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 intercourse for a sufficient amount of time despite having an erection and a certain degree of hardness, thus preventing intercourse or not being able to complete it. There are two kinds of impotence: congenital and pathological. The former is uncommon and not easily cured; the latter is common and has a high cure rate. Liu Xiaodong, Department of Urology, Wuhai People’s Hospital Etiology 1, organic diseases (1) vascular origin including any diseases that may lead to reduced blood flow in the cavernous arteries of the penis, such as atherosclerosis, arterial injury, arterial stenosis, pubic artery shunt and abnormal cardiac function, or venous leakage due to reduced smooth muscle in the penile white membrane and penile cavernous sinus that hinders venous return and closure mechanism. (2) Neurogenic central and peripheral nerve disease or injury can lead to impotence. (3) Surgery and trauma Major vascular surgery, radical surgery for prostate cancer, radical surgery for abdominal, perineal and rectal cancer, etc. and pelvic fractures, lumbar compression fractures or straddling injuries can cause vascular and nerve injuries related to penile erection, leading to impotence. (4) Endocrine diseases There are many cases of impotence caused by endocrine diseases, mainly due to diabetes, hypothalamic-pituitary abnormalities and primary gonadal insufficiency. According to foreign reports, 23% to 60% of men with diabetes mellitus have varying degrees of impotence secondary to the disease. The mechanism of its occurrence is mainly related to autonomic fiber lesions on the penile corpus cavernosum, penile vascular stenosis, endocrine abnormalities and mental factors. 2, the penis itself diseases such as penile sclerosis, penile curvature deformity, severe prepuce and glansitis of the foreskin. 3, genitourinary malformation congenital penile curvature, double penis, small penis, penile scrotal displacement, bladder backward, urethral fissure, congenital testicular absence or dysplasia, penile cavernous fibrous scar formation, varicocele, etc. and cannot be erected. 4, genitourinary diseases Chronic inflammation of the genitourinary organs secondary to impotence is more common, such as orchitis, epididymitis, urethritis, cystitis, prostatitis, etc., of which impotence is most common in chronic prostatitis. Genitourinary surgery and certain injuries, such as prostate enlargement, prostatectomy, urethral rupture, penile and testicular injuries, can cause impotence. Impotence often occurs in patients with chronic renal failure due to testicular atrophy and testosterone decline. 5.Other factors Radiation exposure, heavy metal poisoning, etc. Chronic diseases and long-term use of certain drugs can also cause impotence. 6.Psychological causes Impotence caused by mental psychological factors such as tension, stress, depression, anxiety and marital discord. 7.Mixed causes impotence caused by both psychosomatic and organic causes. In addition, as organic impotence is not treated in time, the patient’s psychological pressure is aggravated and fear of failure of sexual intercourse makes impotence treatment more complicated. Clinical manifestations Impotence manifests itself when a man cannot get an erection or can get an erection but it is not hard enough to engage in sexual intercourse activities and sexual intercourse difficulties occur in the presence of sexual desire. If the penis cannot be erected at all, it is called complete impotence. If the penis can be erected but does not have sufficient hardness for sexual intercourse, it is called incomplete impotence. The main symptoms of impotence are: 1. The penis cannot be fully erected or the erection is not firm, so that you cannot have a normal sex life successfully. 2.Young people experience anxiety and impatience with impotence due to inadequate emotional communication with sexual partners or inconsistent sexual habits. 3, Occasional occurrence of impotence, in the next sex completely normal, may be a momentary tension or exertion, not a pathology. 4. Although impotence occurs frequently, the penis can be erected in the early morning or during masturbation and can be maintained for a period of time, which is mostly caused by psychological factors. 5.Impotence persists and progresses, mostly caused by organic lesions. (1) Neurological examination to distinguish between functional and organic impotence. (2) Psychological examinations Psychological investigations and question and answer scores are conducted to clarify whether functional impotence is present. (3) Penile blood pressure measurement Normal penile blood pressure is lower than cerebral artery blood pressure, with a difference of 266 kPa. (4) Penile pulse volume measurement To find out whether there is vascular pathology. (5) Penile blood flow measurement The blood flow is reduced during penile erection in impotent patients. (6) Doppler penile artery ultrasonography To determine vascular impotence. (7) Drug-induced penile erection test Used to identify vascular impotence. (8) Penile arteriography To examine the function of the internal pubic artery. (9) Penile cavernosography Injecting the contrast agent directly into the penile corpus cavernosum for radiographic imaging. (10) Electromyography to measure the bulbocavernosus muscle reflex A test to diagnose neurogenic impotence. (11) Bladder pressure volume measurement To observe whether the bladder pressure volume curve is abnormal. 