Trends in psychogenic erectile dysfunction research: a bibliometric and visualized study

Psychogenic erectile dysfunction (pED) is more common in the population of young and middle-aged males. Research relating to pED has increased significantly over the past 20 years. However, few studies have performed comprehensive statistical analysis on these publications. In this study, we highlight the current research hotspots and emerging trends relating to pED from 2000 to 2022, as determined by a focused review of the literature. Relevant articles were identified by searching the PubMed and Web of Science databases between 2000 and 2022. VOSviewer and Origin software were then used to analyze and verify emerging trends. A total of 118 articles relating to pED were included in our final analysis. Our analysis showed that research on pED is dominated by clinical studies and concentrated in journals relating to male and sexual medicine. Chinese researchers have produced the highest number of publications. In addition, over the past 20 years, pED research has focused more on pathogenesis, diagnosis and treatment. In this study, we reviewed articles related to pED that were published over the last 20 years; our findings may provide reference guidelines for researchers when designing future research on pED.

Psychogenic erectile dysfunction; Mechanism; Diagnosis; Treatment

[1] Salonia A, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, et al. European association of urology guidelines on sexual and reproductive health—2021 update: male sexual dysfunction. European Urology. 2021; 80: 333–357.

[2] Jiang T, Osadchiy V, Mills JN, Eleswarapu SV. Is it all in my head? Self-reported psychogenic erectile dysfunction and depression are common among young men seeking advice on social media. Urology. 2020; 142: 133–140.

[3] Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile dysfunction in young men—a review of the prevalence and risk factors. Sexual Medicine Reviews. 2017; 5: 508–520.

[4] Zhang X, Yang B, Li N, Li H. Prevalence and risk factors for erectile dysfunction in Chinese adult males. The Journal of Sexual Medicine. 2017; 14: 1201–1208.

[5] Feng S, Dong L, Yan B, Zheng S, Feng Z, Li X, et al. Altered functional connectivity of large-scale brain networks in psychogenic erectile dysfunction associated with cognitive impairments. Neuropsychiatric Disease and Treatment. 2023; 19: 1925–1933.

[6] Rajkumar RP. The impact of disrupted childhood attachment on the presentation of psychogenic erectile dysfunction: an exploratory study. The Journal of Sexual Medicine. 2015; 12: 798–803.

[7] Wiggins A, Tsambarlis PN, Abdelsayed G, Levine LA. A treatment algorithm for healthy young men with erectile dysfunction. BJU International. 2019; 123: 173–179.

[8] Sevim M, Alkis O, Kartal İG, Telli S, Aras B. A factor not to be ignored in post-COVID-19 erectile dysfunction; psychological effect, a prospective study. Andrologia. 2022; 54: e14443.

[9] Zhang X, Zhou Y, Wei N, Shou X, Fan S, You Y, et al. A bibliometric analysis of heart failure with preserved ejection fraction from 2000 to 2021. Current Problems in Cardiology. 2022; 47: 101243.

[10] Rosen RC. Psychogenic erectile dysfunction. Classification and management. Urologic Clinics of North America. 2001; 28: 269–278.

[11] Banner LL, Anderson RU. Integrated sildenafil and cognitive-behavior sex therapy for psychogenic erectile dysfunction: a pilot study. The Journal of Sexual Medicine. 2007; 4: 1117–1125.

[12] De Rose AF, Giglio M, Traverso P, Lantieri P, Carmignani G. Combined oral therapy with sildenafil and doxazosin for the treatment of non-organic erectile dysfunction refractory to sildenafil monotherapy. International Journal of Impotence Research. 2002; 14: 50–53.

[13] Melis M, Argiolas A. Central oxytocinergic neurotransmission: a drug target for the therapy of psychogenic erectile dysfunction. Current Drug Targets. 2003; 4: 55–66.

[14] Montorsi F, Perani D, Anchisi D, Salonia A, Scifo P, Rigiroli P, et al. Brain activation patterns during video sexual stimulation following the administration of apomorphine: results of a placebo-controlled study. European Urology. 2003; 43: 405–411.

[15] Melnik T, Abdo CH. Psychogenic erectile dysfunction: comparative study of three therapeutic approaches. Journal of Sex & Marital Therapy. 2005; 31: 243–255.

[16] Olsson AM, Speakman MJ, Dinsmore WW, Giuliano F, Gingell C, Maytom M, et al. Sildenafil citrate (Viagra) is effective and well tolerated for treating erectile dysfunction of psychogenic or mixed aetiology. International Journal of Clinical Practice. 2000; 54: 561–566.

