Treatment Model for Young Patients with Psychogenic Erectile Dysfunction and Resultant Infertility

Summary

An integrated treatment model for unconsummated marriage (UCM) due to psychogenic erectile dysfunction is presented, offering streamlined management from assessment to intervention. Emphasizing patient-centered care and communication, preliminary results show improved success rates and satisfaction, supporting its effectiveness in addressing infertility in UCM from the male perspective.

Abstract

Conventional management of erectile dysfunction (ED)-related non-consummation and infertility often overlooks psychosocial determinants and dyadic involvement, leading to suboptimal therapeutic outcomes, including persistent sexual dysfunction and reduced couple satisfaction. This study proposes and validates a novel, patient-centric intervention tailored for young individuals with psychogenic ED (pED), targeting both erectile recovery and infertility resolution. The "Streamlined Clinical Process" incorporates structured treatment strategies for both the patient and their partner, including evidence-based sexual health education, psychological support, partner-inclusive counseling, sensate focus training, lifestyle modification, on-demand pharmacotherapy, and structured follow-up. Following comprehensive baseline assessments (medical history, physical examination, and diagnostics), the treatment team collaboratively formulates individualized 16-week regimens with active partner engagement. Three key innovations distinguish this protocol: (1) The implementation of the GLTC (Goodwill-Listening-Talking-Cooperation) communication framework, which addresses patients' psychological needs and promotes effective communication strategies; (2) The application of Hawton's psychosexual stratification to identify specific psychological factors, with the aim of reshaping negative sexual beliefs, alleviating anxiety, improving sexual function, and rebuilding mutual trust and emotional connection between partners; (3) The development of easy-to-understand videos for psychological education to enhance treatment adherence through iterative patient-provider dialogue. Results demonstrate clinically meaningful improvements in erectile function recovery rates, coital success frequency, and couple satisfaction. Notable challenges include patient adherence to the treatment plan and the timely effectiveness of non-pharmacological interventions. In conclusion, this model presents a scalable and effective strategy for addressing sexual dysfunction-related infertility in young patients, offering a valuable framework for clinical practice and future research in sexual medicine.

Introduction

Erectile dysfunction (ED), defined as the persistent inability to attain or sustain an erection adequate for satisfactory sexual performance, is predominantly associated with psychological factors -- termed psychogenic erectile dysfunction (pED) -- which account for 85%-90% of cases^1,2. Although ED may result from vascular disease, hormonal dysregulation, or neurological impairments, pED is characterized by the absence of significant organic abnormalities. Instead, its etiology involves factors such as anxiety, depressive disorders, chronic stress, or adverse sexual experiences that interfere with the neurovascular mechanisms required for erectile function.

Notably, pED disproportionately affects individuals under the age of 40³, a demographic that experiences elevated anxiety levels due to psychosocial stressors. A subset of patients presents with persistent sexual dysfunction beginning at the time of marriage or cohabitation, clinically referred to as unconsummated marriage (UCM) or "honeymoon-phase ED"^4,5. The prevalence of UCM in male outpatient clinics ranges from 4% to 17%, with variability influenced by cultural norms (e.g., stigmatization of premarital sexual health education), diagnostic heterogeneity, healthcare access limitations, and cohort selection biases.

Anxiety disorders are present in 74.4% of UCM cases, with pED identified as the principal etiological factor in affected males^6,7. Post-cohabitation infertility affects 65% of UCM couples. Consultation for infertility often occurs under pressure from familial expectations (e.g., intergenerational desire for offspring) and societal stigma (e.g., cultural taboos surrounding male sexual health). These sociocultural dynamics contribute to delayed treatment-seeking behavior, driven by fear of social judgment and internalized stress related to nonconformity with normative gender roles, as reported at the 2019 Joint Meeting of the International Society for Sexual Medicine⁸.

