Impotence, also known as erectile dysfunction (internationally referred to as ED), refers to the inability of the penis to get an erection or a weak erection when sexually desired, or the inability to maintain sexual intercourse for a sufficient amount of time despite having an erection and a certain degree of hardness, thus preventing sexual intercourse or the inability to complete it. The incidence of erectile dysfunction accounts for about 50% of adult men. Male sexual dysfunction includes hypoactive sexual desire, erectile dysfunction, orgasmic and ejaculatory dysfunction, and penile weakness dysfunction, of which erectile dysfunction is the most common male sexual dysfunction. Etiology of the disease A complex process when men have an erection, involving multiple brain, hormonal, emotional, neurological, muscular and vascular issues. Erectile dysfunction may be related to 1 or more of these causes. Classification Erectile dysfunction can be classified as psychological erectile dysfunction and organic erectile dysfunction according to the cause. Organic erectile dysfunction accounts for 50% of erectile dysfunction, mainly including vascular, neurological, endocrine, diabetic, and penile cavernous fibrosis. Erectile dysfunction can be divided into mild, moderate and severe according to the degree of severity, of which severe erectile dysfunction refers to long-term persistent most of the time can not complete a satisfactory sexual life. Diagnosis 1. Medical history As sexual life involves both husband and wife, the patient’s sexual function is judged by patiently listening to the accounts of both husband and wife. Some patients are difficult to express can also use written or form to fill out the way, the main content should include: the cause of erectile dysfunction, the length of the disease, the severity; night, morning awakening, masturbation and visual stimulation can erection; sexual position change on erectile hardness has no effect; libido and ejaculation have changed; social, family psychological trauma; the presence of chronic diseases, drugs and surgical trauma history; smoking, alcohol and drug abuse. History of smoking, alcoholism and drug abuse. Each patient should be examined comprehensively and systematically, with emphasis on the development of the reproductive system, secondary sexual characteristics and cardiovascular and neurological examinations. Abnormalities in the development of the reproductive system and secondary sex characteristics often suggest primary or secondary hypogonadism and endocrine erectile dysfunction due to pituitary lesions. The dorsalis pedis artery is not palpable or the bulbocavernosus reflex disappears, and the perineal sensation is blunted, indicating the possibility of vascular or neurogenic erectile dysfunction. 3.Laboratory tests Focus on testing for heart disease, diabetes mellitus, low testosterone level and other related diseases. 4.Mental psychological test The Multiple Personality Inventory (MMPI), Derogatis Sexual Function Inventory, California Personality Inventory, etc. are of reference value for identifying psychological and organic erectile dysfunction, but cannot be used as an important basis. 5.Ultrasonic testing Mainly detects the structure and blood flow of penile cavernous body, and if necessary, the cavernous body is injected with vasodilator drugs to observe the change of blood flow rate. 6.Nocturnal penile erection monitoring This test is less affected by psychological factors and can respond more objectively to the erectile function of the penis. In normal people, the erection of the penis is 3–5 times per night and lasts 25–40 minutes during the state of rapid motion sleep. The sensitivity of monitoring the change of erectile hardness at night by penile erectile hardness meter (rigiscan) reaches 70%. 7.Penile cavernosal perfusion test and penile cavernosography Penile cavernosography is to observe whether there is abnormal venous reflux during erection by injecting contrast agent, several common abnormal refluxes are: deep dorsal penile vein to prostatic plexus and internal pubic vein, penile cavernous vein to prostatic plexus and internal pubic vein, leakage between penile corpus cavernosum and urethral corpus cavernosum. 8.Selective penile artery angiography For suspected penile artery supply disorder, bilateral internal pubic artery angiography should be performed via femoral artery before performing penile artery reconstruction to observe the lesions of dorsal penile artery and cavernous artery on both sides. The nerves play an important role in the erection mechanism, so routine testing of the erection-related nervous system is crucial in the etiological diagnosis, especially in patients with a history of cranial, cremasteric, pelvic trauma and diabetes mellitus. Treatment 1, general treatment change poor lifestyle, prevention and control of high-risk factors, such as increased exercise, weight loss and drugs that can cause ED, active treatment of diabetes, hypertension of the original law of the disease. If testosterone secretion deficiency caused by primary testicular disease or secondary to pituitary, hypothalamic disease and middle-aged and elderly late gonadal dysfunction can take testosterone supplementation therapy 2, psychotherapy For patients with obvious psychosomatic diseases, psychosexual treatment can be carried out alone or with other treatment modalities. However, psychosexual treatment takes time and its efficacy is uncertain. 3.First-line therapy Phosphodiesterase 5 (PDE5) is an enzyme widely distributed in penile cavernous tissue, which can hydrolyze cyclic ornithine phosphate (cGMP). Inhibition of PDE5 activity can block cGMP hydrolysis and increase its concentration, inducing relaxation of penile blood vessels and cavernous sinus smooth muscle, which can lead to increased blood flow in penile arteries and induce penile erection. The current highly selective PDE5 inhibitors, sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Elidel), are clinically effective at 70–80% when taken before sex. The most common side effects of PDE5 inhibitors are headache, flushing, dyspepsia, and nasal congestion, all of which act through the nitric oxide – cyclic ornithine phosphate (NO – cGMP) pathway, and are contraindicated in patients taking long-acting or short-acting nitrates. Patients. The following patients may be at risk for taking PDE5 inhibitors: active coronary artery disease, congenital heart disease with cardiac insufficiency, hypotension, significant cardiac enlargement, use of combination drugs against hypertension, use of drugs that prolong the half-life of PDE5. 4.Second-line treatment (1) Vacuum negative pressure device therapy When using negative pressure device, a negative pressure ring is placed at the root of the penis to stop blood return, and the negative pressure acts on the cavernous body of the penis to attract blood into the penis and make the penis passively erect. Generally, young patients are not easy to accept the negative pressure device. Older patients with erectile dysfunction who have less frequent intercourse and those who prefer non-invasive, non-pharmaceutical treatment are more likely to accept negative pressure therapy. The side effects are penile pain, numbness and inability to ejaculate. (2) Penile cavernosal drug injection therapy Injection of vasodilating drugs such as prostaglandin E1, poppyrine and phentolamine into the penile cavernosum can induce penile erection through local vasodilatation. However, the dosage and method of drug injection must be determined under medical supervision to avoid serious complications. The clinical effectiveness of penile cavernous drug injection therapy reaches 70 – 80%. Adverse effects include prolonged erection or persistent abnormal erection, penile pain or cavernous fibrosis. If the penis is persistently erect for more than 4h, immediate urological consultation for emergency treatment should be made. 5. Third-line treatment Surgical treatment with penile erectile device implantation is an option for severe ED treatment where first-line and second-line treatments are not effective. There are two types of erectors to choose from, a flexable (semi-rigid) and an expandable erector (two, or three piece set). Most patients prefer the three-piece expandable erector because it provides a more “natural” erection, but has the disadvantage of the potential for mechanical failure and other complications, and is more expensive. The two-piece prosthesis has a lower incidence of mechanical failure and is simpler to implant. The clinical efficacy of penile erectile device implantation is up to 95%, the main complications are mechanical failure and infection, the incidence of mechanical failure is less than 5 – 10% within 10 years after penile erectile device implantation and can be replaced again.