Effectiveness of Physiotherapy Interventions in the Management Male Sexual Dysfunction: A Systematic Review

Abstract

Background

Male sexual dysfunction is a common disorder with consequential implications. Hitherto, treatment was based on pharmacological approach which has yielded little success in sustainability and produced attendant complications including overweight/obesity, and cardiovascular problems. Hence, the paradigm is toward non-pharmacological approach, but their efficacy is yet to be summarized for clinical practice. This study summarized efficacy of physiotherapy for male sexual dysfunction to inform clinical decision-making and practice.

Methodology

Electronic search of clinical trials on PubMed, Physiotherapy Evidence Database (PEDro), Cochrane Central, Scopus, and Google Scholar was conducted covering from inception till July 2021 using words, such as male sexual dysfunction and physiotherapy and further refined to erectile dysfunction, premature ejaculation, exercises, electrical stimulation, biofeedback. Search strategy included expansion via medical subject headings (MeSH) and truncation of keywords. Boolean operators “AND” and “OR” were utilized.

Results

Out of 239 studies, 13 eligible ones were included in this study. Outcome measures used were full/abridged versions of International Index of Erectile Function (IIEF/IIEF-5), Manometric, or digital anal pressure measurement. Eleven studies were on erectile dysfunction/erectile dysfunction with climacturia and two on premature ejaculation. Physiotherapy was for 6–12 weeks covering 9–20 sessions. Physiotherapy used was standalone/combinations of pelvic floor muscle exercises, electrical stimulation, or biofeedback. PEDro scores of the studies were 4–9/10. Studies involved 912 participants (472/440 intervention/control) between 19 and 83 years with erectile dysfunction lasting 6–360 months. There was significant (0.0001 ≤ p ≤ .05) improvement in sexual function (interventions > controls). Nothing determines the efficacy of physiotherapy or choice of approach.

Conclusion

Physiotherapy is an effective non-pharmacological treatment approach for male sexual dysfunction.

Introduction

Male sexual dysfunction constitutes a global burden and it is a major cause of stressor in marriages and spousal relationships because of repeated inability to achieve normal sexual intercourse or sexual satisfaction. It includes premature ejaculation, retrograded, retarded, or inhibited ejaculation, erectile dysfunction, arousal difficulties, reduced libido, compulsive sexual behavior, orgasmic disorder, and failure of detumescence which often occurs due to pelvic floor muscle dysfunction. Erectile dysfunction and premature ejaculation are high, occurring in more than 50% of the general population (Hatzimouratidis et al., 2016). It is often associ8ated with a reduction in the tone of the pelvic floor muscles and alterations in its functions especially from atrophy of the ischiocarvenosus muscles which may directly impact erectile strength and ejaculation process (Cohen et al., 2016; Kannan et al., 2019).

Despite the inherent pelvic floor muscular dysfunction, traditional management of male sexual dysfunction has focused on lifestyle modifications and pharmaceutical prescriptions. However, there is less focus on addressing the underlying pelvic floor dysfunction. This has led to the new paradigm involving different interventions to manage it. These approaches include pelvic floor muscle exercises alone or pelvic floor muscle exercises in combination with other modalities (Dorey, 2000; Dorey et al., 2004; Rosenbaum, 2007).

Although major lifestyle factors (cigarette smoking, alcohol intake, physical activity, etc.) have been associated with male sexual dysfunctions (erectile dysfunction and premature ejaculation). However, moderate to high physical activity reduces the risk of male sexual dysfunctions (Rosenbaum, 2007). Nevertheless, pelvic floor muscle exercises have proven effective for people who refused surgery for treatments of erectile dysfunction. Hence, physiotherapeutic approaches especially pelvic floor muscle exercises with or without other modalities have been shown to be of remarkable prospect in the management of male sexual dysfunction. However, it is not yet known which patients are the best candidate for an approach or the others. Therefore, there is the need for a study that will explicitly explore the efficacy of each of these approaches and clearly delineate the best approach for each of the types of male sexual dysfunctions. This will help in clinical decision-making and clinical reasoning in the choice of the most effective approach when there is a need to manage a patient with male sexual dysfunction. Since these approaches are noninvasive and could be self-administered, the outcome of such a study will provide a better choice for individuals with male sexual dysfunction as well as the clinicians for the most effective outcomes. Hence, this study aims at summarizing the efficacy of Physiotherapy for male sexual dysfunction to inform clinical reasoning and decision-making with a specific interest in answering vital questions, such as What physiotherapy interventions are being used to manage male sexual dysfunction? What are the factors that determine the choice of protocol/approach for the management of male sexual dysfunction? What is the effectiveness of the physiotherapy interventions for the management of male sexual dysfunction? What factors are related/associated with the outcomes of intervention in the management of male sexual dysfunction? What are the determinants of the effectiveness of the choice outcome intervention in the management of male sexual dysfunction? The review question interrogated the determinants of the effectiveness of physiotherapy interventions and clinical protocols used in the management of male sexual dysfunctions?

Methodology

This systematic review was developed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and protocols (Moher et al., 2009).