[17] Cera N, Di Pierro ED, Ferretti A, Tartaro A, Romani GL, Perrucci MG. Brain networks during free viewing of complex erotic movie: new insights on psychogenic erectile dysfunction. PLOS ONE. 2014; 9: e105336.

[18] Chen CJ, Kuo TB, Tseng Y, Yang CC. Combined cardiac sympathetic excitation and vagal impairment in patients with non-organic erectile dysfunction. Clinical Neurophysiology. 2009; 120: 348–352.

[19] Cera N, Delli Pizzi S, Di Pierro ED, Gambi F, Tartaro A, Vicentini C, et al. Macrostructural alterations of subcortical grey matter in psychogenic erectile dysfunction. PLOS ONE. 2012; 7: e39118.

[20] Zhang T, Yuan P, Cui Y, Yuan W, Jiang D. Convergent and divergent structural connectivity of brain white matter network between patients with erectile dysfunction and premature ejaculation: a graph theory analysis study. Frontiers in Neurology. 2022; 13: 804207.

[21] Liu T, Xu Z, Guan Y, Yuan M. Comparison of RigiScan and penile color duplex ultrasound in evaluation of erectile dysfunction. Annals of Palliative Medicine. 2020; 9: 2988–2992.

[22] Chen JH, Chen GT, Chen Y, Yao ZJ, Lu Q, Dai YT. Correlation of abnormal topological properties of the white matter fibers connecting the left amygdale with psychogenic erectile dysfunction. National journal of andrology. 2017; 23: 323–328. (In Chinese)

[23] Zhang P, Liu J, Li G, Pan J, Li Z, Liu Q, et al. White matter microstructural changes in psychogenic erectile dysfunction patients. Andrology. 2014; 2: 379–385.

[24] Chen J, Chen Y, Gao Q, Chen G, Dai Y, Yao Z, et al. Brain structural network topological alterations of the left prefrontal and limbic cortex in psychogenic erectile dysfunction. International Journal of Neuroscience. 2018; 128: 393–403.

[25] Zhao L, Guan M, Zhang X, Karama S, Khundrakpam B, Wang M, et al. Structural insights into aberrant cortical morphometry and network organization in psychogenic erectile dysfunction. Human Brain Mapping. 2015; 36: 4469–4482.

[26] Ma Z, Ren F, Huang X, Yang X, Li H, Li G, et al. Decreased gray matter volume of the anterior insular cortex in patients with psychogenic erectile dysfunction: a voxel-based morphometry study. Journal of Psychiatric Research. 2022; 145: 125–131.

[27] Wang Y, Dong M, Guan M, Wu J, He Z, Zou Z, et al. Aberrant insula-centered functional connectivity in psychogenic erectile dysfunction patients: a resting-state fMRI study. Frontiers in Human Neuroscience. 2017; 11: 221.

[28] Chen J, Wu J, Huang X, Sun R, Xiang Z, Xu Y, et al. Differences in structural connectivity between diabetic and psychological erectile dysfunction revealed by network-based statistic: a diffusion tensor imaging study. Frontiers in Endocrinology. 2022; 13: 892563.

[29] Chen J, Chen Y, Gao Q, Chen G, Dai Y, Yao Z, et al. Impaired prefrontal-amygdala pathway, self-reported emotion, and erection in psychogenic erectile dysfunction patients with normal nocturnal erection. Frontiers in Human Neuroscience. 2018; 12: 157.

[30] Yin T, Ren FQ, Ma ZY, Huang XP, Chang DG, Zhang PH. Alterations of regional homogeneity in patients with psychogenic erectile dysfunction: a study by resting-state functional MRI. National Journal of Andrology. 2020; 26: 118–122. (In Chinese)

[31] Yin T, Liu Q, Ma Z, Li Z, Sun R, Ren F, et al. Associations between altered cerebral activity patterns and psychosocial disorders in patients with psychogenic erectile dysfunction: a mediation analysis of fMRI. Frontiers in Psychiatry. 2020; 11: 583619.

[32] Jin C, Guan M, Dong M, Wu J, He Z, Chen X, et al. Aberrant baseline brain activity in psychogenic erectile dysfunction patients: a resting state fMRI study. Brain Imaging and Behavior. 2018; 12: 1393–1404.

