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pISSN 2287-4208  eISSN 2287-4690
    World J Mens Health. 2023 Apr;41(2):330-341. English.
    Published online Jan 01, 2023.
    https://doi.org/10.5534/wjmh.220124
    Copyright © 2023 Korean Society for Sexual Medicine and Andrology
    Original Article

    Effects of Sexual Rehabilitation on Sexual Dysfunction in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis

    Jae Joon Park,1,* Seung Whan Doo,1,* Allison Kwon,2 Do Kyung Kim,1 Won Jae Yang,1 Yun Seob Song,1 Sung Ryul Shim,3 and Jae Heon Kim1
      • 1Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
      • 2Department of Biochemistry, College of Biological Science, University of California, Davis, Davis, CA, USA.
      • 3Department of Health and Medical Informatics, Kyungnam University College of Health Sciences, Changwon, Korea.
    • Correspondence to: Jae Heon Kim. Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea. Tel: +82-2-709-9378, Fax: +82-2-710-3190, Email: piacekjh@hanmail.net
      Correspondence to: Sung Ryul Shim. Department of Health and Medical Informatics, Kyungnam University College of Health Sciences, 7 Kyungnamdaehak-ro, Masanhappo-gu, Changwon 51767, Korea. Tel: +82-55-249-2729, Fax: +82-505-182-8972, Email: sungryul.shim@gmail.com

      *These authors contributed equally to this work as co-first authors.
    Received June 23, 2022; Revised July 31, 2022; Accepted August 10, 2022.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Purpose

    Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89%. Ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems. Therefore, sexual rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment, appropriate counseling, a multidisciplinary approach, and partner rehabilitation. In this study, systematic review and meta-analysis was performed to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD.

    Materials and Methods

    Comprehensive literature searches were conducted using MEDLINE, Cochrane Library electronic database, and EMBASE through June 2022. Questionnaire scores at the end point as outcomes of the study were recorded as were standardized mean difference (SMD) with their 95% confidence intervals (CIs). Meta-regression analysis was conducted for each moderator. We performed a risk of bias evaluation for included studies using the RoB 2 tool.

    Results

    The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226–0.633). There was a statistical difference between groups. SMD changes were 0.674 (95% CI, 0.308–1.039) at one month and 0.320 (95% CI, 0.074–0.565) at six months. The regression analysis with all variables (number of patients, study duration, and questionnaire types) revealed no significance.

    Conclusions

    This study indicates that sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, for clinical application, well-designed studies with many patients should be conducted in the future and the standardization of rehabilitation protocols is required.

    Keywords
    Cardiovascular disease; Erectile dysfunction; Sexual dysfunction; Sexual rehabilitation

    INTRODUCTION

    Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide [1, 2, 3]. The prevalence of CVD is rapidly increasing. CVD accounts for half of the causes of annual deaths in developing countries [2, 4]. Coronary artery disease, the most common type of CVD, can cause physical and psychological problems and affect a patient’s quality of life (QOL). In addition, since it can cause a high morbidity and induce a high level of anxiety, it often leaves patients with psychological sequelae due to the lack of confidence in their health after a cardiac event [1, 5, 6].

    Physical and mental problems induced by CVD mentioned above can also cause problems with sexual activity. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people [7]. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89% [2, 8]. The risk of sexual dysfunction is high in both men and women patients with CVD, with sexual dysfunction being more common in men than in women [1, 2, 9]. Specifically, erectile dysfunction (ED) occurs in up to three-quarters of men with myocardial infarction (MI) and up to 57% of men with implanted external defibrillators [10, 11, 12]. Symptoms of sexual disorders in CVD patients mainly include decreased or loss of libido, avoidance of sexual activity, and sexual dissatisfaction [1, 13]. The prevalence of ED in patients with CVD is increasing. ED is known to reduce the QOL and cause mental problems. Thus, more attention should be paid to sexual dysfunction in CVD patients [2, 14]. The high incidence of ED in patients with CVD can be explained by the pathological mechanism applicable to both ED and CVD, including occlusion of blood vessels by atherosclerotic plaques. The artery size hypothesis has suggested that ED is a risk factor of CVD due to the relatively small diameter of blood vessels in the penile arterial system [15, 16].

