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Erectile dysfunction: Definition and materia medica of Bapedi traditional

healers in Limpopo province, South Africa

Article in Journal of Medicinal Plants Research · January 2015

DOI: 10.5897/JMPR2012.940

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 Vol. 9(3), pp. 71-77, 17 February, 2015
DOI: 10.5897/JMPR2012.940
Article number: 15C2E9E50289
ISSN 1996-0875 Journal of Medicinal Plants Research
Copyright © 2015
Author(s) retain the copyright of this article
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Full Length Research Paper

Erectile dysfunction: Definition and materia medica of

Bapedi traditional healers in Limpopo province,
South Africa
Lourens Johannes Christoffel Erasmus1*, Marthienus Johannes Potgieter2 and
Sebua Silas Semenya2
1
Department of Physiology and Environmental Health, School of Molecular and Life Sciences, University of Limpopo,
Private Bag X1106, Sovenga, 0727, South Africa.
2
Departement of Biodiversity, School of Molecular and Life Sciences, University of Limpopo, Private Bag X1106,
Sovenga, 0727, South Africa.
Received 19 June, 2012; Accepted 19 August, 2013

Erectile dysfunction (ED) is a neurovascular event modulated by various factors impacting on the
physiological functioning of the penile tissue. Interest in therapeutic substances of plant origin, used to
treat ED, has progressively increased in the last decades. This ethnobotanical study on Bapedi
aphrodisiacs was undertaken during 2010/2011 to document the floral diversity, species utilization,
extract preparation and administration. The emphasis was on the customs of traditional healers residing
in 17 municipalities, in three districts in the Limpopo province of South Africa. Data was obtained, from
34 healers, using a semi-structured questionnaire. According to these traditional healers, ED entails the
inability to sustain an erection during coitus as well as a decreased libido. Findings indicated the use of
12 species, 10 of them with new documentations. Among these species, Zanthoxylum humile was the
most frequently used species, and only Osyris lanceolata and Securidaca longepedunculata were
previously recorded in the treatment of ED. There was a definite selection for underground parts.
Preparation was uncomplicated; with cooking and pounding of the preferred methods. Administration
was mostly attained via oral administration; however, the vehicle for administration varied. This
manuscript validated the application of two species as aphrodisiacs. It is concluded that the major
contribution is the 10 species that have not been documented earlier.

Key words: Bapedi, aphrodisiacs, erectile dysfunction, Limpopo province, Zanthoxylum humile.

INTRODUCTION

The dependence on aphrodisiacs by cultures such as the that “the erect penis has always been a symbol of power,
Chinese, Romans and Greeks, to enhance sexual virility and fertility”. It is therefore not surprising that in the
performance, has been demonstrated for millennia presence of observed sexual enhancing properties, and
(Elferink, 2000). Guirguis (1998), quite eloquently stated the lack of scientific support, the use of such “love drugs”

*Corresponding author. E-mail: [email protected]. Tel: +27 15 268 2483. Fax: +27 15 268 2483.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
72 J. Med. Plants Res.

