Effects and Moderators of Exercise Training on Erectile function in Male Adults with diagnosed erectile dysfunction: A Systematic Review and Meta-Analysis

Effects and Moderators of Exercise Training on Erectile function in Male Adults with diagnosed erectile dysfunction: A Systematic Review and Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects and Moderators of Exercise Training on Erectile function in Male Adults with diagnosed erectile dysfunction: A Systematic Review and Meta-Analysis Haiyang Sun, Yan Zhao, Xinyue Liao, Francisco B. Ortega, Qingguo Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6075962/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Erectile dysfunction (ED) is widespread among adult men and affects their quality of life and psychological health. There is increasing evidence that physical exercise and sports training can effectively improve erectile function, but the effects of these interventions and the influencing factors require further systematic analysis. Objectives To evaluate the intervention effect of exercise training on erectile dysfunction (ED) in adult men through a systematic review and meta-analysis. Second, to explore the moderating effect of different exercise modes, intensity, and other factors on the intervention effect. Methods Electronic searches were conducted in Embase, Cochrane Central, Scopus, Ovid MEDLINE, PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) up to October 2024. Randomized controlled trials (RCTs) involving adult men with a precise diagnosis of erectile dysfunction (IIEF-5 scores <21) were included to investigate the effect of exercise training on erectile function (EF). The bias risk included in the studies was assessed using the Cochrane Risk of Bias tool 2.0 (Rob2). In addition, subgroup analyses were performed to identify the relative advantages of each intervention method in improving erectile function. Results 12 randomized controlled trials with 818 adult men were included in the meta-analysis. The results demonstrated that exercise training significantly improved erectile function by 2.9 points (95% CI 1.7–4.1, p < 0.001). Sub-group analyses by intervention types showed that the most considerable significant effects were observed for aerobic exercise combined with pharmacological treatment (MD = 3.04, 95% CI 1.15 to 4.92, p = 0.002) and traditional Asian exercise combined with pharmacological treatment (MD = 4.28, 95% CI 2.95 to 5.61, p < 0.001). Other subgroup analyses show consistent exercise effects in different age or medical condition groups and a tendency to have a more significant effect in low-intensity than moderate- or high-intensity exercise. Conclusions Interventions including exercise significantly improve erectile dysfunction in adult men, with subgroup analysis indicating that combining exercise with pharmacological treatments yields the greatest benefits. PROSPERO Registration CRD42024593228. Exercise Training erectile dysfunction Systematic Review Meta-Analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Key Points Interventions including exercise have a significant effect on improving erectile dysfunction in adult men, with the most significant effects observed when exercise is combined with pharmacological treatments. A subgroup analysis further revealed the effects of different intervention types, exercise programs, languages of publication, health status, age groups, disease severity, follow-up duration, and exercise intensity on the intervention effect. Providing a more specific reference for developing personalized treatment plans in the future. Although this study strictly follows the best practice guidelines for systematic reviews and meta-analyses, the evidence is limited to populations with a precise diagnosis of erectile dysfunction (ED). It does not include healthy individuals, which represents a key limitation. Future studies are needed to explore the effects of intervention programs in healthy populations to provide a more comprehensive evidence base. 1 Introduction Erectile dysfunction (ED) is defined as the persistent inability of a man to achieve and maintain an adequate erection for satisfactory sexual performance. This sexual dysfunction is widespread among men worldwide, and the incidence rate increases with age, from 8% among men aged 20–30 to 37% among men aged 70–75[ 1 ]. ED not only affects quality of life but is also closely related to a variety of health problems, such as psychological stress, depression, and cardiovascular disease[ 2 – 5 ]. Therefore, the presence of ED often indicates a need for comprehensive assessment and management of underlying cardiovascular risk factors. Although drug therapy, such as phosphodiesterase type 5 inhibitors (PDE5i), is the primary treatment for ED, it has limited efficacy and may be accompanied by adverse reactions in some patients[ 6 ]. In recent years, more and more studies have shown that exercise training can effectively improve erectile function[ 7 – 9 ]. Exercise is considered to have potential benefits for the management of ED by improving cardiovascular health, metabolic function, and psychological state [ 10 , 11 ]. However, further systematic research is needed on the effects of different exercise modes and intensities. Existing research shows that the mechanism of ED is complex, involving multiple aspects such as vascular endothelial dysfunction, metabolic disorders, endocrine disorders, and psychological factors[ 12 – 14 ]. Lifestyle changes can influence these physiological and psychological factors, especially physical exercise. Exercise can improve erectile function by enhancing endothelial function, improving blood circulation, regulating body weight and metabolic indicators, and relieving stress and anxiety[ 9 ]. Although drug therapy plays an important role in the management of ED, sole reliance on drugs may not completely solve the problem[ 15 ]. This is especially true when other health risk factors are present. Based on this theoretical background, exercise training as a non-pharmacological intervention has recently become a research hotspot. It is considered to be synergistic with drug therapy to improve overall efficacy. Although existing systematic reviews and meta-analyses have shown that physical activity and exercise interventions positively improve erectile dysfunction (ED)[ 16 – 19 ], there are some limitations regarding the type of intervention, sample characteristics, follow-up time, and bias control. This study has made several innovative expansions, providing more comprehensive data support for the evidence-based basis of ED intervention. First, this study significantly expands on the types of interventions compared to existing studies, including recent meta-analyses published in 2023 and 2024. While previous research primarily focused on aerobic and pelvic muscle training[ 20 – 22 ]. The diversity of exercise interventions and combined treatment models was not thoroughly explored. This study broadens the scope by incorporating traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi) in combination with comprehensive drug interventions, offering culturally diverse and adaptable treatment options[ 23 – 31 ]. This inclusion fills a gap in the existing literature and provides insights into the effectiveness of culturally specific interventions, which are often underrepresented in global research. By addressing the limitation of intervention singularity in earlier studies, this study provides a more comprehensive foundation for developing personalized clinical treatment strategies that can be applied across different cultural contexts. Second, this study addresses the lack of diversity in sample characteristics seen in previous research. The research samples of Silva and others were mainly from Europe and the United States, and most of the patient groups had cardiovascular risk factors, which limited the applicability of the research results to patient groups with different health statuses [ 16 ]. These limitations reduced the generalizability of their findings to broader patient groups with varying health statuses and cultural backgrounds. In contrast, this study incorporates a broader range of health states, including metabolic syndrome and psychogenic ED, and includes studies from diverse geographical and cultural contexts, particularly East Asia. This broader representation not only enhances the external validity of the results but also compensates for the lack of diversity in previous research, making the findings more applicable to ED patients with diverse health conditions and cultural backgrounds. In addition, this study systematically improved the follow-up design. While Silva et al.[ 16 ] included studies with follow-up periods ranging from 8 weeks to 2 years, they did not systematically analyze the effects of interventions over short-, medium-, and long-term durations. This study fills this gap by categorizing follow-up periods into short-term ( 6 months), allowing for a more granular evaluation of intervention persistence and its impact on treatment outcomes. These findings enable clinicians to make more precise recommendations for intervention duration and follow-up planning tailored to the needs of individual patients. This study also conducts a more detailed subgroup analysis than previous work. While recent meta-analyses primarily focused on subgroup differences in cardiovascular risk factors and intervention types, this study takes a more multi-dimensional approach. It adds the effects of intervention intensity (e.g., low, moderate, high), different age groups, and varying health states (e.g., severe and psychogenic ED). Moreover, this study is the first to systematically incorporate Chinese-language studies, significantly expanding the evidence base by including key data from East Asian populations. These studies are often excluded in prior meta-analyses due to language bias, which increases the risk of missing critical data. Including these studies not only enhances the comprehensiveness of the analysis but also provides a more globally representative perspective on ED interventions. By refining subgroup analyses, this study offers a more accurate assessment of how patient and intervention characteristics influence treatment outcomes, providing robust data to support personalized treatment planning. Additionally, this study adopts a more rigorous approach to bias control and data processing. While recent meta-analyses demonstrated moderate to high risks of bias, mainly due to challenges in blinding and subjective patient reports, this study applies more stringent methodologies. It systematically evaluates small-sample effects and publication bias using sensitivity analyses, funnel plots, and Egger regression tests, significantly improving the robustness of the results. These measures help address potential biases and ensure that the conclusions are reliable and valid. Finally, this study emphasizes translating research findings into actionable clinical guidance. While existing studies have highlighted the positive effects of moderate- to high-intensity aerobic exercise, they have rarely addressed how these findings can be effectively applied in real-world clinical practice. This study integrates traditional Chinese medicine with exercise interventions, explores the potential for multidisciplinary collaboration, and proposes exercise prescription recommendations tailored to different patient groups. By prioritizing clinical translatability, this study provides a practical reference for developing personalized interventions and advancing health policy in ED management. In summary, this study builds upon and significantly extends the findings of previous meta-analyses by broadening the diversity of interventions and sample characteristics, introducing a systematic follow-up design, refining subgroup analyses, and employing rigorous bias control. These contributions enhance the robustness and generalizability of the data and lay a solid foundation for developing culturally diverse and personalized ED treatment strategies. The primary objective of this systematic review and meta-analysis is to assess the efficacy of physical activity and exercise interventions for improving erectile function in adult men by systematically collecting and analyzing published randomized controlled trials (RCTs). In particular, this study will explore the differences in the efficacy of different exercise interventions (e.g., aerobic exercise, pelvic muscle training, and their combinations), intervention intensity and frequency, and combination with drugs. By integrating and analyzing these data, we hope to provide a more precise scientific basis for personalized treatment options for ED in clinical practice and help clinicians better understand the potential value and applicability of exercise interventions in managing ED. 2 Methods The study protocol for this systematic review was registered on Oct 17, 2024, in the international Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42024593228), and the results are reported by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines[ 32 ]. 2.1 Eligibility Criteria This systematic review selected studies for inclusion according to the PICOS criteria and detailed the inclusion and exclusion criteria. The included participants were adult men aged 18 years and above with a precise diagnosis of erectile dysfunction (ED), and the diagnostic tool was the International Index of Erectile Function (IIEF). ED was defined based on IIEF-5 scores: 22–25 indicating normal erectile function, 17–21 mild ED, 12–16 mild-to-moderate ED, 8–11 moderate ED, and 1–7 severe ED. Studies included participants with IIEF-5 scores < 21, representing mild to severe ED[ 1 , 33 ]. The health conditions reported in the included studies, such as ischaemic heart disease, hypertension, coronary heart disease, metabolic syndrome, obesity, psychogenic erectile dysfunction, and the rehabilitation period after prostatectomy, reflect the characteristics of the study populations rather than predefined eligibility criteria. Interventions included aerobic exercise combined with medication, aerobic exercise combined with pelvic muscle training, aerobic exercise alone, traditional exercise combined with medication, comprehensive intervention, and exercise intervention alone. The intensity of the interventions was not limited and included low-, medium- and high-intensity exercise. The control group included standard care without specific exercise, health education, relaxation training, stretching activities, and drug therapy alone. Some studies used a placebo-controlled or wait-and-see group. The primary outcome was improved erectile function, assessed using the International Index of Erectile Function (IIEF) scoring quantifying tool[ 1 ]. Only randomized controlled trials (RCTs) were included, and only published, peer-reviewed studies. The data sources covered English and Chinese core journals, with no language restrictions, and included both trials published in full text and studies reported in abstracts only. Exclusion criteria included non-human studies, animal experiments, conference abstracts, book chapters, reviews or unpublished articles, and studies for which it was impossible to obtain or extract valid data even after contacting the authors. To better evaluate the effect of the intervention in the analysis of the results, the included studies were grouped according to the following dimensions: type of intervention (e.g., aerobic exercise, pelvic muscle training, and their combination), intervention intensity (low, medium and high intensity), follow-up time (short term, medium term, and long term) Through detailed inclusion and exclusion criteria and a reasonable grouping strategy, this systematic review aims to provide comprehensive and systematic evidence on the use of exercise interventions in the treatment of ED and provide a reliable basis for clinical personalized treatment plans. 2.2 Search Strategy We systematically searched Embase, Cochrane Central, Scopus, Ovid MEDLINE, PubMed, Web of Science, and a Chinese database, CNKI, from inception to October 2024. The search strategy combined keywords and Medical Subject Headings (MeSH), including 'exercise,' 'aerobic exercise,' 'traditional sport,' 'pelvic floor muscle training,' 'erectile dysfunction,' 'randomized controlled trial,' and others. 2.3 Study Selection This study used EndNote 21 as the reference management system[ 34 ]. After the database search was complete, two researchers (H.Y.S. and Y.Z.) independently screened the titles and abstracts of the selected studies for initial screening based on the PICOS criteria. For potentially eligible studies, full-text assessment and review were conducted. If the two researchers disagreed on the eligibility of an article, a third researcher (X. Y. L.) would be involved in the discussion, and consensus would be reached. In addition, to ensure comprehensiveness, we manually searched the reference lists of the included studies and relevant systematic reviews and consulted experts in the field. 