Journal of Andrology, Vol. 33, No.

2, March/April 2012
Copyright E American Society of Andrology

Physical Activity and Erectile Minireview

Dysfunction in Middle-Aged Men
SANDRO LA VIGNERA, ROSITA CONDORELLI, ENZO VICARI, ROSARIO D’AGATA, AND
ALDO E. CALOGERO
From the Section of Endocrinology, Andrology, and Internal Medicine and Master in Andrological, Human
Reproduction, and Biotechnology Sciences, Department of Internal Medicine and Systemic Diseases, University of
Catania, Catania, Italy.

ABSTRACT: The prevalence of erectile dysfunction is high in men ment in vascular function (eg, increased endothelial function). This
of all ages and increases greatly in the elderly. In particular, severity brief review shows the main clinical evidence of benefits induced by
and prevalence both increase with aging. Because erectile dysfunction physical activity on erectile and endothelial dysfunction. The literature
is a symptom, physicians should diagnose underlying pathologies that shows that erectile dysfunction in middle-aged men is often an early
might lead to it instead of focusing only on finding a viable treatment. event in endothelial damage, and physical activity is able to improve
Physical inactivity negatively impacts on erectile function; experimen- both erectile and endothelial dysfunction. There are conflicting data
tal and clinical exercise interventions have been shown to improve regarding the effects of exercise on androgen status. In clinical
sexual responses and overall cardiovascular health. Several studies practice it would be recommended to add regular physical activity to
have confirmed that combining 2 interventions (Mediterranean diet balanced diet and drugs to achieve better therapeutic results.
and physical activity) provides additional benefit to erectile function, Key words: Endothelial dysfunction, endothelial microparticles,
likely via reduced metabolic disturbances (eg, inflammatory markers, endothelial progenitor cells.
insulin resistance), decreased visceral adipose tissue, and improve- J Androl 2012;33:154–161

E rectile dysfunction (ED) is experienced at least

some of the time by most men who have reached
45 years of age, and it is projected to affect 322 million
for achieving or maintaining erection. Alterations in
penile vessels can be observed in the elderly, and in
particular, lack of androgens might lead to a reduction
men worldwide by 2025; its prevalence is high in of smooth muscle cell content in the penis and an
men of all ages and increases greatly in the elderly increase in the caliber of vascular spaces (Galiano
(Seftel, 2003). ED’s severity and prevalence both et al, 2010).
increase with aging; because ED is a symptom, physi- About 60% of the elderly population express an
cians should diagnose underlying pathologies that interest in maintaining sexual activity. Although
might lead to it instead of focusing only on finding a aging and functional decline may affect sexual
viable treatment. function, when sexual dysfunction is diagnosed,
Cardiovascular alterations occur in the elderly, and physicians should rule out disease or side effects of
might lead to ED because of penile blood flow medications. Common disorders related to sexual
impairment; diabetes, smoking, and sedentary life- dysfunction include cardiovascular disease, diabetes,
style, being risk factors for vascular pathologies, can lower urinary tract symptoms, and depression. Early
affect erectile function. Metabolic syndrome and control of cardiovascular risk factors may improve
psychological factors are highly prevalent in aging endothelial function and reduce the occurrence of ED.
men, and might be other important determinants of Treating those disorders or modifying lifestyle-related
ED. Drugs play a role in the pathogenesis of ED, as risk factors (eg, obesity) may help prevent sexual
they can alter hormonal or vascular mechanics needed dysfunction in the elderly (Camacho and Reyes-Ortiz,
2005).
Correspondence to: Dr Sandro La Vignera, Section of Endocrinol- Physical inactivity negatively impacts erectile func-
ogy, Andrology, and Internal Medicine, Department of Internal tion, and experimental and clinical exercise interven-
Medicine and Systemic Diseases, Catania University, Policlinico ‘‘G. tions have been shown to improve sexual responses
Rodolico’’, S Sofia 78th St, Bldg 4, Rm 2C82, 95123 Catania, Italy and overall cardiovascular health. Mediterranean-style
(e-mail: [email protected]).