(Drewes et al., 2003) remain in high demand. often used by the Zulu, in KwaZulu-Natal, to treat ED.
These drugs are almost exclusively used to enhance Rakuambo et al. (2006) and Meyer et al. (2008) con-
male sexual performance, more specifically the ability to centrated on species used by the Vha-Venda, residing in
perform optimally during coitus. Worldwide, the Limpopo province.
approximately 152 million males suffer from erectile The latter two studies predominantly focussed on
dysfunction (ED) (McKinlay, 2000). ED is broadly defined Securidaca longepedunculata, and concluded that
as the persistent inability to attain and maintain an extracts showed potential as a therapeutic lead. In con-
erection sufficient to permit satisfactory sexual trast to this, the Bapedi, the most dominant ethnic group
performance (Lue et al., 2004). Drewes et al. (2003) in the Limpopo province (Monning, 1967) has received no
noted that the introduction of phosphodiesterase type 5 attention with regard to their herbal remedies used to
inhibitors (PDE5i), such as the designer drug VIAGRA® treat ED. It is well documented that male sexual
(Pfizer, 235 East 42nd Street, NY 10017) captivated the performance and prowess is influenced by a multitude of
public’s imagination. It also sparked a reassessment of factors. Amongst these factors, social and cultural norms
older natural products for possible value in the treatment play an important role in male sexual behaviour and per-
of ED, as well as the search for novel natural products to formance; highlighting the fact that sexual performance is
compete effectively against such synthetic drugs. The well correlated with self-esteem (Silberschmidt, 2001;
pursuit for more cost-effective herbal alternatives to Ahmed and Bhugra, 2007). The question thus remains
compete against designer drugs is of the utmost whether the traditional definition of ED, among the
importance as it will grant those with socio-economic Bapedi, is in line with its clinical definition. This study will
constraints, access to treatment. Efficacy of these herbal also address to what extent they depend on herbal
substitutes depends on their potential to alter remedies to alleviate the symptoms of ED. Therefore, this
phosphodiesterase activity in the penile tissue. study was conducted to investigate the species diversity,
Phosphodiesterases are a class of enzymes with the plant parts used, and specific preparation and
capability to cleave the phosphodiester bond in either administration of extracts used by this group to treat ED.
cyclic adenosine monophosphate (cAMP) or cyclic
guanosine monophosphate (cGMP), to yield 5’-cyclic
nucleotides. They are therefore responsible for the METHODOLOGY
cellular regulation of cAMP and cGMP levels (Omori and
Kotera, 2007). The human genome encode 21 PDE Study area and study population
genes; categorised into 11 families based on their protein
sequence, structure, substrate specificity, enzymatic The study area is situated in the Limpopo province, in the far North
properties, tissue distribution, and sensitivity to selective of South Africa (Figure 1). Data was collected from three districts
inhibitors (Kotera et al., 2005). Of interest in the treatment (Capricorn, Sekhukhune and Waterberg) covering 17 local
municipalities (Table 1). These districts were selected due to their
of ED is PDE5, a highly specific cGMP enzyme. It is sizeable population of Bapedi; a cultural group that resides primarily
predominantly distributed in the smooth muscles located in the central, Southern and Western parts of the Limpopo province.
in the blood vessels and corpora cavernosa of the penis. A total of 34 traditional healers (2 per local municipality) were
This enzyme forms part of a cascade of mechanisms, selected from the listed local municipalities (Table 1).
where its inhibition leads to the accumulation of cGMP
(Drewes et al., 2003). Therefore, any therapeutic inter-
vention, from either natural products or designer drugs, Survey
targeting cGMP-binding will promote the cellular elevation
of cGMP. These elevated levels induce a low Ca2+ state, This study was conducted from July 2010 to February 2011.
Traditional healers were identified by convenience sampling, that is,
which supports muscle relaxation (Williams and Melman, with the assistance of colleagues and recommendations from
2012). The resultant relaxation of the trabecular smooth villagers. Prior informed consent was obtained, and a semi-
muscle causes vasodilation, which increases blood flow structured questionnaire was used to obtain information regarding
into the corpora cavernosa via the pudendal artery. the diversity of species used, plant parts used, as well as how these
Consequently, the penis becomes engorged with blood remedies were prepared and administered. Traditional healers were
interviewed individually, in the confines of their consultation rooms.
and becomes erect (Andersson and Wagner, 1995); a The primary researcher accompanied traditional healers to the
purely hemodynamic event. collection sites to confirm the identity of species and to collect
Regardless of the advances in modern medicine, samples. At the Larry Leach Herbarium (UNIN) these samples were
traditional medicine is still the mainstay of primary health taxonomically identified and voucher numbers allocated.
care for many people (Meyer et al., 2008); where herbal
remedies are used to treat various diseases and dis-
orders, including ED. In South Africa, a number of in vitro RESULTS
studies on species used to treat ED have been
conducted. Drewes et al. (2002) evaluated pyrano-iso- Among the participants, there was broad consensus
flavones isolated from Eriosema kraussianum, a species regarding the definition of ED. According to them, ED is
 Erasmus et al 73

Figure 1. Map depicting the study area (Limpopo Province, South Africa), excluding the districts.
Source: http://geoinfo.statssa.gov.za

Table 1. Districts and local municipalities included in this study.

