Connective Tissue Massage Improves Symptoms, Autonomic Dysfunctions and Wellbeing in Erectile Dysfunction: A Randomized Controlled Trial

Connective Tissue Massage Improves Symptoms, Autonomic Dysfunctions and Wellbeing in Erectile Dysfunction: A Randomized Controlled Trial | 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 Connective Tissue Massage Improves Symptoms, Autonomic Dysfunctions and Wellbeing in Erectile Dysfunction: A Randomized Controlled Trial Mesut Arslan, Derya Ozer Kaya, Seyda Toprak Celenay This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7211844/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background One of the most common sexual dysfunctions in men is erectile dysfunction (ED). Connective tissue massage (CTM) is a physiotherapy approach that produces autonomic response through cuteno-visceral reflexes. However, there are no studies investigating the effect of CTM on erectile functions. To investigate the effects of CTM on symptom severity, autonomic dysfunction severity and wellbeing such as psychological status and quality of life in individuals with ED. Methods This randomized controlled study included sexually active individuals aged 20–65 years with ED. They were divided into 2 groups as CTM (n = 15, age = 44.67 years, body mass index = 25.51 kg/m 2 ) and control (n = 15, age = 45.67 years, body mass index = 28.07 kg/m 2 ) groups. The control group received standard treatment and the CTM group received CTM 3 days a week for 4 weeks in addition to standard treatment. ED severity (International Index of Erectile Function (IIEF-5)), autonomic dysfunction symptoms (Composite Autonomic Symptom Score (COMPASS-31)), psychological status (Depression Anxiety Stress Scale (DASS-21)), and quality of life (Quality of Life-Short Form Survey (SF-36)) were evaluated before and after the intervention. The study began in December 2023 and ended in December 2024. Results When the pre- and post-intervention scores of the groups were compared, IIEF-5 (p = 0.018), SF-36-physical (p = 0.004) and SF-36-mental health (p < 0.001) scores increased, COMPASS-31 (p = 0. 005), DASS-21-anxiety (p = 0.015) and DASS-21-stress scores (p = 0.013) decreased in the CTM group, while there was no significant change for any parameter in the control group (p > 0.05). Moreover, IIEF-5 (p = 0.037) and SF-36-mental health (p = 0.002) scores were higher, COMPASS-31 (p = 0.037) and DASS-21-depression (p = 0.049) scores were lower in the CTM group compared to the control group. Conclusion CTM was found to improve ED and autonomic dysfunction severity, psychological status and quality of life in individuals with ED. According to these results, CTM can be used as a complementary application in the treatment of ED. Erectile dysfunction Connective tissue massage Autonomic functions Psychological state Quality of life Figures Figure 1 Figure 2 Introduction One of the most common sexual dysfunctions in men is erectile dysfunction (ED). ED is defined as the inability to achieve and maintain penile erection required for sexual intercourse for at least 6 months [ 1 ]. Its prevalence generally varies between 37.2% and 48.6% [ 2 ]. In a study conducted in individuals over 40 years of age, the prevalence of ED was reported to be 33% [ 3 ]. The incidence of ED increases with the number of comorbidities such as hypertension, diabetes, dyslipidemia, smoking, atherosclerosis and cardiovascular diseases [ 4 ]. Penile erection is a hemodynamic process involving increased arterial inflow and restricted venous outflow, coordinated with corpus cavernosum and penile arterial smooth muscle relaxation. This process is controlled by the autonomic nervous system [ 5 ]. Any problem in this mechanism results in ED, and its etiology is generally multifactorial such as neurologic, endocrine, psychogenic, or vascular [ 6 ]. ED is one of the first manifestations of endothelial damage in men with vascular risk factors and the first clinical manifestation of these comorbidities [ 7 ]. ED affects a man's mental health and quality of life and can also negatively affect his partner's sexual health and psychosocial status [ 8 ]. In the literature, it has been reported that various treatment methods can be used in ED. These are lifestyle changes, medications, vacuum devices, penile prostheses, physiotherapy and rehabilitation approaches (pelvic floor muscle training, aerobic exercise, etc.)[ 8 – 10 ]. Connective tissue massage (CTM), one of the physiotherapy approaches, is also a method that produces autonomic response through cuteno-visceral reflexes [ 11 ]. The local, segmental and general effects of this massage can improve visceral functions, balance autonomic functions and cause vasodilation [ 12 , 13 ]. It has been reported in the literature that CTM has positive effects on visceral, autonomic or psychogenic problems and supports the healing process related to the internal organs[ 11 , 12 , 14 – 18 ]. Therefore, CTM may be effective on management of ED. However, although the effects of ED have been investigated in different patient groups (dysmenorrhea, bladder dysfunctions, etc.) 14,16 , there are no studies investigating the effect of CTM on erectile functions. Thus, this study aimed to investigate the effect of CTM on ED symptom severity, autonomic dysfunction severity and wellbeing in individuals with ED. The hypothesis of the study was that CTM would be effective on improving ED symptom severity, autonomic dysfunctions and wellbeing. Materials and Methods Study Design and Participants This study, planned as a randomized controlled trial, was approved by Ankara Yıldırım Beyazıt University, Health Sciences Ethics Committee (approval no-date: 04-13.04.2023). The study was conducted in urology outpatient clinics of two State Hospitals in accordance with the Declaration of Helsinki. The study began in December 2023 and ended in December 2024. Voluntary consent form was obtained from the individuals. This randomized controlled trial was registered at ClinicalTrials.gov (ID: NCT06163157 on 21/12/2023) prior to participant enrollment. Inclusion criteria were sexually active male individuals aged between 20–65 years diagnosed with ED by a physician for at least 6 months who were willing to participate in the study. This age range was included because chronic diseases and mental problems can be seen in individuals over the age of 65 and all these conditions can affect ED and treatment of ED. Exclusion criteria were neurologic disease (stroke, multiple sclerosis, Parkinson's disease etc.), psychiatric disease (Alzheimer's disease, schizophrenia etc.), uncontrolled endocrine disorder, history of malignancy, infection, priapism, surgery involving the abdominal, lumbar and pelvic region within the last 1 year and presence of open wounds in the massage application area. Outcome Measures Individuals' physical characteristics, ED duration, sexual intercourse frequency, smoking/alcohol use, and drug use were questioned. The types of drugs for ED used were not changed throughout the study. In addition, individuals' physical activity levels were assessed using the International Physical Activity Questionnaire (IPAQ-7), which has Turkish validity and reliability. This questionnaire includes a total of 7 questions. The total score is calculated with the duration (minutes) and frequency (days) of walking, moderate-vigorous, and vigorous activities performed for at least 10 minutes at a time in the last week. According to the total score, individuals' physical activity levels were classified as inactive ( 3000 MET-min/week) [ 19 ]. ED symptom severity, autonomic dysfunction severity and wellbeing such as psychological status and quality of life before and after the intervention. ED symptom severity was evaluated with the 5-question International Index of Erectile Function (IIEF-5), which has Turkish validity. The total score of the scale ranges from 1 to 25. A total score above 21 indicates normal erectile function, while a score of 21 and below indicates ED. According to the total score on the scale, ED is divided into 4 categories. Severe (1–7), moderate (8–11), moderate to mild (12–16), mild (17–21) and no ED (22–25) [ 20 , 21 ]. Autonomic dysfunction symptoms were assessed with the Composite Autonomic Symptom Score (COMPASS 31), which consists of 31 items and has validity and reliability in Turkish. The total score ranges from 0 to 100. A high score on the scale indicates the severity of autonomic dysfunction [ 22 , 23 ]. Psychological status was assessed with the Depression Anxiety Stress Scale (DASS-21), which consists of 21 items and was adapted for Turkish society. The scale consists of three subscales: depression, anxiety, and stress, and each subscale consists of seven items. The total score ranges from 0 to 21 for each item. A higher total score is indicative of elevated levels of