Unconsummated marriage: etiology and treatment of erectile dysfunction in newlywed men—a narrative review with a focus on China

Introduction

Unconsummated marriage, also referred to as newlywed erectile dysfunction (ED) or “honeymoon impotence”, refers to the condition in which adult men, during the initial attempts at sexual intercourse after marriage or the commencement of cohabitation, are unable to achieve or maintain a penile erection of sufficient rigidity for satisfactory sexual activity (1). Colloquially termed “honeymoon impotence”, it can be categorized based on etiology as organic, psychogenic, or mixed. As a specific situational form of ED, it not only impacts male self-esteem, confidence, and partner relationships but may also establish a foundation for chronic sexual dysfunction. A retrospective study showed that the consultation rate for newly married individuals who had not completed their marriages was only 17% (2). The actual prevalence rate was significantly higher than the consultation rate ratio. Stigma, sexual shame, privacy concerns, and lack of knowledge about sexual health were the core factors hindering patients from seeking medical treatment actively (3).

Notably, in the context of this review, “newlywed” does not refer solely to the legal status of marriage but rather emphasizes the transitional period during which a couple establishes a regular sexual relationship for the first time or early in their union. Additionally, the age at first sexual intercourse represents a critical variable influencing sexual adjustment during the newlywed period. In China, under the combined influence of conservative cultural traditions and insufficient sex education, a substantial proportion of men—particularly those from rural areas or families with traditional values—delay their sexual debut until the wedding night. These men often lack basic sexual skills and physiological knowledge; moreover, having been socialized in an environment that systematically mystifies sexuality, they tend to experience pronounced tension and a strong sense of unfamiliarity during their first real sexual encounter. In traditional Chinese society, male sexual function is directly bound up with the familial obligation to produce heirs and ensure lineage continuity; consequently, the failure to consummate a marriage can readily escalate from a personal physiological issue into a family crisis. This cultural specificity makes China an ideal case for studying how social and cultural factors affect ED among newlyweds. Therefore, analyzing its etiological factors and advances in diagnosis and treatment holds significant reference value for the clinical management of such patients. This article aims to examine the causes of newlywed ED from sociocultural, psychological, and physiological dimensions, adopting a global perspective. It focuses particularly on China as a case study and explores comprehensive treatment strategies applicable across diverse cultural contexts. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0515/rc).

Methods

This narrative review aims to provide a comprehensive literature overview and qualitative synthesis of the sociocultural, psychological, physiological factors, and integrated treatment strategies related to ED in newlyweds. We conducted extensive literature searches across PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data, covering periods from each database’s inception through May 2026. English search terms included “unconsummated marriage”, “honeymoon impotence”, “erectile dysfunction”, “psychological factors”, “sociocultural factors”, “sexual performance anxiety”, and “Chinese cultural context”, which were combined with their corresponding Chinese counterparts. Studies were screened based on relevance to the review topic and academic contribution, with priority given to high-quality original research, systematic reviews, and clinical guidelines. Ultimately, we synthesized and organized relevant literature around the pathogenesis and clinical management pathways of ED in newlyweds. The summary of the search strategy is presented in Table 1.

Discussion

Etiology

The etiology of newlywed ED does not result from the isolated action of a single factor, but is associated with a multitude of elements encompassing sociocultural, psychological, and physiological dimensions. The following sections will delineate the core components of these etiological factors and analyze their interrelationships (Figure 1).

Figure 1 Analysis framework diagram of causes of newlywed ED. Sociocultural factors contribute to psychological stress (e.g., wedding night anxiety, sexual performance pressure), which disrupts the neuro-vascular-endocrine regulation of penile hemodynamics and, together with organic physiological factors, leads to ED. These three dimensions form a hierarchical, interactive relationship characterized as “cultural origins—psychological mediation—physiological manifestation”. ED, erectile dysfunction.

Sociocultural factors

The newlywed or cohabitation phase represents the initiation and critical adaptive period of an intimate relationship. The success or failure of sexual intercourse during this stage is not merely a matter of physiological function; rather, it constitutes a concentrated projection of deeply internalized cultural values and societal expectations onto the specific context of the wedding night. For a subset of men, ED arising in this context not only undermines their psychological and physical well-being but also precipitates tension and rupture within the intimate relationship, thereby escalating into an urgent personal and familial issue requiring resolution.

Gender role expectations and traditional constraints

According to social gender theory, masculinity is not a biologically determined trait but rather a product of cultural construction. Both Western individualism and traditional Chinese gender norms tend to position male sexual performance as a core marker of masculinity and self-worth. Within traditional Chinese culture, the Confucian gender-role hierarchy of “male superiority and female inferiority” and “men outside, women inside” has assigned men the role of “the strong” and “the dominant”, directly linking sexual function to male value (4). Societal gender-role expectations—specifically, the demand for unfailing sexual performance—render men highly vulnerable to self-stigmatization following even a few episodes of sexual failure, generating intense anxiety and fear.

Manalo et al. have demonstrated significant associations between ED and both depressive and anxiety symptoms (5). This simplistic equation of masculinity with sexual prowess introduces persistent performance pressure into the intimate relationship, keeping men in a state of sympathetic hyperarousal that precludes natural relaxation during sexual activity.

More critically, traditional Chinese society has always been family-centered, with procreation historically endowed with profound moral and ethical significance. The Confucian adage “There are three forms of unfilial conduct, of which the gravest is to have no descendants” persists to this day and continues to exert considerable influence on public perceptions of marriage and family (6). In many traditional households, elders actively impose procreative pressure on newlywed couples through repeated exhortations or prescribed conception plans, effectively designating reproduction as the primary objective of marriage.

A considerable number of families equate the very meaning of marriage with the continuation of the family lineage, reducing the intimacy of the wedding night to a procreative task performed under obligation. Under the weight of such entrenched familial expectations and secular pressures, the warmth, physical and emotional bonding, and mutual affection that should characterize sexual intimacy are diluted, leaving only the utilitarian imperative of successful conception (7). This heavy psychological burden strips newlywed couples of the ease and pleasure that should accompany intimacy, casting an invisible psychological shackle over the wedding night and transforming it into a potent source of emotional tension and dysfunction.

Furthermore, the deep-rooted traditional virginity complex, which has persisted for millennia in China, has long and erroneously regarded the presence or absence of blood on the wedding night as the sole criterion for judging female chastity and moral character. Influenced by these conventional beliefs, many men harbor exceedingly high psychological expectations in this regard; when reality fails to meet these expectations, they readily develop suspicion, disappointment, resentment, and even anger. This profound psychological gap and emotional impact not only directly precipitates psychogenic ED but also instantaneously shatters the nascent trust between husband and wife, intensifying emotional conflict. The wedding night, which should be tender and fulfilling, becomes the starting point of estrangement and discord, potentially laying the groundwork for long-term marital dissolution (8).