Data search and identification and selection of studies

A computerized/electronic literature search of the following databases was undertaken for relevant literature: PubMed, Physiotherapy Evidence Database (PEDro), Cochrane central, Scopus, and Google Scholar. The search was carried out between June and July 2021 and the databases were searched from inception till July 2021. The electronic search was supplemented by a hand search of relevant references in the selected studies and previous reviews were also checked for additional references. The search strategy encompassed two key concepts from the research question: dysfunction (male sexual dysfunction, erectile dysfunction, pelvic floor muscle dysfunction) and intervention (physiotherapy, pelvic floor muscle exercises, electrical stimulation, biofeedback, and physical activity). The search strategy included expansion via medical subject headings (MeSH) and truncation of keywords. Boolean operators “AND” and “OR” were also utilized.

The selection criteria were based on randomized controlled trials, and randomized crossover trials, and the use of one or a combination of the following physiotherapy interventions: pelvic floor muscle exercises, electrical stimulation, biofeedback, physical activity with a specific focus on studies that used at least one of the following outcomes for erectile function: International Index of Erectile Function (IIEF) or the 5-item abridged version (IIEF-5), Intravaginal Ejaculatory Latency Time (IELT) and Premature Ejaculation Diagnostic Tool (PEDT). However, studies involving male sexual dysfunction from multiple sclerosis, Parkinson’s disease, stroke, spinal cord injury, or any history of neurological disorder were excluded (Table 1).

Table 1.

Inclusion and Exclusion Criteria for the Study.

Inclusion criteria	Exclusion criteria
Type of study: Randomized controlled trials Randomized crossover trials	Multiple sclerosis Stroke Myasthenia
Physiotherapy interventions: Pelvic floor muscle exercises Electrical stimulation Biofeedback Physical activity Exercises Aerobics	Neurodegenerative disorder/Parkinson’s disorders Neuropathy/Polyneuropathy/Guillain Barre syndrome Multiple sclerosis
Outcomes measure: International Index of Erectile Function or the 5-item abridged version Premature Ejaculation Diagnostic Tool Manometric measurement Digital anal pressure measurement	Congenital/genetic disorder (spinal bifida, muscular dystrophy) History of spinal surgery Spinal cord injury History of spinal trauma

Literature search

The literature search was conducted by one reviewer. After excluding duplicates of the selected articles, two reviewers then independently screened the title and abstracts of identified papers in the initial search strategy to identify eligible studies according to the inclusion and exclusion criteria. Potentially relevant studies were then retrieved for independent full-text evaluation. Their references were also checked for additional relevant studies. Any discrepancies/disagreements between reviewers were discussed until a consensus was reached.

Data extraction and analysis

Data was extracted into Microsoft Word. The study features extracted from each study include publication details, study design, participants demographics, sample size, interventions (including frequency, intensity, time, and type), attrition rates, number of patients randomized to control and intervention groups, mean or range age of participants, follow-up duration, a description of the intervention and control groups, mean baseline erectile function score, method of ascertainment of outcome and a summary of the primary study outcome.

Key characteristics, such as sample size, age of participants, quantitative and qualitative intervention characteristics relevant to the aim of the review was summarized in tables. These were extracted by one reviewer and consolidated by a second reviewer to ensure accuracy. Authors of the studies included for review were also contacted for necessary information that could not be accessed in the full text of the articles. Due to considerable heterogeneity in the interventions, duration and intensity, controls, and results of the included studies, a narrative review of the evidence was undertaken.

Methodological quality assessment

This was assessed using the PEDro Scale. Factors considered include adequate sequence generation, allocation sequence concealment, blinding, and incomplete outcome data. The PEDro Scale was developed by the physiotherapy evidence database to assess the methodological quality of a clinical trial. It is used to determine clinical trials that are likely to be internally valid and have sufficient statistical information to guide clinical decision-making. There are 11 items, but each trial report is given a total PEDro score which ranges from 0 to 10. This is because the eligibility criteria are not added to the score.

Results

Electronic searches of databases and manual searching of reference lists of included studies and similar systematic reviews identified 329 potential studies. A total of 85 duplicates were removed and the abstracts/full texts of five studies were not accessible. A total of 239 studies were screened by title and abstract and 21 of these were assessed in full text. Of these 21 studies, 13 eligible trials were identified and included in the review. The flow of studies through the review and the reasons for the exclusion of studies are presented in Figure 1.

Figure 1.

Flow-chart for identification of preferred reporting items for systematic reviews and meta-analysis (PRISMA) in the selection of studies.

Continental spread of the studies

The studies included in the review were performed on four continents: one in Asia (Lin et al., 2012), two in Africa (Lamina et al., 2009; Rislanu et al., 2020), three in South America (Begot et al., 2015; Carboni et al., 2018; Prota et al., 2012), and seven in Europe (Dorey et al., 2004; Geraerts et al., 2016; Kałka et al., 2013; Kilinc et al., 2018; Palm et al., 2019; Pastore et al., 2012; Yüksela et al., 2015).

Duration and coverage periods of the studies

The study duration ranged from 10 to 34 months and follow-up period ranged from 6 weeks to 15 months. The studies were carried out from June 2000 to October 2019, while the articles were published between November 2004 and November 2020.

