The Aging Male

ISSN: 1368-5538 (Print) 1473-0790 (Online) Journal homepage: https://www.tandfonline.com/loi/itam20

Regular aerobic exercise improves sexual

function assessed by the Aging Males’ Symptoms
questionnaire in adult men

Hiroshi Kumagai, Kanae Myoenzono, Toru Yoshikawa, Takehiko Tsujimoto,

Kosei Shimomura & Seiji Maeda

To cite this article: Hiroshi Kumagai, Kanae Myoenzono, Toru Yoshikawa, Takehiko Tsujimoto,
Kosei Shimomura & Seiji Maeda (2020): Regular aerobic exercise improves sexual function
assessed by the Aging Males’ Symptoms questionnaire in adult men, The Aging Male, DOI:
10.1080/13685538.2020.1724940

To link to this article: https://doi.org/10.1080/13685538.2020.1724940

Published online: 12 Feb 2020.

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THE AGING MALE
https://doi.org/10.1080/13685538.2020.1724940

ORIGINAL ARTICLE

Regular aerobic exercise improves sexual function assessed by the Aging

Males’ Symptoms questionnaire in adult men
Hiroshi Kumagaia,b,c, Kanae Myoenzonod, Toru Yoshikawae, Takehiko Tsujimotof, Kosei Shimomurad and
Seiji Maedaa
a
Division of Sports Medicine, Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Japan; bGraduate School of
Health and Sports Science, Juntendo University, Chiba, Japan; cJapan Society for the Promotion of Science, Tokyo, Japan;
d
Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; eFaculty of Sports and Health Science,
Ryutsu Keizai University, Ryugasaki, Japan; fFaculty of Human Sciences, Shimane University, Matsue, Japan

ABSTRACT ARTICLE HISTORY

The leading cause of aging-induced male-specific disorders such as physical, mental and/or sex- Received 27 October 2019
ual symptoms is testosterone deficiency. Although aerobic exercise is suggested to improves cir- Accepted 29 January 2020
culating testosterone levels, physical fitness, depressive symptoms, and sexual function, the Published online 11 February
effect of regular aerobic exercise on aging-induced disorders has not yet been clarified. Here we 2020
performed cross-sectional and interventional studies to identify the effect of aerobic exercise on KEYWORDS
aging-induced disorders assessed by the Aging Males’ Symptoms questionnaire (AMS). In study Physical fitness; peak
1, the relationship between aerobic exercise capacity (i.e. peak oxygen consumption) and AMS oxygen consumption;
scores were cross-sectionally examined in 169 adult men. In study 2, the effect of a 12-week aerobic exercise;
regular aerobic exercise on AMS scores was longitudinally investigated in 18 adult men. In study testosterone; male sexual
1, the AMS-total, AMS-somatic, AMS-psychological, and AMS-sexual scores were significantly cor- function
related to aerobic exercise capacity even after considering age and testosterone levels. In study
2, 12-week aerobic exercise training significantly improved AMS-sexual and tended to improve
AMS-total scores. Additionally, an increase in vigorous physical activity was correlated to
improve in the AMS-sexual score. These results suggest that regular aerobic exercise is an effect-
ive strategy to improve aging-induced disorders in men.

Introduction depressive symptoms [21], and physical fitness [22,23].

