acupuncture for treatment of erectile dysfunction: a ... · erectile dysfunction (ed), also called...
TRANSCRIPT
INTRODUCTION
Erectile dysfunction (ED), also called impotence, is defined as an inability to obtain or maintain a penile erection sufficient for satisfactory sexual intercourse
[1]. ED is a common clinical condition, affecting men of all ages, particularly the elderly. ED affects around 52% in men aged 40 to 70 years, with more than 320 million men predicted to suffer from ED by 2025 years worldwide [2]. ED can result in considerable distress
Received: Oct 7, 2018 Revised: Jan 18, 2019 Accepted: Feb 4, 2019 Published online Mar 15, 2019Correspondence to: Jian-ping Liu https://orcid.org/0000-0002-0320-061X Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing 100029, China.Tel: +86-10-64286760, Fax: +86-10-64286871, E-mail: [email protected]
Copyright © 2019 Korean Society for Sexual Medicine and Andrology
Original ArticlepISSN: 2287-4208 / eISSN: 2287-4690World J Mens Health Published online Mar 15, 2019https://doi.org/10.5534/wjmh.180090
Acupuncture for Treatment of Erectile Dysfunction: A Systematic Review and Meta-Analysis
Bao-yong Lai1 , Hui-juan Cao1 , Guo-yan Yang2 , Li-yan Jia3 , Suzanne Grant2 , Yu-tong Fei1 , Emma Wong 2 , Xin-lin Li1 , Xiao-ying Yang1 , Jian-ping Liu1,4
1Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing , China, 2NICM Health Research Institute, Western Sydney University, Penrith, Australia, 3School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China, 4Institute of Integrated Traditional Chinese Medicine and Western Medicine, Guangzhou Medical University, Guangzhou, China
Purpose: To assess the effectiveness and safety of acupuncture for erectile dysfunction (ED).Materials and Methods: We searched six major English and Chinese databases included randomized controlled trials (RCTs) testing acupuncture alone or in combination for ED. Dichotomous data were presented as risk ratio (RR) and continuous data were presented as mean difference (MD) both with 95% confidence interval (CI). The Revman (v.5.3) was used for data analyses. Quality of evidence across studies was assessed by the online GRADEpro tool.Results: We identified 22 RCTs, fourteen of them involving psychogenic ED. Most of the included RCTs had high or unclear risk of bias. There was no difference between electro-acupuncture and sham acupuncture with electrical stimulation on the rate of satisfaction and self-assessment (RR, 1.50; 95% CI, 0.71–3.16; 1 trial). Acupuncture combined with tadalafil appeared to have better effect on increasing cure rate (RR, 1.31; 95% CI, 1.00–1.71; 2 trials), and International Index of Erectile Func-tion-5 scores (MD, 5.38; 95% CI, 4.46–6.29; 2 trials). When acupuncture plus herbal medicine compared with herbal medi-cine alone, the combination therapy showed significant better improvement in erectile function (RR, 1.68; 95% CI, 1.31–2.15; 7 trials). Only two trials reported facial red and dizziness cases, and needle sticking and pruritus cases in acupuncture group. Conclusions: Low quality evidence shows beneficial effect of acupuncture as adjunctive treatment for people mainly with psychogenic ED. Safety of acupuncture was insufficiently reported. The findings should be confirmed in large, rigorously de-signed and well- reported trials.
Keywords: Acupuncture; Erectile dysfunction; Meta-analysis; Randomized controlled trial; Systematic review
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.
https://doi.org/10.5534/wjmh.180090
2 www.wjmh.org
and lowered quality of life. As it is associated with a wide variety of underlying conditions such as diabetes and cardiovascular co-morbidities, treatment options depend upon the associated factors and diverse ap-proaches in different settings [3]. Current treatment for ED included oral drugs, intrapenile therapies and penile prosthesis implantation, but with uncertain ef-fect [4]. Alternative options such as non-pharmaceutical therapies are needed and expected.
Acupuncture, part of traditional Chinese medicine (TCM), is increasingly used for the treatment of ED. There are different ways for its use, including stimula-tion of acupoints with needling, heating (moxibustion), electrical current, or injecting drugs into acupoints [5]. TCM theory states that ED is usually caused by the decline of fire from the life gate (Ming men), sexual indulgence or frequent masturbation, and emotional disturbances. Thus, the principle of acupuncture treat-ment is to invigorate the kidney qi and nourish the heart and spleen. As such, and selecting acupoints from the Kidney Meridian of Foot-Shaoyin and the Ren Meridian and back-shu points is commonly used for treating ED, and moxibustion can be used as well dur-ing the treatment [6,7].
The potential mechanism of action by how acupunc-ture may have an effect on ED is unclear. However, there is some indication that acupuncture may stimu-late nerve endings, and induce nerve impulses which then impact on levels of norepinephrine, acetylcholine, and their biological enzymes in the central nervous system [8]. Some clinical trials have been conducted to investigate the effect of acupuncture in the treatment of ED. A systematic review published in 2016 con-cluded with insufficient results about the effect of acu-puncture when comparing with sham acupuncture and psychological therapy [9]. Another recent systematic review summarized evidence of acupuncture for ED [10]. However, this review searched literature mainly from Chinese databases, and its control groups were only Chinese herbal medicine. As a result, the interpreta-tion of the findings may be limited. Our review aims to comprehensively review the current evidence of acu-puncture for ED.
MATERIALS AND METHODS
1. Inclusion/exclusion criteria We included both parallel, cross-over, randomized
clinical trials, regardless of blinding and publica-tion status. Types of participants included men who were diagnosed as ED by any recognized national or international criteria, regardless of psychogenic and organic origin of impotence. Interventions included as verum acupuncture (defined as needling stimula-tion of acupuncture points or trigger points by manual acupuncture with or without heating [moxibustion]), electro-stimulating, acupoint injection, acupressure and laser acupuncture [5,6]. Controls included no treatment, sham acupuncture, herbal medicine, or conventional medicine. Co-interventions were allowed as long as they were given equally to all randomized arms.
1) Primary outcomes (1) Patient erectile function and partner satisfaction
measured by International Index of Erectile Function-5 (IIEF-5) score and its components [11]; (2) The effect and quality of sexual intercourse presented as “cure”, or “markedly improved on erectile function” based on validated measurement tools or scales. “Cure” was de-fined as symptom disappearance with successful sexual activity and/or with IIEF-5 score ≥22 [11]. “Markedly improved on erectile function” referred to that all the three below items were met: the self-report disappear-ance of clinical symptoms, the erection angle of penis is more than 90 degrees in sexual activity, and the suc-cess rate of sexual intercourse is over 75%.
2) Secondary outcomes(1) The quality of sexual activity measured by “sat-
isfaction and self-assessment”, which defined as the self-reported satisfaction by patients or their partners. They reported that the symptoms disappeared, at same time, erectile function and sexual life returned to normal; (2) Angle of penile erection measured by self-assessment tools or scales; (3) Adverse events.
2. Search strategy We searched for published studies in two English
and four Chinese electronic databases from their in-ception to August 31st, 2018, including PubMed, the Cochrane Library, Sinomed Database, China National Knowledge Infrastructure, Wanfang Database, and China Science Technology Journal Database. The search terms included acupuncture-related terms (i.e., “acupuncture”, “electro-acupuncture”, “auricular therapy”, “warm needling”, “fire needling”, “shark hook
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
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needling”, “magnet needle”, “acupoint injection”, “point injection”, “moxibustion”, “acupressure”), combined with erectile dysfunction related terms (i.e., “erectile dysfunction [Mesh terms]”, “impotence”, “yang wei”). Search term strategies were adapted for each specific database.
3. Study selection and data extractionTwo authors (Lai BY and Jia LY) independently
selected the trials included in the review according to the inclusion/exclusion criteria. Any disagreement was resolved by discussion. We performed data extrac-tion using a self-developed data extraction form. If the necessary data were not available in the trial reports, further information was sought by contacting corre-sponding author.
4. Assessment of methodological qualityThe risk of bias of the included trials was assessed
independently according to the criteria from the Co-chrane Handbook for Systematic Reviews of Interven-tions [12]. Criteria included adequacy of generation of the allocation sequence, allocation concealment, blind-ing (blinding of participants and personnel, blinding of outcome assessors), incomplete outcome data or not, whether selected reporting the results and other bias (e.g., imbalance of the baseline information). Risk of bias for each trial was assessed as low, high, or unclear. A trial was considered as having low risk of bias when all the items met the criteria; a trial was considered at high risk of bias when at least one of the items was not met; and a trial was considered unclear risk of bias
where insufficient information was available to make the judgment. Any difference in the quality assess-ment of trials was resolved by discussion in order to reach consensus. Quality of evidence across studies for each important outcome was assessed using the online GRADE approach to support the recommendations us-ing the online GRADEpro tool (https://gradepro.org/).
5. Data analysisMeta-analysis was performed within comparisons
of the same type of acupuncture versus the similar control. Dichotomous data were presented as risk ratio (RR) and continuous outcomes as mean difference (MD), both with 95% confidence intervals (CI). We used I-square value to detect statistical heterogeneity and to measure the percentage of the variability in effect siz-es between studies that is due to heterogeneity rather than to sampling error. We used random effects model to combine the results in this review due to potential sources of clinical heterogeneity [12]. If the I2>75%, we did not pool the data and results from each individual trial were presented respectively. The statistical analy-sis was carried out using Revman 5.3 software. If a sufficient numbers of randomized trials were identi-fied and data available, subgroup analysis would be performed according to the comparisons.
