International Journal of Impotence Research (1999) 11, 41±46

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The use of acupuncture in the treatment of erectile dysfunction

HG Kho1*, CGJ Sweep2, X Chen3, PRI Rabsztyn2 and EJH Meuleman2
1
Institute of Anesthesiology, University Hospital Nijmegen; 2Department of Chemical Endocrinology, University Hospital
Nijmegen; 3Department of Anaesthesia of Renji hospital, Shanghai, China; and 4Department of Urology, University
Hospital Nijmegen, The Netherlands

The ef®cacy of acupuncture as a mono-therapy was evaluated in a pilot study of 16 patients

suffering from erectile dysfunction (ED). In nine patients no organic co-morbidity was
encountered. In a period of four weeks, acupuncture treatment was performed twice a week for
a total of eight sessions. Each treatment session consisted of puncture of the same eight acupoints,
four of which were connected to a Swiss made constant current Doltron ESA 600 stimulator. Low
frequency electrical stimulation (5 Hz and 10 mA) was applied to these four acupoints, whereas no
stimulation was applied to the other four points. After 30 min, the electrical stimulation was
terminated and all needles removed. Blood samples were drawn according to a ®xed time
schedule, to study the pro®le of a number of stress hormones, for example, adrenocorticotropic
hormone, antidiuretic hormone and cortisol, the gonadotrophines follicle stimulating hormone
and leutinizing hormone, and the sex steroid testosterone and its binding globulin, within the
treatment period. Based on a diary of both patient and partner, and an interview one month after
the end of treatment, the changes of sexual activity were evaluated over a period of 12 weeks,
starting from the four weeks prior to the treatment, the four weeks during the treatment period and
the four weeks after the treatment. An improvement of the quality of erection was experienced by
15% of patients, while 31% reported an increase in their sexual activity. No changes in the pro®les
of hormones were detected. The use of acupuncture as a mono-therapeutic modality in ED, did not
in¯uence the pro®le of the stress and sex hormones, but did improve the quality of erection and
restored the sexual activity with an overall effect of 39%. No de®nite conclusions can be drawn
from this pilot study. A controlled and blinded study including more patients will be needed before
any de®nitive conclusion can be reached.

Keywords: erectile dysfunction; acupuncture; hormones

Introduction success rates of these therapies are disappointing.2

Other treatments, including oral drugs, are in the
experimental stage.3 Therefore, an ideal solution for
Nowadays more patients are seeking help for sexual ED has not yet been achieved.
dysfunction (SDS). This suggests that the incidence Traditional medicine (TM) as an alternative
of SDS is increasing and=or that sexual issues are approach to the modern health care system is
more easily discussed.1 In recent years, several increasing in popularity. Each year, fully one third
therapeutic modalities for patients suffering from of all US residents seek service from TM for
erectile dysfunction (ED) have become available. disorders which may not respond to modern
The treatment for psychogenic ED is sex-therapy. medicine.4 In 1991, the WHO adopted resolution
For organic ED, which accounts for more than 50% WHA44.34. It urged member states to intensify
of cases, the clinical guideline panel of the Amer- cooperation between TM and modern health care,
ican Urological Association recommends three especially concerning the effectiveness and safety of
alternatives, that is, vacuum constriction devices, approved treatment methods of TM. The aim of this
injection of vasoactive drugs and=or implantation of resolution was to reduce the national budget of
a penile prosthesis. The majority of patients dis- drugs.5
continue non-surgical treatment because of sexuo- Acupuncture has been practised for many cen-
logical and relational determinants or turies and is one of the most important branches of
dissatisfaction with the method. The long-term traditional Chinese medicine (TCM). Modern med-
icine understands the Yin ± Yang balance because in
*Correspondence: Dr HG Kho, University Hospital Nijmegen,
a healthy body as an equilibrium of the autonomic
PO Box 9101, 6500 HB Nijmegen, The Netherlands. nervous system (ANS) i.e. sympathetic and para-
Received 29 January 1998; accepted in revised form sympathetic nervous systems. Based on the homeo-
1 October 1998. static in¯uence of the ANS, acupuncture may have a
 Acupuncture in the treatment of erectile dysfunction
HG Kho et al
42
positive in¯uence on the pathophysiology of ED. Exclusion criteria
Several studies indicate a high success rate after
TCM treatment, including acupuncture, in patients
suffering from psychogenic ED.6 ± 10 Increasing evi- The only exclusion criterium was if the patient did
dence demonstrates that a number of neuropeptides not ful®l the inclusion criteria.
are involved in the mechanisms of pain relief after
acupuncture.11 Neuropeptides have also been re-
cognized as important substrates in the central Study design
control of male sexual behaviour.12 ± 14 This present
study was designed to evaluate the effect of acu-
puncture as a mono-therapy in patients with ED. At the ®rst visit all patients included in the study
The results are discussed against the background of underwent an extensive sexual history and medical
literature data of the well-known therapies of ED. In examination, including Penile Pharmaco Duplex
addition, the pro®les of a stress and pituitary and Ultrasonography. After informed consent was ob-
gonadal sex hormones were studied within the tained from the patient and partner, they were
treatment sessions. instructed to ®ll in diaries, with the patient on a
daily basis and his partner on weekly basis con-
tinuously for a period of 12 weeks, starting from four
weeks prior to the treatment. This diary contained
Patients and methods
questions on the frequency of sexual intercourse and
the quality of erection during intercourse according
The protocol was approved by the hospital Ethics to a four point scale. A month after the end of the
Committee. Between September 1995 and March study period a ®nal interview was arranged for all
1996, 16 consecutive patients suffering from ED patients, in which attention was focused on items as
were included in the study. sexual fantasy, libido, sexual arousal, penile erec-
tion, orgasm and ejaculation.

