Effects and Mechanism of Action of a Tribulus terrestris Extract on Penile Erection

Tribulus terrestris for management of patients with erectile dysfunction: a systematic review and meta-analysis of randomized trials

Tribulus terrestris is a medicinal herb purported to enhance reproductive function, particularly in instances of erectile dysfunction (ED). This study aims to assess the effectiveness and safety of administering Tribulus terrestris to patients with ED. We performed a systematic literature review in the Cochrane Library, Medline, Scopus, and Europe PMC databases utilizing particular keywords. The primary endpoint in this study is International Index of Erectile Function, that may be in abridged form (IIEF-5) or full form (IIEF-15). The outcomes of continuous variables were aggregated into the mean difference (MD) with corresponding 95% confidence intervals (95% CI) utilizing random-effects models. Eight studies were selected for inclusion. After the intervention with Tribulus terrestris, the IIEF-5 [MD 4.21, p < 0.00001] and IIEF-15 scores [MD 15.88, p = 0.0004] were markedly elevated compared to their pre-supplementation levels, as per our comprehensive analysis. Additionally, on both the IIEF-5 [MD 3.23 (95%CI 1.89, 4.58), p < 0.00001] and IIEF-15 [MD 14.44 (95%CI 5.75, 23.14), p = 0.001], Tribulus terrestris outperformed placebo. However, the two groups were not significantly different in terms of total testosterone levels. We observed no difference in the incidence of adverse events between Tribulus terrestris and placebo. Tribulus terrestris supplementation may offer benefits in improving erectile function among patients with ED with a relatively good safety profile.

A Randomized, Multicenter, Double-Blind, Placebo-Controlled Clinical Trial to Assess the Efficacy and Safety of a Polyherbal Formulation in Men With Erectile Dysfunction

Introduction Erectile dysfunction (ED) is a prevalent condition impacting men worldwide, often causing significant reductions in quality of life, emotional well-being, and relationship satisfaction. ED currently affects approximately 100 million men worldwide, with its prevalence projected to rise to 320 million by 2025, particularly in developing nations. Notably, nearly half of all men aged 40 and above experience some degree of ED, underscoring its widespread impact on male health. Existing treatments, while available, frequently fall short in terms of efficacy and safety, underscoring the demand for innovative and safer therapeutic alternatives. Methods Eighty-five participants completed the study and were randomly assigned to receive either the test treatment (polyherbal formulation) or a placebo, utilizing a computer-generated randomization list. The study protocol included screening (up to 14 days prior), baseline assessment (Day 0), and follow-up visits at day 30, day 60, and day 90 (± 5 days), allowing for thorough monitoring of outcomes. Results The test group exhibited significantly greater improvements in erectile function (92.2% vs. 34.8%), along with enhancements in sexual desire, orgasmic function, intercourse satisfaction, and overall satisfaction compared to the placebo group. Quality of erection scores also showed marked improvement in the test group. Additionally, serum testosterone levels increased by 46.5% in the test group compared to a mere 3.3% in the placebo group. Adverse events were mild and occurred with similar frequency in both groups (9.3% vs. 9.5%). Overall, the test group demonstrated robust efficacy and a favorable safety profile, presenting a promising therapeutic option for the management of ED. Conclusion The in-vitro phosphodiesterase type 5 (PDE5) assay and clinical study demonstrate the effectiveness of test intervention in managing ED and improving sexual health, with a favorable safety profile. Its synergistic herbal ingredients enhance efficacy, making it a promising solution in the management of ED.

Botanical drugs for treating erectile dysfunction: clinical evidence

Phosphodiesterase-5 inhibitors (PDE5-i) have been widely used in clinical practice for the treatment of erectile dysfunction (ED). However, due to its suboptimal therapeutic effects and side effects, it is necessary to develop new medicines for ED treatment. Botanical drugs have been widely investigated as potential ED treatment drugs and have shown promising therapeutic effects. This review summarized 34 studies, including five botanical drugs with PDE5 inhibitory activity, seven botanical drugs without PDE5 inhibitory activity, and six mixed botanical drugs. The results of clinical studies regarding the aforementioned botanical drugs and relevant mechanisms are summarized in this study. It is necessary to conduct high-quality clinical trials to verify the dosage, targeted patients and therapeutic effects, and further pharmacology experiments are also needed to identify the active compounds.