An aging-induced decrease in circulating testosterone
levels adversely influences several functions such as
physical, psychological, and/or sexual functions [1–5]
and lowers the quality of life in men [6]. In clinical sit-
uations, the typical treatment for these disorders is
testosterone replacement therapy, and it shows
positive effects on physical fitness, mood, and sexual
function [7–11]. However, testosterone replacement
therapy also has the potential risk for side effects in
men [12]. Therefore, it is preferable to establish an
alternative treatment or a method that maximizes the
effect of testosterone supplementation on aging-
induced disorders in men.
Previous studies have suggested that regular aer-
obic exercise improved circulating testosterone levels
in healthy young, old, or overweight/obese men
[13–18]. Besides, aerobic exercise is also associated
with improvements in sexual function [19,20],
Hence, improved aerobic fitness may be effective for
not only circulating testosterone levels but also aging-
induced disorders in men. However, these possible
associations among aerobic fitness and aging-induced
disorders in men have not been fully clarified yet.
Here we hypothesized that aerobic exercise is pro-
tective against aging-induced disorders in men. To
confirm our hypothesis, we performed cross-sectional
and interventional studies to identify the effect of aer-
obic exercise on aging-induced disorders in men.
Materials and methods
Study design and participants
Study 1: cross sectional study
Participants were recruited through local newspaper
advertisements and personal contacts. The inclusion
criteria were as follows: (1) men; (2) age
20 years.

CONTACT Seiji Maeda maeda.seiji.gn@u.tsukuba.ac.jp Division of Sports Medicine, Faculty of Health and Sport Sciences, University of Tsukuba,
Tsukuba, Ibaraki305-8574, Japan
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 H. KUMAGAI ET AL.
The exclusion criteria for the present study were as
follows: (1) under 35 years old; (2) presence or history
of cardio/cerebrovascular disease (e.g. angina, myocar-
dial infarction, and stroke) assessed using a medical
history questionnaire; (3) currently receiving medica-
tions for erectile dysfunction (ED) or depression; (4)
current smokers. In addition, participants who took
meals and/or medications on the morning of the
measurement were excluded. A total of 168 adult men
were included in the analyses; median [interquartile
range] of age was 62 [53–69] years old. The number
of participants who were regularly using antihyperten-
sive medication, antidyslipidemic medication, and
hypoglycemic medication were 20 (11.8%), 14 (8.3%),
and 7 (4.1%), respectively. This study was approved by
the ethical committee of the Faculty of Health and
Sport Sciences at the University of Tsukuba. The study
conformed to the principles outlined in the Helsinki
Declaration, and all participants provided written
informed consent before inclusion in the study.
Study 2: regular aerobic exercise
Participants were recruited through local newspaper
advertisements. The inclusion criteria were as follows:
(1) men; (2) age 30–64 years. The exclusion criteria for
the present study were as follows: (1) under 35 years
old; (2) presence or history of cardio/cerebrovascular
disease (e.g. angina, myocardial infarction, and stroke)
assessed via a medical history questionnaire. Initially,
24 men were enrolled in this study, but three were