Inclusion criteria
Acupuncture treatment procedure
To enter the study: written informed consent; age
between 18 and 75 y, Diagnostic and Statistic Following the `run-in' period of four weeks, acu-
Manual of mental disorders (DSM-III-R) diagnosis puncture treatment was performed twice a week
of ED,15 inability to obtain or maintain erection over a period of four weeks for a total of eight
suf®cient for penetration including intravaginal sessions. Each treatment session consisted of punc-
orgasm in more than 50% of coitus attempts; ture of the same eight acupoints (Guanyuan, Bahui,
complaints not exclusively related to depression, a left and right Sanyinjiao, Taixi and Shenmen). The
positive erectile response following administration correct placement of the needle was con®rmed by
of 0.5 ml of AndroskatR (7.5 mg of papaverine and the characteristic but subjective needle sensation
0.25 mg of phentolamine) intracavernously;15 a `deqi'. It is described as a sudden feeling of
stable sexual relationship that has been sexually numbness, soreness, distension or heaviness in the
functional within this relationship; patient and deep tissue experienced when the inserted needle
partner willing and able to have intercourse at least has reached a certain depth. Four of the inserted
three times a month during the study period. In this needles at the acupoints Guanyuan, Bahui and left
study, the de®nitions are con®ned to partner-related and right Sanyinjiao were connected to a Swiss
sexual activity. made constant current Doltron ESA 600 stimulator.

Table 1 Location of acupoints used in the study

Acupoint Anatomical location

a
Guanyuan (ren 4) Three cuns below the umbilicus, in the midline
Bahuia (du 20) Seven cuns above the posterior hairline, midway on a line connecting the apex of
both ears.
Sanyinjiaoa,b (spleen 6) Three cuns above the tip of the medial malleolus just posterior to tibial border
Taixib (kidney 3) Midway between the tip of medial malleolus and tendo calcaneus
Shenmenb (heart 7) On the ulnar side of the wrist, on the posterior border of the pisiform bone, in the
depression at the radial side of the tendon of musculus ¯exor carpi ulnaris

