erectile dysfunction ( ed ) is a medical condition defined as the inability to attain or 
 maintain a satisfactory erection for sexual intercourse1 , and commonly classified as psychogenic , organic , or mixed 
 psychogenic and organic2 . in 1998 , the 
 national population and family development board of malaysia and the new england research 
 institutes from the usa carried out a cross - national prevalence study on ed , and found that 
 the ed prevalence rate was 16% for individuals aged 40  years and above3 . in addition , the age - adjusted overall prevalence of ed 
 ( mild , moderate and severe ) in a study conducted by pfizer malaysia was 62.1% in 
 malaysia4 , while a recent study 
 reported5 , using the international index 
 for erectile function 5 ( iief-5 ) , that the prevalence of ed increased to 69% ( 30% mild ed , 
 16% moderate ed , and 23% severe ed ) . a meta - analysis in the asian population found pooled 
 random effect age - specific prevalence rates for ed of 15.1% , 29.6% , 40.6% , 54.3% , and 70% 
 for the age groups of 2029 , 3039 , 4049 , 5059 and 6069  years , ed also has a strong association with 
 diabetes types 1 and 2 , ischemic heart disease , hypertension and hypercholesterolaemia10,11,12,13,14,15,16,17,18,19 . additional risk factors that have been identified include smoking ( risk increased with 
 duration of smoking , both in current and former smokers ) , alcohol , peyronie 's disease , 
 neurogenic disorders , and depression10,11,12 , 20,21,22,23 . nocturnal penile tumescence ( npt ) is routinely considered and employed in evaluation and 
 proposition of appropriate management of patients with ed . several tools have been commonly 
 employed to evaluate penile tumescence during sleep , including the stamp test13 , snap gauge14 , rigi scan24 , 
 and nocturnal electrobioimpedance volume assessment ( neva)25 , 26 . the neva measurement 
 has been validated in a reference population with no history of ed27 and ed patients25 , 
 26 , 28 . the international index of erectile dysfunction ( iief ) was used to 
 determine the degree of ed . there are many options available for ed treatment including psychosexual counselling , pde5 
 inhibitor , oral medication , vacuum devices , intracavernous injection therapy , vascular 
 surgery and the use of penile prosthetic implants29 . the most common oral medication used is pde5 inhibitor , and is the 
 first line of treatment in most patients with ed . nevertheless , one of the obstacles in managing ed patients in malaysia is the cost of these 
 treatments . since there is no financial reimbursement in treatment of ed in the malaysian 
 health - care system , the majority of patients without personal healthcare insurance generally 
 do not seek treatment . in addition , based on the feedback of the patients seen in the 
 clinical practice of one of the authors , many patients chose not to continue the prescribed 
 treatment after some time , mainly due the cost involved . on the other hand , physical exercise therapy , particularly involving pelvic floor muscles , 
 has been shown to provide beneficial effects on ed12,13,14 , thus providing complementary noninvasive methods that are easy to 
 perform , painless and inexpensive . thus , it is of particular interest to investigate the 
 possibility of beneficial effects to be gained from performing alternative physical 
 movements that mimic pelvic floor exercises for ed patients , as part of the treatment 
 regime . in this pilot study , muslim prayer ( termed salat in arabic ) 
 movements were selected , since they involve physical movements and act as a slow moderate 
 exercise , and the majority of the malaysian population are muslims . it has previously been 
 shown that salat movements , in addition to improving physical fitness26 , 30,31,32,33,34,35,36 , 
 cardiac blood - flow37 and psychological 
 well - being38 , result in activation of 
 the pelvic floor muscles and were proven to be an effective form of pelvic floor 
 exercise26 , 27 , 39 . the effect that they 
 had on selected malaysian volunteers was measured using the neva device and the iief-5 . the study protocol was approved by the ethics committees of the hospital universiti 
 kebangsaan malaysia ( hukm ) ( ethics code ff-006 - 2007 ) for recruiting muslim subjects and the 
 university of malaya medical centre ( ummc ) ( ethics no 672.16 ) for recruiting both muslim and 
 non - muslim subjects . ten ed subjects ( seven muslims and three non - muslim ) were recruited for this pilot study . the subjects were recruited from patients attending the ed clinic at the division of 
 urology , university of malaya medical centre , kuala lumpur , malaysia , and from patients at 
 the hospital universiti kebangsaan malaysia ( hukm ) . a detailed subject history was taken , 
 and a clinical examination was performed in all subjects . all subjects had an iief score of less than 21 and 
 were previously on a phosphodiesterase-5 ( pde5 ) inhibitor treatment . subjects were also divided based on their religious 
 affiliation ( muslims and non - muslims ) to investigate its relevancy on the obtained 
 results .   a complete cycle of salat or physical activity mimicking salat posture and 
 movement . paul , mn , usa ) used in the study was based on 
 the concept of measuring bioimpedance and nocturnal penile tumescence . this device is 
