Asian Journal of Andrology (2015) 17, 5–10

© 2015 AJA, SIMM & SJTU. All rights reserved 1008-682X

www.asiaandro.com; www.ajandrology.com

Open Access
INVITED REVIEW

Lifestyle modifications and erectile dysfunction:

Sexual Function

what can be expected?

Maria Ida Maiorino1, Giuseppe Bellastella1, Katherine Esposito2

Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED
include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption.
Quite interestingly, all these metabolic conditions are strongly associated with a pro‑inflammatory state that results in endothelial
dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and
nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function.
Moreover, it has also been suggested that lifestyle habits that decrease low‑grade clinical inflammation may have a role in the
improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED
in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing
the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed.
Asian Journal of Andrology (2015) 17, 5–10; doi: 10.4103/1008-682X.137687; published online: 09 September 2014

Keywords: erectile dysfunction; lifestyle changes; physical activity; Mediterranean diet

INTRODUCTION strongly associated with a pro‑inflammatory state that results in

Erectile dysfunction  (ED) is a common medical disorder which endothelial dysfunction and decrease in the availability and activity of
decreases quality of life in men.1,2 It has been estimated that the nitric oxide (NO). As NO is the driving force of the genital blood flow,
worldwide prevalence of ED will be 322 million cases by the year it has been hypothesized and demonstrated that most cardiovascular
2025. Risk factor categories associated with ED include general risk factors are associated with ED in men.12 Moreover, an inverse
health status of the individual, the presence of diabetes mellitus, and association between obesity and low‑testosterone levels has been
of cardiovascular disease (CVD), concurrence of other genitourinary established in healthy men; the prevalence of low‑testosterone levels in
disease, psychiatric/psychological disorders, and sociodemographic obesity may vary from 20% to 64% depending on the population and on
conditions.3 Several cross‑sectional and longitudinal studies showed whether total or free testosterone is used to make a diagnosis.13 A higher
an association between ED and most of the cardiovascular risk factors, prevalence of hypogonadotropic hypogonadism has been described
such as diabetes, smoking, hypertension, hyperlipidemia, metabolic in patients with type 2 diabetes mellitus14 and referred to metabolic
syndrome.4 Moreover, ED is a marker of increased risk of CVD, and disorders causing hypothalamic‑pituitary‑gonadal axis regulation.15
all‑cause mortality.5–7 Testosterone regulates nearly every component of erectile function,
Cardiovascular diseases are the main cause of mortality in both and also modulates the timing of the erectile process, which occurs
sexes worldwide:8,9 behavioral modifications that occurred in the as a function of sexual desire, coordinating penile erection with sex.
last decades have led to the spreading of unhealthy lifestyles, which Lifestyle and nutrition have been recognized as central factors
are believed to be one main cause of the burden of noncommunicable influencing both vascular NO production and erectile function.
diseases worldwide.10 Consequently, there has been a dramatic increase Moreover, it has also been suggested that lifestyle habits that decrease
in the incidence of both type 2 diabetes mellitus and obesity, both in low‑grade clinical inflammation may have a role in reducing the burden
the Westernized and the developing countries. The increasing prevalence of sexual dysfunction.16 Both basic and clinical studies have shown
of obesity has brought about the rising prevalence of metabolic that targeting several lifestyle factors commonly associated with ED,
syndrome, a cluster of risk factors for CVD and type 2 diabetes mellitus, such as smoking, alcohol consumption, obesity, and limited physical
occurring together more often than could be attributed to chance activity can have significant effects on improvement of erectile function
alone. On the basis of the most recent epidemiological analysis using as well as testosterone levels (Figure 1).17–22 Therefore, there may be
the National Cholesterol Education Program/Adult Treatment Panel a role for lifestyle measures to prevent progression or even enhance
III guidelines for cut‑off values, slightly more than one‑third of adults the regression in the earliest manifestations of ED.23 In this review, a
in the United States could be characterized as having the metabolic comprehensive literary search was carried out in order to discuss the
syndrome.11 Quite interestingly, all these metabolic conditions are effects of lifestyle intervention strategies on erectile function, focusing
1
Department of Medical, Surgical, Neurological, Metabolic and Geriatric Science, Second University of Naples, Piazza L. Miraglia n° 2; 2Department of Clinical and
Experimental Medicine, Second University of Naples, via Pansini n° 5, Naples, Italy.
Correspondence: Prof. K Esposito ([email protected])
Received: 05 May 2014; Revised: 27 June 2014; Accepted: 14 July 2014
 Lifestyle modifications and ED
MI Maiorino et al