Received for publication March 14, 2011; accepted for publication
diets and a reduction in caloric intake have been found
May 13, 2011. to improve erectile function in men with aspects of
DOI: 10.2164/jandrol.111.013649 the metabolic syndrome. In addition, several studies

154
La Vignera et al N Physical Activity and ED in Middle-Aged Men 155

have confirmed that combining the 2 interven- intervention group than in the control group. The mean
tions provides additional benefit to erectile function, International Index of Erectile Function (IIEF) score
likely via reduced metabolic disturbances (eg, inflam- improved in the intervention group, but remained stable
matory markers, insulin resistance), decreased visceral in the control group. Seventeen men in the intervention
adipose tissue, and improvement in vascular function group and 3 in the control group reported an IIEF score
(eg, increased endothelial function) (Hannan et al, of 22 or higher. In multivariate analyses, changes in
2009). BMI, PhA, and C-reactive protein were independently
There is now a wealth of sophisticated epidemiolog- associated with changes in IIEF score (Esposito et al,
ical evidence to demonstrate that physical activity 2004).
(PhA) is associated with reduced risk of coronary heart BMI and PhA independently and differentially
disease, obesity, type 2 diabetes, and other chronic affected ED risk. BMI had greatest influence with low
diseases and conditions. Causal relationships between PhA, and PhA exerted greatest influence when BMI was
PhA and cardiovascular disease, type 2 diabetes, colon high.
cancer, and all-cause mortality have been recognized In a population-representative cross-sectional analytic
for some time. More recently, the pertinent issue has study of ED in Hong Kong on 1506 subjects (26–
been the dose-response relationship between PhA 70 years), with 2-stage stratified random sampling, and
and health: What is the minimum dose of activity face-to-face interviews conducted by trained interview-
associated with health and well-being? What doses of ers with structured questionnaires, it was shown that
activity offer greater health benefits? (O’Donovan age, PhA, and general psychological distress were
et al, 2010). independently associated with ED after multivariate
A multidisciplinary approach might be relevant for adjustments. A relationship between BMI and ED was
the treatment of ED; in this context, an adequate observed only among men with no exercise (,1 time/
program of PhA, especially when there are cardiovas- wk), using BMI 21.0–21.9 as reference, adjusted for age
cular risk factors, could be very important. To this end, and smoking status. Being physically active ($1000 kcal/
this review summarizes the major findings of the wk) reduced the risk of ED only in men who were obese,
literature about a direct impact of the PhA on the adjusted for age, smoking status, and BMI (Cheng and
Ng, 2007).
quality of erection and 2 of the main factors involved in
In an evaluation of 3941 adult men (age $20 years),
ED: endothelial dysfunction and androgen status.
logistic regression analyses were used to examine the
Another aim is to stimulate the reader to standardize
relative odds of ED association with categories of BMI,
effective and reproducible protocols of PhA for clinical
waist circumference (WC), and PhA. PhA level was
practice in this area, to combine with drugs and/or
divided into active ($150 min/wk), moderately active
psychological treatment.
(30–149 min/wk), and inactive (,30 min/wk) categories.
PhA and ED Moderately active or inactive men had an approximately
40%–60% greater odds of ED compared with active
PhA has proven to be a protective factor for men. When all 3 predictors (WC, BMI, and PhA level)
normal erectile function in numerous epidemiological were entered into the same logistic regression model,
studies. both a high WC and low PhA level (moderately active
In a recent study conducted from October 2000 to and inactive) were independently associated with greater
October 2003 at a university hospital in Italy, 55 men odds of ED, whereas BMI level was not. Moderate-
randomly assigned to the intervention group received intensity PhA ($150 min/wk) is associated with the
detailed advice about how to achieve a loss of 10% or maintenance of proper erectile function, regardless of
more in their total body weight by reducing caloric BMI level (Janiszewski et al, 2009).