[33] Liu Q, Zhang P, Pan J, Li Z, Liu J, Li G, et al. Cerebral activity changes in different traditional Chinese medicine patterns of psychogenic erectile dysfunction patients. Evidence-Based Complementary and Alternative Medicine. 2015; 2015: 503536.

[34] Zhang X, Guan M, Chen X, Zhang P, Wu J, Zhang X, et al. Identifying neuroimaging biomarkers for psychogenic erectile dysfunction by fusing multi-level brain information: a resting-state functional magnetic resonance imaging study. Andrology. 2022; 10: 1398–1410.

[35] Watts DJ, Strogatz SH. Collective dynamics of ‘small-world’ networks. Nature. 1998; 393: 440–442.

[36] Dai Z, He Y. Disrupted structural and functional brain connectomes in mild cognitive impairment and Alzheimer’s disease. Neuroscience Bulletin. 2014; 30: 217–232.

[37] Rupp HA, James TW, Ketterson ED, Sengelaub DR, Ditzen B, Heiman JR. Lower sexual interest in postpartum women: relationship to amygdala activation and intranasal oxytocin. Hormones and Behavior. 2013; 63: 114–121.

[38] Karama S, Lecours AR, Leroux JM, Bourgouin P, Beaudoin G, Joubert S, et al. Areas of brain activation in males and females during viewing of erotic film excerpts. Human Brain Mapping. 2002; 16: 1–13.

[39] Cheng JC, Secondary J, Burke WH, Fedoroff JP, Dwyer RG. Neuroimaging and sexual behavior: identification of regional and functional differences. Current Psychiatry Reports. 2015; 17: 55.

[40] Georgiadis JR, Holstege G. Human brain activation during sexual stimulation of the penis. Journal of Comparative Neurology. 2005; 493: 33–38.

[41] Redouté J, Stoléru S, Grégoire MC, Costes N, Cinotti L, Lavenne F, et al. Brain processing of visual sexual stimuli in human males. Human Brain Mapping. 2000; 11: 162–177.

[42] Everitt BJ. Sexual motivation: a neural and behavioural analysis of the mechanisms underlying appetitive and copulatory responses of male rats. Neuroscience & Biobehavioral Reviews. 1990; 14: 217–232.

[43] Zahm DS. An integrative neuroanatomical perspective on some subcortical substrates of adaptive responding with emphasis on the nucleus accumbens. Neuroscience & Biobehavioral Reviews. 2000; 24: 85–105.

[44] Henze R, Brunner R, Thiemann U, Parzer P, Klein J, Resch F, et al. White matter alterations in the corpus callosum of adolescents with first-admission schizophrenia. Neuroscience Letters. 2012; 513: 178–182.

[45] Knyazeva MG. Splenium of corpus callosum: patterns of interhemispheric interaction in children and adults. Neural Plasticity. 2013; 2013: 639430.

[46] Cera N, Castelhano J, Oliveira C, Carvalho J, Quinta Gomes AL, Peixoto MM, et al. The role of anterior and posterior insula in male genital response and in visual attention: an exploratory multimodal fMRI study. Scientific Reports. 2020; 10: 18463.

[47] Stoléru S, Fonteille V, Cornélis C, Joyal C, Moulier V. Functional neuroimaging studies of sexual arousal and orgasm in healthy men and women: a review and meta-analysis. Neuroscience & Biobehavioral Reviews. 2012; 36: 1481–1509.

[48] Moulier V, Mouras H, Pélégrini-Issac M, Glutron D, Rouxel R, Grandjean B, et al. Neuroanatomical correlates of penile erection evoked by photographic stimuli in human males. NeuroImage. 2006; 33: 689–699.

[49] Miyagawa Y, Tsujimura A, Fujita K, Matsuoka Y, Takahashi T, Takao T, et al. Differential brain processing of audiovisual sexual stimuli in men: comparative positron emission tomography study of the initiation and maintenance of penile erection during sexual arousal. NeuroImage. 2007; 36: 830–842.

[50] Arnow BA, Desmond JE, Banner LL, Glover GH, Solomon A, Polan ML, et al. Brain activation and sexual arousal in healthy, heterosexual males. Brain. 2002; 125: 1014–1023.

[51] Ferretti A, Caulo M, Del Gratta C, Di Matteo R, Merla A, Montorsi F, et al. Dynamics of male sexual arousal: distinct components of brain activation revealed by fMRI. NeuroImage. 2005; 26: 1086–1096.