    As such, the sexual problem of CVD patients causes various disadvantages to patients themselves and their partners [17]. Despite the high prevalence of sexual dysfunction in CVD patients, they tend to be passive in the expression and medical resolution of sexual problems due to cultural and religious reasons [2]. It has been reported that ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems [18]. However, guidelines for the treatment of sexual problems in patients with CVD other than prescription of phosphodiesterase type 5 (PDE5) inhibitors are not clear. In clinical practice, the sexuality of patients with CVD is rarely addressed [10, 19, 20].

    The classical concept of sexual rehabilitation was limited to rehabilitation of erectile function consisting of methods such as drug treatment. Recently, it refers to a holistic approach aiming to restore sexual function as a whole as well as ED. Such rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment (PFMT), appropriate counseling, a multidisciplinary approach, and partner rehabilitation [21]. Sexual rehabilitation is performed with the purpose of improving sexual dysfunction after prostatectomy or spinal cord injury. Recently, it is also performed with the purpose of improving sexual function in patients with CVD [1, 21, 22].

    Because sexual health of an individual can be permanently altered by treatment of the disease and sexual rehabilitation is far superior to general heart rehabilitation in improving the quality of a patient's sexual behavior, sexual treatment for patients with CVD should be considered essential [2, 23]. Therefore, the objective of this systematic review and meta-analysis was to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD.

    MATERIALS AND METHODS

    This systematic review and meta-analysis was performed according to the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [24]. This article does not contain any studies involving human participants performed by the authors.

    1. Search strategy

    The MEDLINE and the Cochrane Library electronic databases were screened up to June 2022 using Medical Subject Headings (MeSH) terms and text keywords. Subject headings and text keywords included population (cardiovascular disease), interventions (sexual rehabilitation), and outcomes (standardized mean difference of structured questionnaires for sexual dysfunction). The search formula was based on a combination of terms: (("coronary artery disease"[MeSH Terms] OR "coronary artery disease"[Title/Abstract] OR "myocardial ischemia"[MeSH Terms] OR "myocardial ischemia"[Title/Abstract] OR "myocardial infarction"[MeSH Terms] OR "myocardial infarction"[Title/Abstract]) AND "male"[MeSH Terms] AND ("sexual behavior"[MeSH Terms] OR "erectile dysfunction"[MeSH Terms])) AND (randomized controlled trial[Filter]). Searches were limited to human studies. There was no restriction for study type. The same search strategy was adopted for the EMBASE using Emtree (Embase subject headings). Additional studies were identified by two independent investigators (JJP and JHK).

    2. Study selection

    Study inclusion criteria were as follows: (1) the study population in randomized controlled trials (RCTs) comprised patients who were diagnosed with CVD such as coronary artery disease, myocardial ischemia, and MI; (2) interventions included administration of sexual rehabilitation; (3) comparisons were specified for no-treatment of sexual rehabilitation; (4) outcomes were standardized mean difference (SMD) of structured questionnaires such as sexual quality of life (SQOL) or International Index of Erectile Function (IIEF). Two authors (AK and JJP) individually screened the titles and abstracts of all searched articles according to preagreed inclusion criteria. After that, the full-text of the articles were reviewed in the same process, and finally the studies from which data was extracted were selected. The final inclusion was selected based on discussion among all investigators. The authors independently extracted data for analysis using a data extraction form. References and data for each included study were carefully cross-checked to ensure the absence of overlapping data and to maintain the integrity of meta-analysis.

    3. Statistical analysis

    All variables used questionnaire score measurements. Outcomes were recorded with SMD for continuous data. In the study without standard deviation, the estimate of pooled standard deviation of the two groups (before/after) was applied. SMD (Hedges’ g, the difference in pooled mean change between experimental and control groups) along with their 95% confidence intervals (CIs) were calculated for continuous variables. Random-effects model were used to obtain pooled overall effect sizes. Since each study had a different follow-up period, the outcome value at the end point of each study was used.