excluded under 35 years old and other three were
excluded due to a lack of post-training data (n ¼ 1,
relocated; n ¼ 1, time; and n ¼ 1, personal issues). A
total of 18 adult men were included in the analyses;
median [interquartile range] of age was 54 [45–56]
years old. This study was reviewed and approved by
the institutional review board of the University of
Tsukuba. All study procedures and potential risks were
explained to the participants and they provided writ-
ten informed consent to participate in the study. This
study 2 was a pre-specified sub-study (secondary ana-
lysis) of UMIN000027711 [24].
Subjects participated in an aerobic exercise class for
up to 90 min/day, 3 times/week for 12 weeks as previ-
ously described [13,22,25–27]. The exercise program
included a 15–20 min warm-up session followed by an
approximately 40–60 min walking and/or light jogging
session, and concluded with a 15–25 min cool-down
session. Daily steps and physical activity time in both
the aerobic exercise sessions and free-living conditions
were assessed using a tri-axial accelerometer
(ActiveStyle Pro HJA-750IT; Omuron Healthcare Co.
Ltd., Kyoto, Japan). Participants were asked to wear
the accelerometer on a belt over their hip both for 2
weeks prior to the aerobic exercise intervention
(before intervention) and in the last 2 weeks of the
aerobic exercise intervention period (after interven-
tion) and to wear the device at all times while they
were awake except when swimming or bathing. For
data reduction, a valid day was defined as 10 or more
h/day of monitor wear. The PA time was classified as
follows: light-intensity physical activity (LPA), 1.6–2.9
metabolic equivalents (METs); moderate-intensity phys-
ical activity (MPA), 3.0–5.9 METs; vigorous-intensity
physical activity (VPA),
6.0 METs; and moderate to
vigorous-intensity physical activity (MVPA).
Aging Males’ Symptoms questionnaire (AMS)
The AMS is a self-answer type questionnaire and
which assesses aging-induced male specific disorders.
The AMS is consists of 17 items, including five psycho-
logical symptoms score items (questions 6–8, 11 and
13), seven somatic symptoms score items (questions
1–5, 9 and 10), and five sexual symptoms score items
(questions 12 and 14–17) [28,29]. Each item is eval-
uated with five phases, from 1 point (no symptoms) to
5 points (very severe symptoms) and the range of
total scores is 17–85. Severity is classified into four
groups based on the range of scores: 17–26 points as
no/low symptoms, 27–36 points as mild symptoms,
37–49 points as moderate symptoms, and 50–85
points as severe symptoms.
Aerobic exercise capacity
To measure aerobic exercise capacity as an index of
exercise endurance, the subjects performed peak oxy-
gen consumption. To evaluate their aerobic exercise
capacity, the subjects performed an incremental
cycling ergometer exercise consisting of 2 min at 20 W
followed by a 10–20 W increase every one minutes.
Aerobic exercise capacity was measured using an
online computer-assisted circuit spirometry (AE300S;
Minato Medical Science, Osaka, Japan) and peak oxy-
gen consumption was assumed when at least two of
the following criteria were satisfied: (1) the participant
reaching their age-predicted maximal HR (i.e.
220  age), (2) Borg scale >19, (3) respiratory equiva-
lent >1.2, or (4) the participant being unable to main-
tain a pedaling speed <55 rpm [20].
 THE AGING MALE 3