intake and increasing their level of PhA. Men in the In another study by Esposito et al (2009), a total of
control group (n 5 55) were given general information 209 subjects were randomly assigned to 1 of the 2
about healthy food choices and exercise. Measures treatment groups. The 104 men randomly assigned to
included erectile function score; levels of cholesterol the intervention program received detailed advice about
and triglycerides; circulating levels of interleukin 6, how to reduce body weight, improve quality of diet, and
interleukin 8, and C-reactive protein; and endothelial increase PhA. The 105 subjects in the control group
function as assessed by vascular responses to L-arginine. were given general information about healthy food
After 2 years, body mass index (BMI) decreased more in choices and general guidance on increasing their level of
the intervention group than in the control group, as did PhA. Erectile function score improved in the interven-
serum concentrations of interleukin 6, and C-reactive tion group. At baseline, 35 subjects in the intervention
protein. The mean level of PhA increased more in the group and 38 subjects in the control group had normal
156 Journal of Andrology N March ÙApril 2012

erectile function (34% and 36%, respectively). After explain the positive effect of exercise on disease
2 years, these figures were 58 subjects in the intervention progression. They include the decrease in cytokine
group and 40 subjects in the control group, respectively production by the adipose tissue, skeletal muscles,
(56% and 38%). There was a strong correlation between endothelial cells, and blood mononuclear cells, as well
the success score and restoration of erectile function. as the increase in the bioavailability of NO, antioxidant
A recent study on 674 men aged 45–60 years that defenses, and regenerative capacity of endothelium
included a urological physical examination, medical (Ribeiro et al, 2010).
history, and assessment of testosterone (T) and sex Regular exercise training augments the number of
hormone–binding globulin (SHBG) showed a positive EPCs in patients with cardiovascular risk factors and
correlation between the IIEF-5 and the Paffenbarger coronary artery disease and is associated with improved
score (PhA index). The IIEF-5 score increased with an vascular function and NO synthesis; in fact, in a recent
increasing Paffenbarger score up to a level of 4000 kcal/ study, 20 patients with documented coronary artery
wk. T revealed a trend to a significant impact on the disease and/or cardiovascular risk factors joined a 12-
IIEF-5 score, but showed no association with the week supervised running training. Circulating EPCs,
Paffenbarger score. The risk of severe ED was decreased defined by the surface markers CD34, kinase insert
by 82.9% for males with PhA of at least 3000 kcal/wk domain receptor (KDR), and CD133, were measured at
compared with males with PhA under 3000 kcal/wk baseline and after exercise training by flow cytometry,
(Kratzik et al, 2009). with a significant increase in circulating EPCs, which
Finally, in a recent study, a total of 60 patients was positively correlated with both the change of flow-
complaining of ED were evaluated. Patients were mediated dilation (FMD) and the increase of NO
assessed at baseline and after 3 months of study synthesis. Plasma vascular endothelial growth factor
treatment; in this study at baseline, patients were (VEGF) and erythropoietin did not change in response
randomized to receive phosphodiesterase type 5 inhib- to exercise. However, a positive correlation was
itor (PDE5i) alone (group A) or PDE5i plus regular observed between the number of EPCs and erythropoi-
($3 h/wk), aerobic, nonagonistic PhA (group B). All etin at baseline and after training (Steiner et al, 2005).
In another study, EPCs were quantified by flow
subjects completed the IIEF-15 questionnaire and were
cytometry and cell culture in 25 healthy volunteers
tested for total T (TT). Mean PhA was 3.4 h/wk in
undergoing 3 protocols of running exercise.