depression, anxiety, and stress [ 24 ]. Quality of life was assessed with the Short Form (SF-36), which consists of 36 items and 2 main sub-dimensions (physical and mental health) and has validity and reliability in Turkish. Scores of the sub-dimensions range from 0 to 100. A higher score indicates better health-related quality of life [ 25 ]. Randomization Individuals were randomly allocated (ratio 1:1) into either the CTM group or the control group. The control group received standard treatment and the CTM group received CTM in addition to standard treatment. The computer-based block randomization procedure (blocks of four) by an independent investigator who was not involved in the study was used for assignment. Outcome assessor was blinded to group allocation. Interventions Standard treatment: Standard treatment included patient education and lifestyle recommendations. Within the scope of patient education, information was provided about penile erection mechanism, pathophysiological mechanism of ED, risk factors and treatment methods. This patient education was given once at the beginning of the treatment by an experienced physiotherapist. The education lasted approximately 20 minutes. A brochure related to lifestyle recommendations including physical activity, diet, sleep hygiene, stress and smoking/alcohol use was also prepared and given to patients[ 26 ]. CTM application: An experienced physiotherapist (10 years of experience) applied CTM 3 days a week for 4 weeks [ 15 ]. CTM was applied to the lumbosacral, lower thoracic, scapular, interscapular, cervical, abdominal and suprapubic regions. These regions were decided by taking into account both the innervation levels of erectile functions, and the autonomic dysfunction and psychological symptoms associated with ED. During the treatment of the back region, the participant was instructed to sit erect on a stool, with hips, knees, and ankles at 90° flexion, and the thighs and feet were fully supported. The physiotherapist positioned behind the patient on the right or left side, depending on the direction and level of stroke. During the treatment of abdominal and pelvic regions, the patient was in a supine position with pillows placed under the head and knees. The physiotherapist positioned on the right or left side of the patients, depending on the direction and level of the stroke in these regions. Both short and long tissue strokes were applied with the pad of the middle finger during the CTM. The finger was placed on the skin with the distal interphalangeal joint at 45°flexion and moved to cause traction. Each stroke was performed for three times first on the right and then on the left side of all regions. During CTM, the pressure of the stroke was applied in a way that created traction within the subcutaneous tissue and fascia. The application for each region lasted approximately 5 minutes (Fig. 1 ) [ 27 ]. Sample Calculation The sample size required for the study was calculated with the G*Power (G*Power Ver. 3.0.10, Franz Faul, Universität Kiel, Germany) package program. Since there was no similar study on this subject in the literature, a pilot study was conducted and the effect size (1.37) of the pilot study was calculated according to the IIEF-5 score. Therefore, it was determined that a total of 30 people, 15 in each group, were needed to obtain an effect size of 1.37, α = 0.05 and 95% power. In addition, in the post hoc analysis, the effect size was calculated as 0.97 and the power as 82% with the mean and standard deviation data (t test) of the IIEF-5 score. Statistical Analysis The Shapiro-Wilk test was used to evaluate whether the data were normally distributed. For descriptive data, mean and standard deviation (X ± SD), number (n) and percentage (%) values were used. Since the data were normally distributed, Independent Samples t test was used in the analysis of the data between groups, and Paired Samples t test was used in the analysis within groups. Chi-square test was used in the comparison of categorical data between groups. IBM SPSS 21.0 program was used for the analyses. Statistical significance value was accepted as p < 0.05. Effect size (d) was used to evaluate the strength of the effect, which is considered a measure of clinical relevance. Accordingly, 0.2, 0.5 and 0.8 indicate small, medium and large effect sizes, respectively [ 28 ]. Results Forty-five patients with ED were evaluated for eligibility and 30 men completed the study (Fig. 2 ). The mean age of the CTM group was 44.67 years and body mass index was 25.51 kg/m 2 , while the mean age of the control group was 45.67 years and 28.07 kg/m 2 , respectively. There was no difference between the sociodemographic and clinical data of the groups before the intervention (p > 0.05) (Table 1 ). No side effects were observed in the groups throughout the study. Table 1 Comparison of sociodemographic and clinical data of the groups Data CTM Group (n = 15) Control Group (n = 15) p Age (years, X ± SD) 44.67 ± 7.53 45.67 ± 9.06 0.745 a BMI (kg/m 2 , X ± SD) 25.51 ± 4.13 28.07 ± 4.57 0.118 a Duration of ED (months, X ± SD) 31.80 ± 39.63 37.67 ± 39.86 0.689 a International Index of Erectile Function (IIEF-5, n/%) Severe 1 (6.7) 4 (26.7) 0.351 b Moderate 4 (26.7) 4 (26.7) Moderate to mild 9 (60) 5 (33.3) Mild 1 (6.7) 2 (13.3) Frequency of sexual intercourse (times/week, X ± SS) 1.83 ± 0.79 1.73 ± 0.79 0.734 a International Physical Activity Questionnaire (IPAQ-7, n/%) Inactive 9 (60) 8 (53.3) 0.499 b Minimally active 5 (33.3) 7 (46.7) Very active 1 (6.7) 0 (0) Smoking (n, %) Yes 6 (40) 4 (26.7) 0.439 b No 9 (60) 11 (73.3) Alcohol use (n, %) Yes 0 (0) 0 (0) No 15 (100) 15 (100) Use of medication for ED (n, %) Yes 5 (33.3) 5 (33.3) 1.000 b No 10 (66.7) 10 (66.7) X: Mean; SD: Standard deviation; BMI: Body mass index; ED: Erectile dysfunction; a Independent sample t-test; b Chi-square test There was no difference between the IIEF-5, COMPASS-31, DASS-21-depression, DASS-21-anxiety, DASS-21-stress, SF-36 scale scores of the groups before the intervention (p > 0.05). When the pre- and post-intervention scores of the groups were compared; IIEF-5 (p = 0.018), SF-36-physical (p = 0.004) and SF-36-mental health (p < 0.001) scores increased, COMPASS-31 (p = 0. 005), DASS-21-anxiety (p = 0.015) and DASS-21-stress scores (p = 0.013) decreased in the CTM group, while no significant change was found for any parameter in the control group (p > 0.05) (Table 2 ). Moreover, IIEF-5 ([95% confidence interval]{CI}: 0.04 to 1.53, d = 0.80, p = 0.037) and SF-36-mental health (95% CI: 0.48 to 2.06, d = 1.28, p = 0.002) scores were higher, COMPASS-31 (95% CI: -1.53 to -0.04, d = 0.80, p = 0.037) and DASS-21-depression (95% CI: -1.48 to -0.02, d = 0.75, p = 0.049) scores were lower in the CTM group compared to the control group (Table 2 ). Table 2 IIEF-5, COMPASS-31, DASS-21, SF-36 scale scores within and between the groups CTM Group (n = 15) Control Group (n = 15) Difference between means (95% CI) Effect size (d) p ED Symptom Severity IIEF-5 Pre-Intervention 12.67 ± 3.10 11.47 ± 4.22 1.20 (-0.40, 1.04) 0.32 0.383 a Post-Intervention 16.40 ± 5.31 12.73 ± 3.71 3.66 (0.04, 1.53) 0.80 0.037 a P 0.018 c 0.229 c Autonomic Function COMPAS-31 Pre-Intervention 11.60 ± 7.21 13.53 ± 9.73 -1.93 (-0.94, 0.49) 0.22 0.542 a Post-Intervention 5.13 ± 4.54 10.93 ± 9.20 -5.80 (-1.53, -0.04) 0.80 0.037 a P 0.005 c 0.222 c Psychological Status DASS21-Depression Pre-Intervention 3.60 ± 2.09 5.60 ± 3.90 -2.00 (-1.36, 0.10) 0.63 0.095 a Post-Intervention 2.40 ± 2.44 5.40 ± 5.09 -3.00 (-1.48, -0.02) 0.75 0.049 a p 0.138 c 0.872 c DASS21-Anxiety Pre-Intervention 3.07 ± 2.12 3.07 ± 2.81 0.00 (-0.71, -0.69) 0.00 1.000 a Post-Intervention 1.67 ± 2.05 4.53 ± 5.5 -2.86 (-1.42, 0.05) 0.69 0.069 a p 0.015 c 0.257 c DASS21-Stress Pre-Intervention 5.60 ± 3.48 7.07 ± 4.26 -1.46 (-1.09, 0.34) 0.38 0.311 a Post-Intervention 3.33 ± 2.09 6.00 ± 5.05 -2.66 (-1.42, 0.05) 0.69 0.070 a p 0.013 c 0.452 c Quality of Life SF-36-Physical health Pre-Intervention 64.54 ± 17.92 69.35 ± 17.04 -4.83 (-0.99, 0.44) 0.27 0.456 a Post-Intervention 82.50 ± 8.98 75.65 ± 22.98 6.85 (-0.33, 1.11) 0.39 0.291 a P 0.004 c 0.312 c SF-36-Mental health Pre-Intervention 61.70 ± 17.68 60.63 ± 22.59 1.06 (-0.66, 0.76) 0.05 0.887 a Post-Intervention 83.19 ± 8.16 62.85 ± 20.91 20.33 (0.48, 2.06) 1.28 0.002 a P < 0.001 c 0.618 c Bold expression of the numbers indicates significant differences; X: Mean; SD: Standard deviation; CI: Confidence interval, ED: Erectile dysfunction; IIEF-5: International Index of Erectile Function; COMPASS 31: Composite Autonomic Symptom Score; DASS-21: Depression Anxiety Stress Scale; SF-36: Short Form-36; a Independent sample t-test; c Paired Samples t test. Discussion In this study, it was found that CTM improved ED, autonomic dysfunction symptom severity, anxiety and stress symptom severity and improved