Anthropometric measurements Table 1. Characteristics of studied men (n ¼ 169).

Variable n ¼ 169
Body weight was measured to the nearest 0.1 kg using
Age, years 60 ± 12
a digital scale. Height was measured to the nearest Height, cm 167.3 ± 6.7
0.1 cm using a wall-mounted stadiometer. Body mass Body mass, kg 64.6 ± 10.1
BMI, kg/m2 23.0 ± 3.1
index (BMI) was calculated as the participants’ weight Waist circumference, cm 82.9 ± 9.9
(kg) divided by their height (m2). Waist circumference Visceral fat area, cm2 64.1 ± 31.0
HDL cholesterol, mg/dl 65 ± 16
was directly measured on the skin at the level of the LDL cholesterol, mg/dl 126 ± 32
umbilicus with the participant in a standing position; Triglycerides, mg/dl 101 ± 43
Glucose, mg/dl 104 ± 20
measurements were made in duplicate to the nearest HbA1c, mg/dl 5.6 ± 0.6
0.1 cm. Visceral fat area was measured using the dual- Testosterone, nmol/l 20.3 ± 6.5
Aerobic exercise capacity, ml/min/kg 26.7 ± 7.4
impedance analysis method (HSD-2000; Omron AMS-total score, points 29 ± 8
Healthcare, Kyoto, Japan). AMS-somatic score, points 11 ± 3
AMS-psychological score, points 7±2
AMS-sexual score, points 11 ± 4
Data are shown as the median [interquartile range].
Blood biochemistry BMI: body mass index; HDL: high-density lipoprotein; LDL: low-density
lipoprotein; AMS: Aging Males’ Symptoms.
Blood samples were taken in the morning after 12-h Aerobic exercise capacity was assessed by peak oxygen consumption.
overnight fast. Serum concentrations of triglyceride,
total cholesterol, high-density lipoprotein (HDL) chol- Table 2. Relationships between each variable.
esterol, low-density lipoprotein (LDL) cholesterol, and AMS-total AMS-som AMS-psy AMS-sex
plasma concentration of glucose and HbA1c were Age, years 0.152 0.049 0.197 0.396
determined using standard enzymatic techniques. Height, cm 0.194 0.084 0.012 0.252
BMI, kg/m2 0.032 0.073 0.068 0.070
Serum total testosterone levels were measured using Visceral fat area, cm2 0.010 0.100 0.088 0.041
chemiluminescent immunoassay by commercial HDL cholesterol, mg/dl 0.069 0.075 0.099 0.111
LDL cholesterol, mg/dl 0.165 0.114 0.021 0.198
laboratory (LSI medience. Ibaraki, Japan). Triglycerides, mg/dl 0.053 0.026 0.010 0.070
Glucose, mg/dl 0.038 0.006 0.075 0.106
HbA1c, mg/dl 0.072 0.022 0.074 0.155
Statistical analysis Testosterone, nmol/l 0.067 0.011 0.091 0.066
BMI: body mass index; HDL: high-density lipoprotein; LDL: low-density
The Shapiro–Wilk test was used to assess the normal- lipoprotein; VO2peak: peak oxygen consumption; AMS-total: aging male
symptoms-total; AMS-som: aging male symptoms-somatic; AMS-psy:
ity of all parameters. Data are expressed as the mean- aging male symptoms-psychological; AMS-sex: aging male symptoms-
s ± standard deviation (SD) or frequency counts (for sexual.
p < 0.01; p < 0.05.
categorical data). Unpaired Student’s t-test and
Wilcoxon rank sum test were used to assess the group
differences between all parameters. Paired Student’s t-
test and Wilcoxon signed rank test were used to LDL cholesterol (125 mg/dl), triglycerides (92 mg/dl),
assess the group differences between data before and glucose (101 mg/dl), and testosterone (19.8 nmol/l)
after the 12-week regular aerobic exercise. The rela- were within the normal range.
tionships among each parameter were analyzed using Table 2 shows the correlations between each variable.
Spearman’s (rs) correlation coefficient. Independent Age was significantly correlated with the scores of AMS-
correlates of AMS scores were examined by using a total (rs ¼ 0.152, p < 0.05), AMS-psychological
multivariate linear regression analysis (independent (rs ¼ 0.197, p < 0.05), and AMS-sexual (rs ¼ 0.396,
variables: age, aerobic exercise capacity and testoster- p < 0.01) (Table 2). Aerobic exercise capacity was signifi-
one levels). Statistical significance was set a priori at cantly correlated with the scores of AMS-total
p < 0.05 for all comparisons. Statistical analyses were (rs ¼ 0.287, p < 0.01), AMS-somatic (rs ¼ 0.227,
performed using JMP Pro version 12 (SAS Institute). p < 0.01), and AMS-sexual (rs ¼ 0.309, p < 0.01) (Figure
1). On the other hand, serum testosterone levels were
Results not significantly correlated with AMS scores (Table 2).
After considering age and circulating testosterone levels,
Study 1
aerobic exercise capacity was significantly associated
The characteristics of the studied subjects are sum- with AMS-total (b ¼ 0.347, p < 0.01), AMS-somatic
marized in Table 1. Medians of BMI (22.5 kg/m2), waist (b ¼ 0.370, p < 0.01), AMS-psychological (b ¼ 0.225,
circumference (82.0 cm), HDL cholesterol (62 mg/dl), p < 0.05) and AMS-sexual (b ¼ 0.223, p < 0.01).
4 H. KUMAGAI ET AL.

Figure 1. Correlations between aerobic exercise capacity and AMS-total (A), -somatic (B), -psychological (C), and -sexual (D) scores.