Capricorn district Sekhukhune district Waterberg district

Aganang Elias Motsoaledi Bela Bela
Blouberg Fetakgomo Lephalale
Lepelle-Nkumpi Groblersdal Modimolle
Molemole Makhuduthamaga Mogalakwena
Polokwane Marble Hall Mookgophong
- Tubatse Thabazimbi

an inability to complete coitus due to a gradual loss of only two occasions where the bark (O. sphaerocarpa),
tumescence and a decreased libido. This study recorded and the entire plant (Myrothamnus flabellifolius) were
12 plant species (12 families), which was used by the used. Most of the traditional healers preferred to use
interviewees in the treatment of ED (Table 2). Only three pounded material (65%), which was then either dissolved
species, Hypoxis obtusa (2), Ozoroa sphaerocarpa (2) in a cup of hot water or mixed with soft porridge prior to
and Zanthoxylum humile (6) were used more than once. oral consumption. In the Tubatse and Marble Hall
Majority of the species featured as single extracts, and municipalities (Sekhukune district), the pounded material
just three multi extracts were noted; with Z. humile, the was consumed with Mageu, a locally well-known non-
most prominent species (67%) among the multi extract dairy, non-alcoholic energy beverage prepared from Zea
preparations. mays L. In the Fetakgomo municipality, pounded material
Traditional healers from 12 (71%) of the 17 was added to a cup of warm water and administered
municipalities indicated that they treated ED (Table 3). rectally, using a bulb syringe. The oral administration
There was a definite selection for underground parts, with procedure was consistent throughout; one tin cup (± 340
74 J. Med. Plants Res.

Table 2. Diversity and usage frequency of species employed in the treatment of erectile dysfunction.

Frequency
Scientific name and family
Single extract Multi extract with
Ammocharis coranica (Ker Gawl.) Herb. Amaryllidaceae 1 -
Artemesia annua L. Asteraceae 1 -
Asclepias fruticosa L. Apocynaceae 1 -
Carica papaya L. Caricaceae 1 -
Eucomis pallidiflora Baker Hyacinthaceae 0 Hypoxis obtusa
Hypoxis obtusa Burch. ex Ker Gawl. Hypoxidaceae 1 -
Myrothamnus flabellifolius Welw. Myrothamnaceae 1 Zanthoxylum humile
Osyris lanceolata Hochst. & Steud. Santalaceae 1 -
Ozoroa sphaerocarpa R.Fern. & A. Fern. Anacardiaceae 2 -
Prunus persica (L.) Batsch var. persica Rosaceae 1 -
Securidaca longepedunculata Fresen. var. longepedunculata Polygalaceae 0 Zanthoxylum humile
Zanthoxylum humile (E.A.Bruce) P.G.Waterman Rutaceae 4 -

ml) consumed three times per day for a period of one The fact that not all traditional healers use herbal
week. remedies to treat ED was unexpected. Within the socio-
Slightly more than a third (35%, n=5) cooked their plant cultural confines, where virility and sexual prowess is
material. Most of them (n=4) using a cooking time of 20 highly valued, a possible explanation might be that males
min; followed by a single healer favouring 10 min. feel incapacitated, and therefore only a limited number of
those affected consult, leading to an underutilisation of
traditional healers.
DISCUSSION This study found that Bapedi traditional healers used
Ethnopharmacology follows a utilitarian approach 12 species to treat ED. A number of these species, or at
focussing on the experimental investigation and best some genera from the current study, are known for
validation of species with potential medicinal value medicinal uses other than for the treatment of ED. Among
(Balick and Cox, 1996). According to Etkin and the Swazi people (Swaziland), bark from Amorpha
Elisabetsky (2005), the broad perspective is to fruticosa is used to treat asthma (Amusan et al., 2007).
contextualize ecology and address the perception of The Vha-Venda use O. lanceolata to treat sexually
plants; their utilization, pharmacology and physiology in transmitted diseases (STDs) and infertility (Mulaudzi et
human communities. Currently, the human-plant al., 2011). Prozesky et al. (2001) indicated the use of
interface, incorporating the pharmacological basis of Ozoroa species (Ozoroa engleri R.A. Fernandes) in the
plant constituent interactions, compliments this view. An treatment of STDs. However, after a comprehensive
important indicator regarding the medicinal value of the literature search, this study was unable to find information
species, preceding the utilitarian investigation into its regarding the use of the following species in the
medicinal significance, relates to their traditional treatment of ED; Ammocharis coranica, A. fruticosa,
application. The South African floral diversity makes it Artemisia annua, Carica papaya, Eucomis pallidiflora,
virtually impossible to test the bio-active profile of all Holospora obtusa, M. flabellifolius, O. sphaerocarpa,
species, hence the trend to follow-up on traditional Prunus persica var. persica and Z. humile. To the best of
usage. our knowledge, this is a first report describing their
The clinical definition of ED focus on the inability to species-specific use in the treatment of impotence.
attain an erection or when it is attained, to last long However, a recent study (Van Andel et al., 2012) did
enough to successfully complete coitus. Among the indicate the use of the genus Zanthoxylum as an
Bapedi traditional healers, these concepts were well aphrodisiac. A number of these species had limited use
understood and applied in their practices. Their among the healers interviewed, as most of them were
symptomatic diagnosis include: (i) a lack of sexual desire, used in a single municipality (Table 2). This seemingly
which can easily represent an inability to attain an insignificant application of a species should be
erection and (ii) an inability to have coitus for an approached with caution, as it cannot be discarded in the
extended time. In the latter, even with the consideration light of its perceived limited usefulness. As a matter of
that “extended time” is difficult to pin point, it is evident fact to comprehend the value of such a species, it is
that the male partner either reaches orgasm too soon or important to understand that thousands of people reside
that he becomes flaccid before reaching an orgasm. in those municipalities and many of them might be using
 Erasmus et al 75