cun ˆ the distance between two creases marking the joints of the distal and the middle phalanges of the middle ®nger.
a
Indicates the electrical stimulated acupoint.
b
Indicates the symmetrical location of the points, and at the right and left side of the body resp.
 Acupuncture in the treatment of erectile dysfunction
HG Kho et al
43
Low frequency electrical stimulation (5 Hz and up to was incubated for 24 h at room temperature. The
10 mA) was applied to these four acupoints. No supernatant was decanted and the tubes washed two
stimulation was applied to the other four points. times with 0.9% NaCl. Radioactivity in the tubes
The anatomical location of the acupoints is depicted was counted using an automatic gamma-counter
in Table 1. After 30 min, the electrical stimulation (1470 WizardTM Wallac). The sensitivity of the assay
was terminated and all needles removed. was 0.5 pmol=l, and the within- and between-assay
coef®cients of variation of the IRMA procedure were
4.4% and 7.2% respectively. All sample measure-
ments were duplicated. The IRMA speci®cally
Measurement of hormones detects ACTH (1 ± 39). Crossreactivity with ACTH
(1 ± 24), CLIP and beta-endorphin was < 0.1%.
Table 3 shows the characteristics of the assay
Venous blood was collected in pre-chilled K3-EDTA methods for the anti-diuretic hormone (ADH),
tubes between 2 pm and 4 pm following the sche- cortisol, follicle stimulating hormone (FSH), lutei-
dule presented in Table 2. nizing hormone (LH), prolactin (PRL), sex-hormone
Samples were then centrifuged for 10 min at binding globulin (SHBG) and testosterone.
1500 g (4 C) within one hour. The plasma obtained
was aliquoted in polystyrene tubes containing
250 KIU=ml of plasma TrasylolR (aprotonine, Bayer),
frozen and stored at 7 20 C until measurement. Data evaluation
This was carried out within two months.
Adrenocorticotropic hormone (ACTH) in plasma
Variables measured at admission or before the ®rst
was measured by an immunoradiometric assay
treatment were used as control. Data are presented
(IRMA) based on two polyclonal antibodies (Euro-
Diagnostics, Arnhem, The Netherlands). The catch- as mean  s.e.m. and analyzed by repeated measure-
ment analysis of variance (SPSS, Statistical analysis
ing antibody is directed against the C-terminal part
package, version 6.1.3, SPSS Benelux Bv Gorinch-
of the ACTH molecule, and coupled via a sheep
anti-rabbit antibody to a polystyrene tube. The em, The Netherlands). P < 0.05 was the threshold of
detecting antibody is directed against the N-terminal signi®cance.
part of ACTH and radioiodinated. Standard curves
were prepared by spiking ACTH-free plasma with
ACTH (1 ± 39) (MRC 74=555). The assay was per- Results
formed as follows. Two hundred microliters of
sample standard (0 ± 220 pmol=l) was added to the
coated tubes and subsequently iodinated ACTH Sixteen patients entered the study. For three of them
antiserum (250 dpm=200 ml) was added. The mixture the study could not be ®nished. After the ®rst
treatment session, two patients decided not to
continue the therapy and one patient could not ®ll
the diary due to the absence of a partner shortly after
Table 2 Time schedule for drawing blood samples he entered the study. The data of these patients were
excluded. Table 4 shows the clinical data of the 13
Code Time Description
patients completing the study. In four patients, an
T1 30 min Before the ®rst acupuncture treatment organic factor contributing to the ED was present,
T2 30 min Before the third acupuncture treatment the remaining nine patients were classi®ed as
T3 30 min Before the ®fth acupuncture treatment psychogenic ED.
T4 30 min Before the seventh acupuncture treatment
T5 30 min After the last (eight) acupuncture treatment After treatment was completed, two patients had
a better erection (15%) and four patients had an

Table 3 The assay methods for determinants of hormones, their intra- and interassay coef®cients of variation (%), sensitivity (sens), the
reference values (ref) in the non-stressed state, units and literature (lit)

Variable Method Intra Inter Sens Ref Unit Lit

ACTH IRMA 3.6 8.3 0.8 1.3 ± 9.2 pmol.l71 text

ADH RIA < 8.0 < 8.0 0.8 1.2 ± 3.7 pmol.l71 16
Cortisol RIA 5.0 5.8 0.005 0.19 ± 0.55 (8 am) mmol.l71 17
0.06 ± 0.38 (5 pm) mmol.l71 17
FSH IRMA 3.6 8.2 0.6 2.0 ± 7.5 IU.l71 18
LH IRMA 5.5 7.6 0.5 1.8 ± 9.5 IU.l71 18
Prolactine IRMA 3.6 5.7 20 100 ± 700 mIU.l71 18
SHBG IRMA 2.9 4.6 0.5 30 ± 90 nmol.l71 16
Testosterone RIA 5.6 5.8 0.04 11 ± 45 nmol.l71 16
 Acupuncture in the treatment of erectile dysfunction
HG Kho et al
44
increase in sexual activity (31%). The ®nal inter- erection or activity. Presumably, partners were less
view also revealed that ®ve patients, two months focused on performance related sexual domains such
after the ®rst treatment, still experienced improve- as erection and activity. Moreover, they may not have
ment of their sex life in terms of activity and global been involved suf®ciently in the study. Though
quality of erection (39%). The overall improvement limited to a small number of patients, our study was
rate was 54% (7 out of 13 patients). None of the unable to con®rm the reported high success rate of
partners, however, reported any difference. Table 5 acupuncture treatment in ED of at least 70% in other
shows the results of the measurement of plasma studies.6 ± 9 A number of factors are thought to have
levels of the pituitary hormones ACTH, ADH, FSH, affected the results. Firstly, the choice of acupoints
LH and PRL and the steroid hormones cortisol and used in our study was identical in each treatment
testosterone as well as SHBG. session and for all patients, rather than an individual
No signi®cant changes in the levels of these approach as reported by others. After all, TCM
hormones during and after the treatment sessions considers a patient in his totality with a wide
were detected. aetiological spectrum, and takes into account that
illness, health and disease are brought about by
imbalance in human beings. According to TCM, ED
Discussion is caused by a strengthened inhibition to erection in
the cerebral cortex or a functional disorder of the
spinal cord. The disease is related to such organs as
Clinic the kidney, heart, spleen and liver. The majority of ED
may result from insuf®ciency of kidney energy Qi
(functional activities of the kidney) and of roaring ®re
The present pilot study was conducted to determine at the vital portal caused by emission, spermatorrhea,
the effect of acupuncture as a mono-therapy in excessive worries or from injured kidney Qi due to
patients suffering from ED. The results show that it sudden panic weakness of the genitalia but the
has an effect in 54% of patients. It is remarkable that downward ¯ow of damp and heat.19 TCM treats the
none of the partners reported any improvement of body, mind and social relationship, and determines