Study 2 and the effect of regular aerobic exercise on the AMS

Table 3 shows the characteristics of subjects before and
after the 12-week aerobic exercise intervention. Body
mass, BMI, waist circumference, and visceral fat area sig-
nificantly decreased, and physical activity levels and aer-
obic exercise capacity significantly increased after the
aerobic exercise intervention. On the other hand, aerobic
exercise training tended to increase serum testosterone
levels. Figure 2 shows the AMS scores before and after
the intervention. The 12-week regular aerobic exercise
significantly decreased the AMS-sexual score and tended
to reduce the AMS-total score, but not the AMS-somatic
and AMS-psychological scores (Figure 2). Although, the
percentage change in serum testosterone levels did not
correlate to AMS scores, the percentage change in VPA
significantly correlated to that in AMS-sexual score
(rs ¼ 0.539, p < 0.05).
Discussion
In the present study, we investigated the association
between aerobic fitness and AMS scores in adult men,
scores in adult men. In the cross-sectional study, aerobic
fitness was significantly associated with AMS scores in
169 adult men after considering age and testosterone
levels. Furthermore, in the interventional study, the 12-
week regular aerobic exercise significantly decreased
the AMS-sexual score and tended to decrease the AMS-
total score. These results suggest that regular aerobic
exercise is an effective strategy to improve AMS scores,
especially sexual function in adult men.
The AMS questionnaire is used for the assessment of
aging-induced disorders such as somatic, psychological,
and sexual functions in men. Several studies have sug-
gested that aerobic exercise associated with sexual func-
tion [19,20], depressive symptoms [21], and physical
fitness [22,23], implying aerobic exercise effective for
AMS scores. Thus, the present study hypothesized that
regular aerobic exercise was associated with AMS scores.
In the cross-sectional study, high aerobic exercise cap-
acity was associated with low scores of the AMS-total,
AMS-somatic, AMS-psychological, and AMS-sexual after
considering age and serum testosterone levels in adult
 THE AGING MALE 5

Table 3. Characteristics of subjects before and after the aerobic exercise intervention.
n ¼ 18 Before After p-Value
Age, years 51 ± 8  
Height, cm 170.6 ± 7.0  
Body mass, kg 80.0 ± 8.6 78.0 ± 9.1 <0.001
BMI, kg/m2 27.5 ± 2.3 26.8 ± 2.4 <0.001
Waist circumference, cm 95.7 ± 6.8 92.5 ± 6.7 <0.001
Visceral fat area, cm2 93.3 ± 30.5 84.3 ± 26.7 0.004
HDL cholesterol, mg/dl 55 ± 8 56 ± 10 0.326
LDL cholesterol, mg/dl 128 ± 32 128 ± 31 0.998
Triglycerides, mg/dl 126 ± 95 100 ± 45 0.149
Glucose, mg/dl 105 ± 16 101 ± 9 0.142
Testosterone, nmol/l 15.6 ± 5.3 17.2 ± 5.5 0.092
Steps, step/day 8710 ± 4674 10551 ± 3286 0.011
LPA, min/day 315 ± 85 288 ± 83 0.048
MPA, min/day 57 ± 24 64 ± 26 0.079
VPA, min/day 6 ± 23 16 ± 14 0.006
MVPA, min/day 63 ± 45 80 ± 37 0.001
Aerobic exercise capacity, ml/min/kg 26.2 ± 4.1 30.2 ± 4.4 <0.001
BMI: body mass index; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LPA: light physical activity; MPA: moder-
ate physical activity; VPA: vigorous physical activity; MVPA: moderate to vigorous physical activity.
Aerobic exercise capacity was assessed by peak oxygen consumption.
Date are expressed as mean ± SD.