RESULTS
1. Study selectionWe identified 300 studies, of which 68 duplicates
were removed. After screening the abstracts, 190 trials
CNKI(n=92)
VIP(n=39)
Sinomed(n=58)
Wanfang(n=87)
PubMed(n=12)
Cochrane(n=12)
Records after duplicates removed(n=232)
Records after title and abstracts(n=42)
Studies included in quantitative formeta-analysis (n=22)
Titles and abstracts
Full-text reading
Records excluded (total: n=190):unrelated research (n=80), not RCTs(n=3), improper intervention typeand irrelevant comparisons (n=46),animal experiment (n=39),duplicate studies (n=22)
Records excluded (total: n=20):improper intervention types (n=9),not RCTs (n=1), duplicate studies (n=3),irrelevant comparisons (n=7)
Fig. 1. Study selection flow diagram. CNKI: China National Knowledge Infra-structure, VIP: Chinese Science Journal Database, RCT: randomized controlled trial.
https://doi.org/10.5534/wjmh.180090
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were excluded with reasons. Full-texts of the remain-ing 42 trials were retrieved and assessed for eligibility. A total of 22 randomized controlled trial (RCT) met the inclusion criteria. Fig. 1 illustrates a PRISMA flow dia-gram.
2. Description of studies Twenty-two RCTs involving 1,751 participants were
enrolled in this review. All of them were conducted in China, and 2 of them published in English. All trials had parallel comparisons, except one [13] that used a crossover design. The sample size varied from 21 to 176 participants, with an average of 35 patients per group. The participants were male adults aged from 20 to 69 years old. The interventions included manual acupunc-ture with or without moxibustion, electro-acupuncture, and acupuncture point injection. Type of controls in-cluded sham acupuncture, herbal medicine, Western medicine, psychological therapy, and hypnosis therapy. The types of ED of twenty-two trials included 2 trials [14,15] were involving ED participants with type-2 dia-betes, two trials [16,17] were involving ED participants with psychogenic or arterial supply insufficiency, four-teen trials [13,18-30] were ED participants with psycho-genic, and four trials [31-34] not reported ED informa-tion. The characteristics of included studies are shown in Table 1.
3. Description of therapeutic regimen A summary of acupuncture regimen is provided in
Appendix 1, which contains a list of acupoints, treat-ment frequency and duration for each trial (Appendix 1). Participants of included trials accepted acupuncture one session daily for 30 minutes at most of the occa-sions. The principle of acupuncture treatment was to improve the erectile function and the most common used acupoints and involving meridian were Guan Yuan (CV4, the Ren Meridian, 15 trials), San Yin Jiao (SP6, the Splenic Meridian of Foot-taiyin, 15 trials), Shen Shu (BL23, the Bladder Meridian Foot-taiyang, 13 trials), Zu San Li (ST36, the Stomach Meridian of Foot-yangming, 12 trials), Ming Men (DU4, the Du Meridian of Foot-shaoyin, 8 trials), Tai Chong (LR3, the Liver Meridian of Foot-jueyin, 7 trials), Tai Xi (KI3, the Kidney Meridian of Foot-shaoyin, 7 trials) and Ci Liao (BL32, the Bladder Meridian Foot-taiyang, 5 tri-als).
4. Assessment of risk of biasAccording to the pre-defined approach, 22 trials were
found to be either unclear (n=19) or high risk of bias (n=3) due to insufficient or inadequate reporting of the information. Only 6 trials [14,16,19,25,27,30] described that random number table was used to generate the random allocation, thus assessed as having low risk of bias. However, none of the trials reported the alloca-tion concealment. Due to special characteristics of acu-puncture, it is difficult for blinding to practitioners, so only two trials [13,18] used sham acupuncture as con-trol and were assessed as low risk of performance bias regarding to the potential adequate blinding method of participants. Risk of detective bias was assessed to be unclear since none of them reported the method of blinding to outcome assessors or statistician. One trial [18] reported number and reasons for drop-out participants, which was regarded low risk of attrition bias. The other 21 trials did not specify the drop-out, and were all evaluated as unclear risk of attrition bias. Twenty trials were assessed as having unclear risk of selective reporting bias due to the absence of protocol; the remaining three trials [22,25,26] were assessed as high risk of selective reporting bias since they all had obvious problems on primary outcome reporting. Other bias was assessed by comparability between groups on baseline data such as age and duration of ED. Only six trials [16,18,21,24,31,32] reported baseline data including age and duration of dysfunction. There is no statistical description of details, so the risk of bias was assessed as unclear. The methodological quality of all the in-cluded trials is shown in the Fig. 2.
5. Effect estimates Data analysis was conducted according to the type
of comparisons. Table 2 illustrates the details of effect estimates of acupuncture for ED.
1) Acupuncture versus sham acupuncture One trial [18] compared electro-acupuncture with
sham acupuncture (needles inserted into non acu-points), the results showed no difference on the rates of satisfaction and self-assessment between groups (RR, 1.50; 95% CI, 0.71–3.16; 60 participants). Another cross-over trial [13] compared manual acupuncture with sham acupuncture (needle insert into irreverent points) showed significant better effect on the rates of satis-faction and self-assessment (RR, 7.53; 95% CI, 1.13–50.00;
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
5www.wjmh.org
Tabl
e 1.
Cha
ract
erist
ics o
f 22
the
incl
uded
rand
omiz
ed tr
ials
Stud
y ID
Sam
plea
Age
(y)b
Type
of E
D In
terv
entio
nCo
ntro
lD
urat
ion
of
trea
tmen
t(w
k)c
Out
com
e m
easu
re
Aydi
n et
al
(199
7) [1
8]T:
15,
C1: 1
5,C2
: 15,
C3: 1
5
T: 3
6.75
±10.
43,
C1: 3
8.4±
10.7
5,C2
: 35.
1±10
.46,
C3: 3
7.1±
11.3
2
Psyc
hoge
nic
EA, 3
Hz d
irect
-cur
rent
(d
c), 2
0 m
inut
es, t
wic
e a
wee
k
C1: h
ypno
tic th
erap
y, (3
tim
es a
wee
k, la
ter o
nce
a m
onth
)C2
: ora
l pla
cebo
(vita
min
pill
s)C3
: sha
m a
cupu
nctu
re (n
on-a
cupu
nctu
re p
oint
s) 3
Hz
dc, 2
0 m
inut
es, t
wic
e a
wee
k
T: 6
,C1
: 6,
C2: 6
,C3
: 6
Satis
fact
ion
of se
lf-as
sess
men
t rat
e,
adve
rse
effe
cts
Cao
et a
l (20
07)
[31]
T: 3
6,C:
18
T: 2
5–58
,C:
26–
59N
RM
A pl
us co
ntro
l, 30
m
inut
es, o
nce
daily
CHM
(sel
f-pre
scrib
ed h
erba
l dec
octio
n), t
wic
e da
ily
8M
arke
dly
impr
oved
on
erec
tile
func
tion
rate
Chen
g an
d Ca
o (2
009)
[32]
T: 3
2,C:
32
T: 2
0–56
,C:
21–
54
NR
MA
plus
cont
rol,
30
min
utes
, onc
e da
ilyCH
M (s
elf-p
resc
ribed
her
bal d
ecoc
tion)
, tw
ice
daily
4 M
arke
dly
impr
oved
on
erec
tile
func
tion
rate
Chen
et a
l (2
011)
[19]
T: 6
1,C:
62
T: 2
7.62
,C:
27.
58
Psyc
hoge
nic
EA p
lus c
ontr
ol, w
ith
dens
ity w
ave,
30
min
utes
, onc
e da
ily
CHM
(com
poun
d Xu
an Ju
), 3
caps
ules
, 3 ti
mes
dai
ly4
Satis
fact
ion
of se
lf-as
sess
men
t rat
e, II
EF-5
sc
ores
Cui e
t al (
2007
) [1
6]T:
50,
C1: 5
0,C2
: 50
T: 2
0–69
,C1
: 20–
69,
C2: 2
0–69
Psyc
hoge
nic
or
arte
rial s
uppl
y in
suffi
cien
cy
Salv
ia m
iltio
rrhiza
inje
ctio
n an
d bu
pleu
rum
inje
ctio
n on
ce e
very
2 d
ays
C1: a
cupo
int i
njec
tion
with
salin
e, o
nce
ever
y 2
days
C2: C
HM (C
hun
Yi c
apsu
le),
0.5
g/tim
es, 3
tim
es d
aily
3 M
arke
dly
impr
oved
on
erec
tile
func
tion
rate
, IIE
F-5
scor
esD
ai e
t al (
2003
) [2
0]T:
44,
C: 4
1T:
35.
75±3
.17,
C:
36.
24±4
.12
Psyc
hoge
nic
MA
plus
cont
rol,
30
min
utes
, onc
e da
ilyCH
M (K
ang
Wei
Lin
g de
coct
ion)
, 2.5
–4.5
g/t
imes
, tw
ice
daily
4M
arke
dly
impr
oved
on
erec
tile
func
tion
rate
Din
g et
al
(201
2) [3
3]T1
: 88,
C: 4
4T:
41.
3±8.
1,C:
39.
1±6.
7Ps
ycho
geni
cM
A pl
us co
ntro
l, 30
m
inut
es, o
nce
daily
CHM
(Si N
i dec
octio
n), 3
tim
es d
aily
4–8
Mar
kedl
y im
prov
ed o
n er
ectil
e fu
nctio
n ra
te,
peni
le e
rect
ion
angl
eT2
: 44,
C: 4
4T:
38.
3±7.
4,C:
39.
1±6.