Deficiencies in sex education and societal silence

The inadequate dissemination of sexual knowledge in China is neither incidental nor transient; rather, it represents the systemic outcome of an education system long constrained by a shame-based culture. The collective silence surrounding sexuality and deliberate avoidance of the topic have created an “information cocoon” in which misconceptions can proliferate. From an educational standpoint, China’s traditional education system has long treated sex as a sensitive subject. Physiology courses at the primary and secondary school levels seldom move beyond a perfunctory overview of basic reproductive anatomy, while core topics—such as the sexual response cycle, sex-based physiological differences, and contraception—are deliberately avoided (9). In the family context, parents rarely initiate conversations about sexual health with their children, instead framing sex as “dirty” or “shameful”. When confronted with their children’s curious inquiries, they tend toward strategic evasion, rendering sex an unspeakable subject in childhood memory (10). On social media platforms, references to sexuality are also routinely obscured under the pretext of “sensitive content”. As a result, a majority of men entering marriage have had to rely heavily on fragmented online information, pornographic material, or informal exchanges with peers as their primary source of sexual knowledge. A survey by Li et al. (11) reported that nearly half of the respondents had never received formal sex education. The survey found that the main channels through which students acquire knowledge about sex are the internet, new media and movies (12). Sexual knowledge transmitted through these informal channels is often seriously biased and misleading. Such misconceptions lead men to develop unrealistic expectations for their wedding-night sexual experience, and when reality fails to align with these expectations, they rapidly descend into self-doubt and anxiety.

Insufficient sexual knowledge directly precipitates two layers of real-world and clinical difficulties. First, most young men who rely on informal sources for fragmented and erroneous sexual knowledge enter marriage harboring fundamental misconceptions about normal fluctuations in sexual function and the characteristics of female physiological responses. Second, this knowledge deficit further reinforces a pervasive barrier of social silence. More severe than the lack of sexual knowledge itself is the acute shortage of accessible professional help-seeking avenues. When newlywed couples encounter sexual difficulties, they are too ashamed to confide in family or friends and lack convenient, reliable access to professional diagnosis, treatment, or counseling, leaving them to rely passively on online information that is saturated with misleading content (13).

Misleading information and false representations in social media

With the widespread adoption of the internet, pornographic content has readily infiltrated the daily lives of young men, persistently distorting their sexual cognition and perceptions of marriage and romantic relationships. Under the influence of traditional values, formal sex education has long been absent in China, making it difficult for adolescents to acquire scientific sexual knowledge through proper channels; most rely on online pornographic information to learn about sex, which further amplifies the misleading effects of such content. Studies have demonstrated that long-term, frequent exposure to pornography is significantly associated with ED among young men. Pornographic works purely pursue sensory stimulation and construct unrealistic sexual scenarios detached from reality: they deliberately exaggerate male genital size, portray female responses as largely scripted performances, and fabricate false standards of intimacy. Young men with limited life experience and a lack of real-world relationship experience are prone to treating these fictional depictions as real-life benchmarks. When they enter into marriage and engage in genuine intimate relationships, a stark discrepancy between idealized expectations and reality arises, precipitating intense self-doubt. This emotional distress, beginning with concerns about sexual function, progressively evolves into self-denial and masculine identity anxiety, creating a cumulative psychological burden that ultimately predisposes them to newlywed psychogenic ED.

Religious and cultural backgrounds

Religion and traditional culture profoundly influence values and sexual cognition. Improper asceticism and avoidance of sexuality increase psychological burden and trigger psychogenic ED. Chinese Taoism simultaneously spreads two contradictory concepts: harmonizing yin and yang and supplementing yin with yang, as well as cultivating a pure mind and restraining desires. Buddhism advocates purifying the mind and restraining desires, and believers’ suppression of sexual needs can lead to sexual arousal disorders and affect erectile function (14). Islam limits sexual behavior to within marriage and regards sex as a taboo, and believers often view their marital needs as sacrilege, which leads to self-blame and anxiety. The prevalence of psychogenic ED among young Muslims in the Middle East is much higher than the global average (15). Within Christianity, Catholicism advocates that sex is only for procreation and opposes contraception and premarital sex, and its dominant region has a higher incidence of ED among young people; Protestantism is more inclusive. The restraint of desires by religion can easily make believers equate normal sexual needs of couples with violating faith. For example, discussing ED in Pakistan is often regarded as a taboo, hindering sexual health (16). The study on unmarried marriages in Iran found that respondents generally have sexual fears and shame, viewing sexual life as a necessary and successful task. This cultural pressure hinders natural sexual responses (17).

Psychological factors

Psychological factors play a predominant role in the pathogenesis of newlywed ED. Although the reported proportions vary across age groups and study samples, multiple epidemiological surveys indicate that psychogenic and mixed etiologies together account for more than 60% of ED cases (18), with the influence of psychological factors being even more pronounced among patients under 40 years of age. An in-depth analysis of these psychological factors not only advances the understanding of the nature of newlywed ED, but also provides a theoretical foundation for the development of effective therapeutic interventions.

Newlywed anxiety and performance pressure

During the happy period of newlywed life, some men regard their first sexual experience as a proof of their ability. Once they encounter problems such as inability to maintain an erection or insufficient hardness, they will be labeled as not being able. The first sexual performance brings great psychological pressure to men. The more nervous and anxious they are, and the more they care about the performance on their first night, the more likely they are to experience sexual failure during intercourse (19). This anxiety causes men to gradually lose their sexual confidence and develop fear and avoidance mentality, thus forming a vicious cycle (20,21). Patients with long-term anxiety may gradually develop depressive manifestations such as self-blame and hopelessness, which is consistent with the research conclusion of Liu et al. (22)—the risk of ED increases by 39% for patients with depression. This pressure makes sexual behavior become a performance rather than an enjoyable intimate activity. It not only directly affects the current sexual experience but may also trigger or aggravate the ED problem.

Marital relationship and interaction issues

Weak emotional foundation pre-marriage

In the context of increasingly diverse attitudes toward marriage and relationships, “flash marriages” or unions formed rapidly after arranged introductions are not uncommon. Such relationships often prioritize a swift assessment of practical compatibility—encompassing career, family background, and income—before attempting to cultivate emotional bonds. However, this accelerated process can sow the seeds for future relational discord. When sexual disharmony arises, partners in such unions are more prone to mutual blame. In contrast, couples who have experienced a conventional courtship, progressing from initial attraction through deeper mutual understanding, often develop greater empathy and tolerance. This foundation can foster a more supportive and less judgmental response when facing issues like temporary erectile difficulties (23).