investigations indicate that the physical activity has a beneficial effect

on prevention and/or improvements of ED.31–33
In hypertensive patients with ED, an 8-week exercise training
for the duration of 45–60  min day−1, improved ED compared with
controls who remained sedentary during the same period.34 A recent
study evaluated the effect of a standard protocol of aerobic physical
activity (150 min week−1) on quality of ED in middle‑aged patients
with arterial ED.35 After 3 months, compared with controls, patients
in the intervention group showed a significantly higher International
Index of Erectile Function 5 (IIEF‑5) score associated with a reduction
of apoptotic circulating endothelial progenitor cells  (EPCs) and
endothelial microparticles. In a randomized, open‑label study,36 a total
of 60 patients with ED were randomized to receive phosphodiesterase
Figure 1: Behavioral risk factors and principal mechanisms involved in erectile type 5 inhibitor (PDE5i) alone or PDE5i plus regular (≥3 h week−1),
dysfunction. aerobic, nonagonistic physical activity. After 3  months, IIEF
restoration of ED occurred in 77.8%  (intervention group) versus
on the potential mechanisms involved in increasing vascular NO 39.3% (control) (P < 0.004). Moreover, physical activity was the only
production. We searched PubMed for papers published in English independent variable for normal erection (P = 0.010), higher sexual
between 1990 and March 2014, using the key words “ED” and “lifestyle satisfaction (P = 0.022) and normal total IIEF‑15 score (P = 0.023),
changes” “physical activity,” “weight loss,” “diet,” “alcohol,” “smoking;” suggesting that lifestyle changes may significantly increase the benefits
we mainly focused on publications in the past 5 years. Other relevant of medical ED therapy.
articles identified by review of the reference lists of selected articles The mechanisms by which physical activity ameliorates ED include
were also included. improved cardiovascular fitness and endothelial dysfunction,37 increase
in endothelial‑derived NO,38 decrease in oxidative stress,20 and increase
EPIDEMIOLOGY AND RISK FACTORS in regenerative EPCs.39 Moreover, physical exercise showed beneficial
Erectile dysfunction is a frequent sexual problem that increases with effects on self‑esteem and mental health,40 with a positive impact on
age. According to a recent analysis of published works on the prevalence psychological issues associated with sexual dysfunction.
of sexual dysfunction by the International Consultation Committee
Weight loss
for sexual medicine on definitions/epidemiology/risk factors for sexual
Both cross‑sectional and prospective epidemiologic studies suggest
dysfunction,3 the prevalence of ED was 1%–10% in men younger than
that overweight, obesity and metabolic syndrome are associated with
40 years, 2%–9% among men between 40 and 49 years, and it increased
an increased risk of ED.41 In particular, the largest population from the
to 20%–40% among men between 60 and 69 years, reaching the highest
Health Professionals Follow‑up Study in the United States, including
rate in men older than 70 years (50%–100%). Modifiable risk factors for
31 724 men free of ED at baseline, showed a 40% increased risk of
ED include smoking, lack of physical activity, obesity, excessive alcohol
developing ED with obesity.25 Prospective studies31,42,43 of variable
consumption, recreational drug use.24 In the Health Professional’s
duration from 5 to 25  years of follow‑up reported that overweight
Follow‑up Study25 several lifestyle factors, including physical activity or obese men had an increased probability  (70%–96% higher) of
and leanness, were associated with maintenance of good erectile developing ED compared with normal weight men.
function. On the other hand, diabetes mellitus is the most common Both short‑  and long‑term weight‑loss studies including only
risk factor for ED, as diabetic men showed a three‑fold probability of caloric modifications or restrictions demonstrated improvement of
having ED than men without diabetes.26 Moreover, both cross‑sectional ED. In a study examining the effect of weight loss on quality of life
and longitudinal studies have linked the development of ED to CVD, among 37 men and women, after a follow‑up of 28 days, the weight
hypertension, hyperlipidemia, and metabolic syndrome,27–29 all of loss program seemed to have been beneficial on sexual life among
which are largely preventable with an intervention strategy based on men.44 Khoo et al.22 compared the effects of 8 weeks of a low‑calorie
lifestyle changes. diet (LCD) using meal replacements (KicStart) on insulin sensitivity,
EFFECTS OF LIFESTYLE CHANGES ON ERECTILE plasma testosterone levels, erectile function (IIEF‑5), and sexual desire
DYSFUNCTION as measured by the Sexual Desire Inventory (SDI) in abdominally obese
The association of modifiable behavioral factors with ED, primarily men with uncomplicated diabetes (n = 519) or without type 2 diabetes
among men free of comorbidities, represents the rationale for mellitus (n = 525) with a control group of nondiabetic men (n = 526)
intervention strategies addressed to prevent and potentially improve with similar body mass index (BMI) and waist circumference (WC).
erectile function in patients with ED. As NO is a key factor for vascular Weight loss of 10% was significantly associated with increased insulin
health and ED is strongly associated with CVD, maximal attention sensitivity, plasma testosterone levels, and IIEF‑5 and SDI scores in
diabetic as well as nondiabetic men. The same group investigated the
should have to be paid on measures known to increase vascular NO
effects of diet‑induced weight loss on sexual and endothelial function,
production.
lower urinary tract symptoms, and inflammatory markers in obese
Physical activity diabetic men.45 Over 8 weeks, 31 abdominally obese type 2 diabetic men
The only meta-analysis regarding exercise and ED showed that received either a meal replacement‑based LCD ∼1000 kcal day−1 (n = 19)
moderate and high physical activities were associated with a lower risk or low‑fat, high‑protein  (HP), reduced‑carbohydrate diet  (n  =  12).
of ED, with odds ratios at 0.63 (95% confidence interval (CI): 0.43–0.93) Subjects continued on, or were switched to, the HP diet for another
and 0.42  (95% CI: 0.22–0.82), respectively.30 Several prospective 44 weeks. Compared with patients with HP, men with LCD lost more