The Profertility and Aphrodisiac Activities of Tribulus terrestris L.: Evidence from Meta-Analyses

Tribulus terrestris L. (TT) is a traditional medicinal plant, which belongs to the Zygophyllaceae family. TT extracts have been widely used for diuretic, analeptic, aphrodisiac, and profertility properties. To quantitatively evaluate the profertility and aphrodisiac effects of Tribulus terrestris L., we undertook the present meta-analyses on published data. A thorough literature screening was performed to identify articles evaluating the effect of TT on spermatogenesis, male fertility, reproductive, and aphrodisiac parameters. We shortlisted 30 relevant studies conducted on humans and rodents. Meta-analyses were conducted to evaluate the quantitative impact of TT on various fertility parameters. In case of humans, the pooled analysis on 133 subjects showed significant improvements in sperm concentration ( $\text{SDM}=0.624$ , 95% $\text{CI}=0.13$ to 1.117, $p=0.013$ ) and sperm motility ( $\text{SDM}=0.742$ , 95% $\text{CI}=0.331$ to 1.152, $p=0.001$ ). TT resulted in nonsignificant increases in testosterone and LH and a nonsignificant decrease in FSH. Similar to the above, TT improved sperm count, sperm motility, and sperm viability in rodents with normal or compromised fertility. The effect on hormone levels was less credible with frequent variations across studies and animal models. The aphrodisiac activity was studied in castrated animal models or normal rodents, both of which showed significant improvements in mounting frequency and intromission frequency and significant declines in mounting latency and intromission latency. These meta-analyses suggested that TT possesses profertility and aphrodisiac activities.

Molecular Action of Herbal Medicine in Physiology of Erection and its Dysfunction

Erection is a physiological process that involves vascular, hormonal, and nervous factors. Erectile dysfunction is one of the male sexual problems that occur globally and is reported to affect men's quality of life. Herbal plants have been widely used for disease treatment, including the problem of erectile dysfunction. This paper aims to review the molecular potential of various plants in the physiology of erection and to treat erectile dysfunction. The literature search was carried out through the Pubmed and Google Scholar databases regarding the molecular mechanisms of herbal plants and their potential involvement in the physiology of erection and overcoming erectile dysfunction. This paper focuses on six herbal plants: Panax ginseng, Ginkgo biloba, Epimedium, Black pepper, Tribulus terrestris, and Eurycoma longifolia. The six herbal plants have involvement in the erection process and have molecular potential in the treatment of erectile problems

Botanical Medicine and Natural Products Used for Erectile Dysfunction

INTRODUCTION

Erectile dysfunction is the persistent or recurrent inability to achieve or maintain an erection sufficient for intercourse. Despite various treatment options, not all patients respond adequately and their usefulness is limited by adverse effects and cost. Botanical medicine and natural products have been and continue to be invaluable and untapped sources of new drugs, including potentially those to treat erectile dysfunction.

OBJECTIVES

To review the current literature on botanical medicine traditionally used as aphrodisiacs and treatment of erectile dysfunction, in particular, scientific and clinical investigations that have been performed, possible active phytoconstituents, and mechanisms of action and to identify gaps in current knowledge to better guide future research efforts.

METHODS

A comprehensive literature search was conducted via PubMed, Scopus, Science Direct, and Web of Science on English publications, using various keywords, for example, "herb", "natural product", combined with "erectile dysfunction", "aphrodisiac", and "sexual performance".

RESULTS

369 relevant articles studying medicinal plants used for erectile dysfunction were analyzed. A total of 718 plants from 145 families and 499 genera were reported to be used traditionally as aphrodisiacs and treatment of erectile dysfunction. Top plants used include Pausinystalia johimbe, Lepidium meyenii, and Panax ginseng. Different plant parts are used, with roots being the most common. Less than half of these plants have been evaluated scientifically, using various research methodologies. Clinical trials conducted were collated. Current scientific investigation shows mixed results about their usefulness in enhancing sexual performance. A limited number of studies have attempted to elucidate the mechanisms of action of these medicinal plants.