Table 4 Outcome of 13 included patients: diary, interview and partner's diary

Patient Interview partner

Interview
Pt Age Aetiology Erection Activity Patient Erection Activity

1 43 psychogenic un Increased un un un
2 46 DM type 1 un un un un un
3 47 psychogenic un un Improved un un
4 47 psychogenic un un Improved un un
5 48 psychogenic un un un un un
6 53 psychogenic un un un un un
7 53 psychogenic Improved Increased un un un
8 53 Med un Increased Improved un un
9 54 psychogenic un un un un un
10 59 HT,a Medb un un un un un
11 61 psychogenic Improved Increased Improved un un
12 62 psychogenic un un Improved un un
13 65 Art,c HT, Med un un un un un
a
Hypertension.
b
Medication with impact on erectile function.
c
Arteriogenic factor as demonstrated by duplexscanning.
un ˆ unchanged.

Table 5 Mean (s.e.m.) values of plasma peptide hormone levels at different time schedules

Hormones Unit T1 T2 T3 T4 T5
71
ACTH pmol.l 4.49 (0.75) 3.16 (0.35) 4.23 (0.55) 4.35 (0.61) 4.83 (0.66)
ADH pmol.l71 1.27 (0.16) 1.41 (0.25) 1.53 (0.15) 1.54 (0.16) 1.83 (0.20)
Cortisol mmol.l71 0.33 (0.02) 0.25 (0.02) 0.26 (0.03) 0.27 (0.02) 0.30 (0.03)
FSH IU.l71 4.55 (0.45) 4.56 (0.43) 4.68 (0.46) 4.51 (0.53) 5.07 (0.60)
LH IU.l71 3.40 (0.28) 3.18 (0.44) 3.33 (0.40) 3.01 (0.26) 3.32 (0.53)
Prolactine mIU.l71 156 (15) 158 (150 154 (16) 182 (16) 167 (17)
SHBG nmol.l71 30.8 (3.1) 31.8 (3.6) 32.8 (3.9) 31.4 (3.3) 33.7 (3.8)
Testosterone nmol.l71 13.1 (1.4) 12.8 (1.6) 11.7 (1.0) 14.1 (1.8) 12.3 (1.6)
 Acupuncture in the treatment of erectile dysfunction
HG Kho et al
45
the choice of acupoints accordingly in every treat- substances by acupuncture could inhibit the release
ment session. of sex behaviour affecting hormones.12
Secondly, the present study evaluated the effect
of acupuncture performed as a mono-therapeutic
Conclusion
modality in ED patients. The high response by
others was in fact a result of the TCM approach in
which acupuncture was only a part of the treatment This pilot study demonstrated a modulating positive
procedures. effect of acupuncture as a monotherapy on psycho-
Thirdly, not all of the patients included in this genic and non-psychogenic ED, whereas no accom-
study suffered from psychogenic ED, whereas only panying changes in circulating sex and stress
psychogenic ED has been included in other studies. hormones are observed. A large control study is
Four of them had ED due to organic disease; if they needed before any de®nite conclusion can be made.
are not taken into account, the overall effect of 63%
(5 out of 8) approached the success of other studies.
It is noteworthy that one patient labelled to have a Acknowledgements
contributing organic factor reported increased sex-
ual activity and improvement of sexual quality The study was made possible by a grant from the
following treatment. Royal Dutch Academy of Sciences in view of a
Fourthly, cultural background of the patient bilateral exchange between Chinese and Dutch
populations. As acupuncture has been practised scientists, and was supported by Schwa-Medico of
for many centuries in China, the method has been The Netherlands and Foundation for the scienti®c
accepted as a treatment modality for different study of Chinese medicine (SAPOC) of Nijmegen,
complaints and disorders. This might have in¯u- The Netherlands. We thank GJ Pesman for hormone
enced the higher response reported in the Chinese measurement, Caris CTM and WPJ Witjes for critical
studies on the one hand, and the moderate response comments and EN Robertson FRCA for correcting
in this study. the manuscript.

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