[52] Ferris CF, Snowdon CT, King JA, Sullivan JM, Ziegler TE, Olson DP, et al. Activation of neural pathways associated with sexual arousal in non-human primates. Journal of Magnetic Resonance Imaging. 2004; 19: 168–175.

[53] Devinsky O, Morrell MJ, Vogt BA. Contributions of anterior cingulate cortex to behaviour. Brain. 1995; 118: 279–306.

[54] Dua S, Maclean PD. Localization for penile erection in medial frontal lobe. American Physiological Society Journal. 1964; 207: 1425–1434.

[55] Robinson BW, Mishkin M. Penile erection evoked from forebrain structures in macaca mulatta. Archives of Neurology. 1968; 19: 184–198.

[56] Fransson P, Marrelec G. The precuneus/posterior cingulate cortex plays a pivotal role in the default mode network: evidence from a partial correlation network analysis. NeuroImage. 2008; 42: 1178–1184.

[57] Hoefler A, Athenstaedt U, Corcoran K, Ebner F, Ischebeck A. Coping with self-threat and the evaluation of self-related traits: an fMRI study. PLOS ONE. 2015; 10: e0136027.

[58] Georgiadis JR, Farrell MJ, Boessen R, Denton DA, Gavrilescu M, Kortekaas R, et al. Dynamic subcortical blood flow during male sexual activity with ecological validity: a perfusion fMRI study. NeuroImage. 2010; 50: 208–216.

[59] Paredes RG, Baum MJ. Role of the medial preoptic area/anterior hypothalamus in the control of masculine sexual behavior. Annual Review of Sex Research. 1997; 8: 68–101.

[60] Walter M, Bermpohl F, Mouras H, Schiltz K, Tempelmann C, Rotte M, et al. Distinguishing specific sexual and general emotional effects in fMRI—subcortical and cortical arousal during erotic picture viewing. NeuroImage. 2008; 40: 1482–1494.

[61] Kühn S, Gallinat J. A quantitative meta-analysis on cue-induced male sexual arousal. The Journal of Sexual Medicine. 2011; 8: 2269–2275.

[62] Stevens JS, Hamann S. Sex differences in brain activation to emotional stimuli: a meta-analysis of neuroimaging studies. Neuropsychologia. 2012; 50: 1578–1593.

[63] Canli T, Desmond JE, Zhao Z, Gabrieli JD. Sex differences in the neural basis of emotional memories. Proceedings of the National Academy of Sciences of the United States of America. 2002; 99: 10789–10794.

[64] Gold AL, Morey RA, McCarthy G. Amygdala-prefrontal cortex functional connectivity during threat–induced anxiety and goal distraction. Biological Psychiatry. 2015; 77: 394–403.

[65] Kim TH, Kang HK, Jeong GW. Assessment of brain metabolites change during visual sexual stimulation in healthy women using functional MR spectroscopy. The Journal of Sexual Medicine. 2013; 10: 1001–1011.

[66] Wright L, Hardie SM. Are left-handers really more anxious? Laterality. 2012; 17: 629–642.

[67] Hecht D. Depression and the hyperactive right-hemisphere. Neuroscience Research. 2010; 68: 77–87.

[68] Seeley WW, Menon V, Schatzberg AF, Keller J, Glover GH, Kenna H, et al. Dissociable intrinsic connectivity networks for salience processing and executive control. The Journal of Neuroscience. 2007; 27: 2349–2356.

[69] Terzian H, Ore GD. Syndrome of Klüver and Bucy; reproduced in man by bilateral removal of the temporal lobes. Neurology. 1955; 5: 373–380.

[70] Anderson SW, Bechara A, Damasio H, Tranel D, Damasio AR. Impairment of social and moral behavior related to early damage in human prefrontal cortex. Nature Neuroscience. 1999; 2: 1032–1037.

[71] Greene JD, Nystrom LE, Engell AD, Darley JM, Cohen JD. The neural bases of cognitive conflict and control in moral judgment. Neuron. 2004; 44: 389–400.

[72] Koenigs M, Grafman J. The functional neuroanatomy of depression: distinct roles for ventromedial and dorsolateral prefrontal cortex. Behavioural Brain Research. 2009; 201: 239–243.

[73] Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cerebral Cortex. 2000; 10: 295–307.

[74] Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation—a possible prelude to violence. Science. 2000; 289: 591–594.

