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The participants in the present included studies were varied, across different forms of ED including psychogenic or organic, as well as comorbidities such as obesity, hypertension, dyslipidaemia and diabetes, which limits any comparison between studies. Furthermore, specific pelvic floor exercises were found to be effective in improving the IIEF compared to lifestyle changes in two studies [53,54]. Specific aerobic training and interval exercise programmes were shown to be effective in two of the included studies. The association between ED and cardiovascular diseases is mediated in part by endothelial dysfunction, in which poor nutrition and sedentary lifestyle are contributing factors to the shared risk . Overall, the risk of bias was considered to be low (Supplement Fig. 1). Studies with possible bias were excluded from meta-analysis. Deviation from the intended intervention bias showed a generally low risk. 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