2.4 Data Collection In this systematic review, three researchers (H. Y. S., Y. Z., and X. Y. L.) independently extracted data from each included trial based on a standardized data collection form to ensure the accuracy and consistency of the data. If there were any unclear or missing data, the research team would contact the original study authors to obtain or confirm the information and ensure its integrity; a fourth reviewer (Q. G. C.) would decide when necessary. No automated tools were used in this study, and researchers manually extracted and verified all data to ensure data quality. The primary outcome measure extracted was the International Index of Erectile Function (IIEF) score[ 35 – 37 ], which was used to quantify changes in erectile function and record all effect sizes, follow-up time points, and related analysis results in each study. Other extracted variables included participant age, health status, baseline IIEF score, and intervention characteristics (e.g., type of exercise, intensity, frequency, dose, and duration of drug combination therapy), and the specific intervention content of the control group was recorded. (Table 1 ) summarises the main characteristics of the included studies, and the specific intervention protocols in each study are shown in (Table 2 ). We convert continuous variables that cannot be combined directly (such as the median and range) to the mean and standard deviation based on published methods[ 38 – 40 ]. Missing data are not filled in, and no assumptions are made. Table 1 Characteristics of the included studies (n = 12) Study Groups Number Age Health condition Baseline IIEF score Kalka et al. 2013[ 28 ] E: Aerobic exercise་Pharmacological C: Pharmacological E: 103 C: 35 E: 62.07 (8.59) C: 61.43 (8.81) Ischaemic heart disease E: 12.51 (5.98) C: 12.26 (5.83) Maresca et al. 2013[ 29 ] E: Aerobic exercise་Pharmacological C: Pharmacological E:10 C: 10 E: 69.0 (2.8) C: 68.0 (3.6) Metabolic syndrome E: 10.8 (2.0) C: 11.2 (2.1) a Lin et al. 2012[ 21 ] E: Aerobic exercise་Pelvic floor muscle training C: no training E:41 C:31 E: 65.75 (6.12) Not reported or unclear E: 5.06 (0.24) C: 5.00 (0.00) Maio et al. 2010[ 25 ] E: Aerobic exercise་Pharmacological C: Pharmacological E:30 C:30 E: 50.14 (6.28) C: 50.32(6.95) Cardiovascular risk factors E: 15.8 (4.19) C: 15.5 (4.18) Lamina et al. 2009[ 24 ] E: Aerobic exercise་Pharmacological C: Pharmacological E: 25 C: 25 E: 62.10 (5.23) C: 64.00(4.77) Hypertensive E: 11.50 (5.30) C: 8.10 (4.02) Esposito et al. 2004[ 23 ] E: Aerobic exercise C: Health advice 1 E: 55 C: 55 E: 43.5 (4.8) C: 43.0 (5.1) Obesity E:13.9(4.0) C: 13.5(4.0) Dorey et al. 2004[ 20 ] E: Aerobic exercise་Pelvic floor muscle training C: Lifestyle advice 2 E: 28 C: 27 E: 58 (22–78) C: 61 (41–72) Not reported or unclear E: 7.5 (1–28) C: 7.0 (1–17) Begot et al. 2009[ 30 ] E: Aerobic exercise C: no training E: 30 C: 30 55.3 (6.7) Cardiovascular risk factors E: 10.3 C: 10.2 a Feng et al. 2021[ 31 ] E: Aerobic exercise ་Pharmacological C: Pharmacological E: 33 C: 31 E: 34.06 (6.30) C: 33.74(7.45) Not reported or unclear E: 12.5 (4.2) C: 10.3 (3.7) a Shen et al. 2012[ 27 ] E: Traditional exercise་Pharmacological C: Huanshao Capsule E: 27 C: 26 E: 69.0 (2.8) C: 68.0 (3.6) Psychogenic erectile dysfunction E: 10.8 (2.0) C: 11.2 (2.1) a Zeng et al. 2018[ 22 ] E: Aerobic exercise C: Pharmacological E: 30 C: 30 22–60 Coronary heart disease E: 20.0 (3.85) C: 17.5 (2.1) Jing et al. 2012[ 26 ] E: Traditional exercise ་Pharmacological C: Zuogui Pill E: 40 C: 36 E: 37.49(6.22) C: 35.60(5.01) Psychogenic erectile dysfunction E: 16.4 (3.1) C: 14.8 (3.5) n number of included studies, E experimental group, C comparator group,1 A sensible diet, appropriate exercise, and weight management,2 Diet adjustment, smoking cessation, reduced alcohol consumption, stress reduction, and increased physical activity. a Study was published in Chinese language, IIEF International Index of Erectile Function, in which higher scores indicate better erectile function. Table 2 Characteristics of the Exercise training interventions (n = 12) Study Intervention measures Intensity Time Frequency Follow-up duration Outcome indicator Kalka et al. 2013[ 28 ] Aerobic exercise་Pharmacological (stationary cycling)(PDE5) Moderate intensity 45 min 3 times/week 6 months IIEF score Maresca et al. 2013[ 29 ] Aerobic exercise་Pharmacological (stationary cycling)(PDE5) Moderate intensity 30 min 3 times/week 12 weeks IIEF score Lin et al. 2012[ 21 ] Aerobic exercise་Pelvic floor muscle training (stationary cycling) High intensity 50 min 2 times/day 12 months IIEF score Maio et al. 2010[ 25 ] Aerobic exercise་Pharmacological (stationary cycling)(PDE5) Moderate intensity 45 min 3 times/week 3 months IIEF score Lamina et al. 2009[ 24 ] Aerobic exercise་Pharmacological (running)(PDE5) High intensity 45 min 3 times/week 8 weeks IIEF score Esposito et al. 2004[ 23 ] Aerobic exercise (walking) Moderate intensity 30 min 5 times/week 24 months IIEF score Dorey et al. 2004[ 20 ] Aerobic exercise་Pelvic floor muscle training(stationary cycling) Low intensity 30 min 5 times/week 6 months IIEF score Begot et al. 2009[ 30 ] Aerobic exercise (walking) Moderate intensity 45 min 3 times/week 12 weeks IIEF score Feng et al. 2021[ 31 ] Aerobic exercise་Pharmacological (running)(Qingli Xingwei Decoction 1 ) Low intensity 30 min 2 times/day 3 months IIEF score Shen et al. 2012[ 27 ] Traditional exercise་Pharmacological (Tai Chi)(Huanshao Capsule 2 ) Low intensity 30 min 5 times/week 3 months IIEF score Zeng et al. 2018[ 22 ] Aerobic exercise (running) Moderate intensity 20–40 min 5 times/week 12 weeks IIEF score Jing et al. 2012[ 26 ] Traditional exercise་Pharmacological (Wu Qin Xi)(Zuogui Pill 3 ) Low intensity 30 min 1 times/day 6 months IIEF score n number of included studies, E experimental group, C comparator group,1 A traditional Chinese medicine formula containing ingredients such as Gardenia, Bupleurum, Scutellaria, and others, used to treat damp-heat kidney yang deficiency-type impotence,2 A proprietary Chinese medicine with ingredients such as Rehmannia Root, Cornus, Chinese Yam, and others. It nourishes kidney yang and improves psychogenic erectile dysfunction,3 A traditional Chinese medicine formula with key ingredients, including Cooked Rehmannia, Cornus, and Chinese Yam, used to nourish yin and tonify the kidneys. a Study was published in the Chinese language, IIEF International Index of Erectile Function 2.5 Risk of Bias Assessment This study used the Cochrane Risk of Bias Assessment Tool 2.0 (RoB2) to assess the risk of bias in the included randomized controlled trials (RCTs)[ 41 ]. The tool assesses the risk of bias strictly across five key domains: bias arising from the randomization process (e.g., random sequence generation and allocation concealment), bias due to deviations from intended interventions (e.g., adherence to the assigned intervention), bias due to missing outcome data (e.g., handling of missing data and its impact), bias in measurement of the outcome (e.g., validity of measurement tools and blinding of outcome assessors), and bias in selection of the reported result (e.g., selective outcome reporting). Additionally, an overall risk of bias assessment is conducted as an integrated judgment of domain-level evaluations, classifying the overall risk as 'low risk,' 'some concerns,' or 'high risk.' The assessment was independently completed by two researchers (H. Y. S. and Y. Z.) who were not affiliated with the included trials, ensuring the impartiality and objectivity of the assessment process. For each risk of bias item, two reviewers independently rated the risk of bias as either 'low,' ' some concerns, ' or 'high.' No automated tools were used during the assessment process, and all assessments were completed manually to ensure the accuracy of the evaluation. If the two reviewers disagreed on the risk of bias rating, the matter was first resolved through discussion; if there was still a difference of opinion, a third reviewer (X. Y. L.) would intervene and decide. 2.6 Outcomes The primary outcome measure of this study was the change in score on the International Index of Erectile Function (IIEF)[ 42 ], which is used to quantify the improvement in erectile function. The mean difference (MD) was used to measure the effect of the intervention on the IIEF score when pooling the results. We recorded data for each included study at various time points during the follow-up period and used the change in score at the longest follow-up time point for data pooling and presentation. 2.7 Data Synthesis This study used a random effects model to comprehensively analyze the data, with the mean difference (MD) quantifying the effect of continuous variables to ensure robust estimates when there is variation in the effects between different trials[ 43 , 44 ]. The random effects model reasonably reflects the variability between trials and is an appropriate method for dealing with heterogeneity. During the data analysis, the R packages "meta, metafor, funnelplot, forestplot, ggplot2, and forestploter" were used for statistical analysis and result presentation [ 45 – 47 ]. For studies that did not report effect sizes directly, data such as medians and quartiles were converted to means and standard deviations to ensure that all data were consistent when combined for analysis. Eligible studies were strictly screened and included when combining results. The intervention characteristics of each study (such as intervention type, exercise intensity, frequency, and follow-up time) were listed one by one and compared with the grouping criteria predetermined in the original protocol to ensure the consistency and accuracy of data combinations. We used lists and visualization tools (such as forest plots and funnel plots) to display the consistency of intervention characteristics in subgroups to more clearly present the differences and similarities between studies[ 45 ].To examine the heterogeneity between studies, the I² statistic was used to assess the proportion of variability between studies due to heterogeneity, and the τ² value was used to quantify the variance between studies[ 48 ]. The I² value provides a reference for the consistency of results. The specific judgment criteria are as follows: I² between 0% and 40% indicates that heterogeneity may be low and may not be statistically significant; I² between 30% and 60% indicates moderate heterogeneity; I² between 50% and 90% indicates that there may be significant heterogeneity; and I² between 75% and 100% indicates significant heterogeneity, and the source of heterogeneity usually needs to be further explored[ 48 ]. The τ² value directly quantifies the degree of heterogeneity, thus clearly reflecting the variation in research results[ 49 ]. Combining these indicators allows us to fully understand the potential inconsistencies in the research results and their sources, providing an important basis for data integration. To assess the stability of the combined results, this study also conducted a sensitivity analysis to examine the impact of different studies on the final results during the data merging process. To systematically evaluate minor sample effects and publication bias, the reliability and accuracy of the results were ensured by constructing funnel plots with enhanced contours and using Egger regression tests to assess the potential risk of bias due to missing results in the combined data[ 50 ]. When assessing the reliability of the evidence for each outcome, the I² and τ² statistics are used in combination with the heterogeneity analysis, risk of bias, and quality of the study design to comprehensively determine the robustness and consistency of the evidence By combining the assessment of heterogeneity indicators (I² and τ²) with the risk of bias assessment, a comprehensive and rigorous judgment of the credibility of the evidence is ensured, thereby enhancing the robustness and interpretability of the overall conclusions. 2.8 Subgroup analyses This study explored factors that may have caused heterogeneity in the results through multiple predefined subgroup analyses, including intervention type, exercise regimen, language of publication, health status, age group, disease severity, follow-up duration, and exercise intensity (Table 2 ). These subgroup analyses helped identify differences in the improvement of erectile function by exercise intervention under different conditions, providing a basis for explaining the heterogeneity of the research results. 3 Results We retrieved 1,087 records from the following sources: Cochrane (230), EMBASE (142), Ovid (80), CNKI (65), PubMed (53), Scopus (441), and Web of Science (76). After removing duplicate records, 534 articles remained. Initial screening excluded 98 reviews, systematic reviews, commentaries, and animal studies, leaving 436 studies. During the abstract screening stage, 376 studies were excluded due to inconsistent content or interventions/control measures. The remaining 60 studies were screened in full, and 41 studies that did not meet the RCT criteria or had unsatisfactory experimental methods were ultimately excluded, as were seven studies with inconsistent outcome indicators. Twelve eligible studies were included in the meta-analysis, including eight English studies and four Chinese studies. (Fig. 1 ) shows the detailed search and selection process. The excluded studies included studies that met the inclusion criteria but were excluded because of their non-randomized controlled design or lack of consistent outcome indicators. 3.1 Risk of Bias (Fig. 2 ) shows the results of the risk of bias assessment. No study was rated as having a low risk of bias in all areas. In this risk of bias assessment, all studies were rated as having a low risk in terms of random sequence generation (column A) [ 20 – 31 ], indicating that a reasonable randomization method was used, the baseline balance between the experimental group and the control group was ensured, and the possibility of selection bias was reduced. All studies were at moderate risk of allocation concealment (column B) [ 20 – 31 ]. The lack of clear information on allocation concealment could have resulted in knowledge of the group allocation during the conduct of the trial, thus posing a potential risk of selection bias. In terms of blinding control (column C) of participants and researchers, most studies were shown to be at high risk[ 20 , 21 , 23 – 31 ], indicating that most studies failed to implement effective blinding control of participants and researchers, which may introduce subjective bias and affect the objectivity of the intervention effect. Most studies also showed a high risk regarding blinding of outcome assessment (column D). Failure to blind the assessor may lead to detection bias, significantly impacting more subjective outcome indicators. All studies were at low risk of handling missing data (column E) [ 20 – 31 ], indicating that data integrity was effectively ensured in these studies and that there was no significant bias in the results due to missing data. Concerning selective reporting bias (column F), all studies were at low risk[ 20 – 31 ], all pre-specified outcome measures were reported in full, and no selective omissions were found, indicating high data transparency. In addition, concerning other systematic biases (column G), all studies were at low risk[ 20 – 31 ], and no significant systematic bias was observed in the trial design or implementation. Overall, these studies performed well in terms of random sequence generation, missing data handling, selective reporting, and other systematic biases, and the transparency and robustness of data management and result reporting were high. However, there was a specific risk of bias in allocation concealment, blinding of participants and researchers, and blinding of outcome assessment, which may affect the impartiality and accuracy of some results, especially when blinding is insufficient. Therefore, when interpreting the conclusions of these studies, special attention should be paid to these bias factors to ensure an accurate assessment of the effect of the intervention. In addition, due to the particular nature of exercise interventions, almost all studies have difficulty blinding participants and researchers, which may introduce detection bias. Due to these risks of bias, we have reduced the confidence in the evidence for the outcome indicators. 3.2 Primary Outcome Twelve randomized controlled trials involving 818 participants provided data for the primary outcome, as detailed in Table 1 [ 20 – 31 ]. A random-effects model meta-analysis revealed a statistically significant improvement in the International Index of Erectile Function (IIEF) scores following exercise interventions, with a mean difference (MD) of 2.94 (95% CI 1.74 to 4.14, p < 0.001). However, substantial heterogeneity was observed (τ²=3.25, I²=78.79%), likely attributable to differences in intervention types, exercise intensities, participant populations, and study designs. Despite this, visual inspection of the funnel plot and results of Egger's regression test did not suggest significant small-study effects (Fig. 3 ), indicating that the findings are unlikely to be biased by publication or sample size. 3.3 Subgroup Analysis The subgroup analysis of this study (Fig. 4 ) analyzed the significant effects of different intervention characteristics and patient characteristics on the improvement of erectile function. The following elaboration is based on each parameter. 