[75] Tang Z, Li D, Zhang X, Yi L, Zhu X, Zeng X, et al. Comparison of the simplified international index of erectile function (IIEF-5) in patients of erectile dysfunction with different pathophysiologies. BMC Urology. 2014; 14: 52.

[76] Wespes E, Amar E, Hatzichristou D, Hatzimouratidis K, Montorsi F, Pryor J, et al. EAU guidelines on erectile dysfunction: an update. European Urology. 2006; 49: 806–815.

[77] Wang ZY, Song LJ. Application of nocturnal penile tumescence test in the diagnosis of erectile dysfunction. National journal of andrology. 2019; 25: 356–359. (In Chinese)

[78] Yaman O, Tokatli Z, Ozdiler E, Anafarta K. Effect of aging on quality of nocturnal erections: evaluation with NPTR testing. International Journal of Impotence Research. 2004; 16: 150–153.

[79] Schober JM, Pfaff D. The neurophysiology of sexual arousal. Best Practice & Research Clinical Endocrinology & Metabolism. 2007; 21: 445–461.

[80] Hatzichristou DG, Hatzimouratidis K, Ioannides E, Yannakoyorgos K, Dimitriadis G, Kalinderis A. Nocturnal penile tumescence and rigidity monitoring in young potent volunteers: reproducibility, evaluation criteria and the effect of sexual intercourse. Journal of Urology. 1998; 159: 1921–1926.

[81] Levine LA, Lenting EL. Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction. Urologic Clinics of North America. 1995; 22: 775–788.

[82] Morales A, Condra M, Reid K. The role of nocturnal penile tumescence monitoring in the diagnosis of impotence: a review. Journal of Urology. 1990; 143: 441–446.

[83] Hatzichristou DG, Hatzimouratidis K, Apostolidis A, Ioannidis E, Yannakoyorgos K, Kalinderis A. Hemodynamic characterization of a functional erection. Arterial and corporeal veno-occlusive function in patients with a positive intracavernosal injection test. European Urology. 1999; 36: 60–67.

[84] Meuleman EJ, Diemont WL. Investigation of erectile dysfunction. Diagnostic testing for vascular factors in erectile dysfunction. Urologic Clinics of North America. 1995; 22: 803–819.

[85] Bari V, Ahmed MN, Rafique MZ, Ashraf K, Memon WA, Usman MU. Evaluation of erectile dysfunction with color doppler sonography. Journal of the Pakistan Medical Association. 2006; 56: 258–261.

[86] Donatucci CF, Lue TF. The combined intracavernous injection and stimulation test: diagnostic accuracy. Journal of Urology. 1992; 148: 61–62.

[87] Hatzichristou DG, De Tejada I, Kupferman S, Namburi S, Pescatori ES, Udelson D, et al. In vivo assessment of trabecular smooth muscle tone, its application in pharmaco-cavernosometry and analysis of intracavernous pressure determinants. Journal of Urology. 1995; 153: 1126–1135.

[88] Santi D, Spaggiari G, Simoni M, Granata ARM. Accurate and time-saving, two-step intracavernosal injection procedure to diagnose psychological erectile dysfunction. Andrology. 2022; 10: 852–862.

[89] Beglinger LJ, Gaydos B, Tangphao-Daniels O, Duff K, Kareken DA, Crawford J, et al. Practice effects and the use of alternate forms in serial neuropsychological testing. Archives of Clinical Neuropsychology. 2005; 20: 517–529.

[90] Ivnik RJ, Smith GE, Lucas JA, Petersen RC, Boeve BF, Kokmen E, et al. Testing normal older people three or four times at 1- to 2-year intervals: defining normal variance. Neuropsychology. 1999; 13: 121–127.

[91] Carneiro F, Nascimento B, Miranda EP, Cury J, Cerri GG, Chammas MC. Audiovisual sexual stimulation improves diagnostic accuracy of penile doppler ultrasound in patients with erectile dysfunction. The Journal of Sexual Medicine. 2020; 17: 249–256.

[92] Mizuno I, Fuse H, Fujiuchi Y, Nakagawa O, Akashi T. Comparative study between audiovisualsexual stimulation test and nocturnal penile tumescence test using RigiScan plus in the evaluatio n of erectile dysfunction. Urologia Internationalis. 2004; 72: 221–224.

[93] Wang T, Zhuan L, Liu Z, Li M, Yang J, Wang SG, et al. Audiovisual sexual stimulation and RigiScan test for the diagnosis of erectile dysfunction. Chinese Medical Journal. 2018; 131: 1465–1471.