7Ps
ycho
geni
cM
A, 3
0 m
inut
es, o
nce
daily
CHM
(mod
ified
her
bal d
ecoc
tion)
, 3 ti
mes
dai
ly4–
8 M
arke
dly
impr
oved
on
erec
tile
func
tion
rate
, pe
nile
ere
ctio
n an
gle
Dua
n (2
007)
[1
7]T:
30,
C: 3
0T:
27–
55,
C: 2
9–52
Psyc
hoge
nic
or
arte
rial s
uppl
y in
suffi
cien
cy
MA,
30
min
utes
, onc
e da
ilyCH
M (Y
ou G
ui p
ill),
one
pill,
twic
e da
ily4
Mar
kedl
y im
prov
ed o
n er
ectil
e fu
nctio
n ra
te
Enge
lhar
dt
et a
l (20
03)
[13]
T: 1
0,C:
11
T: 3
8.9,
C: 3
8.9
Psyc
hoge
nic
MA,
20
min
utes
, onc
e or
tw
ice
wee
kly
Sham
acu
punc
ture
aga
inst
hea
dach
e ac
upoi
nt, 2
0 m
inut
es, o
nce
or tw
ice
wee
kly
6.2
(4–1
0)Sa
tisfa
ctio
n of
self-
asse
ssm
ent r
ate,
IIEF
sc
ores
, adv
erse
effe
cts
Jiang
et a
l (2
014)
[21]
T: 6
4,C:
64
T: 2
1–64
,C:
22–
65Ps
ycho
geni
cM
A pl
us co
ntro
l, 30
m
inut
es, o
nce
daily
CHM
(sel
f-pre
scrib
ed h
erba
l dec
octio
n), t
wic
e da
ily3–
5 Cu
re ra
te, I
IEF
scor
es
Jiang
et a
l (2
012)
[22]
T: 5
1,C:
51
T: 2
8.73
±3.2
7,C:
27.
67±4
.12
Psyc
hoge
nic
MA
plus
cont
rol,
30
min
utes
, onc
e da
ilyPh
ysic
al tr
aini
ng, 5
–15
min
utes
eac
h tim
e, 1
2 tim
es
from
15
days
4Sa
tisfa
ctio
n of
self-
asse
ssm
ent r
ate
Lin
et a
l (20
05)
[23]
T: 6
4,C:
32
T: 3
8.3±
8.1,
C: 3
9.1±
6.7
Psyc
hoge
nic
MA
plus
cont
rol,
30
min
utes
, onc
e da
ilyCH
M (s
elf-p
resc
ribed
her
bal d
ecoc
tion)
, tw
ice
daily
4–8
Mar
kedl
y im
prov
ed o
n er
ectil
e fu
nctio
n ra
te,
peni
le e
rect
ion
angl
eLi
u et
al (
2016
) [2
4]T:
32,
C: 3
0T:
32,
C: 3
0Ps
ycho
geni
cAI
HE p
lus c
ontr
ol,
inje
ctio
n 1
mL/
time,
on
ce e
very
2 d
ay
Tada
lafil
tabl
et, 5
mg/
times
, onc
e da
ily12
Cure
rate
, IIE
F sc
ores
https://doi.org/10.5534/wjmh.180090
6 www.wjmh.org
Tabl
e 1.
Con
tinue
d
Stud
y ID
Sam
plea
Age
(y)b
Type
of E
D In
terv
entio
nCo
ntro
lD
urat
ion
of
trea
tmen
t(w
k)c
Out
com
e m
easu
re
Liu
(201
7) [2
5]T:
31,
C: 3
1T:
42.
68±2
.35,
C: 4
2.56
±2.4
5Ps
ycho
geni
cM
A w
ith m
oxib
ustio
n pl
us co
ntro
l, M
A: 3
0 m
inut
es, o
nce
daily
Tada
lafil
tabl
et, 1
0 m
g/tim
es, 3
tim
es d
aily
4 Cu
re ra
te, a
dver
se e
ffect
s
Liu
and
Ren
(201
5) [1
4]T:
30,
C: 3
0T:
47.
4±6.
01,
C: 4
7.8±
6.51
ED w
ith ty
pe-2
di
abet
esM
A pl
us co
ntro
l, 20
m
inut
es, o
nce
daily
Psyc
hoth
erap
y an
d ex
erci
se8
Cure
rate
, IIE
F sc
ores
Shan
(200
1)
[26]
T: 6
0,C:
30
T: 4
3.6,
C: 4
3.6
NR
MA
plus
cont
rol,
20
min
utes
, onc
e da
ilyCH
M (s
elf-p
resc
ribed
her
bal d
ecoc
tion)
, tw
ice
daily
12M
arke
dly
impr
oved
on
erec
tile
func
tion
rate
Xie
(201
6) [2
7]T:
40,
C: 4
0T:
42.
8±8.
35,
C: 4
3.19
±8.0
7Ps
ycho
geni
c M
A pl
us co
ntro
l, 30
m
inut
es, o
nce
daily
CHM
(Con
g Ro
ng Y
i She
n gr
anul
es),
twic
e da
ily
16Cu
re ra
te, I
IEF
scor
es,
adve
rse
effe
cts
Yang
and
Tia
n (2
008)
[34]
T: 2
0,C:
20
T: 4
0,C:
40
NR
MA
plus
cont
rol,
30
min
utes
, onc
e da
ilyCH
M (s
elf-p
resc
ribed
She
n Q
i Er X
ian
herb
al d
ecoc
tion)
, tw
ice
daily
4–8
Satis
fact
ion
of se
lf-as
sess
men
t rat
eYe
and
Che
n (2
017)
[28]
T: 2
0,C:
20
T: 3
4.15
±6.4
3,C:
36.
25±5
.25
Psyc
hoge
nic
MA
plus
cont
rol,
30
min
utes
, onc
e da
ilyCH
M (H
uan
Shao
cap
sule
), 2.
1 g/
times
, 3 ti
mes
dai
ly4
Cure
rate
, IIE
F sc
ores
Jia (2
018)
[29]
T: 2
0,C:
20
T: 4
0.15
±1.6
8,C:
40.
86±1
.91
Psyc
hoge
nic
MA
with
mox
ibus
tion
plus
cont
rol,
30
min
utes
, onc
e da
ily
Tada
lafil
tabl
et, 5
mg/
times
, onc
e da
ily3
Cure
rate
, IIE
F sc
ores
, ad
vers
e ef
fect
s
Li e
t al (
2018
) [1
5]T:
45,
C: 4
5T:
45.
26±4
.17,
C: 4
6.14
±4.5
1ED
with
type
-2
diab
etes
EPAS
plu
s con
trol
, 4 m
in/
time
for o
ne a
cupo
int,
tota
l 24
min
utes
, onc
e da
ily
Tada
lafil
tabl
et, 5
mg/
times
, onc
e da
ily4
Cure
rate
, IIE
F sc
ores
, ad
vers
e ef
fect
s
Yu e
t al (
2018
) [3
0]T:
20,
C: 2
0T:
34.
15±6
.43,
C: 3
6.25
±5.2
5Ps
ycho
geni
cM
A pl
us co
ntro
l, 30
m
inut
es, o
nce
daily
Sild
enaf
il ta
blet
, 12.
5 m
g/tim
es, t
wic
e da
ily6
Cure
rate
, IIE
F sc
ores
“Cur
ed” r
efer
s to
patie
nts w
ho re
port
ed th
at th
eir c
linic
al sy
mpt
oms d
isapp
eare
d, th
ey h
ad n
o pr
oble
m w
ith se
xual
act
ivity
, and
/or w
ith In
tern
atio
nal I
ndex
of E
rect
ile F
unct
ion
(IIEF
-5) s
core
was
≥2
2 [3
1]. ‘M
arke
dly
impr
oved
on
erec
tile
func
tion’
refe
rs to
that
all
the
thre
e be
low
item
s wer
e m
et: t
he se
lf-re
port
disa
ppea
ranc
e of
clin
ical
sym
ptom
s, th
e er
ectio
n an
gle
of p
enis
is m
ore
than
90
degr
ees i
n se
xual
act
ivity
, and
the
succ
ess r
ate
of se
xual
inte
rcou
rse
is ov
er 7
5%.
ED: e
rect
ile d
ysfu
nctio
n, T
: tre
atm
ent g
roup
, C: c
ontr
ol g
roup
, NR:
not
repo
rted
, EA:
ele
ctro
acu
punc
ture
, MA:
man
ual a
cupu
nctu
re, A
IHE:
acu
poin
t inj
ectio
n of
her
bal e
xtra
ct, E
PAS:
mod
erat
e—fre
quen
cy e
lect
rical
pul
se a
cupo
int s
timul
atio
n, C
HM: C
hine
se h
erba
l med
icin
e.a Va
lues
are
pre
sent
ed a
s num
ber o
nly.
b Valu
es a
re p
rese
nted
as m
ean±
stan
dard
dev
iatio
n, ra
nge,
or m
ean
only
. c Valu
es a
re p
rese
nted
as m
ean
only
, ran
ge o
nly,
or m
edia
n (ra
nge)
.
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
7www.wjmh.org
60 participants). No other results were reported from these two trials.
2) Acupuncture plus western medicine versus western medicine
Two trials [15,24] compared acupuncture plus tadalafil compared with tadalafil alone. The combina-tion therapy showed better effect on increasing cure rate (RR, 1.31; 95% CI, 1.00–1.71; I2=0%; 2 trials; 152 par-ticipants) and IIEF-5 scores (MD, 5.38; 95% CI, 4.46–6.29; I2=0%; 2 trials; 152 participants). Another trial [30] com pared acupuncture plus sildenafil compared with sildenafil alone, and the combination therapy showed better effect on increasing IIEF-5 scores (MD, 3.23; 95% CI, 2.12–4.34; 1 trial; 70 participants). There was no sig-nificant between-group difference in terms of cure rate
(RR, 3.0; 95% CI, 0.65–13.86; 1 trial; 70 participants).
3) Manual acupuncture plus moxibustion versus tadalafil tablet
Two trials [25,29] compared acupuncture plus moxi-bustion compared with tadalafil alone. There was no significant difference between groups in cure rate (RR, 1.40; 95% CI, 0.74–2.66; 2 trials; I2=0%; 102 participants). No difference between groups was found from one trial [29] in IIEF-5 scores (MD, 1.15; 95% CI, 1.37–0.93; 40 participants).
