Clin. Psych 54, 140–148 (1986).
Blashill, A. J. et al. Body dissatisfaction among sexual minority men: psychological and sexual health outcomes. Arch. Sex. Behav. 45, 1241–1247 (2016).
Sabiston, C. M., Pila, E., Vani, M. & Thogersen-Ntoumani, C. Body image, physical activity and sport: a scoping review. Psychol. Sport Exerc. 42, 48–57 (2019).
Hausenblas, H. A. & Fallon, E. A. Exercise and body image: a meta-analysis. Psychol. Health 21, 33–47 (2006).
Campbell, A. & Hausenblas, H. A. Effects of exercise interventions on body image: a meta-analysis. J. Health Psychol. 14, 780–793 (2009).
Frederick, D. A. et al. Desiring the muscular ideal: men’s body satisfaction in the United States, Ukraine, and Ghana. Psychol. Men Masc. 8, 103–117 (2007).
Waldorf, M., Erkens, N., Vocks, S., McCreary, D. R. & Cordes, M. A single bout of resistance training improves state body image in male weight-trainers. Sport Exerc. Perform. Psychol. 6, 53–69 (2017).
SantaBarbara, N. J., Whitworth, J. W. & Ciccolo, J. T. A systematic review of the effects of resistance training on body image. J. Strength Cond. Res. 31, 2880–2888 (2017).
World Health Organization. Global recommendations on physical activity for health (WHO, 2010).
Picorelli, A. M., Pereira, L. S., Pereira, D. S., Felício, D. & Sherrington, C. Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. J. Physiother. 60, 151–156 (2014).
Jansons, P. S., Haines, T. P. & O’Brien, L. Interventions to achieve ongoing exercise adherence for adults with chronic health conditions who have completed a supervised exercise program: systematic review and meta-analysis. Clin. Rehabil. 31, 465–477 (2017).
Posner, J. D. et al. Low to moderate intensity endurance training in healthy older adults: physiological responses after four months. J. Am. Geriatr. Soc. 40, 1–7 (1992).
Melanson, E. L. & Freedson, P. S. The effect of endurance training on resting heart rate variability in sedentary adult males. Eur. J. Appl. Physiol. 85, 442–449 (2001).
Abe, T., Kojima, K., Kearns, C. F., Yohena, H. & Fukuda, J. Whole body muscle hypertrophy from resistance training: distribution and total mass. Br. J. Sports Med. 37, 543–545 (2003).
Chekroud, S. R. et al. Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: a cross-sectional study. Lancet Psychiatry 5, 739–746 (2018).
Maso, F., Lac, G., Filaire, E., Michaux, O. & Robert, A. Salivary testosterone and cortisol in rugby players: correlation with psychological overtraining items. Br. J. Sports Med. 38, 260–263 (2004).
Lee, I. M. & Buchner, D. M. The importance of walking to public health. Med. Sci. Sports Exerc. 40, S512–S518 (2008).
Padilla, J., Harris, R. A., Rink, L. D. & Wallace, J. P. Characterization of the brachial artery shear stress following walking exercise. Vasc. Med. 13, 105–111 (2008).
Jones, T. W., Howatson, G., Russell, M. & French, D. N. Performance and endocrine responses to differing ratios of concurrent strength and endurance training. J. Strength Cond. Res. 30, 693–702 (2016).
Fry, A. C. & Kraemer, W. J. Resistance exercise overtraining and overreaching. Sports Med. 23, 106–129 (1997).
Schoenfeld, B. J., Ogborn, D. & Krieger, J. W. Effects of resistance training frequency on measures of muscle hypertrophy: a systematic review and meta-analysis. Sports Med. 46, 1689–1697 (2016).
Steib, S., Schoene, D. & Pfeifer, K. Dose-response relationship of resistance training in older adults: a meta-analysis. Med. Sci. Sports Exerc. 42, 902–914 (2010).
Padilla, J. et al. Vascular effects of exercise: endothelial adaptations beyond active muscle beds. Physiology 26, 132–145 (2011).
Churchward-Venne, T. A. et al. There are no nonresponders to resistance-type exercise training in older men and women. J. Am. Med. Dir. Assoc. 16, 400–411 (2015).
Woodward, T. W. A review of the effects of martial arts practice on health. WMJ 108, 40–43 (2009).
Sabiston, C. M. et al. Number of years of team and individual sport participation during adolescence and depressive symptoms in early adulthood. J. Sport Exerc. Psychol. 38, 105–110 (2016).
Thompson Coon, J. et al. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ. Sci. Technol. 45, 1761–1772 (2011).
White, M. et al. Blue space: the importance of water for preference, affect, and restorativeness ratings of natural and built scenes. J. Environ. Psychol. 30, 482–493 (2010).
Gidlow, C., Johnston, L. H., Crone, D. & James, D. Attendance of exercise referral schemes in the UK: a systematic review. Health Educ. J. 64, 168–186 (2005).
Craft, L. L. et al. Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol. Biomarkers Prev. 21, 3–19 (2012).
Foster, C. et al. A new approach to monitoring exercise training. J. Strength Cond. Res. 15, 109–115 (2001).
Bhasin, S. et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N. Engl. J. Med. 335, 1–7 (1996).
Fisher, A. J., Medaglia, J. D. & Jeronimus, B. F. Lack of group-to-individual generalizability is a threat to human subjects research. Proc. Natl Acad. Sci. USA 115, E6106–E6115 (2018).
Allen, M. S. & Laborde, S. The role of personality in sport and physical activity. Curr. Dir. Psychol. Sci. 23, 460–465 (2014).
Bauman, A. E. et al. Correlates of physical activity: why are some people physically active and others not? Lancet 380, 258–271 (2012).
Peer review information
Nature Reviews Urology thanks A. Seftel, P. Jern and K. A. Josefsson for their contribution to the peer review of this work.
The author declares no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Allen, M.S. Physical activity as an adjunct treatment for erectile dysfunction. Nat Rev Urol 16, 553–562 (2019). https://doi.org/10.1038/s41585-019-0210-6
A 6-month, double-blind, placebo-controlled, randomized trial to evaluate the effect of Eurycoma longifolia (Tongkat Ali) and concurrent training on erectile function and testosterone levels in androgen deficiency of aging males (ADAM)
Baicalein Alleviates Erectile Dysfunction Associated With Streptozotocin-Induced Type I Diabetes by Ameliorating Endothelial Nitric Oxide Synthase Dysfunction, Inhibiting Oxidative Stress and Fibrosis
The Journal of Sexual Medicine (2020)
Thinking About Pathomechanisms and Current Treatment of Erectile Dysfunction—“The Stanley Beamish Problem.” Review, Recommendations, and Proposals
Sexual Medicine Reviews (2020)
Predictors of Sexual Desire and Sexual Function in Sedentary Middle-Aged Adults: The Role of Lean Mass Index and S-Klotho Plasma Levels. The FIT-AGEING Study
The Journal of Sexual Medicine (2020)
MMW - Fortschritte der Medizin (2019)