quality of life in individuals with ED. However, no improvement was observed in the control group. It was also found that ED severity, autonomic dysfunction symptom severity, depression level and quality of life (mental health only) improved more in the CTM group compared to the control group. Moreover, in the CTM group, there was a large effect size for the symptom severity, autonomic dysfunction symptom severity, and quality of life (SF-36-mental health), while there was a medium effect size for depression, anxiety and stress symptom severity. CTM regulates autonomic functions, causes vasodilation and improves visceral functions by local, segmental and suprasegmental effects through cuteno-visceral reflexes [ 11 – 13 ]. Considering the effects of CTM on the autonomic nervous system and vascular system, it is thought that CTM may have positive effects on individuals with ED. In our study, CTM was applied to individuals with ED and it was seen that CTM improved the severity of ED symptoms. In addition, it has been reported that the clinical significance value of the IIEF-5 is approximately 4 points [ 10 ]. In this study, a difference of approximately 4 points was observed in the CTM group after the intervention. CTM, which is an easily applicable method for improving ED symptoms that negatively affect both the individual and their partner, can be considered in clinics. There are studies in different populations showing that CTM affects autonomic functions [ 29 , 30 ]. In a randomized study examining the effect of CTM and classical massage on autonomic responses (peripheral skin temperature) in patients with chronic mechanical low back pain, it was reported that both types of massage regulated autonomic responses but were not superior to each other [ 29 ]. In another study examining the effect of CTM on autonomic functions (systolic/diastolic blood pressure, respiratory rate) in healthy young women, it was shown that CTM decreased sympathetic activity [ 30 ]. In our study, the effects of CTM on autonomic dysfunctions in individuals with ED were examined. In our study, the severity of autonomic dysfunction, which is an important in the pathophysiology of ED, was evaluated. It was found that CTM decreased the severity of autonomic dysfunction. Since autonomic dysfunction and vascular responses are important in the pathophysiology of ED, CTM may be considered as an alternative application for these individuals. In the literature, there are also studies in different populations showing that CTM affects individuals' psychological state and quality of life [ 12 , 15 , 29 , 31 , 32 ]. For example, in a controlled clinical trial examining the effect of CTM on psychological status and quality of life in women with migraine, CTM was shown to improve psychological status and quality of life [ 15 ]. In a randomized placebo-controlled study examining the effects of CTM on psychological status and quality of life in postmenopausal women, it was shown that CTM improved psychological status and quality of life [ 31 ]. In a different randomized study examining the effect of CTM and classical massage on quality of life in patients with chronic mechanical low back pain, it was reported that both types of massage improved quality of life [ 29 ]. In another randomized controlled study examining the effect of CTM and classical massage on quality of life in patients with chronic constipation, it was shown that CTM and classical massage group were superior to the control group in improving quality of life, but they were not superior to each other [ 32 ]. In another study examining the effect of exercise and exercise plus CTM on quality of life in patients with fibromyalgia, it was reported that the quality of life of individuals in both groups increased and the outcomes were significantly better in the exercise plus CTM group [ 12 ]. In our study, the effects of CTM on psychological status and quality of life in individuals with ED were examined and it was found that stress, anxiety and quality of life improved in the CTM group. It was found that depression and quality of life (mental health parameter) improvements were significantly different in the CTM group compared to the control group. These results may be related to the improving of ED symptoms and autonomic dysfunction by CTM. In addition, the fact that most of those with ED symptoms in our study were mild to moderate and most of them did not use medication for ED suggests that CTM improve confidence and reducing anxiety around sexual activity in this group. To our knowledge, this study is the first randomized controlled trial examining the effects of CTM on individuals with ED. The study also had some limitations, namely that it was conducted in a single region and only subjective evaluation criteria were used. These limit the generalizability of the study results and more objective evaluations can be added to future studies. Another limitation of the study was also that the implementation of lifestyle changes given as part of standard treatment in the control group was not followed up. Lastly, although the current study’ s sample size was calculated based on the IIEF-5 score, the number of samples in the study may seem numerically small. Therefore, the sample size can be calculated considering other outcomes in further studies. Conclusion In the current study, it was found that CTM reduced the severity of ED and autonomic dysfunction, and improved wellbeing such as psychological status and quality of life in individuals with ED. According to these results, CTM can be used as a complementary application in the treatment of ED. In future studies, it may be important to examine the long-term results of the effects of CTM in individuals with ED and to examine the effects of other physiotherapy approaches. Moreover, studies examining the changes in vascularity in CTM and the effects of CTM according to subgroups of patients (those with more stress or those with more affected quality of life) can be conducted. Declarations Ethics Approval and Consent to Participate The present study protocol was reviewed and approved by the institutional review board of Ankara Yıldırım Beyazıt University (approval no-date: 04-13.04.2023). Informed consent was submitted by all subjects when they were enrolled. This randomized controlled trial was registered at ClinicalTrials.gov (ID: NCT06163157 on 21/12/2023) prior to participant enrollment. The study began in December 2023 and ended in December 2024. Consent for publication All authors were duly informed about the trial and provided their consent for publication. We further confirm that written consent has been obtained from every individual whose personal data, images, or case information appears in this manuscript. The consent documentation is retained and can be provided to the editorial team upon request. Availability of data and materials Data available on request due to privacy/ethical restrictions. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Competing Interest The authors declare no competing interests. Funding Springer Nature and Türkiye Bilimsel ve Teknolojik Araştırma Kurumu have an agreement which allows eligible authors to publish open access without paying an article publication charge (APC). The cost of publishing is covered under the terms of the agreement. Authors’ Contribution Mesut Arslan: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing. Derya Ozer Kaya : Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Writing – review & editing. Seyda Toprak Celenay : Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – review & editing. Acknowledgements We would like to thank all the relevant institutional authorities who supported the study and all the patients who participated. References Tuncel A, Güzel Ö, Atan A. Erektil disfonksiyonda rol oynayan risk faktörlerini belirleme. Androloji Bülteni. 2013;54:158-63. Goldstein I, Goren A, Li VW, Tang WY, Hassan TA. Epidemiology Update of Erectile Dysfunction in Eight Countries with High Burden. Sexual medicine reviews. 2020;8(1):48-58. doi: 10.1016/j.sxmr.2019.06.008. Çayan S, Kendirci M, Yaman Ö, Aşçı R, Orhan İ, Usta MF, et al. Prevalence of erectile dysfunction in men over 40 years of age in Turkey: Results from the Turkish Society of Andrology Male Sexual Health Study Group. Turk J Urol. 2017;43(2):122-9. doi: 10.5152/tud.2017.24886. Akkus E, Kadioglu A, Esen A, Doran S, Ergen A, Anafarta K, et al. 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Journal of exercise rehabilitation. 2019;15(2):308-15. doi: 10.12965/jer.1836634.317. Saglam M, Arikan H, Savci S, Inal-Ince D, Bosnak-Guclu M, Karabulut E, et al. International physical activity questionnaire: reliability and validity of the Turkish version. Perceptual and motor skills. 