group B vs 0.43 in group A; mean energy expenditure in
Intensive running, defined as 30 minutes at 100% of
group B was 1868 kcal/wk or 22.8 metabolic equivalents
the velocity at the individual anaerobic threshold (IAT),
(MET)/wk. IIEF restoration of ED occurred in 77.8%
approximately 82% maximal oxygen consumption
(intervention group) vs 39.3% (control). The IIEF-15
(VO2max), as well as moderate running, with 30 minutes
score resulted in statistical improvement in the inter-
at 80% of the velocity at the IAT (approximately 68%
vention group in all domains but 1 (orgasm): erectile
VO2max), increased circulating EPC numbers to 235% 6
function 24.7 vs 26.8; confidence (question 15 on the
93% and 263% 6 106% of control levels, respectively
scale) 3.53 vs 4.07; sexual desire 6.46 vs 7.18; intercourse
(Laufs et al, 2005).
satisfaction 9.85 vs 11.25; total satisfaction 7.17 vs 8.07;
A maximal bout of exercise induced a significant shift
and total score 56.2 vs 61.07. TT was statistically similar
in CD34+ cells toward CD34+/KDR+ cells; this
in the 2 groups; separate analysis in each group showed response was larger in subjects with a less favorable
statistical increase in group B, 4.24 vs 4.55. At lipid profile.
multivariate logistic regression analysis, PhA was the In another study, healthy subjects (group 1, n 5 11;
only independent variable for normal erection, higher group 2, n 5 14) performed a symptom-limited
sexual satisfaction, and normal total IIEF-15 score cardiopulmonary exercise test on a bicycle ergometer.
(Maio et al, 2010). Numbers of CD34+/ KDR+ cells were determined by
flow cytometric analysis, either after magnetic separa-
PhA and Endothelial Dysfunction
tion of CD34+ cells (group 1) or starting from whole
Exercise training consistently improves nitric oxide blood (group 2).
(NO) bioavailability and the number of endothelial Serum concentrations of VEGF and NO metabolites
progenitor cells (EPC) and also diminishes the level of were measured by using enzyme-linked immunosorbent
inflammatory markers, namely proinflammatory cyto- assay (ELISA). Following exercise, EPCs increased by
kines and C-reactive protein. However, the mechanisms 76% (15.4 6 10.7 vs 27.2 6 13.7 cells/mL) in group 1
by which exercise improves endothelial function in and by 69% in group 2 (30.9 6 14.6 vs 52.5 6 42.6 cells/
coronary artery disease patients have not been fully mL). The increase in EPCs correlated positively with
clarified. Several mechanisms have been proposed to low-density lipoprotein and total cholesterol/high-den-
La Vignera et al N Physical Activity and ED in Middle-Aged Men 157

sity lipoprotein ratio and negatively with peak oxygen normalized 24 hours after finishing the test (Möbius-
consumption and oxygen consumption at anaerobic Winkler et al, 2009).
threshold. VEGF levels increased with exercise, with a In a recent study on healthy men subjected to 7 days
strong trend toward significance. NO levels remained of dry immersion (DI) the authors investigated endo-
unchanged (Van Craenenbroeck et al, 2008). thelial properties before, during, and after 7 days of DI
The results of another recent study suggest that involving 8 subjects. Microcirculatory functions were
finishing a marathon race will lead to an inflammatory assessed with laser Doppler in the skin of the calf, and
response and down-regulation of circulating hemato- basal blood flow and endothelium-dependent and
poietic stem cells. With respect to EPCs no change is independent vasodilation were studied.
observed, which may be because of a greater differen- Also, plasma levels of microparticles, a sign of cellular
tiation of the remaining CD34 cells towards EPCs. dysfunction, and soluble endothelial factors, reflecting
Sixty-eight healthy marathon runners (age 57 6 6 years) the endothelial state, were measured. Basal flow and
were included in this study. Blood cell counts were endothelium-dependent vasodilation were reduced by DI
evaluated by standard methods, and circulating progen- (22 6 4 vs 15 6 2 arbitrary units and 29% 6 6% vs 12% 6
itor cells before and immediately after the race were 6%, respectively), and this was accompanied by an
quantified by fluorescence-activated cell sorter. VEGF increase in circulating endothelial microparticles (EMP),
and epidermal growth factor (EGF) were quantified by which was significant on day 3 (42 6 8 vs 65 6 10 EMP/
ELISA. A marathon race led to a significant increase in mL), whereas microparticles from other cell origins
white blood cell count (5283 6 155 vs 13706 6 373 cells/ remained unchanged. Plasma soluble VEGF decreased
mL blood). significantly during DI, whereas VEGF receptor 1 and
Fluorescence-activated cell sorter analysis revealed a soluble CD62E were unchanged, indicating that the
significant decrease of CD34 cells (1829 6 115 vs 1175 6 increase in EMP was associated with a change in anti-
apoptotic tone rather than endothelial activation.