In clinical practice, patients with pED frequently present with performance anxiety or fear of failure during consultations. However, these concerns are often attributed solely to physical causes, with minimal exploration of underlying psychological triggers. For instance, a common clinical scenario involves prescribing phosphodiesterase-5 (PDE5) inhibitors without evaluating psychosocial comorbidities such as relationship discord or a history of sexual trauma. This may be due to a traditional lack of awareness, knowledge, and training among urologists and andrologists in assessing key psychological factors related to ED⁹. Furthermore, cultural and economic disparities across regions pose additional challenges in addressing these issues¹⁰. Major barriers include prolonged patient communication requirements that overwhelm physicians with limited communication skills, a lack of sexual health and psychological education for patients, compounded by the absence of appropriate billing codes to reflect the physician's effort; and the lack of collaborative psychosocial therapy teams or consultation services.

Typically, patients seek treatment from urology or andrology clinics that focus primarily on male factors, rather than on the couple as a unit. As a result, treatment is often narrowly focused on symptom management -- specifically, the administration of PDE5 inhibitors to improve erection hardness and increase the success rate of intercourse¹¹. While this method proves effective for some, it is insufficient for many, as it overlooks the psychological and relational factors critical to patients with pED. These neglected aspects include managing performance anxiety, improving sexual communication between partners, and addressing the emotional impact of repeated sexual failures.

A more holistic approach is essential for long-term treatment success. The limitations of the conventional approach become increasingly evident with a growing number of consulting couples. Problems often arise when patients discontinue PDE5 inhibitor use, resulting in recurrent failures in consummating marriage and growing distrust in the treatment plan. Additionally, unresolved issues of low male self-esteem contribute to new psychological difficulties^12,13, including reliance on medication for sexual performance. Ultimately, these approaches fail to resolve natural conception challenges faced by the couple and may give rise to more complex problems. These include emotional distress such as depression and anxiety from repeated treatment failures, marital strain, family conflicts, societal pressure to bear children, and the stigmatization of infertility.

These challenges necessitate a reevaluation of the psychopathological dimensions within clinical frameworks. Hawton's etiological classification stratifies contributing factors into predisposing, precipitating, and perpetuating elements^14,15, which frequently exhibit comorbidity¹⁶. Under the influence of these factors, patients often experience emotional instability, such as anxiety and strained interpersonal relationships. Their emotions are highly sensitive to the manner of communication. The physician's communication style plays a critical role in gaining the patient's cooperation and trust in the treatment process. Similarly, effective patient sex education and psychological counseling aimed at fostering medical cooperation depend heavily on the healthcare provider's communication skills. Affective dysregulation -- manifesting as anxiety disorders and interpersonal conflict -- typically emerges under these psychodynamic influences. Crucially, patients' emotional states are highly susceptible to clinician communication styles, which fundamentally influence the formation of a therapeutic alliance and adherence to treatment. This interdependence also affects the efficacy of psychosexual education and medical collaboration, both of which rely on the communicative competence of healthcare professionals.

The GLTC (Goodwill-Listening-Talking-Cooperation) framework, through its systematic integration of biomedical protocols and humanistic engagement, demonstrates strong cultural adaptability^17,18. This framework emphasizes improving physicians' listening skills and enhancing verbal communication techniques. By attentively listening to patients and offering timely feedback, physicians can better understand patient needs and build trust. Additionally, using friendly body language, warm verbal expressions, and encouraging dialogue helps foster patient trust, thereby improving the doctor-patient relationship and elevating the quality of care^18,19,20.

This approach is particularly important in treating patients with psychogenic sexual dysfunction. It is recommended that the GLTC communication framework be integrated throughout the entire treatment process, with implementation plans tailored to individual patient differences^17,21. This is especially relevant in the context of andrological therapy. To address the clinical challenges faced by young couples experiencing infertility due to psychogenic ED, a diagnostic and treatment model has been developed that integrates Hawton's classification method¹⁵ with the GLTC communication framework, resulting in notable outcomes.

Protocol

All procedures described below were reviewed and approved by the Institutional Review Board of the Affiliated Panyu Central Hospital of Guangzhou Medical University, under trial registration number ChiCTR1800019279. At the initial consultation beginning in June 2020, participants provided informed consent after receiving a thorough explanation of the treatment purpose, procedures, and data handling protocols. It was ensured that all information would remain confidential and be used exclusively for research purposes. Discussions involving sexual health education and personal histories were conducted privately and with the utmost sensitivity. All interactions were carried out respectfully, with the dignity of each participant preserved. Personal identifiers were removed, and unique codes were assigned to anonymize participant data, which was securely stored on encrypted, password-protected systems and in locked cabinets to prevent identity linkage and unauthorized access. Details of the reagents and equipment used are listed in the Table of Materials.