[94] Etminan M, Sodhi M, Mikelberg FS, Maberley D. Risk of ocular adverse events associated with use of phosphodiesterase 5 inhibitors in men in the us. JAMA Ophthalmology. 2022; 140: 480–484.

[95] Moon KH, Song PH, Park TC. Using a three-dimension head mounted displayer in audio-visual sexual stimulation aids in differential diagnosis of psychogenic from organic erectile dysfunction. International Journal of Impotence Research. 2005; 17: 519–522.

[96] Cavallini G. Resolution of erectile dysfunction after an andrological visit in a selected population of patients affected by psychogenic erectile dysfunction. Asian Journal of Andrology. 2017; 19: 219–222.

[97] Eid JF, Nehra A, Andersson KE, Heaton J, Lewis RW, Morales A, et al. First international conference on the management of erectile dysfunction overview consensus statement. International Journal of Impotence Research. 2000; 12: S2–S5.

[98] Hatzimouratidis K, Amar E, Eardley I, Giuliano F, Hatzichristou D, Montorsi F, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. European Urology. 2010; 57: 804–814.

[99] Gur S, Sikka SC, Kadowitz PJ, Silberstein J, Hellstrom W. 2015 update of erectile dysfunction management following radical prostatectomy: from basic research to clinical management. Current Pharmaceutical Design. 2015; 21: 1440–1454.

[100] Başar M, Tekdogan UY, Yilmaz E, Başar H, Atan A, Batislam E. The efficacy of sildenafil in different etiologies of erectile dysfunction. International Urology and Nephrology. 2001; 32: 403–407.

[101] Munk NE, Knudsen JS, Comerma-Steffensen S, Simonsen U. Systematic review of oral combination therapy for erectile dysfunction when phosphodiesterase type 5 inhibitor monotherapy fails. Sexual Medicine Reviews. 2019; 7: 430–441.

[102] Li G, Lan H, Liang J, Zhang C, Huang C. Efficacy of tadalafil de-escalation in the treatment of psychogenic erectile dysfunction. Urologia Internationalis. 2017; 98: 205–209.

[103] Huang CC, Liang JH, Li GY, Liang SK, Song WR, Zhang X, et al. Low-dose daily de-escalatory administration of tadalafil for psychological erectile dysfunction. National journal of andrology. 2013; 19: 241–246. (In Chinese)

[104] Jenkins LC, Hall M, Deveci S, Guhring P, Parker M, Nelson CJ, et al. An evaluation of a clinical care pathway for the management of men with nonorganic erectile dysfunction. The Journal of Sexual Medicine. 2019; 16: 1541–1546.

[105] Sharlip ID. Evaluation and nonsurgical management of erectile dysfunction. Urologic Clinics of North America. 1998; 25: 647–659.

[106] Lidawi G, Asali M, Majdoub M, Rub R. Short-term intracavernous self-injection treatment of psychogenic erectile dysfunction secondary to sexual performance anxiety in unconsummated marriages. International Journal of Impotence Research. 2022; 34: 407–410.

[107] Wang H, Zhao M, Zhang J, Yan B, Liu S, Zhao F, et al. The efficacy of acupuncture on patients with erectile dysfunction: a review. Evidence-Based Complementary and Alternative Medicine. 2022; 2022: 4807271.

[108] 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. Sexual Medicine. 2022; 10: 100464.

[109] Boddi V, Castellini G, Casale H, Rastrelli G, Boni L, Corona G, et al. An integrated approach with vardenafil orodispersible tablet and cognitive behavioral sex therapy for treatment of erectile dysfunction: a randomized controlled pilot study. Andrology. 2015; 3: 909–918.

[110] Bilal A, Abbasi NUH. Cognitive behavioral sex therapy: an emerging treatment option for nonorganic erectile dysfunction in young men: a feasibility pilot study. Sexual Medicine. 2020; 8: 396–407.

[111] NIH consensus conference. Impotence. NIH consensus development panel on impotence. JAMA. 1993; 270: 83–90.

[112] Fisher WA, Eardley I, McCabe M, Sand M. Erectile dysfunction (ED) is a shared sexual concern of couples I: couple conceptions of ED. The Journal of Sexual Medicine. 2009; 6: 2746–2760.

[113] Wang H, Zhang J, Ma D, Zhao Z, Yan B, Wang F. The role of red ginseng in men's reproductive health: a literature review. Basic and Clinical Andrology. 2023; 33: 27.