3.3.1 Type of Intervention Comprehensive interventions, which combined exercise with pharmacological treatments, demonstrated the most significant improvement in erectile function. The mean difference (MD) for comprehensive interventions was 3.45 (95% CI 2.10 to 4.81, p < 0.001), with a heterogeneity I² of 64.98%. In contrast, exercise interventions alone had a more modest effect (MD 2.41, 95% CI 1.06 to 4.66, p = 0.036), with a higher heterogeneity I² of 87.25%. These results highlight the enhanced efficacy of combining exercise with pharmacological approaches. 3.3.2 Exercise Regimens Subgroup analysis of exercise regimens showed that combining exercise with pharmacological interventions had the most significant effects. Traditional Asian exercises combined with pharmacological interventions demonstrated the most significant improvement (MD 4.28, 95% CI 2.95 to 5.61, p < 0.001, I² = 0.00%), followed by aerobic exercise combined with pharmacological interventions (MD 3.04, 95% CI 1.15 to 4.92, p = 0.002, I² = 71.81%). Aerobic exercise combined with pelvic floor muscle training also showed potential benefits (MD 4.79, 95% CI -1.21 to 10.79, p = 0.117, I² = 85.57%), though the results were not statistically significant. In contrast, aerobic exercise alone had no statistically significant effect on erectile function (MD 1.34, 95% CI -0.92 to 3.59, p = 0.245, I² = 75.84%). These findings suggest that combining exercise with pharmacological treatments is the most effective strategy for improving erectile function. 3.3.3 Language of Publication Subgroup analysis by publication language revealed better outcomes in studies published in English compared to those published in Chinese. Studies in English reported an MD of 3.19 (95% CI 1.79 to 4.58, p < 0.001, I² = 74.52%), while studies in Chinese reported a smaller MD of 2.47 (95% CI 0.08 to 4.87, p = 0.043, I² = 84.43%). 3.3.4 Medical Condition Patients with psychogenic erectile dysfunction benefited the most from interventions (MD 4.28, 95% CI 2.95 to 5.61, p < 0.001, I² = 0.00%), followed by patients with metabolic syndrome (MD 2.45, 95% CI 0.94 to 3.95, p = 0.001, I² = 0.00%). Interventions for cardiovascular disease patients had a smaller but statistically significant effect (MD 2.41, 95% CI 0.03 to 4.78, p = 0.047, I² = 85.04%). Studies where health status was not clearly reported or unclear showed an MD of 3.59 (95% CI 0.86 to 6.90, p = 0.034, I² = 84.91%). 3.3.5 Age Group The subgroup analysis by age group showed the following results: patients aged 30–50 years demonstrated a mean difference (MD) of 3.30 (95% CI 2.18 to 4.43, p < 0.001, I²= 6.94%), the 50–60 year age group showed an MD of 2.35 (95% CI -0.92 to 5.62, p = 0.158, I²= 86.75%), and those aged 60–70 years had an MD of 3.48 (95% CI 1.73 to 5.23, p < 0.001, I²= 79.29%). Considering the observed variation in the mean differences and the overlapping confidence intervals (CI), there is no clear evidence of significant differences in the efficacy of interventions across different age groups. 3.3.6 Severity of Disease Patients with severe erectile dysfunction (ED) experienced the most substantial improvements, with an MD of 5.15 (95% CI 1.59 to 8.72, p = 0.005, I² = 91.12%). Patients with moderate ED showed a more minor but still significant improvement (MD 2.32, 95% CI 1.19 to 3.45, p < 0.001, I² = 61.87%). 3.3.7 Follow-up Period Short-term follow-up (< 3 months) demonstrated the most significant effect, with an MD of 3.54 (95% CI 2.25 to 4.83, p 6 months) also showed a significant improvement (MD 2.25, 95% CI 1.49 to 3.01, p < 0.001, I² = 0.00%). Medium-term follow-up (3–6 months) did not show significant improvements (MD -0.70, 95% CI -2.29 to 0.89, p = 0.388, I² = 0.00%). 3.3.8 Intensity of Exercise Low-intensity exercise interventions produced the most significant improvements in erectile function, with an MD of 4.12 (95% CI 2.55 to 5.69, p < 0.001, I² = 43.19%). Moderate-intensity interventions also showed significant effects (MD 2.34, 95% CI 0.40 to 4.28, p = 0.018, I² = 82.78%), while high-intensity interventions had a more minor but significant effect (MD 2.17, 95% CI 1.38 to 2.96, p < 0.001, I² = 0.00%). 4 Discussion 4.1 Overview of Key Findings This systematic review and meta-analysis demonstrated that exercise interventions significantly improve erectile function (EF) in men with erectile dysfunction (ED). Subgroup analyses revealed that the effectiveness of these interventions varies across intervention type, exercise intensity, follow-up duration, patient characteristics, and publication language. Combining exercise with pharmacological treatments produced the most significant improvements, with traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi) combined with medications showing the most significant effect sizes [ 20 , 21 , 26 , 27 , 31 ], followed by aerobic exercise combined with pharmacological treatments. Exercise-only interventions demonstrated smaller yet significant effects, highlighting that exercise is most effective when paired with pharmacological interventions. Low-intensity exercise produced the most significant improvements compared to moderate-intensity and high-intensity exercise. For follow-up periods, short-term interventions (< 3 months) showed the most significant effects, while medium-term follow-up (3–6 months) yielded weaker results, potentially due to the smaller sample size (N = 60) in this subgroup. Long-term follow-up (> 6 months) demonstrated moderate improvements. Regarding patient characteristics, patients with psychogenic ED experienced the most significant improvements, followed by patients with metabolic syndrome and cardiovascular disease. Patients with severe ED showed the most significant improvement compared to those with moderate ED. Publication language was also a factor, with studies published in English reporting more potent effects compared to those published in Chinese, likely due to differences in study design quality and language bias. Finally, subgroup analysis by age groups showed improvement in erectile function across all age groups, with the mean differences ranging between 2.3 and 3.5. However, the variation in the mean differences and the overlapping confidence intervals (CI) suggest no clear evidence of significant differences in the efficacy of interventions across different age groups. These findings align with previous studies[ 9 , 16 , 18 , 19 , 51 – 55 ]and provide robust evidence for the efficacy of exercise interventions, particularly when combined with pharmacological treatments, supporting the development of personalized treatment strategies for ED. 4.2 Comparison with Existing Studies This study is more diverse than previous literature in terms of the types of exercise interventions included and the scope of subgroup analyses. While prior studies primarily focused on a single exercise modality, such as aerobic exercise or pelvic muscle training[ 9 , 18 , 20 – 22 , 30 , 51 , 53 , 55 ], this study broadens the approach by incorporating comprehensive interventions that combine traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi) with pharmacological treatments. Additionally, this study extends the analysis to factors such as the language of publication, patients' health status, and the cultural adaptability of exercise interventions. These innovations provide more targeted, evidence-based support for the development of personalized treatment plans tailored to diverse patient groups and cultural contexts. 4.3 Interpretation of Results and Possible Mechanisms The improvement of erectile function (EF) through exercise interventions can be attributed to several interconnected mechanisms, including enhancements in cardiovascular health, metabolic regulation, and psychological well-being. Exercise promotes endothelial function and improves blood circulation, which directly supports erectile response by mitigating vascular dysfunction, a key contributor to ED. Additionally, the role of exercise in weight management and metabolic regulation, such as improving insulin sensitivity and reducing systemic inflammation, is particularly beneficial for patients with metabolic syndrome or obesity [ 56 – 63 ]. These mechanisms align with subgroup findings in this study, which showed that patients with psychogenic ED or metabolic syndrome benefited significantly from exercise interventions. Subgroup analysis further highlighted that low-intensity exercise was particularly effective in the short term for patients with moderate ED, with more significant improvements compared to higher-intensity regimens. This may be because low-intensity exercise is more straightforward to adhere to, facilitating sustained engagement and cumulative benefits. Additionally, low-intensity exercise minimizes physiological stress and the risk of overexertion, making it suitable for patients with pre-existing cardiovascular conditions or other health complications. Moreover, this study found that comprehensive interventions combining exercise with pharmacological treatments produced the most significant improvements in EF. This highlights the synergistic effects of exercise and medications, as pharmacological treatments address physiological deficiencies, while exercise enhances systemic health and reinforces psychological resilience. These findings underscore the importance of tailoring exercise regimens to individual patient characteristics, such as disease severity, baseline health status, and adherence capacity, to maximize clinical outcomes. 4.4 Advantages of Research This study has several advantages in terms of research design. First, this study included multiple randomized controlled trials (RCTs) in recent years and used rigorous bias control methods and sensitivity analysis to ensure the robustness of the results. Second, the study included different health states (such as metabolic syndrome, psychogenic ED, and others), which improved the external validity of the results. Furthermore, including studies from Asian populations, particularly those involving traditional exercise interventions (e.g., Tai Chi, Wu Qin Xi), enhances the cultural diversity of the analysis. This provides valuable insights into region-specific intervention approaches and increases the generalizability of the findings by incorporating perspectives often underrepresented in global research. In addition, comprehensive subgroup analyses allowed this study to carefully explore the impact of different intervention characteristics and patient characteristics on EF improvement, providing more detailed data support for developing personalized clinical protocols. 4.5 Limitations and Potential Bias There are still some limitations in this study. First, due to the specific nature of exercise interventions, it is difficult to achieve a double-masked design, which may lead to detection bias. In addition, the included trials were heterogeneous in terms of intervention type, follow-up time, and sample characteristics. Although the impact of bias was reduced by using a random effects model and sensitivity analysis, heterogeneity may still affect the accuracy of the results. Second, due to the small sample sizes of some studies, the statistical power of the analyses may be insufficient; especially in the Chinese literature, the results may be limited by the sample size and the quality of the study design. Finally, although this study provides valuable insights into exercise interventions for populations with a precise diagnosis of erectile dysfunction (ED), the lack of data on healthy individuals represents a limitation. 4.6 Clinical Practice and Policy Recommendations The findings of this study offer important insights for clinical practice and health policy. Exercise interventions should be considered as an effective adjunct to the management of erectile dysfunction (ED), particularly when tailored to patient-specific characteristics. For patients capable of moderate- to high-intensity exercise, structured exercise regimens can serve as a valuable therapeutic option. However, for high-risk populations or those with comorbidities, low- to moderate-intensity exercise interventions may provide safer and more accessible alternatives, ensuring greater adherence and minimizing risks. From a policy perspective, the promotion of exercise interventions should emphasize individualized exercise prescriptions based on patient health status, disease severity, and lifestyle factors. Policymakers should prioritize resources to implement programs that integrate exercise as a standard component of ED management, with a particular focus on enhancing follow-up management to improve compliance and long-term outcomes. Furthermore, public health campaigns should raise awareness about the benefits of culturally diverse interventions, such as traditional Asian exercises, to broaden patient engagement and inclusivity. These efforts would not only improve ED outcomes but also contribute to broader health benefits in high-risk populations. 4.7 Future Research Directions Future research should prioritize high-quality, large-scale, randomized controlled trials (RCTs) to confirm the long-term efficacy of various exercise interventions in managing erectile dysfunction (ED). Particular attention is needed to identify the optimal combination of exercise intensity, frequency, and duration to develop refined, evidence-based, personalized exercise prescriptions. Additionally, future studies should explore the potential benefits of multidisciplinary approaches, such as integrating psychotherapy, dietary modifications, or pharmacological treatments, to enhance the overall therapeutic efficacy of exercise interventions. Expanding research populations is another critical direction. While current studies have primarily focused on clinical populations with ED, future research should also include healthy individuals to investigate preventive effects and broader health implications. This expansion would allow for more generalizable findings and deepen the understanding of exercise interventions in diverse populations. Furthermore, the inclusion of culturally diverse exercise regimens, such as traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi), should be further explored to assess their applicability and effectiveness across different cultural contexts. 5 Conclusions This systematic review and meta-analysis confirm that exercise alone is sufficient to significantly improve erectile function in adult men, and that this effect is further amplified when exercise is combined with pharmacological treatments. Subgroup analyses revealed that interventions combining low-to-moderate-intensity aerobic exercise or traditional exercises (e.g., Tai Chi, Wu Qin Xi) with medications were especially effective in patients with moderate-to-severe ED, with the most pronounced improvements observed during short-term follow-up (< 3 months). These findings underscore the critical role of intervention type, intensity, and duration in determining the effectiveness of ED management strategies. Despite these promising results, the study is limited by the relatively small number of included studies and sample sizes, which restricted more detailed analyses of the effects of specific exercise types and intensities. While this study provides positive evidence supporting exercise interventions in ED management, clear evidence-based guidance on optimizing exercise program parameters—such as type, frequency, and duration—remains lacking. Future research should focus on conducting large-scale randomized controlled trials with extended follow-up periods to comprehensively evaluate the effects of various exercise modalities on diverse ED populations. Additionally, accounting for individual patient characteristics, including baseline health status and ED severity, will be critical to developing more personalized and scientifically robust intervention strategies. These efforts will help establish a more substantial evidence base for clinical practice, supporting the development of effective, tailored treatment protocols for managing ED. Declarations Ethics approval and consent to participate Not applicable. Consent for publication The publications in the meta-analysis report appropriate ethical and consent procedures. Availability of Data and Materials The data supporting this study's findings are available from the authors upon reasonable request. Competing Interests The authors declare that they have no relevant financial or non-financial interests to disclose. Funding F.B.O research activity is supported by the Grant PID2023-148404OB-I00 funded by MICIU/AEI /10.13039/501100011033 and ERDF funds, EU. Authors' contributions H. Y. S. and Y. Z. are co-first authors of this study. H. Y. S. and Y. Z. conceptualized and designed the study; H. Y. S., Y. Z., and X. Y. L. performed the literature search and review. H. Y. S., Q. G. C., Y. Z., and X. 