Poor spousal communication and relationship discord

Among the myriad factors affecting marital quality, spousal communication is considered pivotal (24). Deterioration in the marital relationship is closely associated with the occurrence of ED (25). Research by Ma et al. indicated that “marital discord” accounted for over half (57.05%) of the identified etiological factors (26). A lack of effective emotional communication can gradually create insurmountable emotional distance between partners.

Sexual orientation and pro forma marriage

With the continuous liberalization of societal attitudes and the growing self-identification among sexual minorities, the proportion of overt and latent homosexual individuals in the general population has been steadily increasing (27). However, within the Chinese sociocultural context, the clinical manifestations of this issue are particularly prominent. Under the compounded influence of traditional family ethical pressure, the practical predicament that same-sex marriage remains legally unrecognized, and pervasive social stigma and prejudice against sexual minorities, a considerable proportion of homosexual men, after repeated internal conflict and family compromise, ultimately choose to conceal their true sexual orientation and enter into a pro forma marriage with an opposite-sex partner. Sexual contact in such marriages inherently lacks intrinsic sexual attraction and emotional connection; these men not only fail to achieve natural sexual arousal but also frequently experience denial of self-identity, guilt toward their spouse, and subconscious resistance to sexual activity. This profound identity conflict and moral anxiety ultimately precipitate the onset or exacerbation of ED.

Subconscious fear of marriage

For many, marriage signifies not merely a change in social status but also an accumulation of responsibilities and a fundamental restructuring of life. This transformation can subconsciously breed fear. Even if an individual ostensibly accepts marriage, underlying, unacknowledged anxiety and apprehension may persist. This internal conflict often does not manifest directly as a fear of marriage but may be expressed indirectly through somatic symptoms, with ED being a common signal.

Maladaptive cognitions and psychological imbalance

Sexual misconceptions

In the initial stages of sexual activity, a lack of experience can significantly hinder a man’s confidence. This inexperience often manifests as a fundamental gap in knowledge regarding female anatomy and sexual response. Men may be unaware of female erogenous zones, the rhythm of sexual arousal, or the gradual progression from foreplay to orgasm. Attempting penetration without adequate foreplay can lead to insufficient lubrication, causing discomfort or pain for the female partner, and potentially forcing an abrupt or unsatisfactory end to the encounter. Repeated failures, accompanied by feelings of frustration and shame, may lead the affected individual to invent excuses to avoid sexual contact, sometimes resorting to measures like separate living arrangements (28).

Psychological disparity and past experiences

Men without prior sexual experience who have partners with more extensive romantic or cohabitation histories are susceptible to negative self-comparison. On one hand, they may harbor unresolved discomfort regarding their partner’s past intimate relationships, with thoughts of their partner’s previous sexual experiences triggering intense jealousy, creating a psychological barrier that impedes full emotional and physical engagement. On the other hand, their own lack of experience can breed insecurity and a fear of appearing clumsy or inadequate in sexual performance, failing to satisfy a more experienced partner. This significant disparity in sexual and emotional history can induce psychological imbalance, ultimately manifesting as physiological dysfunction.

Sexual psychological trauma and adverse sexual experiences

Childhood sexual harassment constitutes a profoundly damaging psychological trauma that becomes embedded in the subconscious, often surfacing in adult intimate relationships and potentially directly precipitating erectile difficulties (29). Reports indicate that sexual abuse can lead to issues with erection, ejaculation, orgasm, and performance anxiety in men (30). The shadow cast by such trauma is often enduring, causing affected individuals to experience persistent distress and struggle within intimate relationships, hindering their ability to genuinely enjoy sexual intimacy.

Physiological factors

Although newlywed ED is mainly psychological in nature, the influence of organic causes still needs to be considered, accounting for approximately 15–20% (31). The erection of the penis is a complex process involving neural regulation, vascular filling, and hormone regulation. Any dysfunction or structural defect during this process can lead to ED (32). In patients with organic ED, penile vascular dysfunction is the primary cause, accounting for 50–60% (33). If there is insufficient arterial blood perfusion, the cavernous sinus cannot fully fill, or if the white membrane is damaged, causing venous leakage, it will make it difficult for blood to effectively remain in the penis, all of which will affect the maintenance of erectile hardness. Vascular endothelial injury leads to a decrease in nitric oxide (NO) synthesis and impaired vasodilation function, which in turn causes insufficient blood perfusion in the penile corpus cavernosum, ultimately triggering ED (34). Long-term high blood sugar can damage the vascular endothelium through oxidative stress, induce peripheral neuropathy, and promote fibrosis of the cavernous smooth muscle, thereby causing multiple pathways to impair erectile function (35). Studies have shown that 61.4% of diabetic patients (36) and 61.79% of hypertensive patients (37) have ED. These chronic diseases can damage systemic blood vessels, accelerate atherosclerosis, cause narrowing and obstruction of the penile blood vessel lumen, and ultimately trigger ED (38). It is worth noting that multiple chronic systemic diseases and adverse lifestyles (such as smoking and excessive drinking) often manifest as subclinical functional abnormalities, which are easily overlooked due to the lack of typical symptoms, and their essence is the potential manifestation of early vascular, nerve, or endocrine functional abnormalities. These are triggered or amplified under the stress of the newlywed situation.

Hormonal regulation abnormalities are also an important trigger for organic ED. Testosterone, as the core male sex hormone, in patients with hypogonadism due to low testosterone levels, often experience decreased libido and erectile difficulties. Standard testosterone treatment can effectively improve related symptoms (39); hyperthyroidism or hypothyroidism will indirectly interfere with erectile function through affecting metabolic rate and hormone balance, and such abnormalities can often be reversed by normalizing thyroid hormone levels (40); hyperprolactinemia will inhibit the hypothalamic-pituitary-gonadal axis, reduce the secretion of gonadotropin-releasing hormone and gonadotropins, causing secondary gonadal dysfunction (41). Hyperhomocysteinemia can cause vascular endothelial damage, which in turn leads to vascular-induced ED. Supplementing folic acid can reduce homocysteine levels and repair the vascular endothelium, thereby playing an auxiliary intervention role in this type of ED (42). Additionally, 21% of patients with abnormal anatomical structures of the penis (such as Peyronie’s disease) suffer from ED (43). During penile erection, they experience pain, curvature, and sexual dysfunction, which can lead to severe body image anxiety and avoidance of intimate behaviors. Prostate surgery may also damage pelvic blood vessels and nerve tissues, thereby increasing the risk of ED after surgery (44). Moreover, the side effects of some drugs have been proven to be related to the development of ED, such as antihypertensive drugs, antidepressants, antipsychotics, and hormone drugs (45).