4) Acupuncture versus herbal medicine Two trials [17,33] compared acupuncture with herbal
medicine and another trial [16] compared acupoint injection of herbal extracts with oral herbal medi-cine. There was no difference between acupuncture and herbal medicine in terms of markedly improved on erectile function rate (RR, 1.40; 95% CI, 0.42–4.69; I2=46%; 2 trials; 148 participants) [17,33]. However, the acupoint injection of herbal extracts significantly increased the IIEF-5 scores compared to oral herbal medicine (MD, 4.0; 95% CI, 3.66–4.34; 1 trial; 100 partici-pants) [16].
5) Acupuncture plus herbal medicine versus herbal medicine alone
Acupuncture plus herbal medicine was tested in seven trials [20,23,26,27,31-33], which showed significant better effect on markedly improved rate on erectile function (as measured by the erection angle and suc-cess rate of sexual intercourse) than herbal medicine alone (RR, 1.68; 95% CI, 1.31–2.15; I2=0%; 7 trials; 601 participants).
By excluding three trials [26,31,32] for not reporting types information of ED, remaining four trials only involving ED patients with psychogenic also show that better effect on markedly improved rate on erec-tile function in combination therapy group (RR, 1.63; 95% CI, 1.21–2.19; I2=0%; 4 trials; 393 participants). The pooled results also showed significantly better effects of the combination therapy on cure rate (RR, 1.36; 95% CI, 1.12–1.65, I2=0%; 2 trials; 168 participants) [21,28] and rigidity (as measured by erectile angle) in sexual intercourse (MD, 6.73 degree; 95% CI, 4.10–9.36; I2=0%; 2 trials; 228 participants) [23,33]. However, no difference was found between groups in the rate of satisfaction and self-assessment (RR, 1.67; 95% CI, 0.64–4.36; I2=75%;
Random
sequence
genera
tion
(sele
ctio
nbia
s)
Allo
catio
nconcealm
ent(s
ele
ctio
nbia
s)
Blin
din
gofpartic
ipants
and
pers
onnel (
perform
ance
bia
s)
Blin
din
gofoutc
om
eassessm
ent(d
ete
ctio
nbia
s)
Incom
ple
teoutc
om
edata
(attritio
nbia
s)
Sele
ctiv
ere
portin
g(r
eportin
gbia
s)
Oth
er
bia
s
Aydin et al (1997) [18]
Cao et al (2007) [31]
Cheng and Cao (2009) [32]
Chen et al (2011) [19]
Cui et al (2007) [16]
Dai et al (2003) [20]
Ding et al (2012) [33]
Duan (2007) [17]
Engelhardt et al (2003) [13]
Jia (2018) [29]
Jiang et al (2014) [21]
Jiang et al (2012) [22]
Lin et al (2005) [23]
Li et al (2018) [15]
Liu et al (2016) [24]
Liu (2017) [25]
Liu and Ren (2015) [14]
Shan (2001) [26]
Xie (2016) [27]
Yang and Tian (2008) [34]
Ye and Chen (2017) [28]
Yu et al (2008) [30]
Fig. 2. Risk of bias summary.
https://doi.org/10.5534/wjmh.180090
8 www.wjmh.org
Tabl
e 2.
Effe
ct e
stim
ates
of i
nclu
ded
22 tr
ials
Out
com
e an
d co
mpa
rison
Stud
yPa
rtic
ipan
t Ef
fect
est
imat
e (9
5% C
I) RE
Mp-
valu
eSt
udy
ID
Elec
tron
ic a
cupu
nctu
re v
ersu
s sha
m a
cupu
nctu
re w
ith e
lect
rical
stim
ulat
ion
Sat
isfac
tion
of se
lf-as
sess
men
t rat
e1
60RR
1.5
0 (0
.71–
3.16
)-
Aydi
n et
al (
1997
) [18
]M
anua
l acu
punc
ture
ver
sus s
ham
acu
punc
ture
Sat
isfac
tion
of se
lf-as
sess
men
t rat
e 1
60RR
7.5
3 (1
.13–
50.0
0)
-En
gelh
ardt
et a
l (20
03) [
13]
Acup
unct
ure
plus
tada
lafil
tabl
et v
ersu
s tad
alaf
il ta
blet
Cur
e ra
te
215
2RR
1.3
1 (1
.00–
1.71
), I2 =0
%0.
48Li
u et
al (
2016
) [24
], Li
et a
l (20
18) [
15]
IIE
F-5
scor
e2
152
MD
5.3
8 (4
.46–
6.29
), I2 =0
%0.
04Li
u et
al (
2016
) [24
], Li
et a
l (20
18) [
15]
Acup
unct
ure
plus
sild
enaf
il ta
blet
ver
sus s
ilden
afil
tabl
et C
ure
rate
170
RR 3
.00
(0.6
5–13
.86)
-Yu
et a
l (20
18) [
30]
IIE
F-5
scor
e1
70M
D 3
.23
(2.1
2–4.
34)
-Yu
et a
l (20
18) [
30]
Man
ual a
cupu
nctu
re p
lus m
oxib
ustio
n ve
rsus
tada
lafil
tabl
et C
ure
rate
2
102
RR 1
.40
(0.7
4–2.
66),
I2 =0%
0.3
Liu
(201
7) [2
5], J
ia (2
018)
[29]
IIE
F-5
scor
e1
40M
D 1
.15
(1.3
7–0.
93)
-Jia
(201
8) [2
9]Ac
upun
ctur
e ve
rsus
her
b m
edic
ine
Mar
kedl
y im
prov
ed o
n er
ectil
e fu
nctio
n ra
te
214
8RR
1.4
0 (0
.42–
4.69
), I2 =4
6%,
0.18
Din
g et
al (
2012
) [33
], D
uan
(200
7) [1
7] I
IEF-
5 sc
ore
110
0M
D 4
.00
(3.6
6–4.
34)
-Cu
i et a
l (20
07) [
16]
Acup
unct
ure
poin
t inj
ectio
n of
her
bal e
xtra
cts v
ersu
s ora
l her
bal m
edic
ine
IIE
F-5
scor
e1
100
MD
4.0
(3.6
6–4.
34)
-Cu
i et a
l (20
07) [
16]
Mar
kedl
y im
prov
ed o
n er
ectil
e fu
nctio
n ra
te1
100
RR 1
.94
(0.6
9–5.
43)
-Cu
i et a
l (20
07) [
16]
Acup
unct
ure
plus
her
bal m
edic
ine
vers
us h
erba
l med
icin
e al
one
Cur
e ra
te
216
8RR
1.3
6 (1
.12–
1.65
), I2 =0
%0.
77Jia
ng e
t al (
2014
) [21
], Ye
and
Che
n (2
017)
[28]
Mar
kedl
y im
prov
ed o
n er
ectil
e fu
nctio
n ra
te7
601
RR 1
.68
(1.3
1–2.
15),
I2 =0%
0.90
Cao
et a
l (20
07) [
31],
Chen
g an
d Ca
o (2
009)
[32]
, Dai
et a
l (2
003)
[20]
, Din
g et
al (
2012
) [33
], Li
n et
al (
2005
) [23
], Sh
an
(200
1) [2
6], X
ie (2
016)
[27]
Sat
isfac
tion
of se
lf-as
sess
men
t rat
e 2
163
RR 1
.67
(0.6
4–4.
36),
I2 =75%
0.3
Chen
et a
l (20
11) [
19],
Yang
and
Tia
n (2
008)
[34]
IIE
F-5
scor
e3
331
No
pool
ed d
ata
of tr
ials
for I
2 =95%
<0.0
5Ch
en e
t al (
2011
) [19
], Jia
ng e
t al (
2014
) [21
], Xi
e (2
016)
[27]
Ere
ctile
ang
le
222
8M
D 6
.73°
(4.1
0–9.
36),
I2 =0%
0.94
Din
g et
al (
2012
) [33
], Li
n et
al (
2005
) [23
]M
anua
l acu
punc
ture
plu
s phy
sical
ther
apy
vers
us p
hysic
al th
erap
y C
ure
rate
1
102
RR 1
.56
(0.9
9–2.
43)
-Jia
ng e
t al (
2012
) [22
] I
IEF-
5 sc
ore
160
MD
2.9
0 (2
.59–
3.21
)-
Liu
and
Ren
(201
5) [1
4]
CI: c
onfid
ence
inte
rval
, REM
: ran
dom
effe
ct m
odel
, IIE
F: In
tern
atio
nal I
ndex
of E
rect
ile F
unct
ion,
RR:
risk
ratio
, MD
: mea
n di
ffere
nce.
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
9www.wjmh.org
2 trials; 163 participants) [19,34]. Moreover, three trials [19,21,27] favored the combination therapy of acupunc-ture and herbal medicine in higher IIEF-5 scores (MD, 3.53) to herbal medicine alone, but the results could not be pooled due to high statistical heterogeneity (I2=97%).
6) Acupuncture plus psychological therapy versus psychological therapy
Two trials compared acupuncture plus psychological therapy with psychological therapy alone. One of them [22] found no difference between groups for cure rate (RR, 1.56; 95% CI, 0.99–2.43; 1 trial; 102 participants). Another trial [14] involving 60 ED participants with type-2 diabetes and found the combination therapy ap-peared to be better on higher IIEF-5 scores (MD, 2.90; 95% CI, 2.59–3.21; 1 trial; 60 participants).
6. Adverse events Seven trials reported the outcome of adverse events
and side effects [13,15,16,18,25,27,29]. One trial [16] re-ported five cases of dyspepsia, two cases of dizziness and one case of dry mouth from tadalafil in the control group; and one case having facial red and one case of dizziness in acupuncture group. Another one trial [29] reported three patients suffered from needle sticking and pruritus during treatment in acupuncture group; and there were two cases having dry mouth and head-ache from tadalafil in control group. No adverse effect or side effect was found in the remaining 5 trials.