1. Patient selection

1. Set the inclusion criteria
   1. Select men aged 18-40 who have been unable to complete intercourse despite at least two attempts⁵, and who have been unable to achieve pregnancy after one year of regular, unprotected intercourse.
   2. Select patients with a score <22 on the International Index of Erectile Function (IIEF-5) (Supplementary Table 1).
   3. Ensure that patients exhibit psychological factors as determined by the Hawton classification¹⁵ (Supplementary Table 2 and Supplementary Table 3).
   4. Ensure that patients have normal secondary sexual characteristics.
   5. Ensure that patients are married or in a stable sexual relationship and are capable of engaging in at least one normal intercourse per week from the start to the completion of the study.
   6. Ensure that the female partner does not have significant sexual dysfunction or other factors contributing to the failure to consummate the marriage due to lack of sexual knowledge.
   7. Ensure that patients have not used any erectile dysfunction medications or other drugs intended to improve erectile function within four weeks prior to treatment.
2. Set the exclusion criteria²²
   1. Exclude patients with secondary ED resulting from vascular, endocrine, or medication-induced causes.
   2. Exclude patients with psychiatric disorders caused by schizophrenia or severe mood disorders.
   3. Exclude patients with significant neurological damage or anatomical genital abnormalities.
   4. Exclude patients with severe cardiovascular or cerebrovascular diseases.
   5. Exclude patients with a history of substance abuse, including drug or alcohol dependency.
   6. Exclude patients currently receiving ongoing medical treatments, such as chronic pain management or therapies for autoimmune diseases.

2. Layout of the andrology area

1. Waiting area
   1. Establish a waiting area at the point of registration. Ensure that a guide nurse assesses the patient's needs and introduces the functions of various sections, along with the basic consultation process (see Figure 1A).
2. Form-filling area
   1. Set up a form-filling area. Ensure that patients complete a self-designed erectile dysfunction history questionnaire, including details on onset time, current sexual frequency, marital and reproductive history, masturbation habits, and treatment history.
   2. Include standardized assessment scales such as the International Index of Erectile Function (IIEF-5)²³ and the International Premature Ejaculation Diagnostic Tool (PEDT)²⁴ before the consultation (see Figure 1A).
3. Clinic area
   1. Establish a clinic area consisting of seven independent rooms (see Figure 1A,B).
   2. Set up two andrology consulting rooms. Ensure that physicians working in these rooms are trained in GLTC communication skills.
   3. Set up one health consultation room. Ensure that nurses assigned to this room are also trained in GLTC communication skills.
   4. Set up an educational room. Equip this room with sexual and psychological health literature/videos, anatomical models of reproductive organs, and penis erection hardness models.
   5. Set up a Sensate Focus video room. Present a pre-recorded, accessible, and easy-to-understand video on Sensate Focus techniques^25,26.
   6. Set up a simulated family room. Use this space to demonstrate Sensate Focus techniques to patients and their partners.
   7. Set up a testing room to conduct audiovisual sexual stimulation (AVSS) and penile erection rigidity testing. These tests help exclude organic causes of ED or meet patient requests for further evaluation²⁷.

3. Implementation of the GLTC framework

1. Integrate the three elements of effective doctor-patient communication-Goodwill (G), Listening (L), and Talking (T)-into the consultation process to focus on the patient's needs, emotions, and expectations. This approach fosters a patient-centered method that enhances the doctor-patient relationship and ultimately leads to Cooperation (C), forming a closed-loop communication model.
2. Apply the GLTC framework to the case of a couple seeking consultation due to unconsummated marriage (UCM), as described in the following example:
   1. Goodwill (G)
      1. Be kind and friendly to patients. Provide a quiet room with appropriate decor that ensures privacy, allowing them to communicate in a comfortable and relaxed setting.
   2. Listening (L)
      1. Give the patient ample time to express their doubts and concerns. Avoid interrupting the patient, but respond appropriately when necessary.
      2. Carefully listen and identify the patient's needs and expectations.
   3. Talking (T)
      1. Patiently and clearly answer the patient's questions, building upon active listening and an understanding of the patient's emotional responses.
      2. Address the patient's emotional and psychological needs while actively responding to their expectations to establish the foundation for cooperation.
   4. Cooperation (C)
      1. Promote consensus between the patient and their partner and establish a cooperative doctor-patient relationship to jointly address the medical, psychological, and social challenges associated with UCM.