In summary, the etiological mechanism of newlywed ED fundamentally reflects the dynamic interaction among sociocultural, psychological, and physiological factors. These dimensions do not operate in isolation; rather, they interact through psychological factors as a central nexus, with sociocultural influences as underlying contributors and physiological conditions as a foundational substrate. This interplay creates a self-reinforcing cycle: sociocultural pressures and maladaptive beliefs → psychological anxiety → erectile failure → reinforced misconceptions and heightened anxiety → problem consolidation. This vicious cycle perpetuates and may exacerbate the condition (Figure 2).

Figure 2 The vicious cycle diagram of post-marital ED. Social pressure and misconceptions provoke psychological anxiety and sexual performance anxiety, activating the limbic system. This triggers the HPA axis and sympathetic nervous pathways, leading to the release of stress hormones such as norepinephrine. Consequently, corpus cavernosal smooth muscle contracts, arterial inflow decreases, and venous outflow increases, ultimately resulting in erectile failure. The experience of failure, in turn, reinforces dysfunctional cognitions and anxiety, forming a self-perpetuating vicious cycle. ED, erectile dysfunction; HPA, hypothalamic-pituitary-adrenal; NE, norepinephrine; NO, nitric oxide.

Treatment

The nature of newlywed ED is not merely a deficit in sexual function; rather, it represents the combined outcome of sociocultural pressures, individual psychological anxiety, and underlying physiological factors. A coordinated, multidisciplinary approach is therefore required to effectively address both its organic and psychological components (46). Accurate identification of the underlying etiology is essential for guiding effective and individualized treatment strategies (47), and the role of open, proactive communication by clinicians in improving the diagnosis and management of ED should not be underestimated (48). The treatment of newlywed ED must move beyond the limitations of traditional single-discipline models. Instead, it should embrace a patient-centered, couple-involved comprehensive intervention strategy, innovatively establish a multidisciplinary team (MDT), and formulate individualized treatment plans based on the patient’s specific pathophysiological subtype and psychosocial background. By integrating multiple intervention modalities, full-cycle management can be achieved, spanning from the control of primary pathology to the restoration of the couple’s relationship (49). The goal of treatment extends beyond the restoration of erectile function to encompass helping the couple establish a harmonious and satisfying sexual relationship, thereby breaking the vicious cycle of “anxiety-failure-renewed anxiety” (Figure 3).

Figure 3 Framework diagram for comprehensive treatment of ED in newlywed couples. Treatment is anchored in cognitive restructuring, with psychological therapies—including cognitive behavioral therapy and couple-based interventions—serving as the core. Pharmacological, physical, and surgical modalities are integrated to form a comprehensive intervention within a multidisciplinary, stepped-care framework. The treatment goal is to restore erectile function and rebuild a harmonious intimate partnership. AI, artificial intelligence; ED, erectile dysfunction; PDE5, phosphodiesterase type 5; SSRI, selective serotonin reuptake inhibitor.

Breaking societal silence and reconstructing healthy perceptions

sexual health education

In China, the stigma associated with ED is deeply rooted in some conservative cultures, and the sense of shame often prevents patients from seeking treatment (50). Society should correct traditional gender role biases through sexual health education, abandon the obsession with “masculine qualities”, clarify that sexual function has no necessary connection with male values, alleviate the pressure from elders to continue the family line, and the excessive fixation on virginity complexes. Promote premarital sex education to understand the physiological characteristics of the hymen, dispel the traditional belief that “blood must appear during the first night of marriage”, reduce marital trust crises. Provide guidance to couples with a lack of sexual knowledge, start sexual health education as early as possible, learn about the physiological differences between the sexes, the sexual response cycle, and the importance of foreplay, and fill the gaps in family education and school education (51). Guide couples to have sufficient foreplay, which can be achieved by having the woman in the dominant position and allowing the woman to control the pace of entry, having the man lie flat and relax to reduce performance pressure, and using lubricants as necessary to assist.

Integration and application of emerging media technologies

Seeking professional help actively is a key step in improving ED in newlyweds. With the development of digital health and media technologies, new types of media, such as AI tools and self-media of urology experts, are becoming important supports for reducing stigma and optimizing the medical treatment experience (52). AI tools can accurately identify and block non-formal medical advertisements and false promotions, effectively reducing the risk of being misled, and explain the physiological and psychological mechanisms of ED in plain language, helping to establish scientific cognition and alleviate self-stigma; urology experts’ self-media use text, images, and videos to convey medical knowledge, share success cases and patients’ voices, enhance recognition and hope for recovery, and reduce the psychological burden of “being alone with the illness”. At the same time, patients can learn about the professional concepts and communication styles of doctors online in advance, laying a foundation of trust for offline visits, making them more willing to be honest and express themselves, thereby improving the treatment efficiency and clinical satisfaction (53).

Psychotherapy and behavioral training

Cognitive behavioral therapy (CBT)

CBT is widely utilized in Western countries and has been effectively implemented in clinical settings in China. As a first-line foundational treatment, it helps patients challenge maladaptive beliefs such as “inadequacy”, improves erectile function by reducing anxiety and rebuilding confidence. Studies indicate that CBT tailored for patients with psychogenic ED can enhance erectile control, reduce anxiety and depression associated with intercourse, and promote overall psychological and physical health (54). Derivative approaches, including mindfulness-based cognitive therapy combined with motivational empowerment education (55), psychological intervention models based on PERMA (Positive Emotions, Engagement, Relationships, Meaning, Accomplishment) theory (56), structured group psychotherapy (57), and hypnotic CBT (58), have each demonstrated favorable clinical outcomes from different perspectives in modifying distorted beliefs, instilling positive suggestions, improving erectile function, and enhancing satisfaction. Notably, combined psychological intervention and phosphodiesterase type 5 inhibitor (PDE5i) therapy has shown superior efficacy in improving both erectile function and long-term sexual satisfaction in psychogenic ED compared to either intervention alone (59). Randomized controlled trials have shown that for non-organic ED, compared with sildenafil monotherapy and combined therapy, CBT is more effective in improving depressive symptoms (60). Furthermore, a smartphone application developed by Saito’s team based on acceptance and commitment therapy (ACT) shows potential value in addressing psychosocial factors related to ED (61). The iterative development of diverse cognitive-behavioral psychotherapies has provided a broad range of clinical options for the intervention of psychogenic ED. In summary, CBT and its derivative therapies can correct maladaptive cognitions, alleviate emotional disturbances, and effectively ameliorate psychogenic ED (62).