Type of male sexual dysfunction treated and the study design

Out of the thirteen included trials, ten trials focused on erectile dysfunction (Begot et al., 2015; Carboni et al., 2018; Dorey et al., 2004; Kałka et al., 2013; Lamina et al., 2009; Lin et al., 2012; Palm et al., 2019; Prota et al., 2012; Rislanu et al., 2020; Yüksela et al., 2015), one study focused on erectile dysfunction with climacturia (Geraerts et al., 2016) while the other two focused on premature ejaculation (Kilinc et al., 2018; Pastore et al., 2012). The selected studies included three cross-over studies (Dorey et al., 2004; Geraerts et al., 2016; Lin et al., 2012), one sham-controlled study (Kilinc et al., 2018), one parallel study (Rislanu et al., 2020) and one independent group design (Lamina et al., 2009). The rest were described by the authors as simply randomized controlled trials. A summary of the participants and study characteristics is given in Table 2.

Table 2.

Participants and Study Characteristics.

Authors	Diagnosis	Age (years)	Interv.	Cont.	PEDro score	Study design
Begot et al. (2015)	ED	40–70	41	15	8/10	RCT
Carboni et al. (2018)	ED	40–65	11	11	9/10	RCT
Dorey et al. (2004)	ED	22–72	28	27	6/10	RCT (crossover)
Geraerts et al. (2016)	ED, Climacturia	≥18	16	17	6/10	RCT (crossover)
Kałka et al. (2013)	ED	≥18	103	35	4/10	RCT
Kilinc et al. (2018)	PE	18–45	35	70 (double control)	5/10	RCT (sham control)
Lamina et al. (2009)	ED	50–70	25	25	6/10	RCT
Lin et al. (2012)	ED	52–79	41	31	7/10	RCT (crossover)
Palm et al. (2019)	ED	≥18	75	79	8/10	RCT
Pastore et al. (2012)	PE	19–51	19	21	5/10	RCT
Prota et al. (2012)	ED	≥18	26	26	4/10	RCT
Rislanu et al. (2020)	ED	25–65	15	15	8/10	RCT (parallel)
Yüksela et al. (2015)	ED	32–83	30	30	5/10	RCT

ED: erectile dysfunction; PE: premature ejaculation; RCT: randomized controlled trial; Intervention: number of participants in the intervention group; Control: number of participants in the control group.

Methodological quality assessment

There were variations in the methodological quality of the included trials with PEDro scores ranging from 4/10 to 9/10. The lower scores were attributed to a lack of blinding of the participants, therapists, and assessors, and inadequate allocation concealment in some studies (Table 3).

Table 3.

The Physiotherapy Evidence Database Score of Each of the Studies.

Authors	1	2	3	4	5	6	7	8	9	10	11
Begot et al. (2015)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	No
Carboni et al. (2018)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes
Dorey et al. (2004)	Yes	Yes	Yes	No	No	No	No	Yes	Yes	Yes	Yes
Geraerts et al. (2016)	Yes	Yes	No	No	No	No	Yes	Yes	Yes	Yes	Yes
Kałka et al. (2013)	No	Yes	No	No	No	No	No	Yes	Yes	No	Yes
Kilinc et al. (2018)	Yes	Yes	No	No	No	No	No	Yes	Yes	Yes	Yes
Lamina et al. (2009)	Yes	Yes	No	Yes	No	No	No	Yes	Yes	Yes	Yes
Lin et al. (2012)	Yes	Yes	Yes	Yes	No	No	No	Yes	Yes	Yes	Yes
Palm et al. (2019)	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes
Pastore et al. (2012)	Yes	Yes	No	Yes	No	No	No	No	Yes	Yes	Yes
Prota et al. (2012)	Yes	Yes	No	Yes	No	No	No	No	No	Yes	Yes
Rislanu et al. (2020)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	No	Yes
Yüksela et al. (2015)	Yes	Yes	No	No	No	No	No	Yes	Yes	Yes	Yes

1 = Eligibility criteria specified; 2 = random allocation of subjects; 3 = allocation was concealed; 4 = group similarity; 5 = blinding of subjects; 6 = blinding of therapists; 7 = blinding of assessors; 8 = outcome obtained; 9 = treatment given; 10 = between group comparisons; 11 = point measures and measures of variability.

Outcome measures for assessment of erectile function

Sociodemographic and clinical characteristics of the participants in the studies

A total of 912 participants were randomized from the 13 included studies: 472 to the intervention group and 440 to the control group. Seventy-nine participants dropped out during the studies and were excluded from statistical analysis. The age of participants ranged from 19 to 83 years. The underlying causes for participants identifying as having erectile dysfunction included radical prostatectomy, myocardial infarction, hypertension, ischemic heart disease, venous occlusion, arterial insufficiency, and psychogenic causes. Participants with premature ejaculation were identified as having lifelong premature ejaculation. The severity of erectile dysfunction in all the studies was mild to severe. Erectile dysfunction had lasted between 6 and 360 months in most participants in the studies.