75 cells/mL blood), CD117 cells (2478 6 245 vs 2193 6
This study showed that extreme physical inactivity in
85 cells/mL blood), and CD133 cells (3505 6 286 vs
humans induced by 7 days of DI causes microvascular
2239 6 163 cells/mL blood). No significant change was
impairment with a disturbance of endothelial functions,
observed for EPCs, defined as CD34/VEGF-R2 cells
associated with a selective increase in EMP. Microcir-
(117 6 8 vs 128 6 9 cells/mL blood). With respect to
culatory endothelial dysfunction might contribute to
VEGF, a significant down-regulation was evident
cardiovascular deconditioning as well as to hypodyna-
directly after the race (48.9 6 8.0 vs 34.0 6 7.5 pg/
mia-associated pathologies (Navasiolava et al, 2010).
mL), whereas no change was obvious in EGF levels
Our recent study evaluated the effects of a standard
(Adams et al, 2008).
protocol of aerobic PhA on quality of ED in patients
Finally, higher habitual PhA level in patients with
with arterial ED. Fifty patients (48–62 years) were
coronary artery disease was associated with higher selected and underwent a standard protocol of aerobic
FMD and EPC count. Nonetheless, FMD significantly PhA: 150 minutes of moderate-intensity aerobic activity
correlated only with increased PhA level, and not with per week (group A). Twenty patients, age matched, with
EPCs, suggesting that increased PhA improves endo- vascular ED who did not accept to undergo the standard
thelial function through mechanisms other than increas- PhA protocol represented the control group. All
ing EPC count (Luk et al, 2009). patients were evaluated by IIEF-5 questionnaire admin-
Strenuous activity in healthy individuals leads to a istration, penile echo color Doppler, and flow cytomet-
time-dependent increase in EPCs and endothelial ric analysis for detection of serum concentrations of
microparticles that may be related to VEGF and IL-6. EPCs with original immunophenotype (EPC 5
In a study, 18 healthy young men cycled for 4 hours CD45[neg]/CD34[pos]/CD144[pos]) and EMP (CD45
continuously at 70% of their IAT. Peripheral blood was [neg]/CD34[neg]/CD144[pos]).
drawn at 16 predefined time points during and after After 3 months, group A showed IIEF-5 score and
finishing cycling. A significant rise in heart rate and peak systolic velocity significantly higher compared to
leukocytes was obvious, whereas lactate levels and controls, and significantly lower values of acceleration
hematocrit did not change. time; in addition, serum concentrations of EPCs and
The amounts of circulating progenitor cells, mature EMP were significantly lower in group A compared to
endothelial cells, and microparticles, quantified by flow controls (La Vignera et al, 2011).
cytometry, showed a significant time-dependent increase Finally, a recent cross-sectional multicenter study
at 210/240 minutes. In addition a very early rise in with 6 research groups was undertaken; the purpose
VEGF and later increase in IL-6, both measured by of this study was to analyze the relationship of PhA
ELISA, were evident. All observed changes were and dietary pattern to the circadian pattern of blood
158 Journal of Andrology N March ÙApril 2012

pressure, central and peripheral blood pressure, pulse and 3 treadmill runs of 40, 80, and 120 minutes at 55%
wave velocity, carotid intima-media thickness, and of VO2max. Blood samples were drawn before the session
biological markers of endothelial dysfunction in active and then 1, 2, 3, and 4 hours after the start of the run.