Couple-based psychosexual counseling

Employing a “spouse-synchronized intervention model” (63), this approach encourages both partners to participate in psychological counseling to learn effective communication skills and strengthen emotional bonds. Couples counseling and psychosexual therapy have been shown to significantly improve relationship satisfaction while resolving relational conflicts (64). It is crucial to correctly understand that ED is not simply sexual impotence but is largely related to psychological factors. Patients should be helped to recognize that initial sexual difficulties are common and that a single failure does not equate to a disease, thereby avoiding excessive self-blame. Efforts should focus on alleviating performance anxiety and perfectionistic pressures, emphasizing that the core of newlywed sexuality lies in mutual familiarity and adjustment, and that occasional difficulties are normal. Studies have shown that a good psychological state and sufficient social support can help patients alleviate anxiety and depression (65). When facing an unfamiliar disease, one should adopt an optimistic attitude, seek support, and face it bravely, thereby eliminating the uncertainty of the disease (66). Involving a partner in the treatment is more effective than individual treatment or drug treatment alone, and can improve erectile function, sexual satisfaction, and the relationship between the couple (67).

Rehabilitation training

The “sensate focus training” is a classic and highly effective method, which is the most commonly used behavioral therapy for treating anxiety in patients with ED and their spouses. The basic approach consists of four steps: non-genital sexual focus training, genital sexual focus training, vaginal containment, and normal sexual intercourse. Through gradual exposure and intimate contact, the fear of sexual behavior is eliminated, and confidence is restored (68). For example, online sensory focus exercises, progressing from non-sexual contact to intimate contact, can reduce performance anxiety and promote trust (69). Studies have confirmed that the combined use of sildenafil leads to better results (70). Pelvic floor muscle training (Kegel exercises) aims to enhance muscle strength, improve neuromuscular regulation, and promote local blood circulation through the voluntary contraction and relaxation of the entire pelvic floor musculature, including the bulbocavernosus, ischiocavernosus, and levator ani muscles (71). Studies on the effectiveness in men with sexual dysfunction have shown that after undergoing pelvic floor rehabilitation therapy, erectile function, ejaculation control, and overall sexual satisfaction have improved, with a “cure rate” of approximately 35–47% (72,73). The integrated effectiveness of these approaches has been corroborated by clinical case evidence. For instance, in a case report of an Iranian couple with unconsummated marriage attributable to vaginismus and sexual performance anxiety, the treatment team employed a combination of culturally sensitive CBT, systematic desensitization, pelvic floor muscle training, and couple-involved sex therapy, successfully enabling the couple to achieve consummation without the use of any pharmacotherapy. This confirms that even within relatively conservative cultural contexts regarding sexuality, non-pharmacological comprehensive interventions with psychological counseling and behavioral training as their core can yield favorable clinical outcomes (74).

Physiological interventions

Active management of chronic systemic diseases is essential to reduce vascular endothelial damage, repair impaired nerves, and regulate abnormal hormone levels. Surgical correction of anatomical abnormalities and adjustment of medication regimens to avoid side effects are also important. The most commonly used medications are PDE5i such as sildenafil and tadalafil, which are generally considered first-line treatment for ED and remain the preferred option (75), with a weighted average success rate of approximately 69% per sexual attempt (76). However, a significant proportion of patients with ED (referred to as non-responders to PDE5i) do not respond to PDE5 inhibitors (77). For a minority of patients who do not respond to or have contraindications to oral medications, alternatives such as vacuum constriction devices (VCDs), low-intensity extracorporeal shockwave therapy (Li-ESWT), or intracavernosal injection (ICI) therapy may be considered (78,79). Furthermore, acupuncture, as a traditional Chinese medical therapy, can exert a certain improvement effect on psychological and mild organic ED by regulating the neuroendocrine system and local blood circulation. It can be used as an adjunctive treatment method (80). For patients with severe organic ED who have not responded well to various conservative treatments, penile prosthesis implantation is a reliable ultimate surgical intervention option. After the surgery, both the patients and their partners generally have high satisfaction (81). With the vigorous development of research in gene therapy, stem cells, platelet-rich plasma, and mitochondrial transplantation, these have become new choices for male sexual health treatment (82-84).

Principles of clinical decision-making and expectation management

The key distinction between newlywed ED and other types of ED lies in its pronounced situation dependence and reversibility. Most patients have no underlying organic pathology; erectile failure primarily results from psychological stress and situational pressure, and thus the overall clinical prognosis is more favorable than that of organic ED. Clinical management should adhere to the core principles of “stratified identification, support-first approach, and stepped progression” (as shown in Table 2).

At the initial visit, etiological screening should be conducted through detailed history-taking, physical examination, and assessment with the International Index of Erectile Function-5 (IIEF-5), with emphasis on distinguishing whether the condition is predominantly psychogenic or involves concomitant occult organic abnormalities. For those whose psychological factors play a dominant role, the clinical management should focus on supportive measures such as CBT, sexual concentration training, and couple collaborative intervention. These should be supplemented with sexual health education and practical guidance. In cases where necessary, short-term combined use of PDE5 inhibitors can be employed to help patients break the vicious cycle of “anxiety → failure → intensified anxiety”. Most of these patients are young men with intact penile vascular and nerve structure functions, possessing good potential for treatment reversibility. Most of them can achieve significant improvement after standardized intervention. It should be noted that the newly developed ED in some patients is closely related to their marital relationship quality. For example, flash marriages with weak emotional foundation, negative feedback from partners or poor communication. Such cases require enhanced couple consultation and communication intervention. The efficacy highly depends on the understanding and cooperation of the spouse. For those with underlying organic factors such as hypertension, diabetes, or endocrine disorders, concurrent intervention of the primary underlying diseases is necessary. Combined with physiological treatment and psychological support, the therapeutic effect takes a relatively longer period of time. The clinical expected time window should be appropriately extended. If the initial intervention effect is poor or the patient has severe penile anatomical abnormalities, they should be promptly referred to a male specialty center for assessment of vacuum erection devices, low-energy extracorporeal shock waves, or surgical intervention. Clinicians should avoid making unrealistic short-term promises to patients. Instead, they should guide patients and their partners to jointly establish a reasonable expectation of “step-by-step, joint treatment by both husband and wife”, shifting the treatment goal from a single indicator of “successful sexual intercourse once” to a comprehensive goal of “compatibility in intimate relationship and long-term harmony in sexual relationship”.