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Tables Table 1 Characteristics of the included studies (n=12) Study Groups Number Age Health condition Baseline IIEF score Kalka et al. 2013[28] E: Aerobic exercise＋Pharmacological C: Pharmacological E: 103 C: 35 E: 62.07 (8.59) C: 61.43 (8.81) Ischaemic heart disease E: 12.51 (5.98) C: 12.26 (5.83) Maresca et al. 2013[29] E: Aerobic exercise＋Pharmacological C: Pharmacological E:10 C: 10 E: 69.0 (2.8) C: 68.0 (3.6) Metabolic syndrome E: 10.8 (2.0) C: 11.2 (2.1) a Lin et al. 2012[21] E: Aerobic exercise＋Pelvic floor muscle training C: no training E:41 C:31 E: 65.75 (6.12) Not reported or unclear E: 5.06 (0.24) C: 5.00 (0.00) Maio et al. 2010[25] E: Aerobic exercise＋Pharmacological C: Pharmacological E:30 C:30 E: 50.14 (6.28) C: 50.32(6.95) Cardiovascular risk factors E: 15.8 (4.19) C: 15.5 (4.18) Lamina et al. 2009[24] E: Aerobic exercise＋Pharmacological C: Pharmacological E: 25 C: 25 E: 62.10 (5.23) C: 64.00(4.77) Hypertensive E: 11.50 (5.30) C: 8.10 (4.02) Esposito et al. 2004[23] E: Aerobic exercise C: Health advice 1 E: 55 C: 55 E: 43.5 (4.8) C: 43.0 (5.1) Obesity E:13.9(4.0) C: 13.5(4.0) Dorey et al. 2004[20] E: Aerobic exercise＋Pelvic floor muscle training C: Lifestyle advice 2 E: 28 C: 27 E: 58 (22–78) C: 61 (41–72) Not reported or unclear E: 7.5 (1–28) C: 7.0 (1–17) Begot et al. 2009[30] E: Aerobic exercise C: no training E: 30 C: 30 55.3 (6.7) Cardiovascular risk factors E: 10.3 C: 10.2 a Feng et al. 2021[31] E: Aerobic exercise ＋Pharmacological C: Pharmacological E: 33 C: 31 E: 34.06 (6.30) C: 33.74(7.45) Not reported or unclear E: 12.5 (4.2) C: 10.3 (3.7) a Shen et al. 2012[27] E: Traditional exercise＋Pharmacological C: Huanshao Capsule E: 27 C: 26 E: 69.0 (2.8) C: 68.0 (3.6) Psychogenic erectile dysfunction E: 10.8 (2.0) C: 11.2 (2.1) a Zeng et al. 2018[22] E: Aerobic exercise C: Pharmacological E: 30 C: 30 22–60 Coronary heart disease E: 20.0 (3.85) C: 17.5 (2.1) Jing et al. 2012[26] E: Traditional exercise ＋Pharmacological C: Zuogui Pill E: 40 C: 36 E: 37.49(6.22) C: 35.60(5.01) Psychogenic erectile dysfunction E: 16.4 (3.1) C: 14.8 (3.5) n number of included studies, E experimental group, C comparator group,1 A sensible diet, appropriate exercise, and weight management,2 Diet adjustment, smoking cessation, reduced alcohol consumption, stress reduction, and increased physical activity. a Study was published in Chinese language, IIEF International Index of Erectile Function, in which higher scores indicate better erectile function. Table 2 Characteristics of the Exercise training interventions (n= 12) Study Intervention measures Intensity Time Frequency Follow-up duration Outcome indicator Kalka et al. 2013[28] Aerobic exercise＋Pharmacological (stationary cycling)(PDE5) Moderate intensity 45 min 3 times/week 6 months IIEF score Maresca et al. 2013[29] Aerobic exercise＋Pharmacological (stationary cycling)(PDE5) Moderate intensity 30 min 3 times/week 12 weeks IIEF score Lin et al. 2012[21] Aerobic exercise＋Pelvic floor muscle training (stationary cycling) High intensity 50 min 2 times/day 12 months IIEF score Maio et al. 2010[25] Aerobic exercise＋Pharmacological (stationary cycling)(PDE5) Moderate intensity 45 min 3 times/week 3 months IIEF score Lamina et al. 2009[24] Aerobic exercise＋Pharmacological (running)(PDE5) High intensity 45 min 3 times/week 8 weeks IIEF score Esposito et al. 2004[23] Aerobic exercise (walking) Moderate intensity 30 min 5 times/week 24 months IIEF score Dorey et al. 2004[20] Aerobic exercise＋Pelvic floor muscle training(stationary cycling) Low intensity 30 min 5 times/week 6 months IIEF score Begot et al. 2009[30] Aerobic exercise (walking) Moderate intensity 45 min 3 times/week 12 weeks IIEF score Feng et al. 2021[31] Aerobic exercise＋Pharmacological (running)(Qingli Xingwei Decoction 1 ) Low intensity 30 min 2 times/day 3 months IIEF score Shen et al. 2012[27] Traditional exercise＋Pharmacological (Tai Chi)(Huanshao Capsule 2 ) Low intensity 30 min 5 times/week 3 months IIEF score Zeng et al. 2018[22] Aerobic exercise (running) Moderate intensity 20-40 min 5 times/week 12 weeks IIEF score Jing et al. 2012[26] Traditional exercise＋Pharmacological (Wu Qin Xi)(Zuogui Pill 3 ) Low intensity 30 min 1 times/day 6 months IIEF score n number of included studies, E experimental group, C comparator group,1 A traditional Chinese medicine formula containing ingredients such as Gardenia, Bupleurum, Scutellaria, and others, used to treat damp-heat kidney yang deficiency-type impotence,2 A proprietary Chinese medicine with ingredients such as Rehmannia Root, Cornus, Chinese Yam, and others. It nourishes kidney yang and improves psychogenic erectile dysfunction,3 A traditional Chinese medicine formula with key ingredients, including Cooked Rehmannia, Cornus, and Chinese Yam, used to nourish yin and tonify the kidneys. a Study was published in the Chinese language, IIEF International Index of Erectile Function Supplementary Files SupplementaryMaterialSMO.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6075962","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":437526490,"identity":"8b856b4f-dcd9-4a9a-afcf-d9a924d64e00","order_by":0,"name":"Haiyang Sun","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0004-9933-2511","institution":"Sichuan Normal University","correspondingAuthor":true,"prefix":"","firstName":"Haiyang","middleName":"","lastName":"Sun","suffix":""},{"id":437526491,"identity":"bf79e81c-7619-4e47-aa88-0a5644de49ad","order_by":1,"name":"Yan Zhao","email":"","orcid":"","institution":"Department of Physical Education, Sichuan Normal University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Zhao","suffix":""},{"id":437526492,"identity":"df0718d7-e0ca-4848-ab6a-b25dc186d0d6","order_by":2,"name":"Xinyue Liao","email":"","orcid":"","institution":"Department of Physical Education, Sichuan Normal University","correspondingAuthor":false,"prefix":"","firstName":"Xinyue","middleName":"","lastName":"Liao","suffix":""},{"id":437526493,"identity":"0bfc1567-fd85-42ee-9ea4-aaf283e5d00a","order_by":3,"name":"Francisco B. Ortega","email":"","orcid":"","institution":"1. Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS), University of Granada2. Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä.","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"B.","lastName":"Ortega","suffix":""},{"id":437526494,"identity":"586801a9-c9fd-43f4-996d-50f04af55e3d","order_by":4,"name":"Qingguo Chen","email":"","orcid":"","institution":"Department of Physical Education, Sichuan Normal University","correspondingAuthor":false,"prefix":"","firstName":"Qingguo","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2025-02-21 04:22:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6075962/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6075962/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81290297,"identity":"40991b42-65f4-4f7f-932b-64df2bb7927f","added_by":"auto","created_at":"2025-04-24 11:53:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":145908,"visible":true,"origin":"","legend":"\u003cp\u003eStudies included through the review process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6075962/v1/d558a05adf5f6c6429dfd0b2.png"},{"id":81291189,"identity":"35afb3f1-7c3c-4c93-a90d-13efa9a16baa","added_by":"auto","created_at":"2025-04-24 12:01:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":182967,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of exercise effects on erectile function in adult males\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6075962/v1/d70ff26b4f3ddefa5150ac7b.png"},{"id":81290296,"identity":"0d58045c-e056-4310-be7e-237d06d7eeb3","added_by":"auto","created_at":"2025-04-24 11:53:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":76685,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot assessing publication bias in studies evaluating the effects of exercise training on erectile function in adult males\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6075962/v1/e400049638c2f23a6c304763.png"},{"id":81290300,"identity":"92ae2bca-390c-47d6-a7d8-a1e80ecb783f","added_by":"auto","created_at":"2025-04-24 11:53:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":234448,"visible":true,"origin":"","legend":"\u003cp\u003eSubgroup analysis of exercise training effects on erectile function in adult males based on intervention type, regimen, language, medical condition, age group, disease severity, follow-up period, and exercise intensity\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6075962/v1/8493ce826f756d5cd75da185.png"},{"id":97371168,"identity":"ea751fca-b20c-41a1-b244-6c812c53cd98","added_by":"auto","created_at":"2025-12-03 16:28:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1906908,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6075962/v1/27ced6b6-3fcd-4c09-b59f-7be118268617.pdf"},{"id":81290304,"identity":"d5052c22-ccc5-40bf-bb56-1c55b6d111d3","added_by":"auto","created_at":"2025-04-24 11:53:06","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":484553,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialSMO.docx","url":"https://assets-eu.researchsquare.com/files/rs-6075962/v1/272e2f052b674ab1c660b099.docx"}],"financialInterests":"","formattedTitle":"Effects and Moderators of Exercise Training on Erectile function in Male Adults with diagnosed erectile dysfunction: A Systematic Review and Meta-Analysis","fulltext":[{"header":"Key Points","content":"\u003cp\u003eInterventions including exercise have a significant effect on improving erectile dysfunction in adult men, with the most significant effects observed when exercise is combined with pharmacological treatments.\u003c/p\u003e\u003cp\u003eA subgroup analysis further revealed the effects of different intervention types, exercise programs, languages of publication, health status, age groups, disease severity, follow-up duration, and exercise intensity on the intervention effect. Providing a more specific reference for developing personalized treatment plans in the future.\u003c/p\u003e\u003cp\u003e Although this study strictly follows the best practice guidelines for systematic reviews and meta-analyses, the evidence is limited to populations with a precise diagnosis of erectile dysfunction (ED). It does not include healthy individuals, which represents a key limitation. Future studies are needed to explore the effects of intervention programs in healthy populations to provide a more comprehensive evidence base.\u003c/p\u003e"},{"header":"1 Introduction","content":"\u003cp\u003eErectile dysfunction (ED) is defined as the persistent inability of a man to achieve and maintain an adequate erection for satisfactory sexual performance. This sexual dysfunction is widespread among men worldwide, and the incidence rate increases with age, from 8% among men aged 20\u0026ndash;30 to 37% among men aged 70\u0026ndash;75[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. ED not only affects quality of life but is also closely related to a variety of health problems, such as psychological stress, depression, and cardiovascular disease[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, the presence of ED often indicates a need for comprehensive assessment and management of underlying cardiovascular risk factors.\u003c/p\u003e \u003cp\u003eAlthough drug therapy, such as phosphodiesterase type 5 inhibitors (PDE5i), is the primary treatment for ED, it has limited efficacy and may be accompanied by adverse reactions in some patients[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In recent years, more and more studies have shown that exercise training can effectively improve erectile function[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Exercise is considered to have potential benefits for the management of ED by improving cardiovascular health, metabolic function, and psychological state [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, further systematic research is needed on the effects of different exercise modes and intensities.\u003c/p\u003e \u003cp\u003eExisting research shows that the mechanism of ED is complex, involving multiple aspects such as vascular endothelial dysfunction, metabolic disorders, endocrine disorders, and psychological factors[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Lifestyle changes can influence these physiological and psychological factors, especially physical exercise. Exercise can improve erectile function by enhancing endothelial function, improving blood circulation, regulating body weight and metabolic indicators, and relieving stress and anxiety[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although drug therapy plays an important role in the management of ED, sole reliance on drugs may not completely solve the problem[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This is especially true when other health risk factors are present. Based on this theoretical background, exercise training as a non-pharmacological intervention has recently become a research hotspot. It is considered to be synergistic with drug therapy to improve overall efficacy.\u003c/p\u003e \u003cp\u003eAlthough existing systematic reviews and meta-analyses have shown that physical activity and exercise interventions positively improve erectile dysfunction (ED)[\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], there are some limitations regarding the type of intervention, sample characteristics, follow-up time, and bias control. This study has made several innovative expansions, providing more comprehensive data support for the evidence-based basis of ED intervention.\u003c/p\u003e \u003cp\u003eFirst, this study significantly expands on the types of interventions compared to existing studies, including recent meta-analyses published in 2023 and 2024. While previous research primarily focused on aerobic and pelvic muscle training[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The diversity of exercise interventions and combined treatment models was not thoroughly explored. This study broadens the scope by incorporating traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi) in combination with comprehensive drug interventions, offering culturally diverse and adaptable treatment options[\u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28 CR29 CR30\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This inclusion fills a gap in the existing literature and provides insights into the effectiveness of culturally specific interventions, which are often underrepresented in global research. By addressing the limitation of intervention singularity in earlier studies, this study provides a more comprehensive foundation for developing personalized clinical treatment strategies that can be applied across different cultural contexts.\u003c/p\u003e \u003cp\u003eSecond, this study addresses the lack of diversity in sample characteristics seen in previous research. The research samples of Silva and others were mainly from Europe and the United States, and most of the patient groups had cardiovascular risk factors, which limited the applicability of the research results to patient groups with different health statuses [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These limitations reduced the generalizability of their findings to broader patient groups with varying health statuses and cultural backgrounds. In contrast, this study incorporates a broader range of health states, including metabolic syndrome and psychogenic ED, and includes studies from diverse geographical and cultural contexts, particularly East Asia. This broader representation not only enhances the external validity of the results but also compensates for the lack of diversity in previous research, making the findings more applicable to ED patients with diverse health conditions and cultural backgrounds.\u003c/p\u003e \u003cp\u003eIn addition, this study systematically improved the follow-up design. While Silva et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] included studies with follow-up periods ranging from 8 weeks to 2 years, they did not systematically analyze the effects of interventions over short-, medium-, and long-term durations. This study fills this gap by categorizing follow-up periods into short-term (\u0026lt;\u0026thinsp;3 months), medium-term (3\u0026ndash;6 months), and long-term (\u0026gt;\u0026thinsp;6 months), allowing for a more granular evaluation of intervention persistence and its impact on treatment outcomes. These findings enable clinicians to make more precise recommendations for intervention duration and follow-up planning tailored to the needs of individual patients.