Effect of physical activity on erectile and sexual function in healthy males

Physical activity (PA) has beneficial effects on erectile dysfunction (ED). It has been proposed to affect ED physiologically via the vascular and nervous systems. This study aimed to evaluate the effect of physical activity on endothelial erectile function, sex hormones and sperm production in healthy males. Sixty-one healthy men aged 18–35 years were eligible to participate in this biochemical and questionnaire-based study. The participants were classified into two groups according to their physical activity level: a physically active group (PA = 38) and a physically inactive group (PINA = 23). PA was evaluated using the ACTi graph GT1M accelerometer. Erectile function was evaluated using the International Index of Erectile Function (IIEF-15) questionnaire. The levels of the sex hormones testosterone (T) and free testosterone (f-T), and the nitric oxide (NO) and E-selectin levels were measured by enzyme linked immuno sorbent assay (ELISA). In addition, a complete semen analysis was performed for all subjects. Better sperm production was reported in physically active subjects than in nonactive subjects. There was a significant increase (p = 0.001) in the IIEF-15 score, and the levels of T, f-T, NO and E-selectin were estimated in physically active subjects compared with those in nonactive subjects. Erectile function (IIEF-15 score) correlated positively with PA and with increased levels of T, f-T, NO and E-selectin, whereas the IIEF-15 score correlated negatively with age and adiposity. Seminological parameters such as the spermatozoa concentration, sperm viability, motility, morphology and normal forms were significantly improved in physically active subjects. Physical activity at mild to moderate levels is significantly associated with improved erectile function, increased endothelial function, increased sex hormone levels and better sperm production in healthy men aged 18–35 years. This study proposes that physical activity physiologically affects erectile function and spermatogenesis via cellular free radical-antioxidant mechanisms.

IIEF-15 score; Erectile function; Physical activity; Sex hormone; Endothelial function

[1] Argiolas A, Argiolas FM, Argiolas G, Melis MR. Erectile dysfunction: treatments, advances and new therapeutic strategies. Brain Sciences. 2023; 13: 802.

[2] Lewis RW, Fugl-Meyer KS, Bosch R, Fugl-Meyer AR, Laumann EO, Lizza E, et al. Definitions, classification, and epidemiology of sexual dysfunction. In: Lue TF, Basson R, Rosen R, Giuliano F, Khoury S, Montorsi F, (eds.) Sexual medicine: Sexual dysfunctions in men and women (pp. 37–72). Health Publications Ltd.: Paris, France. 2004.

[3] Fisher WA, Eardley I, McCabe M, Sand M. Erectile dysfunction (ED) is a shared sexual concern of couples I: couple conceptions of ED. The Journal of Sexual Medicine. 2009; 6: 2746–2760.

[4] O’Leary MP, Rhodes T, Girman CJ, Jacobson DJ, Roberts RO, Lieber MM, et al. Distribution of the brief male sexual inventory in community men. International Journal of Impotence Research. 2003; 15: 185–191.

[5] Mulhall JP, Luo X, Zou KH, Stecher V, Galaznik A. Relationship between age and erectile dysfunction diagnosis or treatment using real-world observational data in the USA. International Journal of Clinical Practice. 2016; 70: 1012–1018.

[6] Corona G, Lee DM, Forti G, O’Connor DB, Maggi M, O’Neill TW, et al. Age-related changes in general and sexual health in middle-aged and older men: results from the European male ageing study (EMAS). Journal of Sexual Medicine. 2010; 7: 1362–1380.

[7] Prins J, Blanker MH, Bohnen AM, Thomas S, Bosch JLHR. Prevalence of erectile dysfunction: a systematic review of population-based studies. International Journal of Impotence Research. 2002; 14: 422–432.

[8] Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU International. 1999; 84: 50–56.

[9] Saenz de Tejada I, Angulo J, Cellek S, Gonzalez-Cadavid NF, Heaton J, Pickard R, et al. Physiology of erectile function and pathophysiology of erectile dysfunction. The Journal of Sexual Medicine. 2004; 1(3): 254–265.

[10] Xiong Y, Zhang F, Zhang Y, Wang W, Ran Y, Wu C, et al. Insights into modifiable risk factors of erectile dysfunction, a wide-angled mendelian randomization study. Journal of Advanced Research. 2024; 58: 149–161.