Erectile dysfunction

All 11 studies utilized the gold standard International Index of Erectile Function (IIEF) or the abridged 5-item version of the International Index of Erectile Function (IIEF-5) as the primary outcome. Other measures of sexual function included Manometric measurements and digital anal pressure measurements (Dorey et al., 2004), Erectile function was assessed at baseline and at the follow-up period which ranged from 6 weeks to 15 months. Erectile dysfunction was taken as a score of ≤20IIEF ≤ 25.

Premature ejaculation

The two trials that investigated premature ejaculation used the intravaginal ejaculatory latency time (IELT) as an outcome. The premature ejaculation diagnostic tool (PEDT) was also reported in one trial (Kilinc et al., 2018). One study lasted for 30 days, while the other was done over a 12-week period. Both studies did not report any follow-up period. Premature ejaculation was taken as IELT ≤60 s.

Physiotherapy interventions

Out of the 11 clinical trials erectile dysfunction, one study compared with placebo (Carboni et al., 2018) while one other study compared electrical stimulation to physical activity (Rislanu et al., 2020). The remaining nine studies compared the interventions to usual care. The two clinical trials on premature ejaculation compared the intervention to pharmacological intervention from prescribed dapoxetine [a selective serotonin reuptake inhibitor (SSRI)]. Three studies reported that the interventions were supervised by a physiotherapist (Geraerts et al., 2016; Prota et al., 2012; Yüksela et al., 2015). while the others did not specify who supervised the interventions. The frequency of physiotherapist supervision of interventions ranged from 9 to 20 sessions, with intervention lengths ranging from between 6 and 12 weeks. Interventions used in the studies include pelvic floor exercises (with or without biofeedback), electrical stimulation, aerobic exercises (walking, moderate running, bicycle ergometer, treadmill), and resistance training.

Determinants of the protocol of choice

The studies did not give details of the factors that informed the choice of intervention in each study. The following were however identified as some of the reasons the trials were carried out. Scarcity of studies on the use of the intervention of choice in male sexual dysfunction (Begot et al., 2015; Kilinc et al., 2018; Rislanu et al., 2020). No previous randomized controlled trial using the intervention of choice (Dorey et al., 2004; Geraerts et al., 2016). Exploring the effectiveness of the intervention in erectile dysfunction after it has been used in another related condition (Prota et al., 2012). To determine how the intervention of choice may influence the association between the two variables being investigated (Kałka et al., 2013; Lamina et al., 2009).

Effectiveness of interventions

Two trials used pelvic floor muscle exercises alone (Lin et al., 2012 and Prota et al., 2012); one used pelvic floor muscle exercise, electrical stimulation, and biofeedback (Geraerts et al., 2016), and one used pelvic floor muscle exercise and biofeedback (Dorey et al., 2004). One study used electrical stimulation alone (Carboni et al., 2018), and one used pelvic floor muscle exercise and physical activity (Palm et al., 2019). Four trials used physical activity alone (Begot et al., 2015; Kałka et al., 2013; Lamina et al., 2009; Yüksela et al., 2015), and one compared electrical stimulation to aerobic activity (Rislanu et al., 2020).

The intensity of pelvic floor muscle contractions was similar throughout the studies. Three 10-s maximal contractions were used, followed by 10-s relaxations, twice or thrice daily in three different positions (sitting, lying, and standing). Pelvic floor muscle exercises were also incorporated into daily activities and carried out as home exercise programme.

The current type and parameters used for electrical stimulation differed. One study applied functional electrical stimulation with a frequency of 50 Hz and pulse width of 500 µs, 15 min, twice weekly for 4 weeks (Carboni et al., 2018). The other study applied electrical stimulation with a frequency of 5 Hz and 150 μs pulse width, 30 min each, twice weekly for 6 weeks (Rislanu et al., 2020). The duration of physical activity ranged from 30 to 75 min, carried out between two to five times a week (Table 4).

Table 4.

Efficacy of Physiotherapy Interventions in Male Sexual Dysfunctions.