2010;111(1):278-84. doi: 10.2466/06.08.Pms.111.4.278-284. Turunç T, Deveci S, Güvel S, Peşkircioğlu L. Uluslararası cinsel işlev indeksinin 5 soruluk versiyonunun (IIEF-5) Türkçe geçerlilik çalışmasının değerlendirilmesi. Türk Üroloji Dergisi/Turkish Journal of Urology. 2007;33(1):45-9. Rislanu A, Auwal H, Musa D, Auwal A. Comparative Effectiveness of Electrical Stimulation and Aerobic Exercise in the Management of Erectile Dysfunction: A Randomized Clinical Trial. Ethiop J Health Sci. 2020;30(6):961-70. doi: 10.4314/ejhs.v30i6.14. Sletten DM, Suarez GA, Low PA, Mandrekar J, Singer W. COMPASS 31: a refined and abbreviated Composite Autonomic Symptom Score. Mayo Clinic proceedings. 2012;87(12):1196-201. doi: 10.1016/j.mayocp.2012.10.013. Bal İ, Pala ÖO, Polat M. Kompozit otonom semptom skoru (COMPASS-31) ölçeğinin fibromiyalji hastalarında türkçe geçerlik ve güvenirlik çalışması. Fizyoterapi ve Rehabilitasyon Ana Bilim Dalı. Sivas: Sivas Cumhuriyet Üniversitesi 2023. Sarıçam H. The psychometric properties of Turkish version of Depression Anxiety Stress Scale-21 (DASS-21) in health control and clinical samples. Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi. 2018;7(1):19-30. Koçyiğit H, Aydemir Ö, Fişek G, Ölmez N, Memiş AK. Form-36 (KF-36)’nın Türkçe versiyonunun güvenilirliği ve geçerliliği. Ilaç ve tedavi dergisi. 1999;12(2):102-6. Moyad MA, Park K. What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng. Asian journal of andrology. 2012;14(6):830-41. doi: 10.1038/aja.2012.82. Holey LA, Dixon J. Connective tissue manipulation: a review of theory and clinical evidence. Journal of bodywork and movement therapies. 2014;18(1):112-8. doi: 10.1016/j.jbmt.2013.08.003. Fritz CO, Morris PE, Richler JJ. Effect size estimates: current use, calculations, and interpretation. Journal of experimental psychology General. 2012;141(1):2-18. doi: 10.1037/a0024338. Er G, Yüksel İ. A comparison of the effects of connective tissue massage and classical massage on chronic mechanical low back pain. Medicine. 2023;102(15):e33516. doi: 10.1097/md.0000000000033516. Akbaş E, Ünver B, Erdem EU. Acute Effects of Connective Tissue Manipulation on Autonomic Function in Healthy Young Women. Complementary medicine research. 2019;26(4):250-7. doi: 10.1159/000497618. Albayrak G, Çağlıyan Türk A, Özgül S. Effects of connective tissue massage on physical and emotional symptoms, insomnia, and quality of life in postmenopausal women: A randomized, sham-controlled trial. Maturitas. 2025;191:108149. doi: 10.1016/j.maturitas.2024.108149. Orhan C, Özgül S, Baran E, Üzelpasacı E, Akbayrak T. Comparison of Connective Tissue Manipulation and Abdominal Massage Combined With Usual Care vs Usual Care Alone for Chronic Constipation: A Randomized Controlled Trial. Journal of manipulative and physiological therapeutics. 2020;43(8):768-78. doi: 10.1016/j.jmpt.2019.05.013. Additional Declarations No competing interests reported. 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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-7211844","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516783241,"identity":"6c62cece-146d-40cd-a4db-bc7bfaca2136","order_by":0,"name":"Mesut Arslan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYNCCAgYGfgkwi5lYLQYMDJIzYFrYiNVicINYLboNzM8+/jCwyzO+3XxMgqHCOrFBvvcBXi1mB9iMZ/MYJBeb3TmWJsFwJj2xgY3dgIAWBmNmBgPmxG03cswkGNsOA7UQcJnZAfbPjD8M6hM3z8j/JsH4jygtPMYMPAaHEzdI5LBJMDYQo+UwTzEzj8HxxBl3jhlbJBxLN25jSyOg5Xj7ZsYfFdWJ/bObH974UGMt2898DL8W1OhOYCA2JkfBKBgFo2AU4AUAKjA9nxp/nbUAAAAASUVORK5CYII=","orcid":"","institution":"Bitlis Eren University","correspondingAuthor":true,"prefix":"","firstName":"Mesut","middleName":"","lastName":"Arslan","suffix":""},{"id":516783242,"identity":"2775a601-cc2d-4013-94a3-3083f51a6e9a","order_by":1,"name":"Derya Ozer Kaya","email":"","orcid":"","institution":"Izmir Katip Celebi University","correspondingAuthor":false,"prefix":"","firstName":"Derya","middleName":"Ozer","lastName":"Kaya","suffix":""},{"id":516783244,"identity":"a9e2f1de-b255-4bf6-aefc-18af65610259","order_by":2,"name":"Seyda Toprak Celenay","email":"","orcid":"","institution":"Ankara Yildirim Beyazit University","correspondingAuthor":false,"prefix":"","firstName":"Seyda","middleName":"Toprak","lastName":"Celenay","suffix":""}],"badges":[],"createdAt":"2025-07-25 08:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7211844/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7211844/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91588720,"identity":"b8c7ce5c-1f92-47be-af9e-66b8aa5fabca","added_by":"auto","created_at":"2025-09-18 06:17:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85879,"visible":true,"origin":"","legend":"\u003cp\u003eDirections of connective tissue strokes: a) Lumbosacral, lower thoracic, scapular, interscapular and cervical regions; b) Anterior cervical region; c) Abdominal and suprapubic regions.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7211844/v1/6c23713b33c1fd56f5d9a37c.jpeg"},{"id":91588719,"identity":"562d5fe7-62a9-4d3e-a9ee-d4c268d1d897","added_by":"auto","created_at":"2025-09-18 06:17:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59134,"visible":true,"origin":"","legend":"\u003cp\u003eThe flowchart diagram of the participants.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7211844/v1/cca361eba68554a723bd5aa7.jpeg"},{"id":91590981,"identity":"dfb3ee50-6dbb-4ba2-b90b-4cc36e859dde","added_by":"auto","created_at":"2025-09-18 06:33:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":937430,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7211844/v1/9b700ffc-7fd0-4329-9337-95c6ff1fb699.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Connective Tissue Massage Improves Symptoms, Autonomic Dysfunctions and Wellbeing in Erectile Dysfunction: A Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOne of the most common sexual dysfunctions in men is erectile dysfunction (ED). ED is defined as the inability to achieve and maintain penile erection required for sexual intercourse for at least 6 months [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its prevalence generally varies between 37.2% and 48.6% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In a study conducted in individuals over 40 years of age, the prevalence of ED was reported to be 33% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The incidence of ED increases with the number of comorbidities such as hypertension, diabetes, dyslipidemia, smoking, atherosclerosis and cardiovascular diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePenile erection is a hemodynamic process involving increased arterial inflow and restricted venous outflow, coordinated with corpus cavernosum and penile arterial smooth muscle relaxation. This process is controlled by the autonomic nervous system [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Any problem in this mechanism results in ED, and its etiology is generally multifactorial such as neurologic, endocrine, psychogenic, or vascular [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. ED is one of the first manifestations of endothelial damage in men with vascular risk factors and the first clinical manifestation of these comorbidities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. ED affects a man's mental health and quality of life and can also negatively affect his partner's sexual health and psychosocial status [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the literature, it has been reported that various treatment methods can be used in ED. These are lifestyle changes, medications, vacuum devices, penile prostheses, physiotherapy and rehabilitation approaches (pelvic floor muscle training, aerobic exercise, etc.)[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Connective tissue massage (CTM), one of the physiotherapy approaches, is also a method that produces autonomic response through cuteno-visceral reflexes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The local, segmental and general effects of this massage can improve visceral functions, balance autonomic functions and cause vasodilation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It has been reported in the literature that CTM has positive effects on visceral, autonomic or psychogenic problems and supports the healing process related to the internal organs[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, CTM may be effective on management of ED. However, although the effects of ED have been investigated in different patient groups (dysmenorrhea, bladder dysfunctions, etc.)\u003csup\u003e14,16\u003c/sup\u003e, there are no studies investigating the effect of CTM on erectile functions.\u003c/p\u003e\u003cp\u003eThus, this study aimed to investigate the effect of CTM on ED symptom severity, autonomic dysfunction severity and wellbeing in individuals with ED. The hypothesis of the study was that CTM would be effective on improving ED symptom severity, autonomic dysfunctions and wellbeing.