4. Treatment procedure

1. Initial consultation
   1. Ensure that physicians review the patient's preliminary information and conduct a comprehensive interview using GLTC communication techniques to foster a relaxed and trusting atmosphere.
   2. Identify psychological factors using the Hawton classification¹⁵ to develop a personalized treatment plan (see Figure 1C).
2. Physical examination and testing
   1. Perform a physical examination of the patient.
   2. Conduct additional laboratory tests, such as fasting blood glucose, lipid profile, and testosterone levels. Perform penile rigidity assessments, including audiovisual sexual stimulation (AVSS) or penile erection rigidity testing, if necessary.
3. Sexual and psychological education
   1. Ensure that the nurse provides 15-20 min of education to the patient and their partner, addressing questions and maintaining a supportive environment using the GLTC framework.
4. Self-study on sexual health
   1. Ensure that the patient and their partner spend 20-30 min in the self-study room reviewing educational materials or videos based on the issues identified during earlier sessions.
5. Sensate Focus Demonstration under medical staff guidance
   1. Ensure that the couple watches a 50-min Sensate Focus demonstration video to learn cognitive-behavioral sexual therapy techniques.
      NOTE: Steps 4.3-4.5 can be adjusted based on patient scheduling and progress; however, all must be completed before proceeding to step 4.6.
6. Practicing Sensate Focus in the simulated family room
   1. Ensure that the couple practices key Sensate Focus steps under nurse guidance while clothed.
   2. Ensure that the nurse explains concepts and guides them through the three stages: Non-genital Touching, Genital and/or Breast Touching, and Sensual Intercourse.
   3. Ensure a gynecological examination is conducted for the partner, if necessary, to rule out any contributing female factors.
   4. Instruct the couple to continue practicing these steps at home.
7. Follow-up and adjustment
   1. Schedule an 8-week follow-up visit during the Sensual Intercourse stage to assess outcomes such as sexual performance and anxiety levels (using the IIEF-5 questionnaire), and frequency of intercourse and to guide further treatment.
   2. Encourage the couple to engage in sexual intercourse at least once per week.
   3. Prescribe phosphodiesterase-5 (PDE5) inhibitors (sildenafil citrate tablets) to support the sensual intercourse stage if the patient demonstrates low confidence.

5. Data collection

1. Collect demographic data from the hospital information system.
2. Record the frequency of masturbation based on relevant literature⁽²⁸⁾ to explore its potential association with psychogenic erectile dysfunction (pED), which informs targeted sex education and behavioral therapy.
   NOTE: Light masturbation is defined as an average of one masturbation episode every 4 days or more; Frequent masturbation is defined as an average of one masturbation episode every 3 days or less; Excessive masturbation is defined as frequent masturbation persisting for more than 2 years.
3. Measure the following scores:
   1. International Index of Erectile Function (IIEF-5) score (range: 5-25)²³, used to evaluate erectile function and classify severity as: Severe (5-7), Moderate (8-11), Mild-to-moderate (12-16), Mild (17-21), Normal (22-25). This provides a standardized assessment of treatment efficacy.
   2. Erection Hardness Score (EHS) (range: 0-4)²⁹: 0 - Penis does not enlarge, 1 - Enlarged but not hard, 2 - Hard but not hard enough for penetration, 3 - Hard enough for penetration but not completely hard, 4 - Fully rigid and hard. This offers a simple evaluation of erectile quality.
   3. The number of patients responding "yes" to Sexual Encounter Profile questions: SEP-Q2: Was the erection hard enough for penetration? SEP-Q3: Was the erection maintained long enough for successful intercourse?^30,31.
   4. Sexual Satisfaction Score for Women (SSS-W) (scale: 1-5)³²: 1 - Very dissatisfied, 2 - Dissatisfied, 3 - Neutral, 4 - Satisfied, 5 - Very satisfied. This provides a straightforward assessment of the female partner's sexual satisfaction.
   5. Record the number of patients who received phosphodiesterase-5 (PDE5) inhibitors (sildenafil citrate tablets).
4. Track the number of female partners who achieved pregnancy during the follow-up period.