2. Physical examination Each patient should undergo a comprehensive systematic examination, focusing on the development of the reproductive system, secondary sexual characteristics and cardiovascular and neurological examinations. Abnormal development of the reproductive system and secondary sexual characteristics often indicates endocrine impotence due to primary or secondary hypogonadism and pituitary lesions. The dorsalis pedis artery is not palpable or the bulbocavernosus reflex is absent, and the perineal sensation is blunted, indicating the possibility of vascular or neurological impotence. Blood and urine routine, liver and kidney function as screening tests, focusing on the following items (1) blood glucose and urine sugar Diabetes can often cause vascular and nerve damage, and about 1/2 of diabetic patients have impotence complications. If necessary, a glucose tolerance test should be performed to detect occult diabetic patients. (2) Special tests ①Mental psychological test The Minnesota Multiple Personality Inventory (MMPI), Derogatis Sexual Function Inventory, California Personality Inventory, etc. are of reference value in identifying psychological and organic impotence, but cannot be used as an important basis. ② Nocturnal penile enlargement test In 1970, Karacan first used the physiological phenomenon of natural penile erection at night to identify psychological and organic impotence. This test is less influenced by psychological factors and can reflect the erectile function of the penis more objectively. In a normal person in rapid eye movement sleep, the erection is 4-6 times per night and lasts 25-40 minutes. The hardness of the penis is monitored by a hardness tester up to 65%-70%, however, this test still has 15%-20% false negatives. ③Audio-visual sexual stimulation test monitors penile changes under the sexual stimulation of watching a video of sexual behavior. This is closer to the physiological state, to understand the erectile capacity of the penis, but often need to be monitored in conjunction with NPT for comprehensive analysis and judgment. (4) Penile blood flow test Penile vasculopathy is an important cause of organic impotence, i.e. dysfunction of arterial blood supply and venous blocking mechanism. (3) Vasoactive drug-induced erection test Currently, poppy bases, phentolamine or prostaglandin E are mostly used, alone or in combination. Drug injection into the cavernous body, the penis can achieve a hard erection and maintain it for more than 30 minutes, indicating the absence of significant vascular lesions, but there is still a possibility of false negatives. The injection is supplemented by sexual stimulation, which is more reliable. Complications such as bruising, hematoma and abnormal penile erection may occur. (4) Penile Doppler ultrasound monitoring The ratio of penile artery blood pressure to brachial artery blood pressure (PBI) is measured. A value less than 0 or 6 indicates an impaired blood supply to the penile artery. The absolute difference between the two systolic blood pressure values should not exceed 4 kPa (30 mmHg). (5) Penile blood flow index The acceleration of radial artery, dorsal penile artery and cavernous artery was measured with a Doppler ultrasound probe to calculate the penile blood flow index. a PFI <6 indicates normal penile blood supply. < p=""> (6) Penile artery blood flow pulse volume recording The normal penile blood flow pulse volume waveform shows a rapid rise to a sharp peak and then a slow decline, with a double wave pulse tangent. A rounded peak or a slow decline and the disappearance of the double-wave pulse trace suggest a vascular lesion. (7) Color Doppler ultrasonography detects the structure of the cavernous body, the internal diameter of blood vessels, blood flow velocity and vascular diastolic function, and can dynamically detect the hemodynamic changes of penile arteries and veins during erection and cavernous resistance index. (8) Cavernous perfusion test and cavernosography Usually monitor the induction of erection perfusion rate (IF), maintenance of erection minimum flow rate (MF), and cavernous pressure drop gradient (PL) within 30 seconds of stopping perfusion. larger MF and PL values indicate the function of venous leak impotence. Normal PL should be <3,3kPa (25mmHg) within 30 seconds, MF should be <20-40ml/min, and IF should be 80-120ml/min. The spongiogram means 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 intrapubic vein, cavernous vein to prostatic plexus and intrapubic vein, and leakage between the cavernous body of penis and urethral cavernous body. (9) Internal pubic arteriogram In cases of suspected penile artery supply disorders, bilateral internal pubic arteriograms should be performed via the femoral artery to observe the lesions of the dorsal penile artery and cavernous artery on both sides before performing penile artery reconstruction. (10) Erectile nerve testing The nerves play an important role in the erection mechanism, so routine testing of the nervous system related to erection is essential in the etiological diagnosis, especially in patients with a history of cranial, cremasteric, pelvic trauma and diabetes mellitus. (11) Latency time of bulbocavernosal reflex To detect the conduction velocity of the dorsal penile nerve (sensory afferent) to the sacral medulla, and then the motor efferent nerve to the bulbocavernosus muscle, sciatic cavernosus muscle and anal sphincter. (12) Latency time of urethroanal reflex To detect the conduction velocity of autonomic nerve, which should be in the range of 46 to 75 ms. (13) Pubic evoked potential To detect the conduction velocity of the penile nerve along the The normal range is 36-47ms. (14) Single potential analysis of cavernous electrical activity The degree of autonomic nerve and smooth muscle degeneration can be understood by observing cavernous electromyographic activity. 49% (55 cases) of 112 cases of impotence measured by Stief showed abnormal SPACE. (15) Cavernous body biopsy is still controversial. Some scholars believe that the atrophy and loss of smooth muscle structure leading to hypofunction is an important factor in impotence, however, Mealeman and Jevtich believe that there is a difference in structure according to age, and there is no significant difference between normal and sick people. (1) Blood and urine routine Fasting blood glucose, high and low density lipoprotein, and liver and kidney function. (2) Hormone measurement including serum testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH) and prolactin (PRL). If low testosterone secretion is suspected, testosterone level should be measured twice. (3) Chromosome examination If necessary, chromosome examination should be performed. 