Limitations of the study

Although this article provides a comprehensive analysis of newlyweds’ sexual ED in China from sociocultural, psychological, and physiological perspectives, several limitations must be acknowledged. First, as a narrative review, the conclusions are qualitative syntheses rather than systematic evaluations or meta-analyses, resulting in limited evidence quality and making it difficult to quantitatively integrate and compare prevalence rates and treatment outcomes across different cultural contexts. Second, while focusing on Chinese sociocultural settings helps illuminate the impact of traditional beliefs and family pressures, the analytical perspective remains largely confined to the East Asian Confucian cultural sphere. Due to differences in religion and sexual attitudes, the applicability of these findings to non-Western traditional societies such as South Asia, the Middle East, and Africa, as well as to Western regions, remains unclear, requiring cautious extrapolation. Third, newlywed sexual ED is fundamentally a relational challenge that both partners must confront together; however, this review primarily focuses on male patients’ etiology and treatment, with insufficient exploration of female partners’ sexual attitudes, coping strategies, psychological responses, and their roles in the onset, maintenance, and resolution of the condition—thus failing to fully reflect the holistic clinical picture of “couple-based treatment.” Fourth, current research in this field predominantly relies on cross-sectional and retrospective studies, lacking prospective cohort designs, which limits reliable assessment of the natural course of newlywed sexual ED and long-term marital outcomes, thereby constraining causal inference and prognostic evaluation.

Conclusions

In conclusion, new-onset ED in marriage is not merely a deficiency in sexual ability; it is a complex problem deeply rooted in social culture, triggered by psychological anxiety, and manifested as physiological disorders. Its pathogenesis exhibits a multi-layered correlation feature of “cultural roots-psychological core-physiological manifestations”, and it has significant cross-cultural heterogeneity. As a representative of regions with a profound traditional gender concept and a lack of sex education, China’s related research clearly reveals the transmission path between traditional marital and romantic cognition, social silence atmosphere, and psychological anxiety, providing valuable reference models for similar cultural backgrounds in the global context. This phenomenon further substantiates that the diagnosis and treatment of new-onset sexual ED cannot be limited to simple physiological intervention; cultural background must be integrated throughout the diagnosis and treatment process. By integrating professional forces from urology, psychology, endocrinology, vascular surgery, etc., a comprehensive solution that takes into account regional cultural characteristics and individual needs can be constructed. During this process, future research can combine the perspective of Goffman’s dramaturgical theory to explore how to utilize new media such as AI and professional self-media to help patients break through cultural cognitive frameworks, reduce stigma, and thereby optimize doctor-patient communication and treatment experience. The intervention for new-onset sexual ED has formed a three-dimensional framework of “cognitive reshaping-psychological counseling-physiological support”, but still faces many practical challenges. Society, healthcare, and families need to work together to gradually break the vicious cycle of “anxiety-failure-intensified anxiety”, helping newly married couples establish a scientific concept of sexual health and a harmonious intimate relationship, and ultimately promoting the dual improvement of sexual health levels and marriage quality among global newly married couples.

Acknowledgments

The authors wish to express their gratitude to all individuals who contributed to this research.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0515/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0515/prf