    Meta-ANOVA or meta-regression analysis was conducted for each moderator. We analyzed variability in effect sizes due to categorical moderators (e.g., study duration groups and types of questionnaires) and continuous moderators (e.g., number of patients) using a restricted maximum likelihood (REML) [25].

    Statistical heterogeneity was evaluated using Cochran’s Q test and the I2 statistic. Meta-regression analysis was conducted for each moderator. To analyze potential moderators, we used a REML estimator of the variance of true effects. A two-sided p-value <0.05 or a 95% CI not containing the null value (ratio=1) was considered to be significant. R software 4.0.3 (R Foundation for Statistical Computing) was used for all statistical analyzes.

    4. Assessment of methodological quality

    In this study, the Cochrane Collaboration Risk of Bias tool version 2 was used to evaluate the risk of bias. Each included study was evaluated in 5 domains including bias arising from the randomization process (D1), bias due to deviations from the intended intervention (D2), bias due to missing outcome data (D3), bias in measurement of the outcome (D4), and bias in selection of the reported result (D5). All domains were judged as low risk (“Low”), some concern (“Some concerns”), or high risk (“High”) according to their respective evaluation criteria. The overall risk of bias was evaluated by summarizing the evaluation of individual domains.

    5. Assessment of potential publication bias

    Publication bias was explained by funnel plot in this meta-analysis using standard error as the measure of study size and ratio measures of treatment effect. In the absence of publication bias, the combined effect size of the studies would be distributed symmetrically. In addition, we conducted Begg and Mazumdar rank correlation test and Egger’s linear regression test to determine the publication bias [26].

    RESULTS

    1. Study selection

    The initial search identified a total of 136 articles from different electronic databases (PubMed, n=28; Cochrane, n=26; Embase, n=82). Forty two studies that contained overlapping data or appeared in more than one database were excluded. After screening titles and abstracts, 84 studies were eliminated as they were not related to the topic in question. Twelve of the remaining studies were RCTs, making them eligible for further consideration. Of these, one study was further excluded based on the type of document, one study was excluded due to being in another language, three studies were excluded because of no quantitative outcome, and two studies were excluded due to too general. Finally, five studies met our selection criteria for quantitative synthesis (Fig. 1). A systematic review of these five studies was also conducted to assess detailed experimental differences and subject descriptions. The inclusion criteria for included studies were MI, ischemic heart disease (IHD), coronary artery bypass graft (CABG), and a history of coronary artery disease. In included studies, the composition of the sexual rehabilitation program consisted of studies that performed education, physical therapy, or psychotherapy and studies that combined physical therapy and psychotherapy or education and physical therapy (Table 1).

    Fig. 1
    Study selection flow chart.

    Table 1
    Characteristics of included studies

    2. Methodological quality

    We evaluated five sexual rehabilitation studies using five RoB 2 domains to determine the risk of bias for included studies. In D1, all studies were classified as “Low.” In D2, four studies were classified as “Low” and one study as “Some concerns.” In D3, five studies were classified as “Low.” In D4, four studies were classified as “Low” and one study as “Some concerns.” In D5, all studies were classified as “Low.” Based on these evaluations, the overall risk of bias was ranked. Four studies were classified as “Low” and one study as “Some concerns” (Fig. 2).

    Fig. 2
    RoB 2 traffic light plot.

    3. Outcomes

    Detailed findings were classified according to the follow-up period of sexual rehabilitation improvement compared with the control group. They are shown in the forest plot (Fig. 3). The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226–0.633). There was a statistical difference between groups. Heterogeneity test produced p>0.01 and the Higgins’ I2 was 0%. To evaluate study duration, we also conducted subgroup analysis. SMD changes were 0.674 (95% CI, 0.308–1.039) in one month and 0.320 (95% CI, 0.074–0.565) in six months (Fig. 3). Cochran’s Q test showed very low heterogeneity (I2=0%).

    Fig. 3
    Forest plot. The black diamond shows the overall effect size. random, random effect model. Klein et al 2007 [40] excluded due to insufficient numerical values.