7. Overall quality of evidence by GRADEWe graded the overall quality of available evidence
using GRADE criteria. When combination of acupunc-ture compared to tadalafil, the quality of evidence for cure rate and IIEF-5 scores was low. In comparison of other interventions and outcome assessments, the qual-ity of evidence was mainly low or very low due to high risk of bias, imprecision (small number of total events or small sample size), or indirectness (outcome mea-sures). Detail of result is show in Table 3.
8. Additional analysisWe tried to do the subgroup analyses according to
the types of ED participants, but failed, due to the insufficient number of trials and related information. We could not perform other meaningful sensitivity analysis either.
DISCUSSION
1. Summary of the main results Twenty-three RCTs were included in this review.
The majority of the included studies were having high or unclear risk of bias. Low quality evidence showed there was no difference between acupuncture alone and sham acupuncture, tadalafil, or herbal medicine on symptoms improvement for ED. Combination of acupuncture appeared to show beneficial effect of acu-puncture as adjunctive treatment for ED participants with psychogenic or partly with type-2 diabetes, when compared with other conventional therapies (such as tadalafil, psychological therapy or herbal medicine). However, the level of evidence for all outcomes were assessed as “low” or “very low” due to high risk of bias, imprecision or indirectness among included trials. The findings need to be seen as inconclusive due to small sample size and poor methodological quality. Safety of acupuncture was insufficiently reported in the includ-ed trials.
2. Comparison with previous studiesThere are two published reviews on this topic. One
included 3 RCTs involving 183 participants with ED [9], which compared acupuncture with sham acupuncture and psychological therapy respectively. The included RCTs in this review failed to show a specific therapeu-tic effect of acupuncture, and had methodological flaws as concluded by the authors. And the other recent one only involved Chinese database and included 6 RCTs, control treatment were only involving Chinese herbal medicine and details of treatment information were not clearly specified [10]. In addition, the findings of both two reviews of included trials were not finally pooled due to statistical and clinical heterogeneity, which failed to show a specific therapeutic effect of acupuncture for ED. Compared to the previous two reviews, this update review covered a broader combi-nation of studies, including acupuncture with moxibus-tion, the acupoint injection and different comparisons, and additional outcome assessments. We performed analyses based on different comparisons and found that although the strength of the evidence was weak, the findings showed there was a potential add-on effect of acupuncture for patients with ED. A total of 31.8% (7/22) of included trials had reported adverse informa-tion from acupuncture. This review provided latest evi-
https://doi.org/10.5534/wjmh.180090
10 www.wjmh.org
dence of acupuncture for ED. There are also some limitations of this systematic
review. Firstly, the findings are summarized from original included trials with the poor quality and small sample size, which contributed to reduced internal va-lidity of the pooling result. Secondly, it should be point out that although some combination of acupuncture
appeared to show beneficial effect of acupuncture as an adjunctive treatment for ED according to the symptom improvement assessed by IIEF-5 scores scale or self-assessment,our analysis was not able to reach a clear recommendation regarding the effect of acupunc-ture on ED because most studies showed no benefit of acupuncture alone and variable outcome measure-
Table 3. Summary of main findings of RCTs on acupuncture for erectile dysfunction
OutcomeNo. of
participant(No. of RCT)
Quality of the evidence
Relative effect(95% CI)
Anticipated absolute effect
Risk with control
Risk difference with intervention (95% CI)
Electronic acupuncture versus sham acupuncture Satisfaction of self-assessment rate 30 (1) ⨁○○○acd RR 1.50 (0.71–3.16) 400 per 1,000 200 more per 1,000 (116 more
to 864 more)Manual acupuncture versus sham acupuncture Satisfaction of self-assessment rate 30 (1) ⨁○○○acd RR 7.53 (1.13–50.00) 91 per 1,000 594 more per 1,000 (12 more to
1,000 more)Acupuncture plus tadalafil tablet versus tadalafil tablet Cure rate 152 (2) ⨁⨁○○ac RR 1.31 (1.00–1.71) 467 per 1,000 145 more per 1,000 (0 more to
331 more) IIEF-5 score 152 (2) ⨁⨁○○ac N/A MD 5.38 higher (4.46 higher to
6.29 higher)Acupuncture versus herb medicine M arkedly improved on erectile
function rate204 (3) ⨁○○○acd RR 1.51 (0.96–2.38) 194 per 1,000 99 more per 1,000 (8 fewer to
268 more) IIEF-5 score 100 (1) ⨁⨁○○ac N/A MD 4 higher (3.66 higher to 4.34
higher)Acupuncture plus herb medicine versus herb medicine Cure rate 168 (2) ⨁⨁○○ac RR 1.36 (1.12–1.65) 607 per 1,000 219 more per 1,000 (73 more to
395 more) M arkedly improved on erectile
function rate601 (7) ⨁○○○acd RR 1.68 (1.31–2.17) 241 per 1,000 164 more per 1,000 (75 more to
281 more) Satisfaction of self-assessment rate 163 (2) ⨁○○○abc RR 1.67 (0.64–4.36) 463 per 1,000 310 more per 1,000 (167 fewer
to 1,557 more) IIEF-5 score 331 (3) ⨁⨁○○ab N/A MD 3.53 higher (0.65 higher to
6.4 higher) Erectile angle 228 (2) ⨁○○○acd N/A MD 6.73 higher (4.1 higher to
9.36 higher)
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially dif-ferent from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substan-tially different from the estimate of effect.RCT: randomized controlled trial, CI: confidence interval, IIEF: International Index of Erectile Function, RR: risk ratio, N/A: not applicable, MD: mean difference.aRisk of bias: All the trials had high risk of performance bias for not blinding the participants. Methodological quality of these trials was graded as “high risk of bias,” due to the design of comparison (acupuncture therapy versus conventional medications) is difficult to blind personnel and par-ticipants. The trials also had unclear risk of performance bias for not reporting blinding the outcome assessor. bInconsistency; There is significantly statistical heterogeneity indicating by I2 value. cImprecision: For dichotomous outcomes, the total number of events is less than 300, for continu-ous outcomes, the total population size is less than 400 or pooled results included no effects. dIndirectness. For outcomes of satisfaction of self-assessment rate, markedly improved on erectile function rate, and erectile angle. This was not internationally applied outcome measures. ⨁: Very low quality of the evidence; ⨁⨁: Low quality of the evidence.
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
11www.wjmh.org
ments used among studies. It is difficult to draw a conclusion addressing the usage of acupuncture in ED without well-designed trials with a definitive outcome measurement.
3. Implications for practiceAccording to this review, the main acupuncture
points used in the treatment of ED were Guan Yuan (CV4), San Yin Jiao (SP6), Shen Shu (BL23), Zu San Li (ST36), Ming Men (DU4), Tai Chong (LR3), Tai Xi (KI3), and Ci Liao (BL32). The stimulation of these acupionts aimed to achieve the needle sensation (de qi) during treatment. In addition, selecting acupionts of abdominal and lumbosacral regions (such as Guan Yuan [CV4], Ci Liao [BL32]) were expected to spread the sensation to the front of the penis or the perineum during the treatment period as well. TCM theory states that ED is usually caused by kidney yang or qi deficiency, the treating acupionts of Shen Shu (BL23), Zhao Hai (KI6) and San Yin Jiao (SP6) were pre-scribed accordingly [21,23,27,33]. ED may also be caused by other TCM pathophysiological factors such as “the damp-heat pouring downward”, the treating acupionts of Qu Quan (LR8), Zhong Wan (RN12), and Yin Ling Quan (SP9) were prescribed accordingly [23,29,33]. How-ever, current clinical evidence is insufficient to support its clinical use. Considering potential therapeutic ef-fects of acupuncture, practitioners may consider its use based clinical experience and preference of patients.
4. Implications for researchConsidering the variety of acupuncture therapy for
ED, future trials should develop optimal acupuncture regimens for ED through Delphi process and/or experts’ consensus, validated measurements or tools, such as IIEF-5 scales, to support appropriate interpretation of the findings [11]. In addition, the rational of acupunc-ture regimen and control should be specified appro-priately, and avoid using of comparisons with unclear evidence of effect. To analyze if acupuncture therapy was effective in what kind of ED, the type information of ED participants will be expected to specify clearly in future trials. Furthermore, long-term effect of acu-puncture for ED remains unclear. We suggest a follow-up period should be considered in future trials for the assessment of quality of sexual intercourse or sexual life progression.
To improve the quality of trial design and transpar-
ent reporting, we strongly suggest future trials should be prospectively registered on international registry platforms, conducted according to “good clinical prac-tice”, and reported according to the Consolidated Stan-dards of Reporting Trials (CONSORT) and Standards for Reporting Interventions in Clinical Trials of Acu-puncture (STRICTA) statement [35].
CONCLUSIONS
Due to insufficient and weak evidence that was summarized, the potential effect of acupuncture as adjunctive treatment (such as compared with tadalafil, psychological therapy or herbal medicine) mainly on psychogenic ED participants is inconclusive and safety of acupuncture was insufficiently reported. Findings of this review should be confirmed in large, rigorously designed and well-reported trial with a definitive out-come measurement.
ACKNOWLEDGEMENTS
This work is supported by the fund from Beijing University of Chinese Medicine for the Project on Re-search and Development of Evidence-Based Medicine of Clinical Scientific Research Capacity and Inter-national Development in TCM (No.2016-ZXFZJJ-011; No.1000061020008). JP Liu was partially supported by the NCCIH grant (AT001293 with subaward no. 020468C).
Disclosure
The authors have no potential conflicts of interest to disclose.