Asian Journal of Andrology

 Lifestyle modifications and ED
MI Maiorino et al

weight (5% vs 10%). Moreover, both diets significantly improved plasma the week before the meeting with a nutritionist. Men in the control
glucose, low‑density lipoprotein, sex hormone‑binding globulin, group were given general oral and written information about healthy
IIEF‑5, SDI, and endothelial function  (increased flow‑mediated food choices and exercise at baseline and subsequent bimonthly visits,
dilatation, reduced soluble E‑selectin). At 52  weeks, reductions in but no specific individualized programs were offered to them. After
weight, WC, and C‑reactive protein were maintained, and IIEF‑5, 2 years, men randomized to the intervention lost significantly more
and SDI scores improved further. Similar results were obtained with weight, increased their physical activity, experienced favorable changes
bariatric surgery‑induced weight loss. In a randomized controlled in physiologic measures of endothelial dysfunction, and had significant
trial,46 surgery‑induced weight loss increased erectile function quality improvement in their ED score compared with men in the control
measured by IIEF‑5, with increased total testosterone, free testosterone, group. The same group used their database of subjects participating
follicle‑stimulating hormone, and reduced prolactin levels. Moreover, in randomized controlled trials to evaluate whether improvements in
significant improvements in all domains of the Brief Sexual Function erectile function were related to success in achieving lifestyle changes.20
Inventory, including erectile function, were also demonstrated in a After ranking men according to their success in achieving the goals of
2 years study of bariatric surgery‑induced weight loss.47 intervention (weight loss, low intake of saturated fat, high consumption
Increased visceral adiposity and related risk factors are associated of monounsaturated fat and fiber, and moderate physical activity), a
with a pro‑inflammatory state that results in a decrease in the availability strong correlation was observed between the success score and the
and activity of NO; the reduced testosterone levels associated with restoration of erectile function. Moreover, at the 2 years examination
obesity and the metabolic syndrome may worsen both insulin resistance point, the number of men without ED was significantly higher in the
and endothelial function, thereby contributing to ED.48 Moreover, body group randomized to intensive lifestyle changes compared with that
weight loss, obtained either by lifestyle or bariatric intervention, is of men in the control group. Wing et al.57 evaluated 1 year changes
associated with a decline in estrogen levels and a rise in gonadotropins in erectile function in 306 overweight men with type  2 diabetes
and testosterone, which is greater in those who lose more body weight.49 mellitus participating in the Look Action for Health in Diabetes trial;
from baseline to 1 year, 8% of men assigned to an intensive lifestyle
Dietary factors
intervention reported a worsening of erectile function compared to 22%
Dietary patterns with high content of whole grain foods and legumes
of the control participants. Moreover, the overall IIEF score improved
and vegetables and fruits, and that limit red meat, full‑fat dairy products,
from 17.3 to 18.6 (P = 0.04 and P = 0.06, after adjusting for baseline
and food and beverages high in added sugars are associated with a
differences) in the intervention group.
reduced risk of ED.50 The greater adherence to a Mediterranean‑style
The suggested mechanisms by which weight loss, healthy diet,
diet, in particular, has been associated with a lower prevalence of ED
and physical exercise can improve erectile function include the
in both diabetic and nondiabetic men.51,52