Table 3. District and municipality distribution of species used to treat erectile dysfunction; including extract preparation and administration.

District Municipality Species and part used Preparation Administration

Carica papaya (root)
Aganang Pounded material Five teaspoons of material taken with soft porridge.
Prunus persica (root)
Five teaspoons of material, from each species, taken with
Blouberg Securidaca longependuculata (root) and Zanthoxylem humile (root) Pounded material
Capricorn soft porridge.
Myrothamnus flabellifolius (root) and Zanthoxylem humile (root) Pounded material Five teaspoons in a cup of warm water.
Lepelle-Nkumpi
Osyris lanceolata (root) A piece of root cooked for 20 min -
Molemole Zanthoxylem humile (root) Pounded Five teaspoons in a cup of warm water.

Equal amounts added to one cup of warm water and taken

Eucomis pallidiflora (bulb) and Hypoxis obtusa (tuber)
Fetakgomo Pounded rectally with a bulb syringe.
Zanthoxylem humile (root) Pounded material taken with soft porridge.

Sekhukhune Makhuduthamaga Ozoroa sphaerocarpa (bark) Pounded Pounded material taken with soft porridge.

Myrothamnus flabellifolius (entire plant) Pounded Five teaspoons of material in a bowl of Mageu.
Marble Hall
Hypoxis obtusa (tuber) A piece of tuber is cooked for 20 min -

Tubatse Zanthoxylem humile (root) Pounded Four teaspoons in a cup of Mageu.

Bela Bela Ammocharis coranica (fleshy tuber) A piece of tuber is cooked for 10 min -

Lephalale 1. Asclepias fruticosa (root) A piece of root is cooked for 20 min -

Waterberg Modimolle 1. Zanthoxylem humile (root) Pounded Five teaspoons of material taken with soft porridge.

1. Artemesia annua (root) In both cases a piece of root is

Mogalakwena -
2. Ozoroa sphaerocarpa (root) cooked for 20 min

these aphrodisiacs to improve their sexual impotence. Two studies investigated this species Venda, which might explain this specific usage
performance. Therefore, comparing the value of a and concluded that it active compounds causes pattern. In vitro studies by Rakuambo et al. (2006)
medicinal species to the number of healers using smooth muscle relaxation in the corpora and Meyer et al. (2008) confirm the potential of
it, this might be a short-sighted and sub-optimal cavernosum (Meyer et al., 2008; Rakuambo et al., this species in the treatment of ED, subsequently
approach. 2006). Rakuambo et al. (2006) reported its use validating its use by the Bapedi and Vha-Venda.
In this study, only a few number of the species among the Vha-Venda as a general remedy to Evidence supporting the use of O. lanceolata by
had scientific support for their use as sexual per- treat various disorders, including ED. However, its South African ethnic groups to treat ED, could not
formance enhancers. In the case of S. use by the Bapedi is not as extensive and is be located. However, this cannot be considered a
longepedunculata, species-specific proof was restricted to the Blouberg municipality (Capricorn first description, as Muthee et al. (2011) indicated
found of its possible value in the treatment of district), a geographical area in close proximity to its use to treat ED in Kenya.
76 J. Med. Plants Res.