Author Contribution
Conceived of the study: Liu JP. Searched literature, identified studies: Yang XY, Li XL. Extracted data: Li XL, Jia LY, Lai BY. Assessed study quality, analyzed data: Jia LY, Lai BY. Con-ducted the design of the study and drafted the manuscript: Lai BY. Revised the manuscript: Cao HJ, Yang GY, Grant S, Wong E, Fei YT. Read and approved the final manuscript: all authors.
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https://doi.org/10.5534/wjmh.180090
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Appe
ndix
1.
Com
pone
nts o
f int
erve
ntio
n an
d co
ntro
l in
22 in
clud
ed tr
ials
Stud
y ID
Com
paris
onTh
e de
scrip
tion
of a
cupu
nctu
re co
mpo
nent
of p
resc
riptio
n Co
ntro
l tre
atm
ent a
nd co
mpo
nent
of p
resc
riptio
n
Aydi
n et
al
(199
7) [1
8]EA
vs.
C1 o
r C2
or C
3EA
: Qic
hong
(ST3
0), Z
usan
li (S
T36)
, Zha
ohai
(KI6
), Gu
anyu
an (C
V4),
Qih
ai (C
V6).
Follo
w-u
p fo
r 7.6
mon
ths.
C1: H
ypno
tic th
erap
y (3
tim
es a
wee
k, la
ter o
nce
a m
onth
). C2
: pla
cebo
ora
l pla
cebo
(v
itam
in p
ill).
C3: p
lace
bo n
eedl
e di
ffere
nt p
oint
s com
pare
d to
clas
sical
acu
punc
ture
po
ints
, 3 H
z dire
ct-c
urre
nt (d
c). F
ollo
w-u
p fo
r 7.6
mon
ths.
Cao
et a
l (20
07)
[31]
MA
plus
CHM
vs.
CHM
MA:
Gua
nyua
n (C
V4),
Shen
shu
(BL2
3), M
ingm
eng
(EX-
B6),
Zusa
nli (
ST36
), Sa
nyin
jiao
(SP6
), Zh
ibia
n (B
L54)
, Tai
xi
(KI3
), an
d fo
r gua
nyua
n (C
V4) e
xpec
ting
the
sens
e of
ne
edle
to ra
diat
e in
to th
e gl
ans p
enis.
CHM
(sel
f-pre
scrib
ed h
erba
l dec
octio
n): D
odde
r (tu
si zi
) 20
g, E
pim
ediu
m (y
in y
ang
huo)
15
g, C
url (
xian
mao
) 15
g, G
ekko
gec
ko (g
e jie
) 2 g
, Lyc
ium
bar
baru
m (g
ou
qi zi
) 15
g, R
adix
rehm
anni
ae (s
hu d
i hua
ng) 1
8 g,
Yam
(sha
n ya
o) 2
1 g,
Pla
ntag
o (c
he q
ian
zi) 1
2 g,
Gin
seng
(ren
shen
) 10
g, C
hins
es A
ngel
ica
(dan
g gu
i) 12
g,
Achy
rant
hes b
iden
tate
(niu
xi)
12 g
, Lic
oric
e (g
an c
ao) 6
g.
Chen
g an
d Ca
o (2
009)
[32]
MA
plus
CHM
vs.
CHM
MA:
Zhi
bian
(BL5
4). T
he ti
p of
the
need
le to
the
dire
ctio
n of
the
geni
tals,
and
the
need
le se
nsat
ion
radi
ate
to th
e pe
nis w
ith tw
irlin
g an
d lif
ing-
thru
stin
g sli
ghtly
.
CHM
(sel
f-pre
scrib
ed h
erba
l dec
octio
n): D
odde
r (tu
si zi
) 20
g, x
ian
ling
bran
ed (x
ian
ling
pi) 1
5 g,
Cur
l (xi
an m
ao) 1
5 g,
Gek
ko g
ecko
(ge
jie) 2
g, r
hizo
ma
cibo
tii (g
ou ji
) 12
g, R
adix
rehm
anni
ae (s
hu d
i hua
ng) 1
8 g,
Yam
(sha
n ya
o) 2
1 g,
Pla
ntag
o (c
he
qian
zi) 1
2 g,
Gin
seng
(ren
shen
) 10
g, C
hins
es A
ngel
ica
(dan
g gu
i) 12
g, C
istan
che
Cist
anch
e (ro
u co
ng ro
ng) 1
2 g,
Chi
nese
chi
ve se
ed (j
iu c
ai zi
) 10
g.
Chen
et a
l (2
011)
[19]
MA
plus
CHM
vs.
CHM
EA: H
uiya
ng (B
L35)
, Cili
ao (B
L32)
, Qug
u (R
N2)
, Hui
yin
(RN
1), a
ll po
ints
ach
ievi
ng q
i with
ele
ctric
al st
imul
atio
n.CH
M (c
ompo
und
Xuan
Ju):
Blac
k an
ts (h
ei m
a yi
), ep
imed
ium
(yin
yan
g hu
o), L
yciu
m
barb
arum
(gou
qi z
i), a
nd F
ruct
us C
nidi
um (s
he c
huan
g zi
) etc
. Cu
i et a
l (20
07)
[16]
AIHE
vs.
AIS
or C
HMAI
HE: G
uany
uan
(CV4
), Zu
wul
i (LR
36),
Huiy
in (R
N1)
, Ac
upoi
nt in
ject
ion
of h
erba
l ext
ract
(Sal
via
milt
iorr
hiza
in
ject
ion
and
bupl
euru
m in
ject
ion)
, inje
ctio
n 2
mL/
times
, al
l poi
nts a
chie
ving
qi, a
nd th
e ne
edle
sens
atio
n ra
diat
e to
the
peni
s site
for g
uany
uan
(CV4
) and
hui
yin
(RN1
).
C1: G
uany
uan
(CV4
), Zu
wul
i (LR
36),
Huiy
in (R
N1)
, 1 m
L/tim
es, A
cupo
int i
njec
tion
with
sa
line,
inje
ctio
n 2
mL/
times
, inj
ectio
n 2
mL/
times
, all
poin
ts a
chie
ving
qi,
and
the
need
le se
nsat
ion
radi
ate
to th
e pe
nis s
ite; C
2: C
HM (C
hun
Yi c
apsu
le):
Velv
et a
ntle
r (lu
rong
), Ra
dix
Rehm
anni
ae P
repa
rata
(shu
di h
uang
), lo
cust
Yang
(suo
yan
g),
Dod
der (
tu si
zi),
Chin
ese
yam
(sha
n ya
o), P
olyg
onum
mul
tiflo
rum
(he
shou
wu)
, Fl
os S
opho
rae
(hua
i hua
), M
orin
da o
ffici
nalis
(ba
ji tia
n) L
yciu
m b
arba
rum
(gou
qi
zi),
Cist
anch
e Ci
stan
che
(rou
cong
rong
), Ye
llow
ish e
ssen
ce (h
uang
jing
), as
trag
alus
(h
uang
qi),
rhiz
oma
cibo
tii (g
ou ji
), Ps
oral
en (b
u gu
zhi)
etc.,
0.5
g/t
imes
.D
ai e
t al (
2003
) [2
0]M
A pl
us C
HM v
s. CH
MM
A: B
aihu
i (D
U20)
, Sish
enco
ng (E
X-HN
5), Y
inta
ng (E
X-HN
3), Q
ihai
(CV6
), Gu
anyu
an (C
V4),
Sany
injia
o (S
P6),
Taix
i (KI
3), G
ansh
u (B
L18)
, She
nsu
(BL2
3), Y
inlin
gqua
n (S
P9),
Yong
quan
(KI1
), M
ingm
en (E
X-B6
), al
l poi
nts
achi
evin
g qi
, and
the
need
le se
nsat
ion
radi
ate
to th
e pe
nis f
or a
cupi
onts
in a
bdom
en. F
ollo
w-u
p fo
r 2 w
eeks
.
CHM
(Kan
g W
ei L
ing
deco
ctio
n): c
entip
ede
(wu
gong
) 18
g, C
hins
es A
ngel
ica
(dan
g gu
i) 60
g, P
aeon
ia la
ctifl
ora
(bai
shao
) 60
g, L
icor
ice
(gan
cao
) 60
g, 2
.5–4
.5 g
/tim
es.
Follo
w-u
p fo
r 2 w
eeks
.
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
15www.wjmh.org
Appe
ndix
1.
Cont
inue
d 1
Stud
y ID
Com
paris
onTh
e de
scrip
tion
of a
cupu
nctu
re co
mpo
nent
of p
resc
riptio
n Co
ntro
l tre
atm
ent a
nd co
mpo
nent
of p
resc
riptio
n
Ding
et a
l (20
12)
[33]
MA
plus
CHM
vs.
CHM
MA:
Taic
hong
(LR3
), Gu
anyu
an (C
V4),
Zhon
gfen
g (L
R4),
Gans
hu (B
L18)
, Zus
anli
(ST3
6), X
ueha
i (SP
10);
kidn
ey d
efic
ienc
y pl
us S
hens
hu (B
L23)
, San
yinj
iao
(SP6
); da
mpn
ess a
nd h
eat d
ownl
ink
plus
Quq
uan
(LR8
), Zh
ongw
an (B
N12
), Fe
nglo
ng (S
T40)
, all
poin
ts
achi
evin
g qi
, stim
ulat
ing
with
5 m
inut
es in
terv
al.