Funding: This research was supported by the Medical Science Research Project of Hebei Province: Study on the Evolution Trajectory of Functional Disorders Associated with Diabetes (project number 20270593).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0515/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Shamloul R. Management of honeymoon impotence. J Sex Med 2006;3:361-6. [Crossref] [PubMed]
2. Xi Y, Xia T, Colonnello E, et al. Unconsummated marriage among Chinese couples: a retrospective study. Sex Med 2023;11:qfac003. [Crossref] [PubMed]
3. Mark KP, Arenella K, Girard A, et al. Erectile dysfunction prevalence in the United States: report from the 2021 National Survey of Sexual Wellbeing. J Sex Med 2024;21:296-303. [Crossref] [PubMed]
4. Bie YH. Reflections on the traditional thought of "men are superior to women". Leg Syst Soc 2016;10:175-79.
5. Manalo TA, Biermann HD, Patil DH, et al. The Temporal Association of Depression and Anxiety in Young Men With Erectile Dysfunction. J Sex Med 2022;19:201-6. [Crossref] [PubMed]
6. He XF. On rural intergenerational relations: also on the value basis of intergenerational relations. Soc Sci Res 2009;5:84-92.
7. Ali ZE, Liperis G, Mincheva M, et al. From stress to success: exploring methods addressing psychosocial stress in couples trying to conceive. Hum Reprod 2023;38:2277-9. [Crossref] [PubMed]
8. Sleiman Z, Ayed A, Christoforou C, et al. Hymen conservative techniques for vaginal surgery - a practical approach. Prz Menopauzalny 2022;21:64-8. [Crossref] [PubMed]
9. Feng L. A study on the content and methods of infiltrating adolescent sex education in junior high school biology teaching. Knowl Libr 2022;12:127-9.
10. Pei XT. Study on the content of sex education textbooks for primary school students [dissertation]. Wuhan: Central China Normal University; 2018.
11. Li C, Cheng Z, Wu T, et al. The relationships of school-based sexuality education, sexual knowledge and sexual behaviors-a study of 18,000 Chinese college students. Reprod Health 2017;14:103. [Crossref] [PubMed]
12. Yu HY, Huang CP, Zhang Y, et al. Sexual knowledge status and countermeasures of college students in Macau. Chin J Hum Sex 2021;30:149-51.
13. Huang MX, Xiao Y, Wang SF. Investigation on sexual attitudes and behaviors among college students in 6 universities in Guangzhou under the background of the Internet. Chin J Hum Sex 2020;29:157-60.
14. Pu H. Buddhist view of women as seen from Buddhist literature. J Shaanxi Norm Univ (Philos Soc Sci Ed) 2009;38:71-7.
15. Shaeer O, Shaeer K. The Global Online Sexuality Survey (GOSS): erectile dysfunction among Arabic-speaking internet users in the Middle East. J Sex Med 2011;8:2152-60; quiz 2160-3. [Crossref] [PubMed]
16. Sadiq N, Warsi J. Factors Associated With Erectile Dysfunction in Men: A Cross-Sectional Study From Balochistan, Pakistan. Cureus 2025;17:e76928. [Crossref] [PubMed]
17. Setayesh S, Hossein Jalali Nadoushan A, Bakhshandeh R, et al. Experience of individuals with unconsummated marriage in Iran: A qualitative content analysis. Int J Reprod Biomed 2023;21:745-58. [Crossref] [PubMed]
18. Liu SC, Liu LQ, Wu TP. Research progress in the diagnosis and treatment of organic erectile dysfunction. Med Recapit 2017;23:3432-36, 3440.
19. Aierken A, Aimulajiang M, Adili A, et al. Psychological and social factors of unconsummated marriage in young Uyghur men. Natl J Androl 2016;22:715-19.
20. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers 2016;2:16003. [Crossref] [PubMed]
21. Malhi GS, Bell E. Questions in psychiatry (QuiP): Psychological basis for sexual dysfunction in psychiatry. Bipolar Disord 2022;24:830-3. [Crossref] [PubMed]
22. Liu Q, Zhang Y, Wang J, et al. Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis. J Sex Med 2018;15:1073-82. [Crossref] [PubMed]
23. Ye JZ, Wang Y. Is blind-date marriage reliable? A study based on CFPS2014 data. Nankai Econ Stud 2019;1:117-36.
24. Ju XY, Li XM, Xie QH, et al. Immediate and state effects of newlywed couples’ interactive behaviors on marital quality. Stud Psychol Behav 2015;13:162-70.
25. Boddi V, Fanni E, Castellini G, et al. Conflicts Within the Family and Within the Couple as Contextual Factors in the Determinism of Male Sexual Dysfunction. J Sex Med 2015;12:2425-35. [Crossref] [PubMed]
26. Ma QY, Chen X, Zhang CL. Investigation and nursing care of psychological problems in patients with erectile dysfunction. World Latest Med Inf 2018;18:168-69.
27. Liang Y, Hee J, Peng C, et al. Comparing access to sexual and reproductive health services among sexual minority youths and their peers: findings from a national survey in China. BMC Public Health 2022;22:2075. [Crossref] [PubMed]
28. Dewitte M, Bettocchi C, Carvalho J, et al. A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM). Sex Med 2021;9:100434. [Crossref] [PubMed]
29. Yi ZH, Chen QY, Zhao D, et al. Current situation and implementation strategies of sexual abuse prevention education for primary school students. Chin J Hum Sex 2020;29:154-57.
30. Gewirtz-Meydan A, Lahav Y. Sexual Functioning Among Childhood Sexual Abuse Survivors From an Attachment Perspective. J Sex Med 2020;17:1370-82. [Crossref] [PubMed]
31. Papagiannopoulos D, Khare N, Nehra A. Evaluation of young men with organic erectile dysfunction. Asian J Androl 2015;17:11-6. [Crossref] [PubMed]
32. Mitidieri E, Cirino G, d’Emmanuele di Villa Bianca R, et al. Pharmacology and perspectives in erectile dysfunction in man. Pharmacol Ther 2020;208:107493. [Crossref] [PubMed]
33. Zhang MJ, Chang DG, He ZJ, et al. Guideline for the diagnosis and treatment of erectile dysfunction with integrated traditional Chinese and Western medicine (trial version). Natl J Androl 2016;22:751-57.
34. Zhong K, Hu H, Xiao L, et al. Vascular aging-driven erectile dysfunction: pathophysiological mechanisms and emerging therapies-a narrative review. Transl Androl Urol 2025;14:4033-47. [Crossref] [PubMed]
35. Wang H, Li C, Zhang T, et al. From symptomatic relief to restorative medicine: a comprehensive review of diabetic erectile dysfunction. Transl Androl Urol 2026;15:88. [Crossref] [PubMed]
36. Defeudis G, Mazzilli R, Tenuta M, et al. Erectile dysfunction and diabetes: A melting pot of circumstances and treatments. Diabetes Metab Res Rev 2022;38:e3494. [Crossref] [PubMed]
37. Kumar S, Khurana NK, Lohana S, et al. Comparison of the Prevalence of Erectile Dysfunction Between Hypertensive and Normotensive Participants: A Case-Control Study. Cureus 2020;12:e12061. [PubMed]
38. Lyu F, Long W, Ma L. Atherosclerosis-induced arterial erectile dysfunction: pathogenesis, diagnosis, and therapeutic strategies. Transl Androl Urol 2025;14:2732-53. [Crossref] [PubMed]
39. Corona G, Isidori AM, Aversa A, et al. Endocrinologic Control of Men’s Sexual Desire and Arousal/Erection. J Sex Med 2016;13:317-37. [Crossref] [PubMed]
40. Barman M, Giribabu N, Salleh N. Roles of thyroid and leptin hormones and their crosstalk in male reproductive functions: an updated review. Endocrine 2025;87:891-906. [Crossref] [PubMed]
41. Yao S, Song J, Gao J, et al. Cognitive Function and Serum Hormone Levels Are Associated with Gray Matter Volume Decline in Female Patients with Prolactinomas. Front Neurol 2017;8:742. [Crossref] [PubMed]
42. Xie Z, Liu K, Zhang S, et al. Methylenetetrahydrofolate reductase (MTHFR) polymorphisms in andrology-a narrative review. Transl Androl Urol 2024;13:1592-601. [Crossref] [PubMed]
43. Tefekli A, Kandirali E, Erol H, et al. Peyronie’s disease in men under age 40: characteristics and outcome. Int J Impot Res 2001;13:18-23. [Crossref] [PubMed]