The sexual performance enhancing properties of two necessarily based on its availability, but rather on its
other more frequently used species, Z. humile and H. other advantages. Its unique sour taste can easily mask
obtusa could not be validated, but other species from the taste of plant material, and similar to the use of soft
these genera had reported pharmacological value in the porridge it can delay the absorption of bio-active
treatment of ED. This is a first report of Z. humile being compounds in the digestive tract, thereby prolonging the
used to treat ED; however, roots of Z. capense are used bio-availability of compounds. With the exception of the
by the Zulu to treat ED (Corrigan et al., 2011). This multi-extract preparation involving E. pallidiflora and H.
observation reflects positively on the potential value of Z. obtusa, which is administered as an enema, all other
humile in the treatment of ED. Furthermore, combining administrations in this study were done orally.
this species with S. longepedunculata in the Blouberg A thorough literature search could not reflect on the
municipality, highlights the fact that ethnic groups, such presence of PDE inhibitors in majority of species being
as the Bapedi and Vha-Venda, residing in close proximity used by Bapedi to treat ED. However, S.
to one another, often employ similar species or longepedunculata has been linked to smooth muscle
combinations, as distribution and availability of species relaxation. Meyer et al. (2008) noted that an isolated
are relevant predictors of usage. This is significant when xanthone from this species stimulated smooth muscle
it is considered that Z. humile has a very limited relaxation in the corpus cavernosa in a frequency
distribution (Germishuizen and Meyer, 2003). dependent manner. Vasodilation of blood vessels results
The report by Drewes et al. (2008) shed light on the in engorgement of the corpus cavernosa, leading to an
use of Hypoxis species, however, within the context of erection.
their study, it can be accepted that specific reference was Although not species-specific, the genus Zanthoxylum
made to the use of H. hemerocallidea, and not H. obtusa. was noted to exhibit cAMP PDEI activity (Borges et al.,
Therefore, this study seems to be a first species-specific 2005). The unique Bapedi custom to combine S.
report of the therapeutic application of H. obtusa in the longepedunculata and Z. humile allude to a possible
treatment of ED. synergistic action between these two species. This
In this study ED was almost exclusively treated using warrants further investigation.
underground parts such as bulbs, tubers and roots. The Results from this study confirm that, among the Bapedi,
most feasible explanation for this is the cultural belief that plant resources are widely used to treat ED. The absence
the underground parts, due to their close contact with the of a definite usage pattern, excluding Z. humile, among
soil, contain the highest concentration of bio-active the municipalities and districts reveals that the Bapedi
compounds. The nearly exclusive use of O. does not have a universal species used to treat
sphaerocarpa bark, instead of the expected use of its impotence. The relative, yet not overwhelming, consistent
root, needs further investigation. Rankoana (2000), use of Z. humile warrants further investigation. Similarly,
however, reported that the bark of this species is used by 10 new species records have been disclosed, and can be
the Bapedi to treat gall-sickness among cattle. Thus it important leading to the discovery of natural products
would seem that among the Bapedi there is a propensity with PDE5 activity, and thus the ability to compete
for the use of bark from this species. The exclusive use of effectively against designer drugs.
Ozoroa (O. engleri) bark is also reported by Mabogo This study has a number of invariant limitations. These
(1990) for the Vha-Venda, where it is used as a remedy include: (i) sample size and (ii) data collection was limited
for STDs. to three of the five districts, even though these districts
When herbal remedies are used, the dosage form, as represent the vast majority of Bapedi in the Limpopo
well as the method of preparation and administration is province, South Africa.
very important (Steenkamp, 2003), as it will determine In conclusion, certainty exists regarding the degree to
bio-availability. This availability is dependent on which the Bapedi definition of ED corresponds to its
geographical distribution patterns (Van Wyk and Albrecht, clinical definition. A wide range of species and
2008), which supports findings from this study where no applications are employed to treat this debilitating male
trends of consistency within and among municipalities reproductive disorder.
was recorded. Arnold and Gulumian (1984) reported that
the Vha-Venda prefer to prepare a decoction of the plant
part in the form of a soft porridge. Similarly, evidence of Conflict of Interest
this practice was noted among Bapedi traditional healers
who mixed pounded plant material with soft porridge. In Authors declare no conflict of interest.
some cases, Mageu was used to substitute the soft
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