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

International Journal of Impotence Research volume 38, pages 11–18 (2026)Cite this article

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Abstract

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.

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Fig. 1
Fig. 2: Forest plot for IIEF-5 outcome.
Fig. 3: Forest plot for IIEF-15 outcome.

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Data availability

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its Supplementary Materials.

References

  1. NIH Consensus Conference. Impotence. NIH consensus development panel on impotence. JAMA. 1993;270:83–90.

  2. Kessler A, Sollie S, Challacombe B, Briggs K, Van Hemelrijck M. The global prevalence of erectile dysfunction: a review. BJU Int. 2019;124:587–99. https://doi.org/10.1111/bju.14813

    Article  PubMed  Google Scholar 

  3. Elterman DS, Bhattacharyya SK, Mafilios M, Woodward E, Nitschelm K, Burnett AL. The quality of life and economic burden of erectile dysfunction. Res Rep Urol. 2021;13:79–86. https://doi.org/10.2147/RRU.S283097

    Article  PubMed  PubMed Central  Google Scholar 

  4. Huang SA, Lie JD. Phosphodiesterase-5 (PDE5) inhibitors in the management of erectile dysfunction. P T. 2013;38:407–19.

    PubMed  PubMed Central  Google Scholar 

  5. Masuku NP, Unuofin JO, Lebelo SL. Promising role of medicinal plants in the regulation and management of male erectile dysfunction. Biomed Pharmacother. 2020;130:110555. https://doi.org/10.1016/j.biopha.2020.110555

    Article  CAS  PubMed  Google Scholar 

  6. Meier BP, Lappas CM. The influence of safety, efficacy, and medical condition severity on natural versus synthetic drug preference. Med Decis Mak. 2016;36:1011–9. https://doi.org/10.1177/0272989X15621877

    Article  Google Scholar 

  7. Saeed M, Munawar M, Bi JB, Ahmed S, Ahmad MZ, Kamboh AA, et al. Promising phytopharmacology, nutritional potential, health benefits, and traditional usage of Tribulus terrestris L. herb. Heliyon. 2024;10:e25549 https://doi.org/10.1016/j.heliyon.2024.e25549

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Do J, Choi S, Choi J, Hyun JS. Effects and mechanism of action of a Tribulus terrestris extract on penile erection. Korean J Urol. 2013;54:183–8. https://doi.org/10.4111/kju.2013.54.3.183

    Article  PubMed  PubMed Central  Google Scholar 

  9. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71 https://doi.org/10.1136/bmj.n71

    Article  PubMed  PubMed Central  Google Scholar 

  10. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM. Development and evaluation of an abridged, 5-item version of the international index of erectile function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11:319–26. https://doi.org/10.1038/sj.ijir.3900472

    Article  CAS  PubMed  Google Scholar 

  11. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822–30. https://doi.org/10.1016/s0090-4295(97)00238-0

    Article  CAS  PubMed  Google Scholar 

  12. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898 https://doi.org/10.1136/bmj.l4898

    Article  PubMed  Google Scholar 

  13. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60. https://doi.org/10.1136/bmj.327.7414.557

    Article  PubMed  PubMed Central  Google Scholar 

  14. Luo D, Wan X, Liu J, Tong T. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res. 2018;27:1785–805. https://doi.org/10.1177/0962280216669183

    Article  PubMed  Google Scholar 

  15. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135 https://doi.org/10.1186/1471-2288-14-135

    Article  PubMed  PubMed Central  Google Scholar 

  16. Reeves BC, Deeks JJ, Higgins JPT, Shea B, Tugwell P, Wells GA Chapter 24: including non-randomized studies on intervention effects [last updated October 2019]. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane handbook for systematic reviews of interventions version 65 Cochrane, 2024. Available from www.training.cochrane.org/handbook

  17. Shah GR, Chaudhari MV, Patankar SB, Pensalwar SV, Sabale VP, Sonawane NA. Evaluation of a multi-herb supplement for erectile dysfunction: a randomized double-blind, placebo-controlled study. BMC Complement Altern Med. 2012;12:155 https://doi.org/10.1186/1472-6882-12-155

    Article  PubMed  PubMed Central  Google Scholar 

  18. Tahvilian R, Golesorkhi MA, Parhoudeh F, Heydarpour F, Hosseini H, Baghshahi H, et al. The effect of the combination of ginseng, Tribulus Terrestris, and L-arginine on the sexual performance of men with erectile dysfunction: a randomized, double-blind, parallel, and placebo-controlled clinical trial. J Pharmacopunct. 2024;27:82–90. https://doi.org/10.3831/KPI.2024.27.2.82

    Article  Google Scholar 

  19. GamalEl Din SF, Abdel Salam MA, Mohamed MS, Ahmed AR, Motawaa AT, Saadeldin OA, et al. Tribulus terrestris versus placebo in the treatment of erectile dysfunction and lower urinary tract symptoms in patients with late-onset hypogonadism: a placebo-controlled study. Urologia. 2019;86:74–8. https://doi.org/10.1177/0391560318802160

    Article  PubMed  Google Scholar 

  20. Kamenov Z, Fileva S, Kalinov K, Jannini EA. Evaluation of the efficacy and safety of Tribulus terrestris in male sexual dysfunction-A prospective, randomized, double-blind, placebo-controlled clinical trial. Maturitas. 2017;99:20–6. https://doi.org/10.1016/j.maturitas.2017.01.011