 categorized as class ii according to the iec classification , and has been clinically proven 
 to be safe . the neva system determines changes in the penile volume , length and area by 
 measuring the impedance within the penis , using alternating current ( ac ) of 150 a at a 
 frequency of 5 khz delivered via an electrode attached to the subject 's hip . the baseline 
 nocturnal penile tumescence ( npt ) measurement was obtained for two consecutive days . measurement was performed from when the patient fell asleep until the patient woke up in the 
 morning . measurement was conducted on two consecutive nights32 , before and after the period of intervention , with the average 
 measurements taken as the baseline and intervention measurements , respectively . the iief 
 questionnaire was also given to the ed subjects before and after the intervention . each of the subjects was briefed on the complete set of physical movements required in the 
 performance of salat ( fig . practice sessions were held prior to the commencement of the intervention period , to ensure 
 the movements were performed uniformly and consistently . of particular importance is the 
 period of time in performing each of the movement types ; the movements are variable in 
 length , ranging between 6 to 60 seconds . as shown in fig . 1 , each movement cycle of the 
 prayer consists of standing , bowing , prostration , and sitting . the subjects were required to 
 perform three sessions per week for a duration of 4 months , consisting of 12 cycles of 
 movements in each session . group ii consisted of the non - muslim subjects mimicking 
 salat movements and postures without the recitation . group i consisted of 
 muslim subjects . for muslim subjects , this was a new intervention for them because these 
 sessions were conducted in addition to their daily salat . in their daily 
 salat , they prayed 5 times per day , and 2 to 5 movement cycles were 
 performed in each prayer session . the additional salat acted as a slow 
 moderate exercise and consisted of 12 continuous movement cycles of prayer that took 
 approximately 30 to 36 minutes . the time required to complete one cycle of 
 salat movements was approximately 3 minutes . statistical analysis of the data with the nonparametric wilcoxon signed - rank test was 
 conducted using the statistical package for the social sciences ( spss ) version 17 ( spss inc , 
 chicago , il , usa ) with statistical significance at p<0.05 . * statistically significant ( p<0.05 ) ; iief = international index of erectile function ; 
 sd = standard deviation the age range for the subjects of this study was 51 to 66  years old ( n=10 ; 
 mean age and sd , 56 [ 5.9 ] years ) . the neva measurements were conducted for two consecutive 
 nights , before and after the defined intervention period . the level of ed was determined using the iief scores : a score of more than 21 
 is normal ; a score of 16 to 20 is defined as mild ed ; a score of 10 to 15 is defined as 
 moderate ed ; and a score of 0 to 9 is defined as severe ed . in this study , four of the 
 subjects were classified as having moderate ed , while the rest of them were classified as 
 having severe ed . * statistically significant ( p<0.05 ) ; iief = international index of erectile function ; 
 n = number of subjects ; sd = standard deviation following the four - month intervention period , there was a general improvement in the 
 subjects ' npt measurements and iief scores ( table 
 1 ) . all of the measured parameters , namely the number and duration of tumescent 
 events , change in penile volume and iief score showed improvements . improvement was clearly 
 observed in the maximum percent volumetric change over baseline , with the mean of 138% 
 before the intervention increasing to 222% after the intervention ( table 1 ) . these improvements were in accordance with expected 
 results from ed patients that have been prescribed pelvic floor exercises as part of their 
 physiotherapy treatment regime for a similar period of time12,13,14 . m = muslim ; nm = non - muslim ; iief = international index of erectile function in group i ( muslim subjects ) , there was a significant difference ( p<0.05 ) in maximum 
 volume change over baseline in comparison with group ii ( non - muslim subjects ) . this may be due 
 to the fact that muslim subjects performed more movements ( a total of 17 normal cycles in 
 their daily salat and 12 additional cycles ) and were more numerous 
 ( n=7 ) , compared with the non - muslim subjects ( n=3 ) . nevertheless , the results for the iief score in this pilot study collectively appear 
 disappointing . although the differences were statistically significant , the mean iief score 
 increased only two points , and a score of 10 is right on the border between moderate and 
 severe ed . however , table 3 shows that 
 individually there are two subjects ( subjects a and h ) who showed improvement from moderate 
 ed to mild ed and another two subjects ( subjects d and i ) who showed improvement from severe 
 ed to mild ed . out of the ten subjects , only three ( subjects b , e and f ) failed to show 
 positive progress . the results showed that the salat movements produce beneficial effects in 
 ed subjects as a complementary treatment12,13,14 . woo kw39 referred to 