6. Validation of protocol and evaluation of treatment efficacy

1. Follow standard principles for taking a sexual history and differentiate between primarily psychological and primarily organic erectile dysfunction (ED), in conjunction with self-rating scale results (Supplementary File 1, Supplementary Tables 1, and Supplementary Table 2).
2. Identify and document psychological factors contributing to ED using the Hawton classification¹⁵ (Supplementary File 1, and Supplementary Table 3).
3. Clearly explain the treatment process and specific procedural steps to the patient and their partner, and obtain informed consent.
4. Complete at least the first six steps of the protocol (steps 4.1-4.6) once every 2 weeks over a duration of 8 weeks, constituting one full treatment course.
5. Evaluate treatment efficacy following one course using the following criteria:
   1. An increase of three or more points in the patient's International Index of Erectile Function (IIEF-5) score compared to baseline.
   2. An Erection Hardness Score (EHS) of ≥3 for the patient and a Sexual Satisfaction Score for Women (SSS-W) of ≥3 for the partner.
   3. A proportion of "Yes" responses exceeding 80% for both Sexual Encounter Profile questions SEP-Q2 (erection sufficient for penetration) and SEP-Q3 (erection maintained for completion of intercourse) (Supplementary File 1, Supplementary Table 1, Supplementary Table 4, Supplementary Table 5, and Supplementary Table 6).

Results

A total of 64 patients and their partners were admitted to the study. Of these, 22 couples (32.2%) discontinued treatment after the initial assessment. The primary reasons for treatment interruption were time constraints affecting both partners, difficulties related to travel distance, and preference for alternative therapies such as traditional Chinese medicine. Additional contributing factors may have included psychological barriers, such as embarrassment or stigma, lack of immediate treatment effects, and insufficient...

Discussion

In cases of unexplained couple mismatch (UCM), primary erectile dysfunction (pED) is recognized as the predominant etiology in males. It is characterized by cognitive-behavioral constructs such as performance anxiety, self-efficacy deficits, and sexual avoidance patterns, as delineated in Hawton's psychosexual triaxial classification^33,34. Current evidence indicates that monotherapy approaches exhibit limited long-term efficacy³⁵. Cont...