CONCLUSION

A comprehensive literature review on botanical medicine and natural products used for treatment of erectile dysfunction was successfully conducted. Although medicinal plants serve as a potential source of lead compounds for erectile dysfunction drugs, further studies are warranted to further evaluate their efficacy and safety. SinVJ-E, Anand GS, Koh H-L. Botanical Medicine and Natural Products Used for Erectile Dysfunction. Sex Med Rev 2020;XX:XXX-XXX.

A panoramic view of medicinal plants traditionally applied for impotence and erectile dysfunction in Persian medicine

Erectile dysfunction (ED) and impotence are common male sexual problems, and they are highly prevalent in male adults with a history of hypertension or diabetes mellitus. This review aims to bring together the standpoints of the early Persian physicians on these disorders and to identify the respective medication in comparison with conventional contemporary medicine. The main medical and pharmaceutical manuscripts of traditional Persian medicine (TPM) are from 9th-18th century AD. Besides the medieval findings, the current knowledge on ED and impotence, and the related effects of the cited medicinal herbs were studied. In the medieval and traditional literature, male potency is called bāh. According to the TPM approaches, the first step in the mitigation of impotence focuses on the treatment of the main body organs including the heart, brain, and liver. The TPM approaches for diagnosis and treatment include the evaluation of the quality of semen, sexual habit, and quality of urine. The treatment strategies in TPM involve lifestyle modification and prescription of natural medicaments. Many medicinal herbs have been traditionally used for the mitigation of impotency. There could be numerous possibilities for bringing out new natural medicaments with aphrodisiac effects supported by the early medical literature.

Tribulus terrestris extracts alleviate muscle damage and promote anaerobic performance of trained male boxers and its mechanisms: Roles of androgen, IGF-1, and IGF binding protein-3

PURPOSE

To investigate the effects of Tribulus terrestris (TT) extracts on muscle mass, muscle damage, and anaerobic performances of trained male boxers and its mechanisms: roles of plasma androgen, insulin growth factor 1 (IGF-1), and IGF-1 binding protein-3 (IGFBP-3).

METHODS

Fifteen male boxers were divided into exercise group (E, n = 7) and exercise plus TT group (E + TT, n = 8). The 2 groups both undertook 3-week high-intensity and 3-week high-volume trainings separated by a 4-week rest. TT extracts (1250 mg/day) were orally administered by boxers in E + TT group. TT extract compositions were detected by UHPLC-Q-TOF/MS. Before and at the end of the 2 trainings, muscle mass, anaerobic performance, and blood indicators were explored.

RESULTS

Compared with E group, decreases of plasma CK (1591.5 ± 909.6 U/L vs. 2719.9 ± 832.5 U/L) and IGFBP-3 (3075.5 ± 1072.5 ng/mL vs. 3950.8 ± 479.3 ng/mL) as well as increases of mean power (MP, 459.4 ± 122.3 W vs. 434.6 ± 69.5 W) and MP/body weight (MP/BW, 7.5 ± 0.9 W/kg vs. 7.1 ± 1.1 W/kg) were detected in E + TT group after a high-intensity training. For high-volume training, reduction of IGFBP-3 (2946.4 ± 974.1 ng/mL vs. 3632.7 ± 470.1 ng/mL) and increases of MP (508.7 ± 103.2 W vs. 477.8 ± 49.9 W) and MP/BW (8.2 ± 0.3 W/kg vs. 7.5 ± 0.9 W/kg) were detected in E + TT group, compared with E group. Muscle mass, blood levels of testosterone, dihydrotestosterone (DHT), and IGF-1 were not signifiantly changed between the 2 groups.

CONCLUSION

Taking 1250 mg capsules containing TT extracts did not change muscle mass and plasma levels of testosterone, DHT, and IGF-1 but significantly alleviated muscle damage and promoted anaerobic performance of trained male boxers, which may be related to the decrease of plasma IGFBP-3 rather than androgen in plasma.