    4. Moderator analysis

    Table 2 provides an overview of moderator analyses. Regression analysis with 4 variables (number of patients, study duration, and questionnaire types) revealed no significance. With respect to questionnaire types, there was a slightly higher effect size in SQOL. However, the difference was not significant (p=0.558).

    Table 2
    Effects of moderators

    5. Publication bias

    Publication bias was evaluated as shown in Fig. 4. Individual studies are distributed symmetrically about the combined effect size. p-values for the Begg and Mazumdar’s correlation test (0.497) and Egger’s regression coefficient test (0.219) suggested no evidence of publication bias or small-study effect in this meta-analysis.

    Fig. 4
    Funnel plot with peusdo 95% confidence limits of standardised mean difference.

    DISCUSSION

    As far as we know, this is the first systematic review and meta-analysis dealing with effects of sexual rehabilitation on sexual disorders in patients with CVD. In this study, the composition of sexual rehabilitation program and its effects on sexual disorders were analyzed and a statistically significant improvement was found compared to the control group. In our study, compared with the control group, it was possible to confirm the improvement of SQOL or IIEF statistically significantly in the group that performed sexual rehabilitation. Also, in subgroup analysis according to the follow-up period (one month and six months), there was a statistically significant improvement in sexual function. Results of this study suggest the need for more active treatment than what is used at present time for sexual disorders in patients with CVD. Results of this study also indicate that sexual rehabilitation can be an effective treatment for sexual disorders in patients with CVD.

    Components of sexual health include physical health and positive perceptions through good sexual experiences [1, 27, 28]. SQOL, which is affected by various factors such as physical, psychological, and medical factors, occupies a large part of life. It has a great influence on QOL [29, 30]. In particular, in middle-aged life, satisfaction with sexual life tends to be affected by education, sexual dysfunction due to physical or mental problems, and relationships with partners [1, 31]. Sexual health abnormalities that significantly affect our lives can affect our mental and physical health. They can even lead to family disintegration [1, 13].

    ED defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual activity has a prevalence of 20 million in Europe and 30 million in the United States. It is estimated at approximately 150 million worldwide [32, 33]. ED is mainly caused by organic causes such as vascular, hormonal, and neurogenic etiologies. It can also be caused by psychogenic causes such as mental disorders, performance anxiety, interpersonal problems, and worries about physical diseases. Side effects of various medications can also cause ED [10, 34].

    Most ED cases are related to vasculogenic disorder, especially in men over 50 years old. About 40% of ED cases are associated with atherosclerotic disease [32, 35]. The mechanism by which CVD causes ED can be explained by the mechanism of erection. Erection is induced by the interaction between the autonomic nervous system and the vascular endothelium. In rest status, the penis is held flaccid by sympathetic activity that constricts arteries supplying blood to the two corpora cavernosa and corpus spongiosum. By stimulation of genital mechanoreceptors or psychogenic stimulation, tonic sympathetic activity is suppressed and cholinergic parasympathetic fibers are stimulated. This process dilates the smooth muscle of the corpora cavernosa and arteries supplying blood to the two corpora cavernosa and corpus spongiosum. Blood inflow to the penile tissue then gradually increases and the penile structure-induced veno-occlusive mechanism results in stiffening of the penis. CVD, particularly atherosclerotic disease, can cause ED by impairing blood supply to penile tissues through this mechanism [32].

    The main causes of psychogenic sexual problems in patients with CVD include partner’s anxiety and fear of sudden death during sexual activity and depression and stress caused by decreased sexual activity. Seyam et al [36] and Mourad et al [37] have suggested that CVD itself is directly related to psychological factors such as anxiety, depression, and stress. In addition, ED as an organic factor can cause deterioration of mental health due to decreased satisfaction and a sense of deprivation [17].