\u003c/p\u003e \u003cp\u003eThis study also conducts a more detailed subgroup analysis than previous work. While recent meta-analyses primarily focused on subgroup differences in cardiovascular risk factors and intervention types, this study takes a more multi-dimensional approach. It adds the effects of intervention intensity (e.g., low, moderate, high), different age groups, and varying health states (e.g., severe and psychogenic ED). Moreover, this study is the first to systematically incorporate Chinese-language studies, significantly expanding the evidence base by including key data from East Asian populations. These studies are often excluded in prior meta-analyses due to language bias, which increases the risk of missing critical data. Including these studies not only enhances the comprehensiveness of the analysis but also provides a more globally representative perspective on ED interventions. By refining subgroup analyses, this study offers a more accurate assessment of how patient and intervention characteristics influence treatment outcomes, providing robust data to support personalized treatment planning.\u003c/p\u003e \u003cp\u003eAdditionally, this study adopts a more rigorous approach to bias control and data processing. While recent meta-analyses demonstrated moderate to high risks of bias, mainly due to challenges in blinding and subjective patient reports, this study applies more stringent methodologies. It systematically evaluates small-sample effects and publication bias using sensitivity analyses, funnel plots, and Egger regression tests, significantly improving the robustness of the results. These measures help address potential biases and ensure that the conclusions are reliable and valid.\u003c/p\u003e \u003cp\u003eFinally, this study emphasizes translating research findings into actionable clinical guidance. While existing studies have highlighted the positive effects of moderate- to high-intensity aerobic exercise, they have rarely addressed how these findings can be effectively applied in real-world clinical practice. This study integrates traditional Chinese medicine with exercise interventions, explores the potential for multidisciplinary collaboration, and proposes exercise prescription recommendations tailored to different patient groups. By prioritizing clinical translatability, this study provides a practical reference for developing personalized interventions and advancing health policy in ED management.\u003c/p\u003e \u003cp\u003eIn summary, this study builds upon and significantly extends the findings of previous meta-analyses by broadening the diversity of interventions and sample characteristics, introducing a systematic follow-up design, refining subgroup analyses, and employing rigorous bias control. These contributions enhance the robustness and generalizability of the data and lay a solid foundation for developing culturally diverse and personalized ED treatment strategies.\u003c/p\u003e \u003cp\u003eThe primary objective of this systematic review and meta-analysis is to assess the efficacy of physical activity and exercise interventions for improving erectile function in adult men by systematically collecting and analyzing published randomized controlled trials (RCTs). In particular, this study will explore the differences in the efficacy of different exercise interventions (e.g., aerobic exercise, pelvic muscle training, and their combinations), intervention intensity and frequency, and combination with drugs. By integrating and analyzing these data, we hope to provide a more precise scientific basis for personalized treatment options for ED in clinical practice and help clinicians better understand the potential value and applicability of exercise interventions in managing ED.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eThe study protocol for this systematic review was registered on Oct 17, 2024, in the international Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42024593228), and the results are reported by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eThis systematic review selected studies for inclusion according to the PICOS criteria and detailed the inclusion and exclusion criteria. The included participants were adult men aged 18 years and above with a precise diagnosis of erectile dysfunction (ED), and the diagnostic tool was the International Index of Erectile Function (IIEF). ED was defined based on IIEF-5 scores: 22\u0026ndash;25 indicating normal erectile function, 17\u0026ndash;21 mild ED, 12\u0026ndash;16 mild-to-moderate ED, 8\u0026ndash;11 moderate ED, and 1\u0026ndash;7 severe ED. Studies included participants with IIEF-5 scores\u0026thinsp;\u0026lt;\u0026thinsp;21, representing mild to severe ED[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The health conditions reported in the included studies, such as ischaemic heart disease, hypertension, coronary heart disease, metabolic syndrome, obesity, psychogenic erectile dysfunction, and the rehabilitation period after prostatectomy, reflect the characteristics of the study populations rather than predefined eligibility criteria. Interventions included aerobic exercise combined with medication, aerobic exercise combined with pelvic muscle training, aerobic exercise alone, traditional exercise combined with medication, comprehensive intervention, and exercise intervention alone. The intensity of the interventions was not limited and included low-, medium- and high-intensity exercise. The control group included standard care without specific exercise, health education, relaxation training, stretching activities, and drug therapy alone. Some studies used a placebo-controlled or wait-and-see group. The primary outcome was improved erectile function, assessed using the International Index of Erectile Function (IIEF) scoring quantifying tool[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnly randomized controlled trials (RCTs) were included, and only published, peer-reviewed studies. The data sources covered English and Chinese core journals, with no language restrictions, and included both trials published in full text and studies reported in abstracts only. Exclusion criteria included non-human studies, animal experiments, conference abstracts, book chapters, reviews or unpublished articles, and studies for which it was impossible to obtain or extract valid data even after contacting the authors. To better evaluate the effect of the intervention in the analysis of the results, the included studies were grouped according to the following dimensions: type of intervention (e.g., aerobic exercise, pelvic muscle training, and their combination), intervention intensity (low, medium and high intensity), follow-up time (short term, medium term, and long term) Through detailed inclusion and exclusion criteria and a reasonable grouping strategy, this systematic review aims to provide comprehensive and systematic evidence on the use of exercise interventions in the treatment of ED and provide a reliable basis for clinical personalized treatment plans.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Search Strategy\u003c/h2\u003e \u003cp\u003eWe systematically searched Embase, Cochrane Central, Scopus, Ovid MEDLINE, PubMed, Web of Science, and a Chinese database, CNKI, from inception to October 2024. The search strategy combined keywords and Medical Subject Headings (MeSH), including 'exercise,' 'aerobic exercise,' 'traditional sport,' 'pelvic floor muscle training,' 'erectile dysfunction,' 'randomized controlled trial,' and others.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study Selection\u003c/h2\u003e \u003cp\u003eThis study used EndNote 21 as the reference management system[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. After the database search was complete, two researchers (H.Y.S. and Y.Z.) independently screened the titles and abstracts of the selected studies for initial screening based on the PICOS criteria. For potentially eligible studies, full-text assessment and review were conducted. If the two researchers disagreed on the eligibility of an article, a third researcher (X. Y. L.) would be involved in the discussion, and consensus would be reached. In addition, to ensure comprehensiveness, we manually searched the reference lists of the included studies and relevant systematic reviews and consulted experts in the field.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection\u003c/h2\u003e \u003cp\u003eIn this systematic review, three researchers (H. Y. S., Y. Z., and X. Y. L.) independently extracted data from each included trial based on a standardized data collection form to ensure the accuracy and consistency of the data. If there were any unclear or missing data, the research team would contact the original study authors to obtain or confirm the information and ensure its integrity; a fourth reviewer (Q. G. C.) would decide when necessary. No automated tools were used in this study, and researchers manually extracted and verified all data to ensure data quality. The primary outcome measure extracted was the International Index of Erectile Function (IIEF) score[\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which was used to quantify changes in erectile function and record all effect sizes, follow-up time points, and related analysis results in each study. Other extracted variables included participant age, health status, baseline IIEF score, and intervention characteristics (e.g., type of exercise, intensity, frequency, dose, and duration of drug combination therapy), and the specific intervention content of the control group was recorded. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) summarises the main characteristics of the included studies, and the specific intervention protocols in each study are shown in (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). We convert continuous variables that cannot be combined directly (such as the median and range) to the mean and standard deviation based on published methods[\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Missing data are not filled in, and no assumptions are made.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Characteristics of the included studies (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e Study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth condition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBaseline IIEF score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKalka et al. 2013[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise་Pharmacological C: Pharmacological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 103 C: 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 62.07 (8.59) C: 61.43 (8.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIschaemic heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 12.51 (5.98) C: 12.26 (5.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaresca et al. 2013[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise་Pharmacological C: Pharmacological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE:10 C: 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 69.0 (2.8) C: 68.0 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMetabolic syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 10.8 (2.0) C: 11.2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eLin et al. 2012[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise་Pelvic floor muscle training C: no training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE:41 C:31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 65.75 (6.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported or unclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 5.06 (0.24) C: 5.00 (0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaio et al. 2010[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise་Pharmacological C: Pharmacological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE:30 C:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 50.14 (6.28) C: 50.32(6.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCardiovascular risk factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 15.8 (4.19) C: 15.5 (4.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLamina et al. 2009[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise་Pharmacological C: Pharmacological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 25 C: 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 62.10 (5.23) C: 64.00(4.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypertensive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 11.50 (5.30) C: 8.10 (4.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsposito et al. 2004[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise C: Health advice\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 55 C: 55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 43.5 (4.8) C: 43.0 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE:13.9(4.0) C: 13.5(4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDorey et al. 2004[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise་Pelvic floor muscle training C: Lifestyle advice\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 28 C: 27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 58 (22\u0026ndash;78) C: 61 (41\u0026ndash;72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported or unclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 7.5 (1\u0026ndash;28) C: 7.0 (1\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBegot et al. 2009[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise C: no training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 30 C: 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.3 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCardiovascular risk factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 10.3 C: 10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFeng et al. 2021[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise ་Pharmacological C: Pharmacological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 33 C: 31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 34.06 (6.30) C: 33.74(7.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported or unclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 12.5 (4.2) C: 10.3 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eShen et al. 2012[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Traditional exercise་Pharmacological C: Huanshao Capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 27 C: 26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 69.0 (2.8) C: 68.0 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePsychogenic erectile dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 10.8 (2.0) C: 11.2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eZeng et al. 2018[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Aerobic exercise C: Pharmacological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 30 C: 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoronary heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 20.0 (3.85) C: 17.5 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJing et al. 2012[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE: Traditional exercise ་Pharmacological C: Zuogui Pill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE: 40 C: 36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eE: 37.49(6.22) C: 35.60(5.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePsychogenic erectile dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eE: 16.4 (3.1) C: 14.8 (3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003en number of included studies, E experimental group, C comparator group,1 A sensible diet, appropriate exercise, and weight management,2 Diet adjustment, smoking cessation, reduced alcohol consumption, stress reduction, and increased physical activity. \u003csup\u003ea\u003c/sup\u003e Study was published in Chinese language, IIEF International Index of Erectile Function, in which higher scores indicate better erectile function.