 salat as a slow moderate exercise and proved that the range of muscle 
 activation for the maximum voluntary contraction during performance of pelvic floor muscle 
 exercise ( kegel ) and movements mimicking salat comparatively have no 
 significant differences . our study showed a significant increase in the penile volume in ed patients 
 ( table 1 ) , suggesting an improvement of blood 
 flow to the erectile tissue of the penis . basically , regardless of the risk factors , there are only 2 main underlying mechanisms for 
 non - psychogenic ed40 . salat movements , acting similarly to pelvic floor exercise , help to 
 improve ed by increasing the blood flow to the pelvic region , which can increase the blood 
 flow to the erectile tissue over time30 , 35 , 36 , 39 , 41 , 42 . the exact mechanism could be due to 
 individual vessel dilatation or increased neovascularization ( formation of new vessels ) . pde5 inhibitors like sildenafil , tadalafil and vardenafil also work by causing 
 vasodilatation ( dilatation of the blood vessels ) , which increases the blood flow to erectile 
 tissue43 . pde5 inhibitors are also used 
 to treat all patients with ed irrespective of risk factors like diabetes , hypertension , 
 hyperlipidemia , and smoking . however , they have a temporary effect after consumption and 
 have side effects on one 's health . since such an improvement can already be seen within a four - month intervention period , 
 there is a very high possibility that these changes may be further improved if the 
 intervention was extended to a six - month intervention period13 . furthermore , due to the very minimal cost in performing these 
 movements , and the ease by which they can be completed ( particularly for muslim subjects , 
 since the movements are simply additional to their obligatory prayers ) , it is very likely 
 that such a complementary treatment regime will be carried out consistently for a longer 
 period of time . nevertheless , as with the prescription of pelvic floor exercises , these 
 physical movements must be prescribed as a complement to routinely prescribed ed treatment . it is envisaged that these salat movements can be used as an adjunct to 
 oral pde5 inhibitors with potential to reduce the dosage and cost . the main limitation of the study is the small number of subjects used , as well as the short 
 duration of intervention . in the future , it is important to carry out a larger study before 
 the current intervention can be recommended as a possible complementary treatment in 
 patients with ed . the future study will need to include the following criteria : i ) large 
 population , ii ) a muslim group with regular praying only , iii ) a muslim group with regular 
 praying plus pelvic exercise , iv ) a non - muslim group with pelvic exercise only and v ) a 
 non - muslim as a control . it is possible to do a larger study using only the iief as the 
 assessment tool without the neva scan . physical activities consisting of salat movements may be offered as an 
 alternative form of treatment in patients with ed , particularly for muslim patients but also 
 for non - muslim patients , as they provide similar beneficial effects to pelvic floor muscles 
 exercise , and an increase in blood flow to the erectile tissue of the penis , and the 
 possibility of increased treatment compliance . however , it should be noted for all muslims 
 who have performed these salat movements in their daily lives that these 
 movements alone will not guarantee that they will not experience ed . this is because the 
 underlying etiology of ed is multifactorial7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23 , 
 and it is not possible to conclude that all those who carry out the salat 
 movements will not have ed . since this is a pilot study , a larger study , however , is 
 required in the future to validate these findings , particularly in their usage as an adjunct 
 to pde5 inhibitors .
[ purpose ] our objective was to assess the effect of salat and mimicking 
 salat movements and postures on subjects with erectile dysfunction . 
 [ methods ] ten volunteers were recruited in this study . 
 subjects who were muslims ( group i ) 
 were asked to perform their daily salat and a new intervention of an 
 additional 12 movement cycles of salat for three sessions a week . 
 non - muslim subjects ( group ii ) were taught to mimic salat movements , and 
 were asked to perform a total of 12 movement cycles without reading the recitation for 
 three sessions a week . an international index for erectile function 5 ( iief-5 ) 
 questionnaire was given to the subjects before and after the intervention of performing 
 salat or mimicking salat movements and postures . 
 a 
 nocturnal electrobioimpedance volume assessment ( neva ) device was used to measure the 
 nocturnal penile tumescence ( npt ) parameters over two consecutive nights . 
 a nonparametric 
 test was conducted to find the significant npt parameters . 
 [ results ] the results showed 
 that all measured parameters improved significantly , with the largest change observed in 
 the maximum percent volumetric change over the baseline ( from 138 to 222% ) . [ conclusion ] 
 this preliminary study suggests that the alternative approach of salat 
 and mimicking salat movements and postures , may have beneficial effects 
 for ed patients .