    Sexual rehabilitation of patients with CVD has various components such as exercise, diet, smoking cessation, sex education, and psychological support. It is comprehensively categorized into sexual education, physiotherapy, and psychotherapy [2, 38]. Zamani et al [39] have reported that sexual disorders have high correlations with anxiety and depression and that stress, anxiety, and depression caused by sexual dysfunction can be improved by a sexual rehabilitation program. Klein et al [40] have confirmed the effect of sexual rehabilitation on patients participating in cardiac rehabilitation after a cardiac event. They suggested that sexual rehabilitation treatment including education, emotional support, guided imagery, and use of erection inducers contributed to the improvement of the quality of sexual function such as sexual desire, sexual satisfaction, and frequency of erection. Heidari et al [41] have mentioned that sexual education can help raise the awareness of sexuality, improve interaction with partners and satisfaction of overall life, and provide pleasure. Bagheri et al [42] have determined effects of sexual education on anxiety, stress, and depression in MI patients and partners and observed significant reductions in stress and anxiety levels in patients and partners after performing sex education. Soroush et al [7] have studied the effect of a psychosexual counseling program for cardiac rehabilitation patients and found that the psychosexual counseling program can improve patient’s sexual assertiveness and reduce fear of sexual activity. In the present study, sexual rehabilitation was divided into physiotherapy, sexual education, and sexual psychotherapy. Physiotherapy includes general exercise, cardiac rehabilitation, and PFMT.

    Despite various studies have reported that sexual health is important for general health and mental health in patients with CVD as well as in patients with other diseases, sexual rehabilitation, including sexual education, counseling, and exercise therapy, is often ignored due to reasons such as patient shame and cultural factors [43]. In general, since the way an individual thinks about sexuality is formed by various factors including social, cultural, and ideological factors, the social viewpoint on sexuality should be considered even during sexual counseling [2]. A cultural aspect should be included in sexual health assessments as some cultural settings may have conservative views on sexual health and some may be reluctant to freely discuss sexual issues with health care providers [2, 44]. Egholm [45] have suggested that nurses are suitable for counseling about sexuality because nurses who provide care to patients have an intimate character with patients. They also suggest that nurse education program for sexual history taking and sexual counseling is necessary. In addition, sensitive perception of sexual rehabilitation has been confirmed by research participation and adherence to the program. In the study of Palm et al [10], 24% of selected patients agreed to participate in the trial. In the study of Steinke [12], 21% of selected patients agreed to participate in the trial. Also, in Palm et al’s study [10], 75% of participants performed more than 50% of a given program. Such low participation rates and adherence to sexual rehabilitation indicate the sensitive perception about sexuality and the need for more sexual rehabilitation [10, 12, 46].

    Physiotherapy performed in patients with CVD can be divided into general exercise and PFMT. General exercise mainly consists of aerobic exercise. It is helpful for improving risk factors of CVD. It can particularly reduce the progression rate of inflammatory atherosclerosis and the strength of hardening [32, 47, 48, 49]. Kałka et al [32] have reported that exercise tolerance and erection quality are independently and positively improved after cardiac rehabilitation consisting of exercise therapy in patients with IHD who have received invasive treatment, suggesting that cardiac rehabilitation should be used as an important treatment modality in addition to medication therapy. Low levels of physical activity due to other risk factors including CVD are thought to be closely related to the development of ED. Because it is simple compared to other treatment methods, increasing physical activity through lifestyle modifications has been recognized as a form of treatment [50, 51]. This effect of physical activity also appears throughout the coronary artery and the entire arterial system. It has been reported that the quality of penile erection affected by vascular activity is also improved through this positive effect [47, 48, 49]. According to Selvin et al [52], there is a significant correlation between low levels of physical activity and ED through a national data analysis. Derby et al [51] have observed that the risk of ED is decreased in middle-aged men by increasing physical activity through lifestyle changes. In men, pelvic floor muscles activated by sexual stimulation play a pivotal role in penile erection and ejaculation. Therefore, rehabilitation of these pelvic floor muscles occupies a large part of physiotherapy during sexual rehabilitation in patients with CVD. It is a non-invasive treatment that can increase penile rigidity [53]. In a network meta-analysis performed by Sari Motlagh et al [54] that compared effects of various penile rehabilitation programs in a group of patients who underwent nerve sparing radical prostatectomy, PFMT was reported to be the most effective method with an odds ratio value of 5.21.