Study	Intervention	Intensity	Results	Conclusion
Begot et al. (2015)	Home-based walking programme	4 days a week for 1 month	71% Decrease in ED in the walking group	Better improvement in sexual function
Carboni et al. (2018)	Functional electrical stimulation	15 min, twice a week for 4 weeks	Increase in IIEF scores in IG	FES for ED is feasible and beneficial
Dorey et al. (2004)	PFME + BFB + HEP	Three 10 s maximal contractions, twice daily in 3 positions	40% Of participants regained normal function	PFMEs are effective for some men with ED
Geraerts et al. (2016)	PFME + ES	10 min for ES, PFME once a week for 6 weeks, alternate weekly for another 6 weeks	6 Out of 14 in the IG became potent	PFME improved ED and climacturia
Kałka et al. (2013)	Cycle ergometer, resistance training, indoor and outdoor exercises	45 min per session, 5 days a week for 6 months.	Better erection quality with higher exercise tolerance	Exercise training has a positive effect on erection quality
Kilinc et al. (2018)	Running and walking	30 min daily for 30 days	Improved IELT scores	Moderate PA had similar effects with dapoxetine
Lamina et al. (2009)	Aerobic exercise (bicycle ergometer)	45–60 min, thrice weekly for 8 weeks	11.50 ± 5.30 vs. 15.14 ± 4.92 pre and post in IG	Aerobic exercise has a significant effect on ED
Lin et al. (2012)	PFME + HEP	Three 10 s contractions twice daily in 3 positions	t = 2.30, p = 0.28 at 6 months. t = 2.59, p = 0.14 at 12 months	PFME is effective in post prostatectomy patients
Palm et al. (2019)	Aerobic exercises and PFME s	60 min, 3 sessions a week for 12 weeks	Mean difference in IIEF scores from p < 0.0003 to p < 0.0002	Sexual rehab has a beneficial effect on erectile function
Pastore et al. (2012)	Physiokinesitherapy + BFB + ES	Three 60 min sessions weekly for 12 weeks	51% of IG improved IELT	PFME is effective for premature ejaculation
Prota et al. (2012)	PFME + HEP	Once weekly 30 min sessions for 12 weeks	47.1% potency rate in the treatment group	Early PFME has a significant impact on EF
Rislanu et al. (2020)	Electrical stimulation	30 min, 2 sessions weekly for 6 weeks	11.17 ± 1.72 vs. 20.83 ± 1.83 (p < 0.05)	ES is superior to AE in ED management
Yüksela et al. (2015)	Aerobic exercises	75 min/day, 3 days a week for 6 weeks	SSD in post treatment IIEF scores	PA induces increase in penile oxygenation

BFB: biofeedback; PFME: pelvic floor muscle exercises; ED: erectile dysfunction; EF: erectile function; FES: functional electrical stimulation; ES: electrical stimulation; HEP: home exercise programme; IELT: intravaginal ejaculatory latency time.

Pelvic floor muscle exercises

The study by Lin et al. (2012) reports severe male sexual dysfunction in the participants at the beginning of the study, with a significant difference in the experimental and control group at 6 months (t = 2.30, p = .28) and 12 months (t = 2.59, p = .14). The sexual function of the intervention group was better than the control group at 6 and 12 months compared to baseline. The baseline mean and standard deviation for the intervention group was 5.06 (0.24), at 6 months was 6.34 (3.46) and at 12 months 8.14 (4.86). For the control group, baseline mean, and standard deviation was 5.00 (0.00), 5.00(0.00) at 6 months, and 5.96 (0.98) at 12 months. Prota et al. (2012) report that at 12 months post-operation, 47.1% (8 out of 17) participants in the treatment group were potent compared to 12.5% (2 out of 16) participants in the control group.

Pelvic floor muscle exercises and physical activity

In the study by Palm et al. (2019), there was a significant improvement in erectile function, orgasmic function, sexual desire, and satisfaction following sexual rehabilitation (pelvic floor muscle exercises and aerobic exercises). There was a mean difference in IIEF scores of 6.7, 95% CI, 3.1–10.4 (p < .0003) at 4 months, and at 6 months, it was 6.7, 95% CI, 3.2–10.1 (p < .0002).

Electrical stimulation

Carboni et al. (2018) report a statistically significant difference in erectile function in the intervention and control group pre and post-treatment following the application of functional electrical stimulation (p < .05).

Electrical stimulation and physical activity

Rislanu et al. (2020) reported that the post-intervention analysis showed that group A, which was the electrical stimulation group had a better treatment effect compared to group B which was the aerobic exercises group. Pre and post-intervention scores for both groups were 11.17 ± 1.72 vs. 20.83 ± 1.83 and 10.67 ± 1.63 vs. 14.33 ± 2.07 for the electrical stimulation and aerobic exercises group, respectively.

Physical activity on erectile dysfunction

In the study by Begot et al. (2015), there was 84% erectile dysfunction for the overall cohort at discharge. Results after 20 days of intervention however showed a 9% increase in erectile dysfunction in the control group (84–93%) while there was a significant 71% reduction (84–13%) in the physical activity (walking) group. Lamina et al. (2009) reported a significant effect of exercise on erectile dysfunction with differences in the pre and post-intervention IIEF scores of both groups. The exercise group had 11.50 ± 5.30 vs. 15.14 ± 4.92 while the control group had 8.10 ± 4.02 vs. 8.95 ± 3.90. Kałka et al. (2013) reported better erection quality with higher exercise tolerance in the intervention group. Yüksela et al. (2015) reported a statistically significant increase in post-treatment IIEF-5 scores.

Physical activity and pelvic floor muscle exercises on premature ejaculation

Two clinical trials were found to have assessed premature ejaculation. One of the studies used pelvic floor exercises—described as physio-kinesitherapy, biofeedback, and electrical stimulation, while the other incorporated physical activities alone as the intervention. The parameters for the electrical stimulation were not stated but the entire intervention was three 60-min sessions weekly, for 12 weeks. The physical activity group entailed moderate running for one group and walking for another, at least 30 min daily, 5 days a week for 30 days. Kilinc et al. (2018) reported a statistically significant difference in IELT scores compared to the baseline for each group on the 10th, 20th, and 30th day. The PEDT scores on day 30 was significantly smaller than the baseline scores in the intervention and control group. Pastore et al. (2012) reported that at the end of 12 weeks of PFM rehabilitation, 11 0f 19 patients (51%) were able to control the ejaculation reflex, optimizing latency time to ejaculation from the start of intravaginal intercourse. Five patients did not respond to treatment, and two improved after the first 20 sessions and opted to drop out of the study. The results of 11 who responded were maintained throughout the follow-up time of 3 months after the end of 12 weeks of treatment.