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the Exercise training interventions (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention measures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntensity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFollow-up duration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOutcome indicator\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKalka et al. 2013[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pharmacological (stationary cycling)(PDE5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaresca et al. 2013[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pharmacological (stationary cycling)(PDE5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLin et al. 2012[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pelvic floor muscle training (stationary cycling)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 times/day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaio et al. 2010[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pharmacological (stationary cycling)(PDE5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLamina et al. 2009[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pharmacological (running)(PDE5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsposito et al. 2004[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise (walking)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDorey et al. 2004[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pelvic floor muscle training(stationary cycling)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBegot et al. 2009[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise (walking)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeng et al. 2021[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise་Pharmacological (running)(Qingli Xingwei Decoction\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 times/day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShen et al. 2012[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional exercise་Pharmacological (Tai Chi)(Huanshao Capsule\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZeng et al. 2018[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAerobic exercise (running)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u0026ndash;40 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJing et al. 2012[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional exercise་Pharmacological (Wu Qin Xi)(Zuogui Pill\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 times/day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIIEF score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003en number of included studies, E experimental group, C comparator group,1 A traditional Chinese medicine formula containing ingredients such as Gardenia, Bupleurum, Scutellaria, and others, used to treat damp-heat kidney yang deficiency-type impotence,2 A proprietary Chinese medicine with ingredients such as Rehmannia Root, Cornus, Chinese Yam, and others. It nourishes kidney yang and improves psychogenic erectile dysfunction,3 A traditional Chinese medicine formula with key ingredients, including Cooked Rehmannia, Cornus, and Chinese Yam, used to nourish yin and tonify the kidneys. \u003csup\u003ea\u003c/sup\u003e Study was published in the Chinese language, IIEF International Index of Erectile Function\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Risk of Bias Assessment\u003c/h2\u003e \u003cp\u003eThis study used the Cochrane Risk of Bias Assessment Tool 2.0 (RoB2) to assess the risk of bias in the included randomized controlled trials (RCTs)[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The tool assesses the risk of bias strictly across five key domains: bias arising from the randomization process (e.g., random sequence generation and allocation concealment), bias due to deviations from intended interventions (e.g., adherence to the assigned intervention), bias due to missing outcome data (e.g., handling of missing data and its impact), bias in measurement of the outcome (e.g., validity of measurement tools and blinding of outcome assessors), and bias in selection of the reported result (e.g., selective outcome reporting). Additionally, an overall risk of bias assessment is conducted as an integrated judgment of domain-level evaluations, classifying the overall risk as 'low risk,' 'some concerns,' or 'high risk.' The assessment was independently completed by two researchers (H. Y. S. and Y. Z.) who were not affiliated with the included trials, ensuring the impartiality and objectivity of the assessment process. For each risk of bias item, two reviewers independently rated the risk of bias as either 'low,' ' some concerns, ' or 'high.' No automated tools were used during the assessment process, and all assessments were completed manually to ensure the accuracy of the evaluation. If the two reviewers disagreed on the risk of bias rating, the matter was first resolved through discussion; if there was still a difference of opinion, a third reviewer (X. Y. L.) would intervene and decide.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Outcomes\u003c/h2\u003e \u003cp\u003eThe primary outcome measure of this study was the change in score on the International Index of Erectile Function (IIEF)[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], which is used to quantify the improvement in erectile function. The mean difference (MD) was used to measure the effect of the intervention on the IIEF score when pooling the results. We recorded data for each included study at various time points during the follow-up period and used the change in score at the longest follow-up time point for data pooling and presentation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Data Synthesis\u003c/h2\u003e \u003cp\u003eThis study used a random effects model to comprehensively analyze the data, with the mean difference (MD) quantifying the effect of continuous variables to ensure robust estimates when there is variation in the effects between different trials[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The random effects model reasonably reflects the variability between trials and is an appropriate method for dealing with heterogeneity. During the data analysis, the R packages \"meta, metafor, funnelplot, forestplot, ggplot2, and forestploter\" were used for statistical analysis and result presentation [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. For studies that did not report effect sizes directly, data such as medians and quartiles were converted to means and standard deviations to ensure that all data were consistent when combined for analysis. Eligible studies were strictly screened and included when combining results. The intervention characteristics of each study (such as intervention type, exercise intensity, frequency, and follow-up time) were listed one by one and compared with the grouping criteria predetermined in the original protocol to ensure the consistency and accuracy of data combinations. We used lists and visualization tools (such as forest plots and funnel plots) to display the consistency of intervention characteristics in subgroups to more clearly present the differences and similarities between studies[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].To examine the heterogeneity between studies, the I\u0026sup2; statistic was used to assess the proportion of variability between studies due to heterogeneity, and the τ\u0026sup2; value was used to quantify the variance between studies[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The I\u0026sup2; value provides a reference for the consistency of results. The specific judgment criteria are as follows: I\u0026sup2; between 0% and 40% indicates that heterogeneity may be low and may not be statistically significant; I\u0026sup2; between 30% and 60% indicates moderate heterogeneity; I\u0026sup2; between 50% and 90% indicates that there may be significant heterogeneity; and I\u0026sup2; between 75% and 100% indicates significant heterogeneity, and the source of heterogeneity usually needs to be further explored[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The τ\u0026sup2; value directly quantifies the degree of heterogeneity, thus clearly reflecting the variation in research results[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Combining these indicators allows us to fully understand the potential inconsistencies in the research results and their sources, providing an important basis for data integration. To assess the stability of the combined results, this study also conducted a sensitivity analysis to examine the impact of different studies on the final results during the data merging process. To systematically evaluate minor sample effects and publication bias, the reliability and accuracy of the results were ensured by constructing funnel plots with enhanced contours and using Egger regression tests to assess the potential risk of bias due to missing results in the combined data[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. When assessing the reliability of the evidence for each outcome, the I\u0026sup2; and τ\u0026sup2; statistics are used in combination with the heterogeneity analysis, risk of bias, and quality of the study design to comprehensively determine the robustness and consistency of the evidence By combining the assessment of heterogeneity indicators (I\u0026sup2; and τ\u0026sup2;) with the risk of bias assessment, a comprehensive and rigorous judgment of the credibility of the evidence is ensured, thereby enhancing the robustness and interpretability of the overall conclusions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Subgroup analyses\u003c/h2\u003e \u003cp\u003eThis study explored factors that may have caused heterogeneity in the results through multiple predefined subgroup analyses, including intervention type, exercise regimen, language of publication, health status, age group, disease severity, follow-up duration, and exercise intensity (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These subgroup analyses helped identify differences in the improvement of erectile function by exercise intervention under different conditions, providing a basis for explaining the heterogeneity of the research results.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eWe retrieved 1,087 records from the following sources: Cochrane (230), EMBASE (142), Ovid (80), CNKI (65), PubMed (53), Scopus (441), and Web of Science (76). After removing duplicate records, 534 articles remained. Initial screening excluded 98 reviews, systematic reviews, commentaries, and animal studies, leaving 436 studies. During the abstract screening stage, 376 studies were excluded due to inconsistent content or interventions/control measures. The remaining 60 studies were screened in full, and 41 studies that did not meet the RCT criteria or had unsatisfactory experimental methods were ultimately excluded, as were seven studies with inconsistent outcome indicators. Twelve eligible studies were included in the meta-analysis, including eight English studies and four Chinese studies. (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) shows the detailed search and selection process. The excluded studies included studies that met the inclusion criteria but were excluded because of their non-randomized controlled design or lack of consistent outcome indicators.\u003c/p\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Risk of Bias\u003c/h2\u003e\n \u003cp\u003e(Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) shows the results of the risk of bias assessment. No study was rated as having a low risk of bias in all areas. In this risk of bias assessment, all studies were rated as having a low risk in terms of random sequence generation (column A) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], indicating that a reasonable randomization method was used, the baseline balance between the experimental group and the control group was ensured, and the possibility of selection bias was reduced. All studies were at moderate risk of allocation concealment (column B) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. The lack of clear information on allocation concealment could have resulted in knowledge of the group allocation during the conduct of the trial, thus posing a potential risk of selection bias. In terms of blinding control (column C) of participants and researchers, most studies were shown to be at high risk[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], indicating that most studies failed to implement effective blinding control of participants and researchers, which may introduce subjective bias and affect the objectivity of the intervention effect. Most studies also showed a high risk regarding blinding of outcome assessment (column D). Failure to blind the assessor may lead to detection bias, significantly impacting more subjective outcome indicators. All studies were at low risk of handling missing data (column E) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], indicating that data integrity was effectively ensured in these studies and that there was no significant bias in the results due to missing data. Concerning selective reporting bias (column F), all studies were at low risk[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], all pre-specified outcome measures were reported in full, and no selective omissions were found, indicating high data transparency. In addition, concerning other systematic biases (column G), all studies were at low risk[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], and no significant systematic bias was observed in the trial design or implementation. Overall, these studies performed well in terms of random sequence generation, missing data handling, selective reporting, and other systematic biases, and the transparency and robustness of data management and result reporting were high. However, there was a specific risk of bias in allocation concealment, blinding of participants and researchers, and blinding of outcome assessment, which may affect the impartiality and accuracy of some results, especially when blinding is insufficient. Therefore, when interpreting the conclusions of these studies, special attention should be paid to these bias factors to ensure an accurate assessment of the effect of the intervention. In addition, due to the particular nature of exercise interventions, almost all studies have difficulty blinding participants and researchers, which may introduce detection bias. Due to these risks of bias, we have reduced the confidence in the evidence for the outcome indicators.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Primary Outcome\u003c/h2\u003e\n \u003cp\u003eTwelve randomized controlled trials involving 818 participants provided data for the primary outcome, as detailed in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. A random-effects model meta-analysis revealed a statistically significant improvement in the International Index of Erectile Function (IIEF) scores following exercise interventions, with a mean difference (MD) of 2.94 (95% CI 1.74 to 4.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, substantial heterogeneity was observed (\u0026tau;\u0026sup2;=3.25, I\u0026sup2;=78.79%), likely attributable to differences in intervention types, exercise intensities, participant populations, and study designs. Despite this, visual inspection of the funnel plot and results of Egger\u0026apos;s regression test did not suggest significant small-study effects (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), indicating that the findings are unlikely to be biased by publication or sample size.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Subgroup Analysis\u003c/h2\u003e\n \u003cp\u003eThe subgroup analysis of this study (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) analyzed the significant effects of different intervention characteristics and patient characteristics on the improvement of erectile function. The following elaboration is based on each parameter.\u003c/p\u003e\n \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.1 Type of Intervention\u003c/h2\u003e\n \u003cp\u003eComprehensive interventions, which combined exercise with pharmacological treatments, demonstrated the most significant improvement in erectile function. The mean difference (MD) for comprehensive interventions was 3.45 (95% CI 2.10 to 4.81, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a heterogeneity I\u0026sup2; of 64.98%. In contrast, exercise interventions alone had a more modest effect (MD 2.41, 95% CI 1.06 to 4.66, p\u0026thinsp;=\u0026thinsp;0.036), with a higher heterogeneity I\u0026sup2; of 87.25%. These results highlight the enhanced efficacy of combining exercise with pharmacological approaches.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.2 Exercise Regimens\u003c/h2\u003e\n \u003cp\u003eSubgroup analysis of exercise regimens showed that combining exercise with pharmacological interventions had the most significant effects. Traditional Asian exercises combined with pharmacological interventions demonstrated the most significant improvement (MD 4.28, 95% CI 2.95 to 5.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 0.00%), followed by aerobic exercise combined with pharmacological interventions (MD 3.04, 95% CI 1.15 to 4.92, p\u0026thinsp;=\u0026thinsp;0.002, I\u0026sup2; = 71.81%). Aerobic exercise combined with pelvic floor muscle training also showed potential benefits (MD 4.79, 95% CI -1.21 to 10.79, p\u0026thinsp;=\u0026thinsp;0.117, I\u0026sup2; = 85.57%), though the results were not statistically significant. In contrast, aerobic exercise alone had no statistically significant effect on erectile function (MD 1.34, 95% CI -0.92 to 3.59, p\u0026thinsp;=\u0026thinsp;0.245, I\u0026sup2; = 75.84%). These findings suggest that combining exercise with pharmacological treatments is the most effective strategy for improving erectile function.