amelioration of endothelial dysfunction, insulin‑resistance, and
Only few studies assessed the role or the effect of diet on ED.
low‑grade inflammatory state associated with diabetes and metabolic
Esposito et  al.53 studied 65 men with the metabolic syndrome and
diseases – all of which are risk factors for ED.58 The resulting improved
ED; 35 out of them were assigned to the intervention diet and 30 to
inflammatory status may help contribute to reduce the burden of sexual
the control diet. Subjects in the intervention group were advised to
dysfunction in men.
consume at least 250–300  g of fruits, 125–150  g of vegetables, and
25–50 g of nuts per day; in addition, they were encouraged to consume Smoking
400  g of whole grains daily  (legumes, rice, maize, and wheat) and Both the direct use of tobacco and second‑hand exposure seem a
to increase the consumption of olive oil. After 2 years, men on the consolidated risk factor for ED.59,60 A recent meta‑analysis of four
Mediterranean diet consumed more fruits, vegetables, nuts, whole prospective cohort studies and four case‑control studies involving
grain, and olive oil when compared with men on the control diet. IIEF 28 586 participants showed that compared with nonsmokers, the
score increased up to 22 in 13 and 2 men in the intervention group overall odd ratio of ED in prospective cohort studies was 1.51 (95%
and control group, respectively (P = 0.015). CI: 1.34–1.71) for current smokers, and 1.29 (95% CI: 1.07–1.47) for
A substantial body of knowledge demonstrates that the abundant former smokers.61
consumption of vegetables, fruit, and whole grain, and the dietary Harte and Meston62 investigated the association between smoking
patterns rich in these foods produced a markedly lower risk of cessation and indices of physiological and subjective sexual health in
coronary disease.54 The beneficial effect of the Mediterranean diet men: smoking cessation significantly enhanced both physiological
on atherosclerosis in general, and ED in particular can be mediated and self‑reported indices of sexual health in long‑term male smokers,
through multiple biological pathways, including a reduction of irrespective of baseline erectile impairment. In a prospective study,
oxidative stress and subclinical inflammation, amelioration of Pourmand et al.63 reported a beneficial effect on erectile function in
endothelial dysfunction and insulin sensitivity,55,56 which in turn may men who ceased smoking. After 1 year the ED status improved in ≥25%
increase NO release in the penis arteries. of ex‑smokers but in none of the current smokers; moreover, men who
stopped smoking continued to have a significantly better ED status
Overall lifestyle changes
with long‑term follow‑up.
Lifestyle changes, such as increased physical activity, healthy diet, and
reduced caloric intake, have been associated with the amelioration Alcohol
of erectile function in the general male population. Esposito et al.16 The moderate consumption of alcohol may exert a protective effect
conducted a randomized controlled trial involving 110 obese men with on ED in both the general population and in diabetic men.25,64 In
ED. Men assigned to the intervention group were entered in an intensive a recent study aimed at describing the incidence or remission and
weight loss program, involving personalized dietary counseling and bio‑psychosocial predictors of ED in 810 randomly selected Australian
exercise advice, and regular meetings with a nutritionist and personal men aged 35–80, low‑alcohol consumption was predictor of ED.65 The
trainer. The dietary advice was tailored to each man on the basis of food data from a population‑based cross‑sectional study of men’s health
records collected on three nonconsecutive days which had to be done to assess the association between usual alcohol consumption and ED