[11] Andersson KE. Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction. Pharmacological Reviews. 2011; 63: 811–859.

[12] Hehemann MC, Kashania JA. Can lifestyle modification affect men’s erectile function? Translational Andrology and Urology. 2016; 5: 187–194.

[13] Allen MS, Walter EE. Erectile dysfunction: an umbrella review of meta-analyses of risk-factors, treatment, and prevalence outcomes. Journal of Sexual Medicine. 2019; 16: 531–541.

[14] Pellegrino F, Sjoberg DD, Tin AL, Benfante NE, Briganti A, Montorsi F, et al. Relationship between age, comorbidity, and the prevalence of erectile dysfunction. European Urology Focus. 2023; 9: 162–167.

[15] Shin D, Pregenzer Jr G, Gardin J M. Erectile dysfunction: a disease marker for cardiovascular disease. Cardiology in Review. 2011; 19: 5–11.‏

[16] Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical activity to improve erectile function: a systematic review of intervention studies. Sexual Medicine. 2018; 6: 75–89.

[17] Maiorino MI, Bellastella G, Esposito K. Lifestyle modifications and erectile dysfunction: what can be expected? Asian Journal of Andrology. 2015; 17: 5–10.

[18] Johansen PP, Zwisler A, Hastrup-Svendsen J, Frederiksen M, Lindschou J, Winkel P, et al. The CopenHeartSF trial—comprehensive sexual rehabilitation programme for male patients with implantable cardioverter defibrillator or ischaemic heart disease and impaired sexual function: protocol of a randomised clinical trial. BMJ Open. 2013; 3: e003967.

[19] Horasanli K, Boylu U, Kendirci M, et al. Do lifestyle changes work for improving erectile dysfunction? Asian Journal of Andrology. 2008; 101: 28–35.

[20] Hannan JL, Maio MT, Komolova M, Adams MA. Beneficial impact of exercise and obesity interventions on erectile function and its risk factors. The Journal of Sexual Medicine. 2009; 6: 254–261.

[21] Cheng JY, Ng EM, Ko JS, Chen RY. Physical activity and erectile dysfunction: meta-analysis of population-based studies. International Journal of Impotence Research. 2007; 19: 245–252.

[22] Meldrum DR, Gambone JC, Morris MA, Ignarro LJ. A multifaceted approach to maximize erectile function and vascular health. Fertility and Sterility. 2010; 94: 2514–2520.

[23] La Vignera S, Condorelli R, Vicari E, D’Agata R, Calogero AE. Physical activity and erectile dysfunction in middle-aged men. Journal of Andrology. 2012; 33: 154–161.

[24] Apostolopoulos V, Borkoles E, Polman R, Stojanovska L. Physical and immunological aspects of exercise in chronic diseases. Immunotherapy. 2014; 6: 1145–1157.

[25] Durstine JL, Benjamin G, Zhengzhen W, Xijuan L. Chronic disease and the link to physical activity. Journal of Sport and Health Science. 2013; 2: 3–11.

[26] Marquez DX, Aguiñaga S, Vásquez PM, Conroy DE, Erickson KI, Hillman C, et al. A systematic review of physical activity and quality of life and well-being. Translational Behavioral Medicine. 2020; 10: 1098–1109.

[27] Jiannine LM. An investigation of the relationship between physical fitness, self-concept, and sexual functioning. Journal of Education and Health Promotion. 2018; 7: 57.

[28] Almuqahwi A, Alabdrabulridha H, Aljumaiah RM, Alfaifi AJ, Alnaim MF, Alfaifi IA, et al. A systematic review on the relationship between physical activity and sexual function in adults. Cureus. 2023; 15: e51307‏.

[29] Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, D’Andrea F, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004; 291: 2978–2984.

[30] World Health Organization. Global strategy on diet, physical activity and health. (2004).‏ https://www.who.int/publications/i/item /9241592222,

[31] Begot I, Peixoto TC, Gonzaga LR, Bolzan DW, Papa V, Carvalho AC, et al. A home-based walking program improves erectile dysfunction in men with an acute myocardial infarction. The American Journal of Cardiology. 2015; 115: 571–575.