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\u003cp\u003e This study, planned as a randomized controlled trial, was approved by Ankara Yıldırım Beyazıt University, Health Sciences Ethics Committee (approval no-date: 04-13.04.2023). The study was conducted in urology outpatient clinics of two State Hospitals in accordance with the Declaration of Helsinki. The study began in December 2023 and ended in December 2024. Voluntary consent form was obtained from the individuals. This randomized controlled trial was registered at ClinicalTrials.gov (ID: NCT06163157 on 21/12/2023) prior to participant enrollment.\u003c/p\u003e\u003cp\u003eInclusion criteria were sexually active male individuals aged between 20\u0026ndash;65 years diagnosed with ED by a physician for at least 6 months who were willing to participate in the study. This age range was included because chronic diseases and mental problems can be seen in individuals over the age of 65 and all these conditions can affect ED and treatment of ED. Exclusion criteria were neurologic disease (stroke, multiple sclerosis, Parkinson's disease etc.), psychiatric disease (Alzheimer's disease, schizophrenia etc.), uncontrolled endocrine disorder, history of malignancy, infection, priapism, surgery involving the abdominal, lumbar and pelvic region within the last 1 year and presence of open wounds in the massage application area.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eIndividuals' physical characteristics, ED duration, sexual intercourse frequency, smoking/alcohol use, and drug use were questioned. The types of drugs for ED used were not changed throughout the study. In addition, individuals' physical activity levels were assessed using the International Physical Activity Questionnaire (IPAQ-7), which has Turkish validity and reliability. This questionnaire includes a total of 7 questions. The total score is calculated with the duration (minutes) and frequency (days) of walking, moderate-vigorous, and vigorous activities performed for at least 10 minutes at a time in the last week. According to the total score, individuals' physical activity levels were classified as inactive (\u0026lt;\u0026thinsp;600 MET-min/week), minimally active (600\u0026ndash;3000 MET-min/week), and very active (\u0026gt;\u0026thinsp;3000 MET-min/week) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. ED symptom severity, autonomic dysfunction severity and wellbeing such as psychological status and quality of life before and after the intervention.\u003c/p\u003e\u003cp\u003eED symptom severity was evaluated with the 5-question International Index of Erectile Function (IIEF-5), which has Turkish validity. The total score of the scale ranges from 1 to 25. A total score above 21 indicates normal erectile function, while a score of 21 and below indicates ED. According to the total score on the scale, ED is divided into 4 categories. Severe (1\u0026ndash;7), moderate (8\u0026ndash;11), moderate to mild (12\u0026ndash;16), mild (17\u0026ndash;21) and no ED (22\u0026ndash;25) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAutonomic dysfunction symptoms were assessed with the Composite Autonomic Symptom Score (COMPASS 31), which consists of 31 items and has validity and reliability in Turkish.\u003c/p\u003e\u003cp\u003eThe total score ranges from 0 to 100. A high score on the scale indicates the severity of autonomic dysfunction [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePsychological status was assessed with the Depression Anxiety Stress Scale (DASS-21), which consists of 21 items and was adapted for Turkish society. The scale consists of three subscales: depression, anxiety, and stress, and each subscale consists of seven items. The total score ranges from 0 to 21 for each item. A higher total score is indicative of elevated levels of depression, anxiety, and stress [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eQuality of life was assessed with the Short Form (SF-36), which consists of 36 items and 2 main sub-dimensions (physical and mental health) and has validity and reliability in Turkish. Scores of the sub-dimensions range from 0 to 100. A higher score indicates better health-related quality of life [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eRandomization\u003c/h3\u003e\n\u003cp\u003eIndividuals were randomly allocated (ratio 1:1) into either the CTM group or the control group.\u003c/p\u003e\u003cp\u003eThe control group received standard treatment and the CTM group received CTM in addition to standard treatment. The computer-based block randomization procedure (blocks of four) by an independent investigator who was not involved in the study was used for assignment. Outcome assessor was blinded to group allocation.\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eStandard treatment: Standard treatment included patient education and lifestyle recommendations. Within the scope of patient education, information was provided about penile erection mechanism, pathophysiological mechanism of ED, risk factors and treatment methods. This patient education was given once at the beginning of the treatment by an experienced physiotherapist. The education lasted approximately 20 minutes. A brochure related to lifestyle recommendations including physical activity, diet, sleep hygiene, stress and smoking/alcohol use was also prepared and given to patients[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCTM application: An experienced physiotherapist (10 years of experience) applied CTM 3 days a week for 4 weeks [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. CTM was applied to the lumbosacral, lower thoracic, scapular, interscapular, cervical, abdominal and suprapubic regions. These regions were decided by taking into account both the innervation levels of erectile functions, and the autonomic dysfunction and psychological symptoms associated with ED. During the treatment of the back region, the participant was instructed to sit erect on a stool, with hips, knees, and ankles at 90\u0026deg; flexion, and the thighs and feet were fully supported. The physiotherapist positioned behind the patient on the right or left side, depending on the direction and level of stroke. During the treatment of abdominal and pelvic regions, the patient was in a supine position with pillows placed under the head and knees. The physiotherapist positioned on the right or left side of the patients, depending on the direction and level of the stroke in these regions. Both short and long tissue strokes were applied with the pad of the middle finger during the CTM. The finger was placed on the skin with the distal interphalangeal joint at 45\u0026deg;flexion and moved to cause traction. Each stroke was performed for three times first on the right and then on the left side of all regions. During CTM, the pressure of the stroke was applied in a way that created traction within the subcutaneous tissue and fascia. The application for each region lasted approximately 5 minutes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eSample Calculation\u003c/h3\u003e\n\u003cp\u003eThe sample size required for the study was calculated with the G*Power (G*Power Ver. 3.0.10, Franz Faul, Universit\u0026auml;t Kiel, Germany) package program. Since there was no similar study on this subject in the literature, a pilot study was conducted and the effect size (1.37) of the pilot study was calculated according to the IIEF-5 score. Therefore, it was determined that a total of 30 people, 15 in each group, were needed to obtain an effect size of 1.37, α\u0026thinsp;=\u0026thinsp;0.05 and 95% power. In addition, in the post hoc analysis, the effect size was calculated as 0.97 and the power as 82% with the mean and standard deviation data (t test) of the IIEF-5 score.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe Shapiro-Wilk test was used to evaluate whether the data were normally distributed. For descriptive data, mean and standard deviation (X\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), number (n) and percentage (%) values were used. Since the data were normally distributed, Independent Samples t test was used in the analysis of the data between groups, and Paired Samples t test was used in the analysis within groups. Chi-square test was used in the comparison of categorical data between groups. IBM SPSS 21.0 program was used for the analyses. Statistical significance value was accepted as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Effect size (d) was used to evaluate the strength of the effect, which is considered a measure of clinical relevance. Accordingly, 0.2, 0.5 and 0.8 indicate small, medium and large effect sizes, respectively [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eForty-five patients with ED were evaluated for eligibility and 30 men completed the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean age of the CTM group was 44.67 years and body mass index was 25.51 kg/m\u003csup\u003e2\u003c/sup\u003e, while the mean age of the control group was 45.67 years and 28.07 kg/m\u003csup\u003e2\u003c/sup\u003e, respectively. There was no difference between the sociodemographic and clinical data of the groups before the intervention (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No side effects were observed in the groups throughout the study.