Factors associated with outcomes of interventions

Correlation and association of the interventions with outcomes were reported in three of the studies. Begot et al. (2015) showed a significant negative correlation was observed between 6-min walk distance and ED 30 days after hospital discharge (r = −.71, p < .01). Lamina et al. (2009) found that there was a significant negative correlation between changes in C-reactive protein and IIEF scores (r = −.588). Kałka et al. (2013) also reported that the cardiac rehabilitation cycle was associated with a relative increase in exercise tolerance by 29.64% and in erection quality by 15.01%. Initial erection quality showed a significant association with age and initial exercise tolerance. Change in erection quality was significantly associated only with age and initial exercise tolerance.

Discussion

This study aims to synthesize the efficacy of physiotherapy in the management of male sexual dysfunction through a systematic review to enhance clinical reasoning and decision-making. It is obvious that the most common noninvasive and non-pharmacological approach used by physiotherapists is pelvic floor muscle exercises with or without therapeutic adjuncts, such as biofeedback, electrical stimulation, and physical activity for the management of erectile dysfunction and premature ejaculation. This may have been promised on the fact that the major cause of male sexual dysfunction in male individuals is weak pelvic floor muscles. Previous studies have opined that reduction in the tone of the pelvic floor muscles and inadequacies in contractile properties are directly linked to erectile strength and the ejaculatory process (Cohen et al., 2016). So also atrophy of the ischiocarvenosus muscles has been fingered as the principal contributor to erectile dysfunction (Kannan et al., 2019). Hence, strengthening of the pelvic floor muscle may not serve as antidote to erectile dysfunction and premature ejaculation, the involvement of apparently healthy individuals in these exercises may serve as a preventive measure to male sexual dysfunction.

The fact that the various interventions of choice were effective in the management of male sexual dysfunctions shows that physiotherapy provides a treatment of choice for male sexual dysfunction. The good thing about this is that these approaches do not have any complications as compared to what is obtainable with either pharmacological or surgical approaches. Exercises can be taught and be self-administered. It can also be administered through tele-medicine/physiotherapy. Hence, many patients can be treated even remotely. This provides a treatment of choice that can be administered in a less sophisticated environments. Although there was significant heterogeneity, such as study design, reporting methods, and treatment protocols in the trials and varied with respect to physiotherapist supervision, follow-up period, intervention frequency, intensity, and number of sessions which call for caution in the generalization of the results the homogeneity in the report of the efficacies of the approaches is of clinical significance at it have provided an effective treatment of choice with little or no adverse effect when administered as prescribed.

The findings that pelvic floor muscle exercises as a primary intervention significantly improved erectile dysfunction show that pelvic floor exercises alone are a good treatment of choice for adequate results. Hence, physiotherapists should integrate all male clients into pelvic floor muscle exercises and should also be taught for preventive measures. This discovery will reduce time spent in the clinic for the management of this condition as patients will need to visit the clinic less often when they have mastered the exercises. It is very intriguing to note that the improvement achieved persisted in participants even up to a follow-up period of 12 months. This shows the good carry-over effect of the approach and that is the last longing.

The results that pelvic floor muscle exercises are effective and had a significant impact on the recovery of sexual function following radical prostatectomy show that the protocol can also be extended to those who have had surgical interventions for fast and comprehensive recovery of sexual functions. This does not undermine the opinion that there is uncertainty if men who have had a radical prostatectomy will benefit from pelvic floor muscles exercises because of the nerve injuries that may have accoupling such a surgical intervention (Dorey et al., 2009). This debate should be a subject for further research. Hence, surgeons should be cautious during radical prostatectomy to limit the possibility of nerve injury. Both types of fibers are recruited during maximum contraction of the pelvic floor muscles. This maximum voluntary effort results in the hypertrophy of muscles and an increase in their local blood supply. A combination of maximal (short) and submaximal (long) contractions allows for targeted recruitment of the differing skeletal muscle fibers of the pelvic floor (Hall et al., 2018). This in turn allows for the sustained tone required for an erection, as well as the short powerful contractions and reflexive responses necessary for ejaculation (Cohen et al., 2016).

Dorey et al. (2004) had a similar conclusion to Van Kampen and Geraerts (2015). Participants in their studies had ED of various etiology. The best results were however achieved in the group of participants with ED due to venous-occlusive dysfunction. In the Van Kampen and Geraerts (2015) study, 15 out of 20 participants with ED caused by venous-occlusive dysfunction reported a return of penile erection to allow satisfactory sexual intercourse. A physiologic explanation for the improvement of erectile dysfunction is a decrease in the venous outflow. Contractions of the ischiocavernosus and bulbocavernosus muscles produce an increase in the intracavernous pressure and influence penile rigidity. The bulbocavernosus muscle compresses the deep dorsal vein of the penis to prevent the outflow of blood from an engorged penis.