    Among components of sexual rehabilitation, psychotherapy, including sexual consultation, can induce significant improvement in patients' psychological well-being and QOL through mental support [2]. Palm et al [10] reported an improvement of sexual function in a group of CVD patients that performed sexual rehabilitation including physiotherapy and psychotherapy compared to the control group. This sexual rehabilitation included exercise therapy with a physiotherapist and consultation with specially trained nurses on causes of sexual dysfunction, sexual concerns, and levels of sexual activity. However, in the above study, no significant improvement was found in the self-assessment questionnaire on health or mental health because of high score at baseline evaluation [10]. Klein et al [40] has conducted a study on effects of sexual counseling with partner, including taking sexual history, sharing patients' experiences with provided sexual guidance, and obtaining advice from a specialized clinical social worker and physician on future sexual activity and reported positive effects of sexual counseling on sexual desire, confidence in erection, satisfaction with sexual intercourse, and frequency of erection. Although we analyzed several studies on psychotherapy and reported the effect of sexual rehabilitation including this as a result, the methods that actually performed psychotherapy in each study were diverse. Therefore, for clinical application, the protocol of psychotherapy should be established through additional studies.

    Education about the disease and its management is a basic right of patients. However, it was observed that most patients with MI did not receive sufficient explanation on how to perform sexual acts. Thus, this is one of the important contents that require education [36]. Brännström et al [55] have compared sexual knowledge of patients with MI and their spouses and found that only 41% of patients and 31% of spouses are provided information on sexual behavior at one year after a heart event. This lack of sexual knowledge can lead to changes in gender roles of patients and their spouses and sexual deprivation [56]. However, just watching sexual educational videos can improve patients’ anxiety by understanding the disease and possible activity level [57]. Abbasi et al [1] have performed a RCT to confirm the effect of sexual education in patients with MI and reported significant improvement of ED using the SQOL questionnaire as outcome. One of the methods of sexual problem education is combination with peer education. Peer education is when people who share similar experiences share ideas and information, which is effective on sexual issues. Most patients prefer peer education and feel close. Thus, they can exchange information, encourage, and get emotional support in a more comfortable atmosphere [58, 59]. Abbasi et al [1] have reported improvement in anxiety, depression, QOL, and SQOL of patients with CVD through peer education.

    The limitation of this systematic review and meta-analysis was that heterogeneity was high because the composition and method of sexual rehabilitation programs were different for each included study. To overcome this limitation, SMD was used in this meta-analysis. However, heterogeneity was not resolved completely. Therefore, it is necessary to standardize the rehabilitation method for clinical application. Another limitation of this study was that it did not control for various variables affecting sexual problems, which should be considered for modification in the design of future studies.

    CONCLUSIONS

    Sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, well-designed research with many patients is needed to overcome limitations of this study as evidenced by a small number of samples. Standardization of the rehabilitation protocol is also needed for clinical application.

    Notes

    Conflict of Interest:The authors have nothing to disclose.

    Funding:This work was supported by Soonchunhyang University Research Fund.

    Author Contribution:

    • Conceptualization: SRS, JHK, SWD.

    • Data curation: AK, JJP, DKK, WJY, YSS.

    • Formal analysis: SRS, JHK.

    • Funding acquisition: JHK.

    • Investigation: AK, JJP, DKK, WJY, YSS.

    • Methodology: DKK, WJY, YSS.

    • Supervision: SRS, JHK.

    • Writing – original draft: JJP, SRS.

    • Writing – review & editing: SRS, JHK, SWD.

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    MeSH Terms
    Bias
    Cardiovascular Diseases*
    Cause of Death
    Counseling
    Drug Therapy
    Drug-Related Side Effects and Adverse Reactions
    Erectile Dysfunction
    Exercise Therapy
    Humans
    Male
    Pelvic Floor
    Prevalence
    Records
    Rehabilitation*
    Systematic Review*
    Metrics
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