CHM
(Si N
i dec
octio
n): T
ribul
us te
rrest
ris (c
i ji l
i) 30
g, A
met
hyst
(zi s
hi y
ing)
30
g,
Astr
agal
us (h
uang
qi)
30 g
, Pae
onia
lact
iflor
a (b
ai sh
ao) 2
0 g,
Fru
ctus
aur
antii
(zhi
qi
ao) 2
0 g,
Bup
leur
um B
uple
urum
(cha
i hu)
15
g, C
hins
es A
ngel
ica
(dan
g gu
i) 15
g,
Ach
yran
thes
bid
enta
te (n
iu x
i) 15
g, H
ive
(feng
fang
) 10
g, D
odde
r (tu
si zi
) 10
g,
xian
ling
bra
ned
(xia
n lin
g pi
) 10
g, ce
ntip
ede
(wu
gong
) 10
g, k
idne
y yi
n de
ficie
ncy
plus
Lyc
ium
bar
baru
m (g
ou q
i zi)
10 g
, Reh
man
nia
glut
inos
a (s
heng
di h
uang
) 20
g;
kidn
ey y
ang
defic
ienc
y pl
us C
url (
xian
mao
) 15
g, d
ownw
ard
flow
of d
ampn
ess-
heat
pl
us C
oix
seed
(yi y
i ren
) 30
g.M
A vs
. CHM
MA:
Taic
hong
(LR3
), Gu
anyu
an (C
V4),
Zhon
gfen
g (L
R4),
Gans
hu (B
L8),
Zusa
nli (
ST36
), Xu
ehai
(SP1
0),
kidn
ey d
efic
ienc
y pl
us S
hens
hu (B
L23)
, San
yinj
iao
(SP6
), da
mpn
ess a
nd h
eat d
ownl
ink
plus
Quq
uan
(LR8
), Zh
ongw
an (B
N12
), Fe
nglo
ng (S
T40)
, all
poin
ts
achi
evin
g qi
, stim
ulat
ing
ever
y 5
min
utes
.
CHM
(mod
ified
her
bal d
ecoc
tion)
: Trib
ulus
terre
stris
(ci j
i li)
30 g
, Am
ethy
st (z
i shi
yi
ng) 3
0 g,
Ast
raga
lus (
huan
g qi
) 30
g, P
aeon
ia la
ctifl
ora
(bai
shao
) 20
g, F
ruct
us
aura
ntii
(zhi
qia
o) 2
0 g,
Bup
leur
um (c
hai h
u)15
g, C
hins
es A
ngel
ica
(dan
g gu
i) 15
g,
Ach
yran
thes
bid
enta
te (n
iu x
i) 15
g, H
ive
(feng
fang
) 10
g, D
odde
r (tu
si zi
) 10
g,
xian
ling
bra
ned
(xia
n lin
g pi
) 10
g, ce
ntip
ede
(wu
gong
) 10
g, k
idne
y yi
n de
ficie
ncy
plus
Lyc
ium
bar
baru
m (g
ou q
i zi)
10 g
, Reh
man
nia
glut
inos
a (s
heng
di h
uang
) 20
g,
kidn
ey y
ang
defic
ienc
y pl
us C
url (
xian
mao
) 15
g, d
ownw
ard
flow
of d
ampn
ess-
heat
pl
us C
oix
seed
(yi y
i ren
) 30
g.D
uan
(200
7)
[17]
MA
vs. C
HMM
A: S
hens
hu (B
L23)
, Tai
xi (K
I3);
Min
gmen
fire
failu
re p
lus
Min
gmen
(EX-
B6),
all p
oint
s ach
ievi
ng q
i.CH
M (Y
ou G
ui p
ill):
Radi
x re
hman
niae
(shu
di h
uang
), M
onks
hood
(fu
zi),
Cinn
amon
(ro
u gu
i), Ya
m (s
han
yao)
, Fru
ctus
Cor
ni (s
han
zhu
yu),
Dod
der (
tu si
zi),
Antle
r gum
(lu
jiao
jiao
), Ly
cium
bar
baru
m (g
ou q
i zi),
Chi
nses
Ang
elic
a (d
ang
gui).
Enge
lhar
dt
et a
l (20
03)
[13]
MA
vs. s
ham
ac
upun
ctur
eM
A: Z
haoh
ai (K
I6),
Shuf
u (K
I27)
, Gua
nyua
n (C
V4),
Qih
ai
(CV6
), W
angu
(SI4
), Sa
nyin
jiao
(SP6
), Sh
ensh
u (B
L23)
, 6.
2 (ra
nge,
4–1
0 w
eeks
).
Sham
acu
punc
ture
: Xua
nzho
ng (G
B39)
, Jie
xi (S
T41)
, Tia
nshu
(ST2
5) a
cupo
ints
for
head
ache
.
Jiang
et a
l (2
014)
[21]
MA
plus
CHM
vs.
CHM
MA:
Taic
hong
(LR3
), Gu
anyu
an (C
V4),
Qih
ai (C
V6),
Sany
injia
o (S
P6),
Zusa
nli (
ST36
), Ci
liao
(BL3
2), S
hens
hu
(BL2
3), k
idne
y de
ficie
ncy
plus
Zha
ohai
(KI6
), Sh
ensh
u (B
L23)
, liv
er d
epre
ssio
n Ta
ixi (
KI3)
, Gan
shu
(BL1
8), a
ll po
ints
ach
ievi
ng q
i, st
imul
atin
g ev
ery
3-5
min
utes
.
CHM
(sel
f-pre
scrib
ed h
erba
l dec
octio
n): A
stra
galu
s (hu
ang
qi) 2
5 g,
Cur
(xia
n m
ao)
12 g
, Mor
inda
offi
cina
lis (b
a ji
tian)
15 g
, Sal
via
milt
iorr
hiza
(dan
shen
) 25
g, R
adix
Pa
eoni
ae R
ubra
(chi
shao
) 15
g, P
oria
coco
s (fu
ling
) 15
g, P
lant
ago
(che
qia
n zi
) 12
g, F
ruct
us C
orni
(sha
n zh
u yu
) 15
g, A
chyr
anth
es b
iden
tate
(niu
xi)
15 g
, Trib
ulus
te
rrest
ris (b
ai ji
li) 2
0 g.
Jiang
et a
l (2
012)
[22]
MA
plus
phy
sical
tr
aini
ng v
s. ph
ysic
al
trai
ning
MA:
abd
omin
al a
cupo
int:
Qih
ai (C
V6),
Guan
yuan
(CV4
), Zh
ongj
i (BN
3), S
anyi
njia
o (S
P6),
Taic
hong
(LR3
), Xi
ngjia
n (L
R2),
Taix
i (KI
3), Y
ongq
uan
(KI1
), N
eigu
an
(PC6
), Sh
enm
en (H
T7),
Baih
ui (D
U20)
; bac
k ac
upio
nts:
Xins
hu (B
L15)
, She
nmen
(HT7
), Sh
ensh
u (B
L23)
, Q
ihai
shu
(BL2
4), M
ingm
en (D
U4),
mak
ing
the
need
le
sens
atio
n sp
read
s to
peni
s or t
he b
utto
cks f
or a
cupi
onts
in
abd
omen
, all
poin
ts a
chie
ving
qi.
Phys
ical
trai
ning
: car
ess t
rain
ing
for n
on g
enita
lia a
nd g
enita
ls (p
enis)
, enc
oura
ging
pa
tient
s to
have
sexu
al fa
ntas
ies a
nd im
agin
e su
cces
sful
sexu
al in
terc
ours
e, to
in
crea
se th
e st
reng
th o
f the
disg
race
d ca
udal
mus
cle
with
abd
omin
al b
reat
hing
.
https://doi.org/10.5534/wjmh.180090
16 www.wjmh.org
Appe
ndix
1.
Cont
inue
d 2
Stud
y ID
Com
paris
onTh
e de
scrip
tion
of a
cupu
nctu
re co
mpo
nent
of p
resc
riptio
n Co
ntro
l tre
atm
ent a
nd co
mpo
nent
of p
resc
riptio
n
Lin
et a
l (20
05)
[23]
MA
plus
CHM
vs.
CHM
MA:
Taic
hong
(LR3
), Zh
ongf
eng
(LR4
), Ga
nshu
(BL1
8),
Zusa
nli (
ST36
); ki
dney
def
icie
ncy
plus
She
nshu
(BL2
3),
Sany
injia
o (S
P6);
dam
pnes
s and
hea
t dow
nlin
k pl
us
Quq
uan
(LR8
), Zh
ongw
an (B
N12
), al
l poi
nts a
chie
ving
qi
, stim
ulat
ing
need
le e
very
3–5
min
utes
.
CHM
(sel
f-pre
scrib
ed h
erba
l dec
octio
n), p
aeon
iae
alba
(bai
shao
) 20
g, B
uple
urum
(c
hai h
u) 1
5 g,
Chi
nses
Ang
elic
a (d
ang
gui)
15 g
, Ach
yran
thes
bid
enta
te (n
iu x
i) 15
g, P
eric
arp
(qin
g pi
) 15
g, rh
izom
a cy
peri
(xia
ng fu
) 10
g, P
each
ker
nel (
tao
ren)
10
g, C
lem
atis
(wei
ling
xia
n) 1
0 g,
Cen
tiped
e (w
u go
ng) 3
g, k
idne
y yi
n de
ficie
ncy
plus
Lyc
ium
bar
baru
m (g
ou q
i zi)
10 g
, Reh
man
nia
glut
inos
a (s
heng
di h
uang
) 20
g; k
idne
y ya
ng d
efic
ienc
y pl
us C
url (
xian
mao
) 15
g, E
pim
ediu
m (x
ian
ling
pi) 1
5 g,
do
wnw
ard
flow
of d
ampn
ess-
heat
plu
s Phe
llode
ndro
n (h
uang
bai
) 10
g, P
lant
ago
(che
qia
n zi
) 10
g.Li
u et
al (
2016
) [2
4]AI
HE p
lus t
adal
afil
vs.
tada
lafil
AIHE
: Hui
yin
(BN
1), o
nce
ever
y tw
o da
ys , i
njec
tion
of
milt
iorr
hiza
for a
cupo
int,
mak
ing
poin
ts a
chie
ving
qi,
1 m
L/tim
es.