[32] Kalka D, Domagala ZA, Kowalewski P, Rusiecki L, Koleda P, Marciniak W, et al. Effect of endurance cardiovascular training intensity on erectile dysfunction severity in men with ischemic heart disease. American Journal of Men’s Health. 2015; 9: 360–369.

[33] Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. Journal of Psychiatric Research. 2016; 77: 42–51.

[34] Agostini LC, Netto JM, Miranda MV Jr, Figueiredo AA. Erectile dysfunction association with physical activity level and physical fitness in men aged 40–75 years. International Journal of Impotence Research. 2011; 23: 115–121.

[35] Duca Y, Calogero AE, Cannarella R, Giacone F, Mongioi LM, Condorelli RA, et al. Erectile dysfunction, physical activity and physical exercise: recommendations for clinical practice. Andrologia. 2019; 51: e13264.

[36] Vlachopoulos C, Rokkas K, Ioakeimidis N, Stefanadis C. Inflammation, metabolic syndrome, erectile dysfunction, and coronary artery disease: common links. European Urology. 2007; 52: 1590–1600.

[37] Patel DP, Craig JR Jr, Myers JB, Brant WO, Hotaling JM. Serum biomarkers of erectile dysfunction in diabetes mellitus: a systematic review of current literature. Sexual Medicine Reviews. 2017; 5: 339–348.

[38] Wang F, Dai S, Wang M, Morrison H. Erectile dysfunction and fruit/vegetable consumption among diabetic Canadian men. Urology. 2013; 82: 1330–1335.

[39] Sehrawat N, Sharma U, Yadav M, Sharma V, Dey A, Emran TB, et al. Dietary patterns and fertility status in men: Mediterranean diet does make a difference in ameliorating the rise in male infertility problems due to changing lifestyle. International Journal of Surgery. 2023; 109: 564–567.‏

[40] Muscogiuri G, Verde L, Sulu C, Katsiki N, Hassapidou M, Frias-Toral E, et al. Mediterranean diet and obesity-related disorders: what is the evidence? Current Obesity Reports. 2022; 11: 287–304.

[41] Tomada I, Tomada N. Mediterranean diet and male fertility. Endocrines. 2023; 4: 394–406.‏

[42] Cole TJ, Bellizzi MC, Flegal, KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. The BMJ. 2000; 320: 1240–1243.

[43] Ashwel M, Lejeune S, McPherson K. Ratio of waist circumference to height may be better indicator of need for weight management. The BMJ. 1996; 312: 377.

[44] Troiano RP. A timely meeting: objective measurement of physical activity. Medicine & Science in Sports & Exercise. 2005; 37: S487–S489.

[45] Dencker M, Svensson J, El-Naaman B, Bugge A, Andersen LB. Importance of epoch length and registration time on accelerometer measurements in younger children. The Journal of Sports Medicine and Physical Fitness. 2012; 52: 115–121.

[46] Dencker M, Andersen LB. Accelerometer-measured daily physical activity related to aerobic fitness in children and adolescents. Journal of Sports Sciences. 2011; 29: 887–895.

[47] Trost SG. Objective measures of physical activity with youth: current issues, future directions. Exercise and Sport Sciences Reviews. 2001; 29: 32–36.

[48] Plasqui G, Westerterp KR. Physical activity assessment with accelerometers: an evaluation against doubly labeled water. Obesity. 2007; 15: 2371–2379.

[49] Dencker M, Andersen LB. Health related aspects of objectively measured daily physical activity in children. Clinical Physiology and Functional Imaging. 2008; 28: 133–144.

[50] Alghadir AH, Gabr SA, Rizk AA. Physical fitness, adiposity, and diets as surrogate measures of bone health in schoolchildren: a biochemical and cross-sectional survey analysis. Journal of Clinical Densitometry. 2018; 21: 406–419.

[51] Harrell JS, McMurray RG, Baggett CD, Pennell ML, Pearce PF, Bangdiwala SI. Energy costs of physical activities in children and adolescents. Medicine & Science in Sports & Exercise. 2005; 37: 329–336.