and sedentary individuals without arteriosclerotic dis- Plasma was analyzed for LH, free T, and TT. LH was
ease. significantly greater at rest compared to the running
Determining that sustained PhA and the change sessions. Both free T and TT generally increased in the
from sedentary to active as well as a healthy diet first hour of the 80- and 120-minute runs and then
improve circadian pattern, arterial elasticity, and showed a trend for a steady decline for the next 3 hours
carotid intima-media thickness may help to propose of recovery. The results indicate that exercise duration
lifestyle intervention programs. These interventions has independent effects on the hormonal response to
could improve the cardiovascular risk profile in some endurance exercise. At a low intensity, longer-duration
parameters not routinely assessed with traditional risk runs are necessary to stimulate increased levels of T,
scales. From the results of this study, interventional and beyond 80 minutes of running there is a shift to a
approaches could be obtained to delay vascular aging more catabolic hormonal environment (Tremblay et al,
that combine physical exercise and diet (Garcı́a-Ortiz 2005).
et al, 2010). In another study, hormonal measurements were
performed (TT, free T, dehydroepiandrosterone sulfate,
PhA and Androgen Status and estradiol) in a homogenous group of 38 subjects.
Among them were 22 who had not engaged in any PhA
Guilland and colleagues (1984) evaluated androgenic
and 16 who had recreationally exercised for about
status in 5 well-trained mountaineers during the
10 years. The groups did not differ in regard to
different phases of a mountaineering expedition during
hormonal status (Medraś et al, 2005).
the ascent of Mt Pabil (7102 m) in the Ganesh Himal
Gray and colleagues (2006) evaluated 364 males aged
massif. In this study androgenic status was evaluated by
between 20 and 82 comprising a cross-sectional study
measuring T glucuronide, 5 alpha-androstane-3 alpha,
conducted between 1996 and 1998. T levels were
17 beta diol (Adiol), and 17-ketosteroids (17-KS).
measured from serum samples obtained between 0800
Reference values were obtained at Chamonix at 1037 m
and 1100 hours. In analysis of covariance (ANCOVA),
during rest. During trekking, Adiol and 17-KS de- male T levels differed significantly along this rural-to-
creased. The fall in the urinary androgenic pool urban gradient, with members of the most urban group
persisted during the next phases of the expedition. having higher T levels than groups of farmers and
During the return to sea level, the urinary level of these inhabitants of informal housing areas adjacent to towns.
parameters was still high. Further exploratory ANCOVA analyses revealed that
Strüder and colleagues (1999) investigated hypotha- PhA levels were not significantly associated with
lamic-pituitary-gonadal axis regulation in elderly variation in T levels.
distance runners (RUN; n 5 8; age, 68.9 6 4.2 years; Goh and colleagues (2007), in a study conducted on
training, 65 6 20 km/wk over the last 20 years; means 531 healthy Singaporean Chinese men aged between 29
6 SD) and in elderly sedentary individuals (SED; n 5 and 72 years old using multivariate analyses and
11; age, 69.1 6 2.6 years) by an aerobic training over adjusting for age and other related factors, showed that
20 weeks (3 times/wk, 30–60 minutes walking), exercise had positive impacts on androgen levels and
respectively. Results of this study showed that basal body composition.