    Article  PubMed  Google Scholar 

  21. Sansalone S, Leonardi R, Antonini G, Vitarelli A, Vespasiani G, Basic D, et al. Alga Ecklonia bicyclis, Tribulus terrestris, and glucosamine oligosaccharide improve erectile function, sexual quality of life, and ejaculation function in patients with moderate mild-moderate erectile dysfunction: a prospective, randomized, placebo-controlled, single-blinded study. Biomed Res Int. 2014;2014:121396 https://doi.org/10.1155/2014/121396

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Santos CA Jr, Reis LO, Destro-Saade R, Luiza-Reis A, Fregonesi A. Tribulus terrestris versus placebo in the treatment of erectile dysfunction: a prospective, randomized, double blind study. Actas Urol Esp. 2014;38:244–8. https://doi.org/10.1016/j.acuro.2013.09.014

    Article  PubMed  Google Scholar 

  23. Thornton A, Lee P. Publication bias in meta-analysis: its causes and consequences. J Clin Epidemiol. 2000;53:207–16. https://doi.org/10.1016/s0895-4356(99)00161-4

    Article  CAS  PubMed  Google Scholar 

  24. Terrin N, Schmid CH, Lau J, Olkin I. Adjusting for publication bias in the presence of heterogeneity. Stat Med. 2003;22:2113–26. https://doi.org/10.1002/sim.1461

    Article  PubMed  Google Scholar 

  25. Rosen RC, Allen KR, Ni X, Araujo AB. Minimal clinically important differences in the erectile function domain of the International Index of Erectile Function scale. Eur Urol. 2011;60:1010–6. https://doi.org/10.1016/j.eururo.2011.07.053

    Article  PubMed  Google Scholar 

  26. Wilson E. Biophilia. Boston, MA: Harvard University Press; 1984.

    Book  Google Scholar 

  27. Li M, Chapman GB. Why do people like natural? Instrumental and ideational bases for the naturalness preference. J Appl Psychol. 2012;42:2859–78. https://doi.org/10.1111/j.1559-1816.2012.00964.x

    Article  Google Scholar 

  28. Welz AN, Emberger-Klein A, Menrad K. Why people use herbal medicine: insights from a focus-group study in Germany. BMC Complement Altern Med. 2018;18:92 https://doi.org/10.1186/s12906-018-2160-6

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kam SC, Do JM, Choi JH, Jeon BT, Roh GS, Hyun JS. In vivo and in vitro animal investigation of the effect of a mixture of herbal extracts from Tribulus terrestris and Cornus officinalis on penile erection. J Sex Med. 2012;9:2544–51. https://doi.org/10.1111/j.1743-6109.2012.02889.x

    Article  PubMed  Google Scholar 

  30. Gauthaman K, Ganesan AP, Prasad RN. Sexual effects of puncturevine (Tribulus terrestris) extract (protodioscin): an evaluation using a rat model. J Altern Complement Med. 2003;9:257–65. https://doi.org/10.1089/10755530360623374

    Article  PubMed  Google Scholar 

  31. Zhang H, Tong WT, Zhang CR, Li JL, Meng H, Yang HG, et al. Gross saponin of Tribulus terrestris improves erectile dysfunction in type 2 diabetic rats by repairing the endothelial function of the penile corpus cavernosum. Diabetes Metab Syndr Obes. 2019;12:1705–16. https://doi.org/10.2147/DMSO.S205722

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Singh S, Nair V, Gupta YK. Evaluation of the aphrodisiac activity of Tribulus terrestris Linn. in sexually sluggish male albino rats. J Pharmacol Pharmacother. 2012;3:43–7. https://doi.org/10.4103/0976-500X.92512

    Article  PubMed  PubMed Central  Google Scholar 

  33. Borrelli F, Colalto C, Delfino DV, Iriti M, Izzo AA. Herbal dietary supplements for erectile dysfunction: a systematic review and meta-analysis. Drugs. 2018;78:643–73. https://doi.org/10.1007/s40265-018-0897-3

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Andrology Study Program, Department of Biomedical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, 60132, Indonesia

    Sally Suharyani, Bella Amanda & Jesselyn Angellee

  2. Halim Fertility Center, Stella Maris Women’s and Children’s Hospital, Medan, 20152, Indonesia

    Jesselyn Angellee

  3. Department of Medical Biology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, 14440, Indonesia

    William William

  4. Department of Andrology and Fertility, Tzu Chi Hospital Indonesia, Jakarta, 14470, Indonesia

    William William

  5. Faculty of Medicine, Pelita Harapan University, Tangerang, Banten, 15811, Indonesia

    Timotius Ivan Hariyanto

  6. Department of Biomedical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, 60132, Indonesia

    Reny I’tishom

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Contributions

Conceptualization: Sally Suharyani, Bella Amanda, Jesselyn Angellee, William William, Timotius Ivan Hariyanto, Reny I’tishom; Methodology: Sally Suharyani, Bella Amanda, Timotius Ivan Hariyanto; Formal analysis and investigation: Sally Suharyani, Jesselyn Angellee, William William, Reny I’tishom; Writing - original draft preparation: Sally Suharyani, Bella Amanda, Jesslyn Angellee, Timotius Ivan Hariyanto; Writing - review and editing: William William, Reny I’tishom; Resources: Sally Suharyani, Bella Amanda; Supervision: Reny I’tishom.

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Correspondence to Reny I’tishom.

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This is a systematic review and meta-analysis study. The Faculty of Medicine, Airlangga University Research Ethics Committee has confirmed that no ethical approval is required.

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Suharyani, S., Amanda, B., Angellee, J. et al. Tribulus terrestris for management of patients with erectile dysfunction: a systematic review and meta-analysis of randomized trials. Int J Impot Res 38, 11–18 (2026). https://doi.org/10.1038/s41443-025-01086-7

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