Figure 2. The changes in AMS-total (A), AMS-somatic (B), AMS-psychological (C) and AMS-sexual (D) scores before and after the
12-week regular aerobic exercise.

men. Additionally, the 12-week regular aerobic exercise
significantly decreased the AMS-sexual score and tended
to reduce the AMS-total score in the interventional
study. Although there were no significant reductions in
the AMS-somatic and AMS-psychological scores, the
average values of these decreased after the 12-week
intervention. It is possible that the duration of the
exercise intervention was not enough to improve
AMS-somatic and AMS-psychological scores. Taken
together, regular aerobic exercise is effective to improve
in aging-induced disorders, especially AMS-sexual and
AMS-total scores. These findings propose a new option
(i.e. regular exercise) for prevention and treatment for
aging-induced disorders in men.
In clinical situations, testosterone replacement ther-
apy is a typical treatment strategy for aging-induced
6 H. KUMAGAI ET AL.
disorders such as physical, psychological, and/or sex-
ual functions in men [7–11]. However, testosterone
replacement therapy also has the potential risk of
negative effects on health [12]. Therefore, it is neces-
sary to establish a way to maximize the effect of mod-
est testosterone supplementation in men. Several
studies have demonstrated that a combination of tes-
tosterone replacement therapy and exercise had sig-
nificant improvements in circulating testosterone
levels, total AMS score, the International Index of
Erectile Function score, and body compositions com-
pared to testosterone replacement therapy alone
[30–32]. These previous studies suggested the import-
ance of exercise for the treatment of aging-induced
disorders in terms of the combination of testosterone
replacement therapy and exercise.
Aging-induced male-specific disorders are sug-
gested to be caused by a decrease in circulating
testosterone levels that occurs with aging [1–5].
However, in the present cross-sectional study, no sig-
nificant associations were found between serum total
testosterone levels and AMS scores in men with nor-
mal testosterone levels. Besides, changes in serum
total testosterone levels did not correlate to AMS
scores in the present interventional study. Similar to
the present findings, T’Sjoen et al. have reported that
circulating total testosterone levels were not associ-
ated with AMS scores in men with normal testoster-
one levels [33]. These results imply that another factor
that is not testosterone levels is strongly associated
with AMS scores in men with normal testosterone lev-
els. In the present study, we demonstrated that aer-
obic capacity was associated with AMS scores in the
cross-sectional study, and regular aerobic exercise
improved AMS scores in the interventional study.
These results suggest that aerobic capacity is strongly
associated with aging-induced disorders than circulat-
ing testosterone levels in men with normal testoster-
one levels.
Recent studies have suggested that impaired male
functions, namely, deterioration of male sexual func-
tion predicted aging-related diseases such as cardio-
vascular disease [34] or type 2 diabetes [35], and its
risk factors [36,37]. Indeed, the AMS-sexual score sig-
nificantly correlated to HbA1c levels in the present
cross-sectional study. Additionally, the AMS-sexual
score exhibited the strongest correlation with age
among AMS scores. These results suggest that the
AMS-sexual score is useful for predicting aging-related
diseases or disorders in men.
The present study investigated the association
between aerobic fitness and AMS scores in adult men
and the effect of regular aerobic exercise on AMS
scores in adult men. In the cross-sectional study, aer-
obic exercise capacity significantly correlated to the
AMS scores in 169 adult men, after considering age
and testosterone levels. In the interventional study,
the 12-week regular aerobic exercise significantly
decreased the AMS-sexual score and tended to reduce
the AMS-total score. These results suggest that regular
aerobic exercise is an effective strategy to improve
aging-induced male-specific disorders. The present
findings may provide a novel insight into the role of
aerobic exercise to reduce the risk of aging-induced
male-specific disorders and establish a novel treatment
approach against aging in men.
Acknowledgements
We would like to thank the research members of S.M.’s
laboratory at the University of Tsukuba for their technical
assistance.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
Funding
This work was supported by a grant-in-aid for Scientific
Research KAKENHI from the Ministry of Education, Culture,
Sports, Science, and Technology, Japan [15K12692 to S.M.].
H.K. is a recipients of a Grant-in-Aid for JSPS Fellow from the
Japan Society for Promotion of Science.
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