plasma free T concentration was significantly lower in In another recent study, the hormonal response to
RUN (10.23 6 2.41 pg mL21 vs SED 16.6 6 exercise was evaluated in relation to several factors
5.59 pg mL21). Lower plasma free T concentrations including the intensity, duration, mode of exercise
in RUN compared to SED were not caused by (endurance vs resistance), and training status of the
modified luteinizing hormone (LH) synthesis-secretion subject. In this study the steroid hormonal response
capacity. (immediately after a race and 1 week later) to endurance
In a cross-sectional study of 400 independently living exercise was determined under the real conditions of the
men between 40 and 80 years of age, TT, bioavailable T, classic Athens marathon in a group of well-trained,
SHBG, and estradiol were investigated for their middle-aged, nonelite athletes. Blood samples were
relationship with PhA. Multivariate analyses showed drawn 1 week before the race, directly after completion
that higher PhA scores were associated with higher TT of the race, and 1 week later. TT as well as free T
and SHBG levels (Muller et al, 2003). dropped significantly 1 hour after the race but returned
Another study examined 8 endurance-trained males to baseline 1 week later. In this particular group of
(19–49 years) who completed a resting control session nonelite, middle-aged marathon runners, the race
La Vignera et al N Physical Activity and ED in Middle-Aged Men 159

resulted in an acute decline in T level. The aforemen- exercise per week can reduce the risk of chronic diseases
tioned changes returned to baseline 1 week later and premature death (Paffenbarger, 1988).
(Karkoulias et al, 2008). What Duration of Training Sessions?—Although more
Suzuki and colleagues (2009) conducted a cross- research is required, there is some evidence that bouts of
sectional analysis of the association of lifestyle factors less than 10 minutes may also be beneficial to health
with circulating concentrations of androstenedione, 3- (Strath et al, 2008).
alpha-androstanediol glucuronide, T, SHBG, and free What Intensity of Exercise?—PhA is usually expressed
T among 636 men in the European Prospective in absolute terms in prospective cohort studies: moder-
Investigation Into Cancer and Nutrition. The results ate intensity is typically characterized as 3–6 METs
of this study showed that PhA and dietary factors were and vigorous intensity is typically characterized as . 6
not associated with androgen concentrations (Suzuki METs (where 1 MET is equivalent to the energy
et al, 2009). expended at rest). There is compelling evidence of a
Hormonal parameters were measured in a cohort of dose-response relationship between PhA intensity and
387 healthy Caucasian men (aged 24–72 years) from 1 cardiovascular disease: activities of 46 METs are
administrative region of Poland. Their level of PhA was associated with lower risk of cardiovascular disease
determined by means of the International Physical than activities of 3–6 METs, especially in men (Paffen-
Activity Questionnaire. In this study it was found that barger, 1988; Durstine et al, 2001; Cornelissen and
contrary to SHBG concentration, TT, free T, bioavail- Fagard, 2005).
able T, calculated free T, and estradiol were negatively What Are the Risk Groups?—There are clinical
associated with age in the investigated subjects. Apart situations in which the management of PhA can be
from estradiol, PhA did not influence concentrations of different; these conditions are differentiated into nonfa-
the studied parameters. In younger (24–48 years), tal (arthritis, visual impairment, hearing impairment)
physically active males, estradiol was significantly and fatal conditions (ischemic heart disease, chronic
higher than in subjects characterized by a low level of obstructive pulmonary disease, diabetes mellitus, malig-
PhA. The situation was opposite in older males (48– nant neoplasms; Verbrugge and Patrick, 1995). For
72 years). In this age group, a low level of PhA was these subjects, the recommendation is a gradual
associated with a lower concentration of estradiol achievement of the objectives of PhA provided for
(Slowinska-Lisowska et al, 2010). normal adult subjects, but there are no valid references
for all categories.
Practical Recommendations and Special Groups With
Risk Factors Conclusion
Before starting an exercise program, one should answer The study of the literature shows that ED in middle-
the following questions: aged men is often an early event in endothelial damage,
and PhA is able to improve both erectile and endothelial
a) What dose of PhA? dysfunction. In clinical practice it would be recom-
b) What frequency of PhA? mended to add regular PhA to balanced diet and drugs
c) What duration of training sessions? to achieve better therapeutic results. Finally, we need to
d) What intensity of exercise? consider possible hormonal changes induced by PhA
e) What are the risk groups? and standardize reproducible protocols to be used in
clinical practice.
What Dose of PhA?—Depending on body weight,
150 minutes of moderate-intensity aerobic activity per
week or 75 minutes of vigorous-intensity aerobic activity
per week expends around 800–1200 kcal (3349–5023 kJ).
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