\u003c/p\u003e\u003cp\u003e\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\u003eComparison of sociodemographic and clinical data of the groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eData\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCTM Group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (years, X\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.67\u0026thinsp;\u0026plusmn;\u0026thinsp;7.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.67\u0026thinsp;\u0026plusmn;\u0026thinsp;9.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.745\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e, X\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.51\u0026thinsp;\u0026plusmn;\u0026thinsp;4.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.118\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDuration of ED (months, X\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.80\u0026thinsp;\u0026plusmn;\u0026thinsp;39.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.67\u0026thinsp;\u0026plusmn;\u0026thinsp;39.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.689\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eInternational Index of Erectile Function (IIEF-5, n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.351\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate to mild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eFrequency of sexual intercourse (times/week, X\u0026thinsp;\u0026plusmn;\u0026thinsp;SS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.734\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eInternational Physical Activity Questionnaire (IPAQ-7, n/%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInactive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (53.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.499\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimally active\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery active\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSmoking (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.439\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAlcohol use (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUse of medication for ED (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eX: Mean; SD: Standard deviation; BMI: Body mass index; ED: Erectile dysfunction; \u003csup\u003ea\u003c/sup\u003eIndependent sample t-test; \u003csup\u003eb\u003c/sup\u003eChi-square test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was no difference between the IIEF-5, COMPASS-31, DASS-21-depression, DASS-21-anxiety, DASS-21-stress, SF-36 scale scores of the groups before the intervention (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). When the pre- and post-intervention scores of the groups were compared; IIEF-5 (p\u0026thinsp;=\u0026thinsp;0.018), SF-36-physical (p\u0026thinsp;=\u0026thinsp;0.004) and SF-36-mental health (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) scores increased, COMPASS-31 (p\u0026thinsp;=\u0026thinsp;0. 005), DASS-21-anxiety (p\u0026thinsp;=\u0026thinsp;0.015) and DASS-21-stress scores (p\u0026thinsp;=\u0026thinsp;0.013) decreased in the CTM group, while no significant change was found for any parameter in the control group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Moreover, IIEF-5 ([95% confidence interval]{CI}: 0.04 to 1.53, d\u0026thinsp;=\u0026thinsp;0.80, p\u0026thinsp;=\u0026thinsp;0.037) and SF-36-mental health (95% CI: 0.48 to 2.06, d\u0026thinsp;=\u0026thinsp;1.28, p\u0026thinsp;=\u0026thinsp;0.002) scores were higher, COMPASS-31 (95% CI: -1.53 to -0.04, d\u0026thinsp;=\u0026thinsp;0.80, p\u0026thinsp;=\u0026thinsp;0.037) and DASS-21-depression (95% CI: -1.48 to -0.02, d\u0026thinsp;=\u0026thinsp;0.75, p\u0026thinsp;=\u0026thinsp;0.049) scores were lower in the CTM group compared to the control group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eIIEF-5, COMPASS-31, DASS-21, SF-36 scale scores within and between the groups\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=\"char\" char=\".\" 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\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCTM Group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDifference between\u003c/p\u003e\u003cp\u003emeans (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEffect size (d)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eED Symptom Severity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIIEF-5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.20 (-0.40, 1.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.383\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.73\u0026thinsp;\u0026plusmn;\u0026thinsp;3.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.66 (0.04, 1.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.229\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAutonomic Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCOMPAS-31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.60\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.53\u0026thinsp;\u0026plusmn;\u0026thinsp;9.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.93 (-0.94, 0.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.542\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.13\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;9.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-5.80 (-1.53, -0.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.222\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePsychological Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDASS21-Depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.00 (-1.36, 0.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.095\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.00 (-1.48, -0.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.138\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.872\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDASS21-Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.00 (-0.71, -0.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.000\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.53\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.86 (-1.42, 0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.069\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.257\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDASS21-Stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.46 (-1.09, 0.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.311\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.66 (-1.42, 0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.070\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.452\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSF-36-Physical health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.54\u0026thinsp;\u0026plusmn;\u0026thinsp;17.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69.35\u0026thinsp;\u0026plusmn;\u0026thinsp;17.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-4.83 (-0.99, 0.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.456\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.50\u0026thinsp;\u0026plusmn;\u0026thinsp;8.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75.65\u0026thinsp;\u0026plusmn;\u0026thinsp;22.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.85 (-0.33, 1.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.291\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.312\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSF-36-Mental health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.70\u0026thinsp;\u0026plusmn;\u0026thinsp;17.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.63\u0026thinsp;\u0026plusmn;\u0026thinsp;22.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.06 (-0.66, 0.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.887\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePost-Intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.19\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.85\u0026thinsp;\u0026plusmn;\u0026thinsp;20.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.33 (0.48, 2.