Anti-inflammatory effect of tribulusamide D isolated from Tribulus terrestris in lipopolysaccharide-stimulated RAW264.7 macrophages

Tribulus terrestris (T. terrestris) has been used as a traditional medicine for the treatment of a variety of diseases, including inflammation, edema and hypertension. The aqueous and ethanol extracts of T. terrestris contain alkaloids, flavonoids, tannins, quinines and phenolic compounds. Tribulusamide D is a compound that has been isolated from the ethanol extract of T. terrestris. The present study investigated the anti‑inflammatory effect of tribulusamide D on lipopolysaccharide (LPS)‑stimulated RAW 264.7 macrophages. Tribulusamide D inhibited the production of LPS‑induced nitric oxide and prostaglandin E2, by reducing the expression of inducible nitric oxide synthase and cyclooxygenase‑2 expression, respectively. The expression of these genes associated with inflammation was determined using reverse transcription‑polymerase chain reaction and western blot analysis. Furthermore, tribulusamide D reduced the expression of LPS‑induced inflammatory cytokines, including interleukin (IL)‑6, IL‑10 and tumor necrosis factor‑α. They were quantified using an enzyme‑linked immunosorbent assay. In addition, the present study confirmed that the inhibitory effects of tribulusamide D on the inflammatory response were mediated through inactivation of mitogen‑activated protein kinase p38 and inhibition of nuclear localization of nuclear factor‑B, which were also determined by western blot analysis. To the best of our knowledge, the current study is the first to demonstrate that tribulusamide D exerts anti‑inflammatory activity by altering the expression of inflammatory mediators and cytokines, indicating that tribulusamide D could be developed as a potential therapeutic agent for the treatment of inflammatory disorders.

Simultaneous Determination of 5 Flavonoids and 7 Saponins for Quality Control of Traditional Chinese Medicine Preparation Xinnaoshutong Capsule Using HPLC-VWD-ELSD

Xinnaoshutong capsule (XC) is a traditional Chinese prescription derived from the ripe fruit of Tribulus terrestris L. (TT). Although XC has long been considered as an important herbal medicine, no analytical method of marker compounds for quality assessment is registered in the Chinese Pharmacopoeia. A simple analytical method of twelve marker components was developed and validated by HPLC-VWD-ELSD method. Chromatographic separation by HPLC was carried out on a Hedera ODS 2 column (4.6 × 250 mm, 5 μm) by gradient elution with acetonitrile-water (0.1% formic acid) as the mobile phase. Various extraction conditions were optimized to achieve twelve marker compounds with faster extraction and higher recovery. The analytical condition was then validated in terms of the linearity, accuracy and precision, repeatability, and stability. The twelve markers were successfully quantified in 30 batches of commercial samples. The developed HPLC-VWD-ELSD could be used as a rapid and reliable way in the assessment and quality control of XC and TT.

Is the use of plants in Jordanian folk medicine for the treatment of male sexual dysfunction scientifically based? Review of in vitro and in vivo human and animal studies

Male sexual dysfunction is a serious problem which has an impact on the quality of life. In Jordanian folk medicine, 56 plant species were reported to be used by males to improve sexual potency and as aphrodisiacs. The aim of this study was to search for scientific evidence justifying their folk use. Of the 15 studied plants, only five were found to enhance spermatogenesis. The other 10 were reported to decrease spermatogenesis at least by one study. The majority of the studied plants possessed a protective effect on testis in different in vivo models as well as antioxidant activities. The effect of these plants on steroidogenesis and the hypothalamic-gonadal axis was also reviewed. The effect of only five plants was studied on sexual behaviour enhancement and three of them were active. Three of the four studied plants enhanced erection. The mechanism of action of active constituents isolated from the studied plants was also investigated. In conclusion, many plants used in Jordanian folk medicine decreased or had no effect on spermatogenesis in animal models. These plants have antioxidant and/or adaptogenic effects, and this may result in a beneficial action on male reproductive system.