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.3 Language of Publication\u003c/h2\u003e\n \u003cp\u003eSubgroup analysis by publication language revealed better outcomes in studies published in English compared to those published in Chinese. Studies in English reported an MD of 3.19 (95% CI 1.79 to 4.58, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 74.52%), while studies in Chinese reported a smaller MD of 2.47 (95% CI 0.08 to 4.87, p\u0026thinsp;=\u0026thinsp;0.043, I\u0026sup2; = 84.43%).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.4 Medical Condition\u003c/h2\u003e\n \u003cp\u003ePatients with psychogenic erectile dysfunction benefited the most from interventions (MD 4.28, 95% CI 2.95 to 5.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 0.00%), followed by patients with metabolic syndrome (MD 2.45, 95% CI 0.94 to 3.95, p\u0026thinsp;=\u0026thinsp;0.001, I\u0026sup2; = 0.00%). Interventions for cardiovascular disease patients had a smaller but statistically significant effect (MD 2.41, 95% CI 0.03 to 4.78, p\u0026thinsp;=\u0026thinsp;0.047, I\u0026sup2; = 85.04%). Studies where health status was not clearly reported or unclear showed an MD of 3.59 (95% CI 0.86 to 6.90, p\u0026thinsp;=\u0026thinsp;0.034, I\u0026sup2; = 84.91%).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.5 Age Group\u003c/h2\u003e\n \u003cp\u003eThe subgroup analysis by age group showed the following results: patients aged 30\u0026ndash;50 years demonstrated a mean difference (MD) of 3.30 (95% CI 2.18 to 4.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;= 6.94%), the 50\u0026ndash;60 year age group showed an MD of 2.35 (95% CI -0.92 to 5.62, p\u0026thinsp;=\u0026thinsp;0.158, I\u0026sup2;= 86.75%), and those aged 60\u0026ndash;70 years had an MD of 3.48 (95% CI 1.73 to 5.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;= 79.29%). Considering the observed variation in the mean differences and the overlapping confidence intervals (CI), there is no clear evidence of significant differences in the efficacy of interventions across different age groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.6 Severity of Disease\u003c/h2\u003e\n \u003cp\u003ePatients with severe erectile dysfunction (ED) experienced the most substantial improvements, with an MD of 5.15 (95% CI 1.59 to 8.72, p\u0026thinsp;=\u0026thinsp;0.005, I\u0026sup2; = 91.12%). Patients with moderate ED showed a more minor but still significant improvement (MD 2.32, 95% CI 1.19 to 3.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 61.87%).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.7 Follow-up Period\u003c/h2\u003e\n \u003cp\u003eShort-term follow-up (\u0026lt;\u0026thinsp;3 months) demonstrated the most significant effect, with an MD of 3.54 (95% CI 2.25 to 4.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 65.33%). Long-term follow-up (\u0026gt;\u0026thinsp;6 months) also showed a significant improvement (MD 2.25, 95% CI 1.49 to 3.01, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 0.00%). Medium-term follow-up (3\u0026ndash;6 months) did not show significant improvements (MD -0.70, 95% CI -2.29 to 0.89, p\u0026thinsp;=\u0026thinsp;0.388, I\u0026sup2; = 0.00%).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.8 Intensity of Exercise\u003c/h2\u003e\n \u003cp\u003eLow-intensity exercise interventions produced the most significant improvements in erectile function, with an MD of 4.12 (95% CI 2.55 to 5.69, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 43.19%). Moderate-intensity interventions also showed significant effects (MD 2.34, 95% CI 0.40 to 4.28, p\u0026thinsp;=\u0026thinsp;0.018, I\u0026sup2; = 82.78%), while high-intensity interventions had a more minor but significant effect (MD 2.17, 95% CI 1.38 to 2.96, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2; = 0.00%).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Overview of Key Findings\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis demonstrated that exercise interventions significantly improve erectile function (EF) in men with erectile dysfunction (ED). Subgroup analyses revealed that the effectiveness of these interventions varies across intervention type, exercise intensity, follow-up duration, patient characteristics, and publication language. Combining exercise with pharmacological treatments produced the most significant improvements, with traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi) combined with medications showing the most significant effect sizes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], followed by aerobic exercise combined with pharmacological treatments. Exercise-only interventions demonstrated smaller yet significant effects, highlighting that exercise is most effective when paired with pharmacological interventions. Low-intensity exercise produced the most significant improvements compared to moderate-intensity and high-intensity exercise. For follow-up periods, short-term interventions (\u0026lt;\u0026thinsp;3 months) showed the most significant effects, while medium-term follow-up (3\u0026ndash;6 months) yielded weaker results, potentially due to the smaller sample size (N\u0026thinsp;=\u0026thinsp;60) in this subgroup. Long-term follow-up (\u0026gt;\u0026thinsp;6 months) demonstrated moderate improvements. Regarding patient characteristics, patients with psychogenic ED experienced the most significant improvements, followed by patients with metabolic syndrome and cardiovascular disease. Patients with severe ED showed the most significant improvement compared to those with moderate ED. Publication language was also a factor, with studies published in English reporting more potent effects compared to those published in Chinese, likely due to differences in study design quality and language bias. Finally, subgroup analysis by age groups showed improvement in erectile function across all age groups, with the mean differences ranging between 2.3 and 3.5. However, the variation in the mean differences and the overlapping confidence intervals (CI) suggest no clear evidence of significant differences in the efficacy of interventions across different age groups. These findings align with previous studies[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52 CR53 CR54\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]and provide robust evidence for the efficacy of exercise interventions, particularly when combined with pharmacological treatments, supporting the development of personalized treatment strategies for ED.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Comparison with Existing Studies\u003c/h2\u003e \u003cp\u003eThis study is more diverse than previous literature in terms of the types of exercise interventions included and the scope of subgroup analyses. While prior studies primarily focused on a single exercise modality, such as aerobic exercise or pelvic muscle training[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], this study broadens the approach by incorporating comprehensive interventions that combine traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi) with pharmacological treatments. Additionally, this study extends the analysis to factors such as the language of publication, patients' health status, and the cultural adaptability of exercise interventions. These innovations provide more targeted, evidence-based support for the development of personalized treatment plans tailored to diverse patient groups and cultural contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Interpretation of Results and Possible Mechanisms\u003c/h2\u003e \u003cp\u003eThe improvement of erectile function (EF) through exercise interventions can be attributed to several interconnected mechanisms, including enhancements in cardiovascular health, metabolic regulation, and psychological well-being. Exercise promotes endothelial function and improves blood circulation, which directly supports erectile response by mitigating vascular dysfunction, a key contributor to ED. Additionally, the role of exercise in weight management and metabolic regulation, such as improving insulin sensitivity and reducing systemic inflammation, is particularly beneficial for patients with metabolic syndrome or obesity [\u003cspan additionalcitationids=\"CR57 CR58 CR59 CR60 CR61 CR62\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. These mechanisms align with subgroup findings in this study, which showed that patients with psychogenic ED or metabolic syndrome benefited significantly from exercise interventions. Subgroup analysis further highlighted that low-intensity exercise was particularly effective in the short term for patients with moderate ED, with more significant improvements compared to higher-intensity regimens. This may be because low-intensity exercise is more straightforward to adhere to, facilitating sustained engagement and cumulative benefits. Additionally, low-intensity exercise minimizes physiological stress and the risk of overexertion, making it suitable for patients with pre-existing cardiovascular conditions or other health complications. Moreover, this study found that comprehensive interventions combining exercise with pharmacological treatments produced the most significant improvements in EF. This highlights the synergistic effects of exercise and medications, as pharmacological treatments address physiological deficiencies, while exercise enhances systemic health and reinforces psychological resilience. These findings underscore the importance of tailoring exercise regimens to individual patient characteristics, such as disease severity, baseline health status, and adherence capacity, to maximize clinical outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Advantages of Research\u003c/h2\u003e \u003cp\u003eThis study has several advantages in terms of research design. First, this study included multiple randomized controlled trials (RCTs) in recent years and used rigorous bias control methods and sensitivity analysis to ensure the robustness of the results. Second, the study included different health states (such as metabolic syndrome, psychogenic ED, and others), which improved the external validity of the results. Furthermore, including studies from Asian populations, particularly those involving traditional exercise interventions (e.g., Tai Chi, Wu Qin Xi), enhances the cultural diversity of the analysis. This provides valuable insights into region-specific intervention approaches and increases the generalizability of the findings by incorporating perspectives often underrepresented in global research. In addition, comprehensive subgroup analyses allowed this study to carefully explore the impact of different intervention characteristics and patient characteristics on EF improvement, providing more detailed data support for developing personalized clinical protocols.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Limitations and Potential Bias\u003c/h2\u003e \u003cp\u003eThere are still some limitations in this study. First, due to the specific nature of exercise interventions, it is difficult to achieve a double-masked design, which may lead to detection bias. In addition, the included trials were heterogeneous in terms of intervention type, follow-up time, and sample characteristics. Although the impact of bias was reduced by using a random effects model and sensitivity analysis, heterogeneity may still affect the accuracy of the results. Second, due to the small sample sizes of some studies, the statistical power of the analyses may be insufficient; especially in the Chinese literature, the results may be limited by the sample size and the quality of the study design. Finally, although this study provides valuable insights into exercise interventions for populations with a precise diagnosis of erectile dysfunction (ED), the lack of data on healthy individuals represents a limitation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Clinical Practice and Policy Recommendations\u003c/h2\u003e \u003cp\u003eThe findings of this study offer important insights for clinical practice and health policy. Exercise interventions should be considered as an effective adjunct to the management of erectile dysfunction (ED), particularly when tailored to patient-specific characteristics. For patients capable of moderate- to high-intensity exercise, structured exercise regimens can serve as a valuable therapeutic option. However, for high-risk populations or those with comorbidities, low- to moderate-intensity exercise interventions may provide safer and more accessible alternatives, ensuring greater adherence and minimizing risks. From a policy perspective, the promotion of exercise interventions should emphasize individualized exercise prescriptions based on patient health status, disease severity, and lifestyle factors. Policymakers should prioritize resources to implement programs that integrate exercise as a standard component of ED management, with a particular focus on enhancing follow-up management to improve compliance and long-term outcomes. Furthermore, public health campaigns should raise awareness about the benefits of culturally diverse interventions, such as traditional Asian exercises, to broaden patient engagement and inclusivity. These efforts would not only improve ED outcomes but also contribute to broader health benefits in high-risk populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003e4.7 Future Research Directions\u003c/h2\u003e \u003cp\u003eFuture research should prioritize high-quality, large-scale, randomized controlled trials (RCTs) to confirm the long-term efficacy of various exercise interventions in managing erectile dysfunction (ED). Particular attention is needed to identify the optimal combination of exercise intensity, frequency, and duration to develop refined, evidence-based, personalized exercise prescriptions. Additionally, future studies should explore the potential benefits of multidisciplinary approaches, such as integrating psychotherapy, dietary modifications, or pharmacological treatments, to enhance the overall therapeutic efficacy of exercise interventions. Expanding research populations is another critical direction. While current studies have primarily focused on clinical populations with ED, future research should also include healthy individuals to investigate preventive effects and broader health implications. This expansion would allow for more generalizable findings and deepen the understanding of exercise interventions in diverse populations. Furthermore, the inclusion of culturally diverse exercise regimens, such as traditional Asian exercises (e.g., Tai Chi, Wu Qin Xi), should be further explored to assess their applicability and effectiveness across different cultural contexts.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThis systematic review and meta-analysis confirm that exercise alone is sufficient to significantly improve erectile function in adult men, and that this effect is further amplified when exercise is combined with pharmacological treatments. Subgroup analyses revealed that interventions combining low-to-moderate-intensity aerobic exercise or traditional exercises (e.g., Tai Chi, Wu Qin Xi) with medications were especially effective in patients with moderate-to-severe ED, with the most pronounced improvements observed during short-term follow-up (\u0026lt;\u0026thinsp;3 months). These findings underscore the critical role of intervention type, intensity, and duration in determining the effectiveness of ED management strategies. Despite these promising results, the study is limited by the relatively small number of included studies and sample sizes, which restricted more detailed analyses of the effects of specific exercise types and intensities. While this study provides positive evidence supporting exercise interventions in ED management, clear evidence-based guidance on optimizing exercise program parameters\u0026mdash;such as type, frequency, and duration\u0026mdash;remains lacking. Future research should focus on conducting large-scale randomized controlled trials with extended follow-up periods to comprehensively evaluate the effects of various exercise modalities on diverse ED populations. Additionally, accounting for individual patient characteristics, including baseline health status and ED severity, will be critical to developing more personalized and scientifically robust intervention strategies. These efforts will help establish a more substantial evidence base for clinical practice, supporting the development of effective, tailored treatment protocols for managing ED.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e The publications in the meta-analysis report appropriate ethical and consent procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e The data supporting this study\u0026apos;s findings are available from the authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e The authors declare that they have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e F.B.O research activity is supported by the Grant PID2023-148404OB-I00 funded by MICIU/AEI /10.13039/501100011033 and ERDF funds, EU.