Tada
lafil
tabl
et, 5
mg/
times
.
Liu
(201
7) [2
5]M
A pl
us m
oxib
ustio
n vs
. tad
alaf
il ta
blet
MA
plus
mox
ibus
tion:
Taic
hong
(LR3
), Zh
ongf
eng
(LR4
), Ga
nshu
(BL1
8), Z
usan
li (S
T36)
; kid
ney
defic
ienc
y pl
us
Shen
shu
(BL2
3), S
anyi
njia
o (S
P6) d
ownw
ard
flow
of
dam
pnes
s-he
at p
lus Q
uqua
n (L
R8),
Zhon
gwan
(BN
12),
mak
ing
poin
ts o
btai
n qi
, 10
sess
ions
as a
cour
se, f
or 4
w
eeks
, a m
oxib
ustio
n st
ick
was
put
on
the
hand
le o
f th
e ne
edle
, 30
min
utes
.
Tada
lafil
tabl
et, 1
0 m
g/tim
e.
Liu
and
Ren
(201
5) [1
4]M
A pl
us
psyc
hoth
erap
y vs
. ps
ycho
ther
apy
MA:
Min
gmen
(DU4
), Sh
ensh
u (B
L23)
, Gua
nyua
n (C
V4),
Zhon
gji (
BN3)
, Nei
guan
(PC6
), Ta
ixi (
KI3)
, Qih
ai (R
N6)
, Ba
ihui
(DU2
0), S
anyi
njia
o (S
P6),
Zhib
ian
(BL5
4), S
huid
ao
(ST2
8), t
o co
nduc
t the
sens
atio
n of
nee
dle
spre
ad
tow
ards
the
perin
eum
for a
cupi
onts
in a
bdom
en, a
ll po
ints
ach
ievi
ng q
i.
Psyc
hoth
erap
y: n
o de
tail
trea
tmen
t inf
orm
atio
n.
Shan
(200
1) [2
6]M
A pl
us C
HM v
s. CH
MM
A: Z
hong
ji (R
N3)
, Hui
yang
(BL3
5), r
adia
ting
the
sens
e of
nee
dle
into
the
glan
s pen
is, a
ll po
ints
ach
ievi
ng q
i.CH
M (s
elf-p
resc
ribed
her
bal d
ecoc
tion)
: Dod
der (
tu si
zi) 1
5 g,
Rad
ix re
hman
niae
(shu
di
hua
ng)1
5 g,
Lyc
ium
bar
baru
m (g
ou q
i zi)
15 g
, pae
onia
e al
ba (b
ai sh
ao),
Chin
ses
Ange
lica
(dan
g gu
i), S
afflo
wer
(hon
g hu
a) 1
0 g,
Lig
ustic
um w
allic
hii(c
huan
xio
ng)
10 g
, Yam
(sha
n ya
o)10
g, F
ruct
us C
orni
(sha
n zh
u yu
) 10
g, M
ingm
en F
ire fa
ilure
pl
us E
pim
ediu
m (x
ian
ling
pi),
Cist
anch
e Ci
stan
che
(rou
cong
rong
); de
ficie
ncy
of
hear
t and
sple
en p
lus C
odon
opsis
pilo
sula
(dan
g sh
en),
Astr
agal
us m
embr
anac
eus
(hua
ng q
i); d
epre
ssio
n of
live
r-qi
plu
s Bup
leur
um B
uple
urum
(cha
i hu)
, Fru
ctus
au
rant
ii (z
hiqi
ao);
dow
nwar
d flo
w o
f dam
pnes
s-he
at p
lus G
entia
n (lo
ng d
an c
ao),
Scut
ella
ria b
aica
lens
is (h
uang
qin
). Xi
e (2
016)
[27]
MA
plus
CHM
vs.
CHM
MA:
Taic
hong
(LR3
), Gu
anyu
an (C
V4),
Shen
shu
(BL2
3),
Zusa
nli (
ST36
), Sa
nyin
jiao
(SP6
), Ci
liao
(BL3
2), l
iver
de
pres
sion
plus
Gan
shu
(BL1
8), T
aixi
(KI3
); ki
dney
de
ficie
ncy
plus
Yaos
hu (D
U2),
Zhao
hai (
KI6)
, all
poin
ts
achi
evin
g qi
, stim
ulat
ing
need
le e
very
3–5
min
utes
.
CHM
(Con
g Ro
ng Y
i She
n gr
anul
es):
Schi
sand
ra c
hine
nsis
(wu
wei
zi),
Cist
anch
e Ci
stan
che
(rou
cong
rong
), Po
ria co
cos (
fu li
ng),
Dod
der (
tu si
zi).
Bao-yong Lai, et al: Systematic Review on Acupuncture for ED
17www.wjmh.org
Appe
ndix
1.
Cont
inue
d 3
Stud
y ID
Com
paris
onTh
e de
scrip
tion
of a
cupu
nctu
re co
mpo
nent
of p
resc
riptio
n Co
ntro
l tre
atm
ent a
nd co
mpo
nent
of p
resc
riptio
n
Yang
and
Tia
n (2
008)
[34]
MA
plus
CHM
vs.
CHM
MA:
She
nshu
(BL2
3), M
ingm
en (D
U4),
Zhish
i (BL
52),
Cilia
o (B
L32)
, San
yinj
iao
(SP6
), Zu
sanl
i (ST
36),
Qih
ai
(RN
6), G
uany
uan
(CV4
), Q
ugu
(RN
2), a
ll po
ints
ac
hiev
ing
qi, s
timul
atin
g ne
edle
eve
ry 1
0 m
inut
es.
CHM
(sel
f-pre
scrib
ed S
hen
Qi E
r Xia
n he
rbal
dec
octio
n): A
stra
galu
s (hu
ang
qi) 2
5 g,
Sa
lvia
milt
iorr
hiza
(dan
shen
) 30
g, M
orin
da o
ffici
nalis
(ba
ji tia
n) 1
2 g,
Cur
l (xi
an
mao
) 12
g, E
pim
ediu
m (x
ian
ling
pi) 1
2 g,
fruc
tus p
sora
leae
(bu
gu zh
i) 12
g.
Ye a
nd C
hen
(201
7) [2
8]M
A pl
us C
HM v
s. CH
MM
A: G
uany
uan
(CV4
), Sa
nyin
jiao
(SP6
), Q
uqu
an (L
R8),
Min
gmen
(DU4
), Sh
ensh
u (B
L23)
, Zus
anli
(ST3
6), a
ll po
ints
ach
ievi
ng q
i, st
imul
atin
g ne
edle
eve
ry
5 m
inut
es.
CHM
(Hua
n Sh
ao c
apsu
le):
Radi
x re
hman
niae
(shu
di h
uang
), Ly
cium
bar
baru
m (g
ou
qi zi
), Ya
m (s
han
yao)
, Fru
ctus
Cor
ni (s
han
zhu
yu),
Euco
mm
ia u
lmoi
des (
du zh
ong)
, M
orin
da o
ffici
nalis
(ba
ji tia
n), C
istan
che
Cist
anch
e (ro
u co
ng ro
ng),
Schi
sand
ra
chin
ensis
(wu
wei
zi),
Fenn
el (x
iao
hui x
iang
), fru
ctus
bro
usso
netia
e (c
hu sh
i zi),
Ac
hyra
nthe
s bid
enta
te (n
iu x
i), P
oria
coco
s (fu
ling
) etc
. 2.1
g/t
imes
.Jia
(201
8) [2
9]M
A pl
us m
oxib
ustio
n vs
. tad
alaf
il ta
blet
Guan
yuan
(CV4
), Sa
nyin
jiao
(SP6
), Ba
ihua
nshu
(BL3
0),
Huiy
ang
(BL3
5), C
iliao
(BL3
2), Z
usan
li (S
T36)
, all
poin
ts
obta
inin
g qi
, for
bai
huan
shu
(BL3
0), h
uiya
ng (B
L35)
, co
nduc
t ing
the
sens
atio
n of
nee
dle
spre
ad to
war
ds
the
perin
eum
.
Tada
lafil
tabl
et, 5
mg/
times
.
Li e
t al (
2018
) [1
5]EP
AS p
lus t
adal
afil
vs.
tada
lafil
Taic
hong
(LR3
), Gu
anyu
an (C
V4),
Shen
shu
(BL2
3), Z
usan
li (S
T36)
, Cili
ao (B
L32)
, San
yinj
iao
(SP6
), al
l acu
pion
ts
wer
e tr
eate
d w
ith E
PAS.
Tada
lafil
tabl
et, 5
mg/
times
.
Yu e
t al (
2018
) [3
0]M
A pl
us si
lden
afil
vs.
silde
nafil
SHan
glia
o (B
L31)
, Cili
ao (B
L32)
, ZHo
nglia
o (B
L33)
, Xia
liao
(BL3
4), t
he n
eedl
e ha
ndle
is le
ft on
the
skin
flat
and
fix
ed w
ith a
dhes
ive
tape
, mai
ntai
ning
24
hour
s.
Sild
enaf
il ta
blet
, 12.
5 m
g/tim
es, p
lus 2
5 m
g on
e ho
ur b
efor
e se
xual
inte
rcou
rse.
EA: e
lect
ro a
cupu
nctu
re, M
A: M
anua
l Acu
punc
ture
, CHM
: Chi
nese
her
bal m
edic
ine,
AIH
E: a
cupo
int i
njec
tion
of h
erba
l ext
ract
, AIS
: Acu
poin
t inj
ectio
n w
ith sa
line,
EPA
S: m
oder
ate—
frequ
ency
ele
c-tr
ical
pul
se a
cupo
int s
timul
atio
n.