44. Salonia A, Castagna G, Capogrosso P, et al. Prevention and management of post prostatectomy erectile dysfunction. Transl Androl Urol 2015;4:421-37. [PubMed]
45. Leslie SW, Sooriyamoorthy T. Erectile Dysfunction. 2024 Jan 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2026 Jan–.
46. Vasan SS, Pandey S, Rao STS, et al. Association of Sexual Health and Mental Health in Erectile Dysfunction: Expert Opinion From the Indian Context. Cureus 2025;17:e77851. [Crossref] [PubMed]
47. Safa A, Waked C. Erectile Dysfunction in Young Adults: A Narrative Review. Cureus 2025;17:e89918. [Crossref] [PubMed]
48. Muin MRA, Ahmad S, Jasman MH, et al. Improving Erectile Dysfunction Management Among Asian Men With Diabetes Using the Knowledge Translation Intervention. Ann Fam Med 2023;21:502-7. [Crossref] [PubMed]
49. Krishnappa P, Manfredi C, Jayaramaiah S, et al. Unconsummated marriage: a systematic review of etiological factors and clinical management. J Sex Med 2023;21:20-8. [Crossref] [PubMed]
50. Wu TM, Hu P, Che XY, et al. Investigation and analysis of the current status and influencing factors of stigma in male patients with erectile dysfunction. Chin J Hum Sex 2021;30:144-47.
51. Xu WW, Zhang WJ, Xu XM. Status and influencing factors of premarital sexual behavior among migrant adolescents aged 15-24 in Zhuhai. Chin J Hum Sex 2024;33:157-60.
52. Steele Gray C, Shaw J, Baker GR, et al. The Integrated Care World is a Stage: Applying Goffman’s Theory of Dramaturgy to the Activities of Integrated Care. Int J Integr Care 2024;24:17. [Crossref] [PubMed]
53. Liang L. How is patient trust transferred from online medical platforms to offline? Front Public Health 2025;13:1535218. [Crossref] [PubMed]
54. Wang X, Zhu H, Jiang F. Evaluation of the efficacy of psychotherapy based on cognitive behavioral therapy for psychogenic erectile dysfunction. Chin J Androl 2022;36:80-84, 89.
55. Xue MY, Wu HC, Li YL, et al. Effect of Naikan cognitive therapy combined with motivational empowerment education on negative emotions and treatment compliance in male patients with psychogenic erectile dysfunction. Chin J Hum Sex 2022;31:1-4.
56. Liu WR, Li N, Chi YX, et al. Analysis of the therapeutic effect of psychological intervention model based on PERMA theory on psychogenic erectile dysfunction. Chin J Hum Sex 2025;34:10-3.
57. Chang SY, Zhou Y, Zhang HM, et al. Intervention effect of structured group psychotherapy on patients with psychogenic erectile dysfunction. J Nurses Train 2021;36:376-9.
58. Yang N, Wang H, Wu JW, et al. A case report of 6 cases exploring hypnotherapy for male psychogenic ED. Chin J Hum Sex 2020;29:149-51.
59. Atallah S, Haydar A, Jabbour T, et al. The effectiveness of psychological interventions alone, or in combination with phosphodiesterase-5 inhibitors, for the treatment of erectile dysfunction:A systematic review. Arab J Urol 2021;19:310-22. [Crossref] [PubMed]
60. Bilal A, Abbasi NUH. Randomized Placebo Controlled Trial of Sildenafil Citrate, Cognitive Behavior Sex Therapy and Integrated Treatment in Men Diagnosed With Non Organic Erectile Dysfunction. Sex Med 2022;10:100464. [Crossref] [PubMed]
61. Saito J, Kumano H, Ghazizadeh M, et al. An Acceptance and Commitment Therapy Smartphone Application for Erectile Dysfunction: A Feasibility Study. Curr Ther Res Clin Exp 2023;99:100728. [Crossref] [PubMed]
62. Zhou H, Meng P, Zhang X, et al. A survey of feasibility and acceptability: implementing cognitive-behavioral couple therapy for unconsummated marriage couples with genito-pelvic pain/penetration disorder. J Sex Med 2026;23:qdag091. [Crossref] [PubMed]
63. Ma L, Fan PX, Shi XM. The effect of spousal synchronous systemic psychological intervention on young and middleaged type 2 diabetes mellitus patients with erectile dysfunction and long-term poor glycemic control. J Chengdu Med Coll 2016;11:573-77.
64. Ramanathan V, Redelman M. Sexual dysfunctions and sex therapy: The role of a general practitioner. Aust J Gen Pract 2020;49:412-5. [Crossref] [PubMed]
65. Gonzalez-Saenz de Tejada M, Bilbao A, Baré M, et al. Association between social support, functional status, and change in health-related quality of life and changes in anxiety and depression in colorectal cancer patients. Psychooncology 2017;26:1263-9. [Crossref] [PubMed]
66. Liu CH, Song XN, Li Y, et al. Correlation between illness uncertainty and coping styles in patients with unconsummated marriage-related erectile dysfunction. Chin Nurs Res 2017;31:3285-8.
67. Lynn M, Iftekhar N, Adams W, et al. Multidisciplinary approach to the treatment of sexual dysfunction in couples using a biopsychosocial model. J Sex Med 2023;20:991-7. [Crossref] [PubMed]
68. Wu W, Li J, Yuan NF. Clinical application and experience of sexual sensation focus training in the treatment of honeymoon impotence. Chin J Hum Sex 2012;21:15-6.
69. Huang S, Li Z, Santtila P. The Effectiveness of Online Sensate Focus Exercises in Enhancing Sexual Function and Intimacy Among Chinese Heterosexual Couples: A Randomized Controlled Trial. J Sex Marital Ther 2024;50:707-24. [Crossref] [PubMed]
70. Sun XH, Zhao HX, Di HY, et al. Observation on the efficacy of sildenafil citrate combined with sexual sensation focus training in the treatment of erectile dysfunction in newly married men. J Clin Ration Drug Use 2016;9:58-9.
71. Santos JEMD, Brasil VV, Azevedo C, et al. Pelvic floor muscle training in men with post-prostatectomy urinary incontinence: a scoping review. Rev Lat Am Enfermagem 2024;32:e4386. [PubMed]
72. Yaacov D, Nelinger G, Kalichman L. The Effect of Pelvic Floor Rehabilitation on Males with Sexual Dysfunction: A Narrative Review. Sex Med Rev 2022;10:162-7. [Crossref] [PubMed]
73. Beecken WD, Kersting M, Kunert W, et al. Thinking About Pathomechanisms and Current Treatment of Erectile Dysfunction-"The Stanley Beamish Problem." Review, Recommendations, and Proposals. Sex Med Rev 2021;9:445-63. [Crossref] [PubMed]
74. Bokaie M, Khalesi ZB, Yasini-Ardekani SM. Diagnosis and treatment of unconsummated marriage in an Iranian couple. Afr Health Sci 2017;17:632-6. [Crossref] [PubMed]
75. Lowy M, Ramanathan V. Erectile dysfunction: causes, assessment and management options. Aust Prescr 2022;45:159-61. [Crossref] [PubMed]
76. Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2009;151:639-49. [Crossref] [PubMed]
77. Cai Z, Song X, Zhang J, et al. Practical Approaches to Treat ED in PDE5i Nonresponders. Aging Dis 2020;11:1202-18. [Crossref] [PubMed]
78. Lidawi G, Asali M, Majdoub M, et al. Short-term intracavernous self-injection treatment of psychogenic erectile dysfunction secondary to sexual performance anxiety in unconsummated marriages. Int J Impot Res 2022;34:407-10. [Crossref] [PubMed]
79. Yao WJ, Dong JT, Jiang TP, et al. Advances in erectile dysfunction treatment research: a narrative review. Transl Androl Urol 2025;14:2106-17. [Crossref] [PubMed]
80. Wang H, Chang H, Wang A, et al. A narrative review of acupuncture for sexual dysfunction: perspective of traditional Chinese medicine. Transl Androl Urol 2024;13:2587-600. [Crossref] [PubMed]
81. Rodriguez KM, Pastuszak AW. A history of penile implants. Transl Androl Urol 2017;6:S851-7. [Crossref] [PubMed]
82. Liu SZ, Feng DC, Liu ZH, et al. Development of nanotechnology in andrology. Transl Androl Urol 2020;9:702-8. [Crossref] [PubMed]
83. Huang L, Gao Z, Ren X, et al. Platelet-rich plasma in selected urological conditions: a narrative review of biological rationale, current evidence, and limitations. Transl Androl Urol 2026;15:182. [Crossref] [PubMed]
84. Wen C, Cheng Y, Chen Z, et al. Mitochondrial transplantation-a novel therapeutic strategy for erectile dysfunction: a narrative review. Transl Androl Urol 2025;14:3757-70. [Crossref] [PubMed]