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 Lifestyle modifications and ED
MI Maiorino et al

in Australia revealed that among current drinkers (n = 51 374), the exposure to smoking decreases significantly both testosterone levels
odds were lowest for consumption between 1 and 20 standard drinks and the filling rate of corpora cavernosa in mice, when compared with
per week.19 On further adjustment for CVD or cigarette smoking, a control group who was not exposed.73
age‑adjusted odds of ED were reduced by 25%–30% among alcohol
drinkers. In general, the overall findings are suggestive of alcohol WHICH ROLE FOR LIFESTYLE CHANGES IN ERECTILE
consumption of a moderate quantity conferring the highest protection.66 DYSFUNCTION?
The beneficial effects of alcohol on erectile function may be due, in Erectile dysfunction is associated with smoking, excessive alcohol
part, to the long‑term benefits of alcohol on high‑density lipoprotein intake, physical inactivity, abdominal obesity, metabolic syndrome,
cholesterol and other variables that increase the bioavailability of NO. diabetes, hypertension, and decreased anti‑oxidant defenses, all of
which reduce NO availability. Moreover, there has been increasing
Experimental findings involving lifestyle modifications recognition of the many physiological causes of ED and of the potential
Corroborating findings in the clinical studies, several experimental for therapy to improve patient’s quality of life, self‑esteem, and ability to
studies demonstrate beneficial effects of lifestyle‑related factors (exercise, maintain intimate relationships.74 Although epidemiological evidence
calories restriction, dietary factors, alcohol, smoking) on erectile seems to support a role for lifestyle factors, limited data are available
function in animal models of ED. The most frequently reported models suggesting that the treatment of underlying risk factors and coexisting
of ED used rodents as the predominant animal for investigating erectile illnesses  –  for example with diet, exercise, stress reduction, and
function. Experimental animal models of ED include traumatic, smoking cessation – may improve ED.24 It has been demonstrated that
metabolic (diabetes, hypercholesterolemia/lipidemia, and castration) lifestyle‑based intervention strategies improve endothelial function,
and other organic models (smoking, hypertension, and chronic renal NO bio‑availability, and testosterone levels, producing benefits on
failure).67 In male Sprague–Dawley rats, both erectile function and erectile function.12,16,49 The major limitation remains the paucity of
coronary artery erectile function  (CAEF) were blunted in Western intervention studies that have assessed the role of lifestyle changes on
diet‑fed rats who remained sedentary, but were preserved in those ED. Moreover, the studies reviewed are mainly limited to the exiguity
who started physical exercise (aerobic treadmill running) throughout of the study samples. However, the European Association of Urology
the dietary intervention, suggesting that exercise training may be a recently stated that “lifestyle changes and risk factors modification
practical strategy of preventing diet‑induced ED.68 A recent study in must precede or accompany ED treatment” and classified the Level of
the same experimental model of rats demonstrated that the caloric Evidence as 1b with a Grade A.75
restriction preserved both visceral adipose tissue (VAT) accumulation None of the many available treatment options offers a complete
and erectile function; moreover, analysis of body composition showed response in all patients. Thus, as with many other medical diseases,
that enhanced erectile response in calories‑restricted rats was well prevention maybe the most effective approach to alleviate the
correlated with the lower levels of VAT, indicating that the beneficial consequences of ED. Despite the increasing evidence that unhealthy
effect on erectile function may depend on decrease in adipose lifestyles lead to metabolic diseases, including sexual dysfunction,
tissue.69 Hannan et  al.70 showed that a combination of exercise and the majority of adults fail to meet physical activity and nutritional
calories restriction may, in part, attenuated the age‑related decline in guidelines.76 In particular, it is recommended that adults accumulate
apomorphine‑induced erectile function in both normotensive and 30 min of moderate‑intensity aerobic physical activity on most days
hypertensive rats, with an inverse correlation between the number of the week. Moreover, a weight loss of 5%–10% in overweight or
of pharmacologically‑induced erections and body weight. The role of obese nondiabetic or diabetic men can result in effective improvement
dietary anti‑oxidants on erectile function was investigated in a study in erectile function in a short period. The lack of food‑based
of Zhang et al.:71 rabbits with atherosclerosis‑induced ED by balloon recommendations and actual dietary practice of the population could
de‑endothelialization of the iliac arteries were assigned to assumption be an additional limitation. However, dietary pattern which is high
of pomegranate extract as dietary anti‑oxidant or tap water as placebo. in fruit, vegetables, nuts, whole grains, and fish but low in red and
Compared with rabbits receiving placebo, those who assumed processed meat and refined grains are more represented in subjects
pomegranate underwent improvement of intracavernosal blood flow, without ED. Mediterranean diet has been proposed as a healthy
erectile activity, smooth‑muscle relaxation and decrease in oxidative dietary pattern based on evidence that greater adherence to this diet
products, suggesting that dietary anti‑oxidants may have an effect on is associated with lower all‑cause and disease‑specific survival. In
molecular and ultra‑structural alteration involved on ED. Ethanol clinical trials, Mediterranean diet was more effective than a control
may impair the endothelial function of corpus cavernosum producing diet in ameliorating ED or restoring absent ED in people with obesity
endothelial damage, as it abolishes the endothelium‑dependent or metabolic syndrome, so that the adoption of a Mediterranean diet
relaxations induced by acetylcholine in mice.72 Finally, chronic may be associated with an improvement of ED.