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.618\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eBold expression of the numbers indicates significant differences; X: Mean; SD: Standard deviation; CI: Confidence interval, ED: Erectile dysfunction; IIEF-5: International Index of Erectile Function; COMPASS 31: Composite Autonomic Symptom Score; DASS-21: Depression Anxiety Stress Scale; SF-36: Short Form-36; \u003csup\u003ea\u003c/sup\u003eIndependent sample t-test; \u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003ePaired Samples t test.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, it was found that CTM improved ED, autonomic dysfunction symptom severity, anxiety and stress symptom severity and improved quality of life in individuals with ED. However, no improvement was observed in the control group. It was also found that ED severity, autonomic dysfunction symptom severity, depression level and quality of life (mental health only) improved more in the CTM group compared to the control group. Moreover, in the CTM group, there was a large effect size for the symptom severity, autonomic dysfunction symptom severity, and quality of life (SF-36-mental health), while there was a medium effect size for depression, anxiety and stress symptom severity.\u003c/p\u003e\u003cp\u003eCTM regulates autonomic functions, causes vasodilation and improves visceral functions by local, segmental and suprasegmental effects through cuteno-visceral reflexes [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Considering the effects of CTM on the autonomic nervous system and vascular system, it is thought that CTM may have positive effects on individuals with ED. In our study, CTM was applied to individuals with ED and it was seen that CTM improved the severity of ED symptoms. In addition, it has been reported that the clinical significance value of the IIEF-5 is approximately 4 points [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In this study, a difference of approximately 4 points was observed in the CTM group after the intervention. CTM, which is an easily applicable method for improving ED symptoms that negatively affect both the individual and their partner, can be considered in clinics.\u003c/p\u003e\u003cp\u003eThere are studies in different populations showing that CTM affects autonomic functions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In a randomized study examining the effect of CTM and classical massage on autonomic responses (peripheral skin temperature) in patients with chronic mechanical low back pain, it was reported that both types of massage regulated autonomic responses but were not superior to each other [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In another study examining the effect of CTM on autonomic functions (systolic/diastolic blood pressure, respiratory rate) in healthy young women, it was shown that CTM decreased sympathetic activity [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our study, the effects of CTM on autonomic dysfunctions in individuals with ED were examined. In our study, the severity of autonomic dysfunction, which is an important in the pathophysiology of ED, was evaluated. It was found that CTM decreased the severity of autonomic dysfunction. Since autonomic dysfunction and vascular responses are important in the pathophysiology of ED, CTM may be considered as an alternative application for these individuals.\u003c/p\u003e\u003cp\u003eIn the literature, there are also studies in different populations showing that CTM affects individuals' psychological state and quality of life [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. For example, in a controlled clinical trial examining the effect of CTM on psychological status and quality of life in women with migraine, CTM was shown to improve psychological status and quality of life [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In a randomized placebo-controlled study examining the effects of CTM on psychological status and quality of life in postmenopausal women, it was shown that CTM improved psychological status and quality of life [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In a different randomized study examining the effect of CTM and classical massage on quality of life in patients with chronic mechanical low back pain, it was reported that both types of massage improved quality of life [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In another randomized controlled study examining the effect of CTM and classical massage on quality of life in patients with chronic constipation, it was shown that CTM and classical massage group were superior to the control group in improving quality of life, but they were not superior to each other [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In another study examining the effect of exercise and exercise plus CTM on quality of life in patients with fibromyalgia, it was reported that the quality of life of individuals in both groups increased and the outcomes were significantly better in the exercise plus CTM group [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our study, the effects of CTM on psychological status and quality of life in individuals with ED were examined and it was found that stress, anxiety and quality of life improved in the CTM group. It was found that depression and quality of life (mental health parameter) improvements were significantly different in the CTM group compared to the control group. These results may be related to the improving of ED symptoms and autonomic dysfunction by CTM. In addition, the fact that most of those with ED symptoms in our study were mild to moderate and most of them did not use medication for ED suggests that CTM improve confidence and reducing anxiety around sexual activity in this group.\u003c/p\u003e\u003cp\u003eTo our knowledge, this study is the first randomized controlled trial examining the effects of CTM on individuals with ED. The study also had some limitations, namely that it was conducted in a single region and only subjective evaluation criteria were used. These limit the generalizability of the study results and more objective evaluations can be added to future studies. Another limitation of the study was also that the implementation of lifestyle changes given as part of standard treatment in the control group was not followed up. Lastly, although the current study\u0026rsquo; s sample size was calculated based on the IIEF-5 score, the number of samples in the study may seem numerically small. Therefore, the sample size can be calculated considering other outcomes in further studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the current study, it was found that CTM reduced the severity of ED and autonomic dysfunction, and improved wellbeing such as psychological status and quality of life in individuals with ED. According to these results, CTM can be used as a complementary application in the treatment of ED. In future studies, it may be important to examine the long-term results of the effects of CTM in individuals with ED and to examine the effects of other physiotherapy approaches. Moreover, studies examining the changes in vascularity in CTM and the effects of CTM according to subgroups of patients (those with more stress or those with more affected quality of life) can be conducted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study protocol was reviewed and approved by the institutional review board of Ankara Yıldırım Beyazıt University (approval no-date: 04-13.04.2023). Informed consent was submitted by all subjects when they were enrolled. This randomized controlled trial was registered at ClinicalTrials.gov (ID: NCT06163157 on 21/12/2023) prior to participant enrollment.\u0026nbsp;The study began in December 2023 and ended in \u0026nbsp; December 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were duly informed about the trial and provided their consent for publication. We further confirm that written consent has been obtained from every individual whose personal data, images, or case information appears in this manuscript. The consent documentation is retained and can be provided to the editorial team upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData available on request due to privacy/ethical restrictions. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpringer Nature and Türkiye Bilimsel ve Teknolojik Araştırma Kurumu have an agreement which allows eligible authors to publish open access without paying an article publication charge (APC). The cost of publishing is covered under the terms of the agreement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMesut Arslan:\u003c/strong\u003e Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review \u0026amp; editing.\u0026nbsp;\u003cstrong\u003eDerya Ozer Kaya\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Writing – review \u0026amp; editing.\u0026nbsp;\u003cstrong\u003eSeyda Toprak Celenay\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the relevant institutional authorities who supported the study and all the patients who participated.