Herb formula enhances treatment of impotent patients after penile venous stripping: a randomised clinical trials

Herbs have been regarded as aphrodisiacs in treating impotence for many centuries despite little true scientific evidence. Our latest refined penile venous stripping (PVS) technique is effective in treating impotence, although this procedure remains controversial. A synergic effect of PVS and oral herbs was confirmed in our practice but lacked rigorous scientific proof. The objective of this report was to review our experience with this combination. From August 2010 to May 2014, 263 males underwent PVS. Among these, 67 unsatisfied men chose additional salvage therapy and were randomly assigned to oral herbs (n = 35) or placebo treatment (n = 32) which replaced herb eventually. All were evaluated with the international index of erectile function (IIEF-5) scoring and our dual pharmaco-cavernosography. The pre-op IIEF-5 score for the herb group was 9.7 ± 3.7, post-operative 13.9 ± 3.3 and post-herb 19.6 ± 3.4, while the control group scores were as follows: pre-op 9.3 ± 4.1, post-op 14.5 ± 3.6, post-placebo 15.1 ± 3.5 and post-herb 19.9 ± 3.2. Although there was no significant difference between the two groups pre-operatively, post-operatively and post-herb, a statistically significant difference was found post-salvage therapy (19.6 ± 3.4 versus 15.1 ± 3.6, P < 0.001). It appears that the combination of oral herbs and PVS treatment provides an enhanced outcome to impotent patients refractory to medicine and unsatisfied with PVS monotherapy alone.

Quantitative ethnobotanical survey of medicinal flora thriving in Malakand Pass Hills, Khyber Pakhtunkhwa, Pakistan

STUDY OBJECTIVE

Ethnobotanical knowledge is proving to be invaluable for drug discovery in the wake of effective prospecting from biodiversity. On the other hand, the escalating human pressure is threatening the endogenous flora. Situated at the foothill of the Himalayas, Pakistan boasts of rich floristic distribution. However, many lush yet imperiled regions of this country has never been explored. It inspired us to evaluate and document the taxonomic composition, significance of medicinal plants and associated traditional knowledge in the District of Malakand, Khyber Pakhtunkhwa Province.

MATERIALS AND METHODS

Vegetation growing in Malakand pass hills, Pakistan was studied and data were collected using an open-ended questionnaire, in addition to interviewing the local elderly, knowledgeable persons, and herbal practitioners. Relative Frequency Citation (RFC) and Use Value (UV) of the medicinal plants were calculated and their correlation was determined by Pearson correlation coefficient.

RESULTS

This study encompasses 92 plant species belonging to 56 families thriving in the study area. The information gathered includes ethnobotanical inventory and their pharmacological uses. Quantitative analysis throws light on the consistence of RFC and UV. Asteraceae and Lamiaceae were the most abundant families represented by 6 species each. Shoots were the most used parts (23.6%) and wound healing (7.91%) was the most common therapeutic use.

CONCLUSION

The result obtained from the study implies that local inhabitants rely on these plants for their medicinal requirements. Also, the statistics reveal that, the vegetation can be assessed for potential drug leads. However, urban expansion is threatening the existence of indigenous flora and old generation with ancient herbal wisdom is perishing. So, it appears imperative to preserve the traditional knowledge. This survey is expected to contribute to the discovery of novel bioactive constituents, stimulate conservation efforts of the perturbed flora and promote sustainable exploitation of the medicinal bounty.

Clinical Assessment of Tribulus terrestris Extract in the Treatment of Female Sexual Dysfunction

This is a qualitative–quantitative study based on hospital records of female patients of reproductive age, presenting sexual dysfunction, and treated with 250 mg Tribulus terrestris extract (1 tablet thrice daily for 90 days). Safety monitoring included vital signs, physical examination, laboratory tests, and occurrence of adverse events. Efficacy analysis included results of the Female Sexual Function Index (FSFI), dehydroepiandrosterone (DHEA) levels together with total and free testosterone, and the patient and physician assessments. There was a statistically significant improvement in total FSFI scores (P < 0.0001) post-treatment, with improvement among 106 (88.33%) subjects. There was a statistically significant (P < 0.0001) increase in the level of DHEA, while the levels of both serum testosterone (P = 0.284) and free testosterone decreased (P < 0.0001). Most adverse events recorded were related to the gastrointestinal tract. Physical examination showed no significant changes post-treatment. Based on the results, it is concluded that the T. terrestris extract is safe and effective in the treatment of female sexual dysfunction.