[52] Trost SG, Pate RR, Sallis JF, Freedson PS, Taylor WC, Dowda M, et al. Age and gender differences in objectively measured physical activity in youth. Medicine & Science in Sports & Exercise. 2002; 34: 350–355.

[53] Booth M. Assessment of physical activity: an international perspective. Research Quarterly for Exercise and Sport. 2000; 71: S114–S120.

[54] Mäder U, Martin BW, Schutz Y, Marti B. Validity of four short physical activity questionnaires in middle-aged persons. Medicine & Science in Sports & Exercise. 2006; 38: 1255–1266.

[55] Alghadir AH, Iqbal ZA, Gabr SA. Differences among Saudi and expatriate students: body composition indices, sitting time associated with media use and physical activity pattern. International Journal of Environmental Research and Public Health. 2020; 17: 832.

[56] Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectilefunction (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997; 49: 822–830.

[57] Rosen RC, Cappelleri JC, Gendrano N 3rd. The international index of erectile function (IIEF): a state-of-the-science review. International Journal of Impotence Research. 2002; 14: 226–244.

[58] Salas-Huetos A, Muralidharan J, Galiè S, Salas-Salvadó J, Bulló M. Effect of nut consumption on erectile and sexual function in healthy males: a secondary outcome analysis of the FERTINUTS randomized controlled trial. Nutrients. 2019; 11: 1372.

[59] Cadeado AN, Machado CC, Costa MQ, Silva SG. A palm-sized wireless device for colorimetric nitrite determination in water. Microchemical Journal. 2022; 183: 108–138.‏

[60] Sharma V, Boonen J, Chauhan NS, Thakur M, De Spiegeleer B, Dixit VK. Spilanthes acmella ethanolic flower extract: LC-MS alkylamide profiling and its effectson sexual behavior in male rats. Phytomedicine. 2011; 18: 1161–1169.

[61] Vaamonde D, Da Silva-Grigoletto ME, García-Manso JM, Barrera N, Vaamonde-Lemos R. Physically active men show better semen parameters and hormone values than sedentary men. European Journal of Applied Physiology. 2012; 112: 3267–3273.

[62] Esposito K, Ciotola M, Giugliano F, Maiorino MI, Autorino R, De Sio M, et al. Effects of intensive lifestyle changes on erectile dysfunction in men. The Journal of Sexual Medicine. 2009; 6: 243–250.

[63] Kirilmaz U, Guzel O, Aslan Y, Balci M, Tuncel A, Atan A. The effect of lifestyle modification and glycemic control on the efficiency of sildenafil citrate in patients with erectile dysfunction due to type-2 diabetes mellitus. The Aging Male. 2015; 18: 244–248.

[64] Allen MS, Walter EE. Health-related lifestyle factors and sexual dysfunction: a meta-analysis of population-based research. The Journal of Sexual Medicine. 2018; 15: 458–475.

[65] Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, Rimm EB. Sexual function in men older than 50 years of age: results from the health professionals follow-up study. Annals of Internal Medicine. 2003; 139: 161–168.

[66] Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, Rimm EB. A prospective study of risk factors for erectile dysfunction. The Journal of Urology. 2006; 176: 217–221.

[67] Kongkanand A. Prevalence of erectile dysfunction in Thailand. Thai erectile dysfunction epidemiological study group. International Journal of Andrology. 2000; 23: 77–80.

[68] Kratzik CW, Lackner JE, Märk I, Rücklinger E, Schmidbauer J, Lunglmayr G, et al. How much physical activity is needed to maintain erectile function? Results of the Androx Vienna Municipality Study. European Urology. 2009; 55: 509–516.

[69] Leslie SW, Sooriyamoorthy T. Erectile Dysfunction. 2004. Available at: https://www.ncbi.nlm.nih.gov/books/NBK562253/ (Accessed: 9 January 2024).

[70] Araña Rosaínz Mde J, Ojeda MO, Acosta JR, Elías-Calles LC, González NO, Herrera OT, et al. Imbalanced low-grade inflammation and endothelial activation inpatients with type 2 diabetes mellitus and erectile dysfunction. The Journal of Sexual Medicine. 2011; 8: 2017–2030.

[71] Maio G, Saraeb S, Marchiori A. Physical activity and PDE5 inhibitors in the treatment of erectile dysfunction: results of a randomized controlled study. The Journal of Sexual Medicine. 2010; 7: 2201–2208.