Table 1: Suggested recommendations on lifestyle changes to be observed in order to prevent/treat erectile dysfunction
Risk factor Strategy Recommendation Level of evidence
Sedentary lifestyle Physical activity 30 min at least per day or 150 min week−1 of moderate intensity aerobic activity A*
Overweight/obesity Weight loss 5%–10% of weight reduction A*
Unhealthy diet Improvement of diet quality Increase in consumption of fruit and vegetables, whole grains and legumes; A*
limit red meat and processed food; reduction of saturated fat to <10%
calories, increase in intake of monounsaturated and polyunsaturated fatty
acids; abolishment of added sugars‑beverages
Alcohol abuse Avoid excessive alcohol consumption 1–2 drinks maximum per day B
Cigarette smoking Educate on current cessation options Smoking cessation B*
A: evidence from intervention studies; B: evidence from prospective cohort studies or case‑control studies. *Few studies with small number

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MI Maiorino et al

CONCLUSIONS 24 Shamloul R, Ghanem H. Erectile dysfunction. Lancet 2013; 381: 153–65.

25 Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, et al. Sexual
Improvement of sexual (erectile) function in men should be added function in men older than 50 years of age: results from the health professionals
to the growing list of clinical benefits brought about by healthy follow‑up study. Ann Intern Med 2003; 139: 161–8.
lifestyles in human beings. Current recommendation that patients 26 Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and
its medical and psychosocial correlates: results of the Massachusetts Male Aging
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exercise, reducing weight (5%–10% or achieving a BMI ≤ 30 kg m−2), 27 Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, et al. Erectile
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or hypertension, are present lifestyle modifications may be important 28 Giuliano FA, Leriche A, Jaudinot EO, de Gendre AS. Prevalence of erectile
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in preventing or reducing sexual dysfunction.4 From this point of 2004; 64: 1196–201.
view, promotion of healthful lifestyles for primary prevention among 29 Esposito K, Giugliano F, Martedì E, Feola G, Marfella R, et al. High proportions of
individuals at all ages would yield great benefits and reduce the burden erectile dysfunction in men with the metabolic syndrome. Diabetes Care 2005;
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of noncommunicable diseases, including sexual dysfunction. Efforts,
30 Cheng JY, Ng EM, Ko JS, Chen RY. Physical activity and erectile dysfunction:
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to be addressed. 31 Feldman HA, Johannes CB, Derby CA, Kleinman KP, Mohr BA, et al. Erectile
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