The study by Pastore et al. (2012) reported a 51% improvement in the pelvic floor rehabilitation group at the end of a 12-weeks intervention period. This was evidenced by an ability to control the ejaculation reflex, optimizing latency time to ejaculation from the start of intravaginal intercourse. They compared pelvic floor exercises with on demand dapoxetine which is a selective serotonin reuptake inhibitor. Post-intervention IELT was also significant in the trial of Kalka et al. (2015). Comparing pelvic floor muscle exercises and Setraline alone and as a combination, they reported that with pelvic floor exercise alone, the IELT improvement was significantly higher than that of sertraline alone. However, the amount of statistical, objective, and subjective improvement was significantly higher with sertraline on demand therapy plus pelvic floor exercises, than with either of the treatment as a monotherapy. The improvement in IELT made in the Pastore et al. (2012) study persisted by the 3 months follow-up time. They however did not have a dapoxetine plus pelvic floor exercise group for comparison of treatment effect.

Carboni et al. (2018) and Rislanu et al. (2020) evaluated electrical stimulation for the treatment of ED, with Rislanu et al. (2020) comparing it with aerobic exercise. Carboni et al. (2018) reported a statistically significant difference in erectile function in the intervention group, compared to the control group, post-intervention. Rislanu et al. (2020) reported that the electrical stimulation group had a higher mean IIEF score post-intervention compared to the aerobic exercise group. It was thus suggested that electrical stimulation was more superior to aerobic exercises in ED management. Also, functional electrical stimulation for ED is feasible and has some beneficial effects on erectile capacity. A limitation of both studies, however, is the small number of participants. A similar finding to both studies on the effect of electrical stimulation on erectile function has been reported by Kayigil et al. (2007). In their study, transanal pelvic plexus stimulation caused an erection in 57% of the participants.

Electron microscopy studies have shown that ED is often caused by cavernous smooth-muscle degeneration (Hatzimouratidis et al., 2010; Jiang et al., 2009). Upon sexual stimulation, penile erection, occurring in response to the activation of pro-erectile autonomic pathways, is greatly dependent on the adequate inflow of blood to the erectile tissue and requires coordinated arterial endothelium-dependent vasodilatation and sinusoidal endothelium-dependent cavernosal smooth muscle relaxation. Nitric oxide is the principal peripheral pro-erectile neurotransmitter, released both by parasympathetic-nitrergic autonomic nerves and by the sinusoidal endothelium to produce cyclic GMP (cGMP) and relax cavernosal smooth muscle, ultimately resulting in increased intracavernosal pressure

A 2019 study by Limanjaya et al., demonstrated the ability of electrical stimulation to restore erectile function after cavernosal nerve injury by inducing nerve regeneration through pericytes. Pericytes are bionanoparticle that are distributed in the erectile tissue and play important roles in the regulation of penile erection, including promoting angiogenesis and neurogenesis through interacting with endothelial cells. The increased penile strength and the resulting gain in muscular mass will improve the venous occlusion mechanism leading to the required filling of corpus cavernosal bodies with blood (Shafik, 2000; Sturny et al., 2019).

The studies by Begot et al. (2015), Kałka et al. (2013), Lamina et al. (2009), and Yüksela et al. (2015) investigated physical activity as an intervention in ED. The ED in these studies was of cardiovascular etiology (Acute myocardial infarction, hypertension, and ischemic heart disease). Kilinc et al. (2018) investigated physical activity as a therapy option for PE. Compared with the on-demand dapoxetine group, there was a similar effectiveness of the moderate physical activity. There was no long-term follow-up, so there’s no certainty on how long the effect of the intervention was maintained. All studies employed aerobic exercises and Kałka et al. (2013) added resistance training. There was a wide variation in the dose of physical activity and training periods. Sessions ranged from 30 to 75 min and were carried out between 3 and 5 days a week, that is, 150–300 min per week. The intensity of the exercises was minimal to moderate intensity. The training period ranged from 30 days to 6 months. All the studies reported an improvement in erectile function with a marked 71% improvement in the Begot et al. (2015) study. Kilinc et al. (2018) also reported a statistically significant difference in IELT scores in the intervention group and the difference was observed by the 30th day of the intervention.

This is in line with the findings in the systematic review and meta-analysis of Silva et al. (2017). They reported that physical activity and exercise improved erectile dysfunction symptoms, evidenced by a 3.85-point increase in the erectile function parameter of the IIEF questionnaire.

Their subgroup analyses also suggested that any physical activity and exercise modality is beneficial in patients with increased cardiovascular risk alone, coronary heart disease, or radical prostatectomy. Also, both short-term and long-term interventions, whether used alone or with usual care, were associated with a beneficial effect.