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eH. Y. S. and Y. Z. are co-first authors of this study. H. Y. S. and Y. Z. conceptualized and designed the study; H. Y. S., Y. Z., and X. Y. L. performed the literature search and review. H. Y. S., Q. G. C., Y. Z., and X. Y. L. performed the data extraction and quality assessment. H. Y. S. and Y. Z. performed the data analysis. The results were interpreted by H. Y. S., Q. G. C., and X. Y. L. H. Y. S., who wrote the first draft of the paper. F. B. O. provided critical feedback on the study design, data interpretation, and manuscript drafting and significantly contributed to the revision and refinement of the paper. H. Y. S., Q. G. C., Y. Z., and X. Y. L. revised the paper. All authors read and approved the final manuscript. Q. G. C. is the corresponding author of this article.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e We thank Mingyue Yin from Shanghai University of Sport for providing constructive suggestions for the writing of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSalonia A, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, et al. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol. 2021 Sep;80(3):333-57.\u003c/li\u003e\n\u003cli\u003eImprialos K, Koutsampasopoulos K, Manolis A, Doumas M. Erectile Dysfunction as a Cardiovascular Risk Factor: Time to Step Up? Curr Vasc Pharmacol. 2021;19(3):301-12.\u003c/li\u003e\n\u003cli\u003ePang K, Pan D, Xu H, Ma Y, Wang J, Xu P, et al. Advances in physical diagnosis and treatment of male erectile dysfunction. 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Am J Clin Dermatol. 2023 May;24(3):343-57.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1011\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eCharacteristics of the included studies (n=12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth condition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline IIEF score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eKalka et al. 2013[28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: Pharmacological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 103 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 62.07 (8.59) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 61.43 (8.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eIschaemic heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 12.51 (5.98) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 12.26 (5.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eMaresca et al. 2013[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: Pharmacological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE:10 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 69.0 (2.8) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 68.0 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eMetabolic syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 10.8 (2.0) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 11.2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eLin et al. 2012[21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise＋Pelvic floor muscle training \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: no training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE:41 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C:31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 65.75 (6.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eNot reported or unclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 5.06 (0.24) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 5.00 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eMaio et al. 2010[25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Pharmacological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE:30 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C:30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 50.14 (6.28) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 50.32(6.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eCardiovascular risk factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 15.8 (4.19) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 15.5 (4.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eLamina et al. 2009[24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Pharmacological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 25 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 62.10 (5.23) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 64.00(4.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eHypertensive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 11.50 (5.30) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 8.10 (4.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eEsposito et al. 2004[23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: Health advice\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 55 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 43.5 (4.8) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 43.0 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eObesity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE:13.9(4.0) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 13.5(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eDorey et al. 2004[20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise＋Pelvic floor muscle training \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Lifestyle advice\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 28 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 58 (22\u0026ndash;78) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 61 (41\u0026ndash;72)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eNot reported or unclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 7.5 (1\u0026ndash;28) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 7.0 (1\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eBegot et al. 2009[30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: no training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 30 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003e55.3 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eCardiovascular risk factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 10.3 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFeng et al. 2021[31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise ＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Pharmacological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 33 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 34.06 (6.30) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 33.74(7.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eNot reported or unclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 12.5 (4.2) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 10.3 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eShen et al. 2012[27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Traditional exercise＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Huanshao Capsule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 27 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 69.0 (2.8) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 68.0 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003ePsychogenic erectile dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 10.8 (2.0) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 11.2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eZeng et al. 2018[22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Aerobic exercise \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Pharmacological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 30 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003e22\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eCoronary heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 20.0 (3.85) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 17.5 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003eJing et al. 2012[26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.1019%;\"\u003e\n \u003cp\u003eE: Traditional exercise ＋Pharmacological \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: Zuogui Pill \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 40 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1662%;\"\u003e\n \u003cp\u003eE: 37.49(6.22) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; C: 35.60(5.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.815%;\"\u003e\n \u003cp\u003ePsychogenic erectile dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9357%;\"\u003e\n \u003cp\u003eE: 16.4 (3.1) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;C: 14.8 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003en number of included studies, E experimental group, C comparator group,1 A sensible diet, appropriate exercise, and weight management,2 Diet adjustment, smoking cessation, reduced alcohol consumption, stress reduction, and increased physical activity. \u003csup\u003ea\u0026nbsp;\u003c/sup\u003eStudy was published in Chinese language, IIEF International Index of Erectile Function, in which higher scores indicate better erectile function.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"1009\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 1009px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eCharacteristics of the Exercise training interventions (n= 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eIntervention measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIntensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eFollow-up duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eOutcome indicator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eKalka et al. 2013[28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pharmacological (stationary cycling)(PDE5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eModerate intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eMaresca et al. 2013[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pharmacological (stationary cycling)(PDE5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eModerate intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eLin et al. 2012[21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pelvic floor muscle training (stationary cycling)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eHigh intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e50 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 times/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eMaio et al. 2010[25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pharmacological \u0026nbsp;(stationary cycling)(PDE5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eModerate intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eLamina et al. 2009[24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pharmacological (running)(PDE5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eHigh intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eEsposito et al. 2004[23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise (walking)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eModerate intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e24 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eDorey et al. 2004[20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pelvic floor muscle training(stationary cycling)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLow intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBegot et al. 2009[30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise (walking)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eModerate intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eFeng et al. 2021[31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise＋Pharmacological (running)(Qingli Xingwei Decoction\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLow intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 times/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eShen et al. 2012[27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eTraditional exercise＋Pharmacological \u0026nbsp;(Tai Chi)(Huanshao Capsule\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLow intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eZeng et al. 2018[22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAerobic exercise (running)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eModerate intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e20-40 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 times/week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eJing et al. 2012[26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eTraditional exercise＋Pharmacological \u0026nbsp;(Wu Qin Xi)(Zuogui Pill\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLow intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1 times/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eIIEF score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003en\u0026nbsp;number of included studies,\u0026nbsp;E\u0026nbsp;experimental group,\u0026nbsp;C\u0026nbsp;comparator group,1\u0026nbsp;A traditional Chinese medicine formula containing ingredients such as Gardenia, Bupleurum, Scutellaria, and others, used to treat damp-heat kidney yang deficiency-type impotence,2\u0026nbsp;A proprietary Chinese medicine with ingredients such as Rehmannia Root, Cornus, Chinese Yam, and others. It nourishes kidney yang and improves psychogenic erectile dysfunction,3\u0026nbsp;A traditional Chinese medicine formula with key ingredients, including Cooked Rehmannia, Cornus, and Chinese Yam, used to nourish yin and tonify the kidneys.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eStudy was published in the Chinese language, IIEF International Index of Erectile Function\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Exercise Training, erectile dysfunction, Systematic Review, Meta-Analysis","lastPublishedDoi":"10.21203/rs.3.rs-6075962/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6075962/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eErectile dysfunction (ED) is widespread among adult men and affects their quality of life and psychological health. There is increasing evidence that physical exercise and sports training can effectively improve erectile function, but the effects of these interventions and the influencing factors require further systematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives \u003c/strong\u003eTo evaluate the intervention effect of exercise training on erectile dysfunction (ED) in adult men through a systematic review and meta-analysis. Second, to explore the moderating effect of different exercise modes, intensity, and other factors on the intervention effect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Electronic searches were conducted in Embase, Cochrane Central, Scopus, Ovid MEDLINE, PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) up to October 2024. Randomized controlled trials (RCTs) involving adult men with a precise diagnosis of erectile dysfunction (IIEF-5 scores \u0026lt;21) were included to investigate the effect of exercise training on erectile function (EF). The bias risk included in the studies was assessed using the Cochrane Risk of Bias tool 2.0 (Rob2). In addition, subgroup analyses were performed to identify the relative advantages of each intervention method in improving erectile function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003e12 randomized controlled trials with 818 adult men were included in the meta-analysis. The results demonstrated that exercise training significantly improved erectile function by 2.9 points (95% CI 1.7–4.1, p \u0026lt; 0.001). Sub-group analyses by intervention types showed that the most considerable significant effects were observed for aerobic exercise combined with pharmacological treatment (MD = 3.04, 95% CI 1.15 to 4.92, p = 0.002) and traditional Asian exercise combined with pharmacological treatment (MD = 4.28, 95% CI 2.95 to 5.61, p \u0026lt; 0.001). Other subgroup analyses show consistent exercise effects in different age or medical condition groups and a tendency to have a more significant effect in low-intensity than moderate- or high-intensity exercise.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eInterventions including exercise significantly improve erectile dysfunction in adult men, with subgroup analysis indicating that combining exercise with pharmacological treatments yields the greatest benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePROSPERO Registration \u003c/strong\u003eCRD42024593228.\u003c/p\u003e","manuscriptTitle":"Effects and Moderators of Exercise Training on Erectile function in Male Adults with diagnosed erectile dysfunction: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-24 11:53:01","doi":"10.21203/rs.3.rs-6075962/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"40e88c0b-7f13-425c-9fe4-1852c8373097","owner":[],"postedDate":"April 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-03T10:29:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-24 11:53:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6075962","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6075962","identity":"rs-6075962","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}