[72] Ari Z, Kutlu N, Uyanik BS, Taneli F, Buyukyazi G, Tavli T. Serum testosterone, growth hormone, and insulin-like growth factor-1 levels, mental reaction time, and maximal aerobic exercise in sedentary and long-term physically trained elderly males. International Journal of Neuroscience. 2004; 114: 623–637.

[73] Muller M, den Tonkelaar I, Thijssen JH, Grobbee DE, van der Schouw YT. Endogenous sex hormones in men aged 40–80 years. European Journal of Endocrinology. 2003; 149: 583–589.

[74] Izquierdo M, Häkkinen K, Ibañez J, Garrues M, Antón A, Zúñiga A, et al. Effects of strength training on muscle power and serum hormones in middle-aged and older men. Journal of Applied Physiology. 2001; 90: 1497–1507.

[75] Nicklas BJ, Ryan AJ, Treuth MM, Harman SM, Blackman MR, Hurley BF, et al. Testosterone, growth hormone and IGF-I responses to acute and chronic resistive exercise in men aged 55–70 years. International Journal of Sports Medicine. 1995; 16: 445–450.

[76] Kratzik CW, Schatzl G, Lunglmayr G, Rucklinger EJ. The impact of age, body mass index and testosterone on erectile dysfunction. The Journal of Urology. 2005; 174: 240–243.

[77] Mark S A, Emma EW. Health-Related Lifestyle Factors and Sexual Dysfunction: A Meta-Analysis of Population-Based Research, The Journal of Sexual Medicine, Volume 15, Issue 4, 2018; 15(4): 458475, https://doi.org/10.1016/j.jsxm.2018.02.008

[78] Feldman HA, Johannes CB, Derby CA, Kleinman KP, Mohr BA, Araujo AB, et al. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Preventive Medicine. 2000; 30: 328–338.

[79] Tan JK, Hong CY, Png DJ, Liew LC, Wong ML. Erectile dysfunction in Singapore: prevalence and its associated factors–a population-based study. Singapore Medical Journal. 2003; 44: 20–26.

[80] Grandys M, Majerczak J, Duda K, Zapart-Bukowska J, Kulpa J, Zoladz JA. Endurance training of moderate intensity increases testosterone concentration in young, healthy men. International Journal of Sports Medicine. 2009; 30: 489–495.

[81] Radak Z, Chung HY, Goto S. Systemic adaptation to oxidative challenge induced by regular exercise. Free Radical Biology and Medicine. 2008; 44: 153–159.

[82] Sachdev S, Davies KJ. Production, detection, and adaptive responses to free radicals in exercise. Free Radical Biology and Medicine. 2008; 44: 215–223.

[83] Safarinejad MR, Azma K, Kolahi AA. The effects of intensive, long-term treadmill running on reproductive hormones, hypothalamus–pituitary–testis axis, and semen quality: a randomized controlled study. Journal of Endocrinology. 2009; 200: 259–271.

[84] Kostaropoulos IA, Nikolaidis MG, Jamurtas AZ, Ikonomou GV, Makrygiannis V, Papadopoulos G, et al. Comparison of the blood redox status between long-distance and short-distance runners. Physiological Research. 2006; 55: 611–616.

[85] Pentikäinen V, Suomalainen L, Erkkilä K, Martelin E, Parvinen M, Pentikäinen MO, et al. Nuclear factor kB activation in human testicular apoptosis. The American Journal of Pathology. 2002; 160: 205–218.

[86] Rogers R, Ouellet G, Brown C, Moyer B, Rasoulpour T, Hixon M. Cross-talk between the Akt and NF-kB signaling pathways inhibits MEHP-induced germ cell apoptosis. Toxicological Sciences. 2008; 106: 497–508.

[87] Li MW, Mruk DD, Cheng CY. Mitogen-activated protein kinases in male reproductive function. Trends in Molecular Medicine. 2009; 15: 159–168.

[88] Wang CM, Wu BR, Xiang P, Xiao J, Hu XC. Management of male erectile dysfunction: from the past to the future. Frontiers in Endocrinology. 2023; 14: 1148834.