In the review by Hehemann and Kashanian (2016), the American Heart Association (AHA) and American College of Cardiology (ACC) Task Force published Grade B recommendations for physical activity for the reduction of hypertension, which can be suggested as guidelines for men with ED. They recommend 3–4 sessions of moderate to vigorous intensity physical activity lasting 40 min per session corresponding to 160 min a week. The range of intensity of physical activity by the studies included in this review fall within this recommendation of the AHA and ACC.

Khoo et al. (2013) indicated that weekly exercise of 200–300 min of moderate-intensity training results in a much greater improvement of IIEF score in obese men than 90–150 min of weekly training. However, because their study group included obese men, they didn’t know if their findings would be applicable to normal-weight men with arterial ED. The study of Yüksela et al. (2015), scheduled 30 participants for 6 weeks of vigorous aerobic exercise program to be carried out for 75 min a day, 3 days a week (a total of 225 min per week). This led to a statistically significant increase in post-treatment IIEF scores.

One of the debates on physical activity is related to its duration, with uncertainties relating to the duration and dosage of exercise. Various studies have indicated that based on the body weight, an individual performing an aerobic activity of moderate intensity lasting for 150 min or vigorous activity of 75 min a week will spend 800–1200 kcal (3349–5023 kJ) which might be sufficient for an adequate endothelial function (O'Donovan et al., 2010). Yüksela et al. (2015) concluded that physical activity induces increases in both pelvic blood supply and penile oxygenation (improvement in endothelial function), and exercise capacity achieved secondary to weight loss. These all have favorable effects on the maintenance and recovery of penile erectile function. The small number of participants in their study is however a limitation to extrapolate the effect of this study as suggested by Khoo et al. (2013).

According to the World Health Organization, healthy adults should exercise for at least 150 min of moderate-intensity aerobic physical activity or 75 min of vigorous-intensity physical activity per week. This constitutes slightly lower levels of physical activity than needed to decrease ED according to the results of this review. The recommendations by the World Health Organization (WHO) to gain additional health effects are to increase the intensity and number of weekly minutes. Thus, by following the general advice regarding physical activity, ED should be decreased (Hehemann & Kashanian, 2016).

Kałka et al. (2013) used a combination of aerobic exercise and resistance training (cardiac rehabilitation) which yielded a positive effect on exercise tolerance and erection quality. A possible physiological basis for this could be an improvement in the testosterone concentration in the body since testosterone levels have been reported to rise after resistance training (Hooper et al., 2017).

The physiological basis of the therapeutic effect of aerobic exercise on ED could be attributed to both immediate and long-term changes in the blood vessel walls (Lamina et al., 2011). The repetitive physical activity-induced increased blood flow and vascular shear stress lead to substantial remodeling of the vascular system (Hawley et al., 2014). This adaptive response alters the endothelium by increasing the expression of nitric oxide synthase mRNA; resulting in increased synthesis of nitric oxide and improved endothelial function (Rislanu et al., 2020).

Geraerts et al. (2016) investigated a combination of pelvic floor muscle exercises and electrical stimulation with biofeedback in their study. Palm et al. (2019) on the other hand combined pelvic floor muscle exercises and physical activity (sexual rehabilitation). Both studies reported that the intervention group scored significantly better in their IIEF scores, compared to the controls (Van Kampen & Geraerts, 2015). Palm et al. (2019) applied a similar protocol to Geraerts et al. (2016) as both studies used a symmetric biphasic low-frequency current was applied. The pulse frequency was 50 Hz for both studies, but the pulse duration was 200 μs, 15 min, and 600 μs for 10 min, respectively. Electrical stimulation was added to improve awareness of the muscles of the pelvic region and to assist the patient in contracting the ischiocavernous and bulbocavernous muscles. The participant’s performance was further enhanced using electromyographic biofeedback to visualize and quantify the muscle contractions.

Pastore et al. (2012) combined pelvic floor muscle exercises and electrical stimulation. The effect may have been beneficial because the addition of electrical stimulation may increase the rate, intensity, and synchronization of motor unit firing (Myers & Smith, 2019). Thus, through additional motor unit recruitment and altered frequency of firing, corrected patterns of contraction of the bulbocavernosus muscle can occur, allowing greater conscious control of the ejaculatory process (Siegel, 2014; Yoshida et al., 2019).

Conclusion

Physiotherapy is an effective non-pharmacological and noninvasive intervention in the treatment of erectile male dysfunction and premature ejaculation. Pelvic floor muscle exercises (with or without biofeedback), electrical stimulation, and physical activity are currently in use as non-pharmacological interventions for erectile dysfunction and premature ejaculation. These interventions have been shown to be effective either as a standalone therapy or as a combination therapy. An erectile dysfunction of various etiology has been shown to benefit from these approaches, though the interventions seemed to have greater effects on erectile dysfunction of vascular origin. However, due to the wide variability of protocol, it is difficult to draw informed conclusions about the efficacy of individual protocols and the exact protocol and dosage of the protocol that is required to achieve the best results. The level of an individual’s physical activity and fitness level has been shown to influence the erectile function and biomarkers of systemic vascular inflammation, leading to improvement in endothelial function. Physiotherapy interventions could thus be proposed as the first line of treatment for patients with male sexual dysfunctions seeking alternate options to medications.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.