Materials

Name	Company	Catalog Number	Comments
Anatomical Illustrations of the Male and Female Reproductive Systems	Rui'an Shengxiao Plastic Products, China	L08	llustrations for educational purposes.
Anatomical Model of Female Reproductive System	Rui'an Shengxiao Plastic Products, China	A200	Detailed anatomical model for educational purposes.
Anatomical Model of Male Reproductive System	Rui'an Shengxiao Plastic Products, China	A100	Detailed anatomical model for educational purposes.
Andrology Consulting Rooms	N/A	N/A	Two dedicated andrology consulting rooms designed for comprehensive doctor-patient and partner communication. See Figure 1B.
Andrology Consulting Rooms	N/A	N/A	Used for doctor-patient/partner communication, each doctor trained in GLTC communication skills.
Audiovisual Sexual Stimulation (AVSS) / Penile Erection Rigidity Testing Room	N/A	N/A	This specialized room is equipped for audiovisual sexual stimulation (AVSS) and penile erection rigidity testing. It provides a controlled environment for evaluating erectile function. See Figure 1B.
Checklist of Psychological factors associated with erectile dysfunction Modified from Hawton classification, conducted in interview.	N/A	N/A	Supplemental Table S3.
Clinic Area	N/A	N/A	This are is the core of the clinic, featuring multiple consultation and examination rooms for various diagnostic and treatment activities. The layout with seven independent Rooms is carefully designed to ensure  efficient workflows and privacy. See Figure 1A.
Data collecting table	N/A	N/A	The header columns in the table display the necessary information or evaluation criteria to be collected during the diagnosis and treatment process.See Data available.xls.
Doctor-Patient Communication (2nd Edition)	People's Medical Publishing House, China	ISBN 978-7-117-26404-4	GLTC communication skills Training Materials.
Educational Room	N/A	N/A	Educational room is a resource-rich environment, stocked with a variety of health education materials designed to cater to the diverse needs of our patients sexual and psychological health. It features anatomical models of male and female reproductive organs and penis erection hardness models and includes educational Videos. Educational Videos provide visual and auditory learning experiences, making complex medical concepts more accessible. These videos cover a range of topics, including preventive health measures, treatment options, and lifestyle modifications. This room serves as an educational hub, allowing patients and their partners to gain a deeper understanding of reproductive health through hands-on learning and reading materials. See Figure 1B.
Form of characteristics for distinguishing psychologic from organic sexual dysfunction, conducted in interview.	N/A	N/A	Supplemental Table S2.
Form of the Erection Hardness Score (EHS)	N/A	N/A	Supplemental Table S4.
Form-Filling Area	N/A	N/A	Equipped with desks, chairs, pens, and all required forms and materials to ensure that patients can easily complete their necessary medical information and questionnaires. Electronic form can be another option. See Figure 1A.
Functional zoning of the Andrology Clinic area	N/A	N/A	Including Waiting Area, Form-Filling Area and  Clinic Area. This functional zoning not only maximizes the use of limited space but also ensures a rational and efficient diagnostic process. Through scientific layout and zoning, we can provide a better service experience for patients while improving the quality and efficiency of our medical services. See Figure 1A.
Health Consultation Room	N/A	N/A	Used for nurse-patient/partner communication, each nurse trained in GLTC communication skills,  ensuring that patients receive well-rounded care and support. See Figure 1B.
Layout of the seven independent Rooms	N/A	N/A	The clinic area recommended  comprises seven independent rooms, each tailored to specific aspects of patient care and education. See Figure 1B-1C.
Penis Erection Hardness Models	Pfizer Inc.	EHM-001	The Erection Hardness Model by Pfizer Inc. is a comprehensive educational tool designed to help healthcare professionals assess and discuss erectile function with patients. The model illustrates various levels of erection hardness, providing a clear and practical reference for both diagnosis and patient education. This tool aids in improving communication and understanding between doctors and patients regarding erectile health.
RigiScan	Gotop Medica, US	Plus	RigiScan Plus is a product of Gesiva Medical, which specializes in medical devices for diagnosing and assessing erectile dysfunction.
Sensate Focus video	MFP Power Supply Company		Sensate Focus video room featuring videos from the “SEX, A Life Long Pleasure”, produced by MFP Power Supply Company, presented by Belgian and American sexologists and psychologists.
Sensate Focus Video Room	N/A	N/A	This room is dedicated to Sensate Focus training, featuring instructional videos from the series "SEX, A Life Long Pleasure," produced by MFP Power Supply Company. The videos are presented by renowned Belgian and American sexologists and psychologists, providing patients and their partners with expert guidance on maintaining a healthy sexual life. See Figure 1B.
Sexual Encounter Profile (SEP) questions 2, 3	N/A	N/A	Supplemental Table S6.
Sildenafil citrate tablet	Pfizer Inc.	Film coated, 5x100mg/capsule	For patients with Erectile Dysfunction when necessary.
Simulated Family Room	N/A	N/A	The simulated family room is used exclusively to demonstrate to patients and their partners with normal dresses how to practice each step of Sensate Focus at home. This realistic setting helps couples learn and rehearse the techniques in a familiar environment, enhancing the effectiveness of their home practice. See Figure 1B.
The International Index of Erectile Function 5 (IIEF-5) questionnaire	N/A	N/A	Table S1.
The Sexual Satisfaction Scale for Women (SSS-W)	N/A	N/A	Supplemental Table S5.
Waiting Area	N/A	N/A	Equipped with comfortable seating, reading materials, and health education videos to help patients understand more about their health and the diagnostic process during their wait. See Figure 1A.