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTuncel A, G\u0026uuml;zel \u0026Ouml;, Atan A. 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Uluslararası cinsel işlev indeksinin 5 soruluk versiyonunun (IIEF-5) T\u0026uuml;rk\u0026ccedil;e ge\u0026ccedil;erlilik \u0026ccedil;alışmasının değerlendirilmesi. T\u0026uuml;rk \u0026Uuml;roloji Dergisi/Turkish Journal of Urology. 2007;33(1):45-9. \u003c/li\u003e\n\u003cli\u003eRislanu A, Auwal H, Musa D, Auwal A. Comparative Effectiveness of Electrical Stimulation and Aerobic Exercise in the Management of Erectile Dysfunction: A Randomized Clinical Trial. Ethiop J Health Sci. 2020;30(6):961-70. doi: 10.4314/ejhs.v30i6.14.\u003c/li\u003e\n\u003cli\u003eSletten DM, Suarez GA, Low PA, Mandrekar J, Singer W. COMPASS 31: a refined and abbreviated Composite Autonomic Symptom Score. Mayo Clinic proceedings. 2012;87(12):1196-201. doi: 10.1016/j.mayocp.2012.10.013.\u003c/li\u003e\n\u003cli\u003eBal İ, Pala \u0026Ouml;O, Polat M. Kompozit otonom semptom skoru (COMPASS-31) \u0026ouml;l\u0026ccedil;eğinin fibromiyalji hastalarında t\u0026uuml;rk\u0026ccedil;e ge\u0026ccedil;erlik ve g\u0026uuml;venirlik \u0026ccedil;alışması. Fizyoterapi ve Rehabilitasyon Ana Bilim Dalı. Sivas: Sivas Cumhuriyet \u0026Uuml;niversitesi 2023.\u003c/li\u003e\n\u003cli\u003eSarı\u0026ccedil;am H. The psychometric properties of Turkish version of Depression Anxiety Stress Scale-21 (DASS-21) in health control and clinical samples. Bilişsel Davranış\u0026ccedil;ı Psikoterapi ve Araştırmalar Dergisi. 2018;7(1):19-30. \u003c/li\u003e\n\u003cli\u003eKo\u0026ccedil;yiğit H, Aydemir \u0026Ouml;, Fişek G, \u0026Ouml;lmez N, Memiş AK. Form-36 (KF-36)\u0026rsquo;nın T\u0026uuml;rk\u0026ccedil;e versiyonunun g\u0026uuml;venilirliği ve ge\u0026ccedil;erliliği. Ila\u0026ccedil; ve tedavi dergisi. 1999;12(2):102-6. \u003c/li\u003e\n\u003cli\u003eMoyad MA, Park K. What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng. Asian journal of andrology. 2012;14(6):830-41. doi: 10.1038/aja.2012.82.\u003c/li\u003e\n\u003cli\u003eHoley LA, Dixon J. Connective tissue manipulation: a review of theory and clinical evidence. Journal of bodywork and movement therapies. 2014;18(1):112-8. doi: 10.1016/j.jbmt.2013.08.003.\u003c/li\u003e\n\u003cli\u003eFritz CO, Morris PE, Richler JJ. Effect size estimates: current use, calculations, and interpretation. Journal of experimental psychology General. 2012;141(1):2-18. doi: 10.1037/a0024338.\u003c/li\u003e\n\u003cli\u003eEr G, Y\u0026uuml;ksel İ. A comparison of the effects of connective tissue massage and classical massage on chronic mechanical low back pain. Medicine. 2023;102(15):e33516. doi: 10.1097/md.0000000000033516.\u003c/li\u003e\n\u003cli\u003eAkbaş E, \u0026Uuml;nver B, Erdem EU. Acute Effects of Connective Tissue Manipulation on Autonomic Function in Healthy Young Women. Complementary medicine research. 2019;26(4):250-7. doi: 10.1159/000497618.\u003c/li\u003e\n\u003cli\u003eAlbayrak G, \u0026Ccedil;ağlıyan T\u0026uuml;rk A, \u0026Ouml;zg\u0026uuml;l S. Effects of connective tissue massage on physical and emotional symptoms, insomnia, and quality of life in postmenopausal women: A randomized, sham-controlled trial. Maturitas. 2025;191:108149. doi: 10.1016/j.maturitas.2024.108149.\u003c/li\u003e\n\u003cli\u003eOrhan C, \u0026Ouml;zg\u0026uuml;l S, Baran E, \u0026Uuml;zelpasacı E, Akbayrak T. Comparison of Connective Tissue Manipulation and Abdominal Massage Combined With Usual Care vs Usual Care Alone for Chronic Constipation: A Randomized Controlled Trial. Journal of manipulative and physiological therapeutics. 2020;43(8):768-78. doi: 10.1016/j.jmpt.2019.05.013.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Erectile dysfunction, Connective tissue massage, Autonomic functions, Psychological state, Quality of life","lastPublishedDoi":"10.21203/rs.3.rs-7211844/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7211844/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOne of the most common sexual dysfunctions in men is erectile dysfunction (ED). Connective tissue massage (CTM) is a physiotherapy approach that produces autonomic response through cuteno-visceral reflexes. However, there are no studies investigating the effect of CTM on erectile functions. To investigate the effects of CTM on symptom severity, autonomic dysfunction severity and wellbeing such as psychological status and quality of life in individuals with ED.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis randomized controlled study included sexually active individuals aged 20\u0026ndash;65 years with ED. They were divided into 2 groups as CTM (n\u0026thinsp;=\u0026thinsp;15, age\u0026thinsp;=\u0026thinsp;44.67 years, body mass index\u0026thinsp;=\u0026thinsp;25.51 kg/m\u003csup\u003e2\u003c/sup\u003e) and control (n\u0026thinsp;=\u0026thinsp;15, age\u0026thinsp;=\u0026thinsp;45.67 years, body mass index\u0026thinsp;=\u0026thinsp;28.07 kg/m\u003csup\u003e2\u003c/sup\u003e) groups. The control group received standard treatment and the CTM group received CTM 3 days a week for 4 weeks in addition to standard treatment. ED severity (International Index of Erectile Function (IIEF-5)), autonomic dysfunction symptoms (Composite Autonomic Symptom Score (COMPASS-31)), psychological status (Depression Anxiety Stress Scale (DASS-21)), and quality of life (Quality of Life-Short Form Survey (SF-36)) were evaluated before and after the intervention. The study began in December 2023 and ended in December 2024.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWhen the pre- and post-intervention scores of the groups were compared, IIEF-5 (p\u0026thinsp;=\u0026thinsp;0.018), SF-36-physical (p\u0026thinsp;=\u0026thinsp;0.004) and SF-36-mental health (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) scores increased, COMPASS-31 (p\u0026thinsp;=\u0026thinsp;0. 005), DASS-21-anxiety (p\u0026thinsp;=\u0026thinsp;0.015) and DASS-21-stress scores (p\u0026thinsp;=\u0026thinsp;0.013) decreased in the CTM group, while there was no significant change for any parameter in the control group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Moreover, IIEF-5 (p\u0026thinsp;=\u0026thinsp;0.037) and SF-36-mental health (p\u0026thinsp;=\u0026thinsp;0.002) scores were higher, COMPASS-31 (p\u0026thinsp;=\u0026thinsp;0.037) and DASS-21-depression (p\u0026thinsp;=\u0026thinsp;0.049) scores were lower in the CTM group compared to the control group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCTM was found to improve ED and autonomic dysfunction severity, psychological status and quality of life in individuals with ED. According to these results, CTM can be used as a complementary application in the treatment of ED.\u003c/p\u003e","manuscriptTitle":"Connective Tissue Massage Improves Symptoms, Autonomic Dysfunctions and Wellbeing in Erectile Dysfunction: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-18 06:01:39","doi":"10.21203/rs.3.rs-7211844/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-30T13:09:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T21:24:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T16:28:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144197732899010513729637478857920539761","date":"2025-09-19T16:46:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38015104335814373970340882369065295487","date":"2025-09-18T08:46:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T01:34:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T22:57:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166944001784499563550562190262650176774","date":"2025-09-17T15:07:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-12T22:10:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153901364991069127757236267430611657025","date":"2025-09-12T21:44:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330790496710898236533941652842004410233","date":"2025-09-12T20:53:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217762794847898349374881136429728865703","date":"2025-09-11T08:40:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-10T21:43:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-20T20:55:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-20T09:19:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-20T09:18:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-07-25T07:56:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86e5c4c1-ce1c-4748-9486-6377a5247694","owner":[],"postedDate":"September 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-07T06:23:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-18 06:01:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7211844","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7211844","identity":"rs-7211844","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}