5.Contrast examination For suspected venous fistula. Vasoactive substance is injected to induce erection, then 30-100ml of 30% pantothenic glucosamine is injected into the corpus cavernosum rapidly, and frontal and lateral x-ray of the penis is taken immediately. There may be significant changes in those with venous fistulae. Selective penile arteriography is the main method to assess the localization and characterization of abnormal blood supply to the penis. It is an invasive test and is contraindicated in those suffering from severe hypertension, diabetes, myocardial infarction and vasculitis. 6, neurological examination (1) autonomic nerve detection There is no direct examination method, but only indirect understanding through the functional status and nerve distribution of organs and systems involved in autonomic neuropathy and the relationship between them and autonomic nerves to evaluate their neurological function. The examination includes: heart rate control test, reflex detection test of cardiovascular, skin reaction of sympathetic nerves, cavernous electromyography, temperature threshold test, and urinary anal reflex. (2) somatic nervous system examination including penile biological threshold measurement test, sacral nerve stimulation response, pubic nerve conduction velocity, somatosensory nerve evoked potential. 7.Color dual-function ultrasonography (CDU) is a non-invasive examination. The high-frequency probe can observe whether there are pathological changes in the penis, and the 4.5MHz pulse ranging probe can perform blood flow analysis and determine the blood flow rate, combined with ICI to observe the penile blood flow before and after injection, and understand the penile arterial blood supply and venous closure mechanism. 8.Cavernosometry (CM) is an effective method to diagnose venous impotence, in which the perfusion flow rate (MF) to maintain erection is directly related to venous fistula. MF>10ml/min can be considered as venous closure. Diagnosis 1. Initial symptoms of impotence (1) Psychogenic impotence The onset is acute, with spontaneous erection of the penis, which occurs at night during sleep or first awakening, during masturbation or erotic association, but cannot be erected when sexual intercourse is desired. The penis may be hard and erect when it first touches the female body, but then withers when attempting to penetrate. In addition, accompanied by mental symptoms, such as anxiety, anxiety, depression, mental depression, etc., some may be accompanied by premature ejaculation or sexual intercourse without ejaculation. (2) Organic impotence is mainly manifested by the inability of the penis to get an erection under any circumstances, with a slow onset and a progressive increase. In addition, accompanied by symptoms of the corresponding organic diseases, such as diabetes mellitus. 2, medical history As sexual ability involves both husband and wife, the judgment of the patient’s sexual ability should be patiently listen to the narrative of both husband and wife. The main contents should include: ① the cause of impotence, the length and severity of the disease; ② whether the erection can be achieved at night, in the morning, during masturbation and continuous stimulation; ③ whether the change of sexual position has any effect on the hardness of erection; ④ changes in sexual desire and ejaculation; ⑤ psychological and mental trauma in society and family; ⑥ whether there is a history of chronic diseases, medication and surgical trauma (7) history of smoking, alcoholism, and drug abuse. The information obtained from the medical history can give an initial impression to identify psychological or organic impotence. Psychological impotence is often seen in young adults, and those with a history of psychological trauma show sudden, intermittent or situational impotence, with normal erections at night or during masturbation, and no change in libido or ejaculatory function, and no history of trauma, surgery, chronic disease or long-term medication. Differential diagnosis 1. Psychogenic erectile dysfunction Also manifests as erectile dysfunction. However, the patient often has a history of trauma, homosexuality, marital discord or mental anxiety and depression, and can have normal erection under certain specific circumstances, such as during masturbation, during sleep or when with another partner. Normal nocturnal penile erection. Penile blood flow examination is normal. 2.Neurogenic erectile dysfunction It refers to erectile dysfunction that occurs when the structural and functional integrity of the nerve pathways in the pubic area are damaged. When the peripheral nerves are damaged physical examination can reveal the weakening or disappearance of the anal finger reflex and cavernous muscle reflex, and the weakening and disappearance of reflex penile erection. Differential diagnosis can also be made by neurophysiological testing. 3. Arterial erectile dysfunction refers to erectile dysfunction caused by lesions or abnormalities in the penile arteries. Application of pharmacological penile dual function ultrasonography (PPDU) can understand the diameter of cavernous arteries, maximum systolic flow velocity and blood flow acceleration. 4.Venous erectile dysfunction refers to erectile dysfunction caused by lesions or abnormalities in penile veins. The presence or absence of venous fistula can be understood by applying cavernous manometry and cavernosography. 5. Thyroid disorders There is an obvious link between thyroid disorders and impotence, and the appearance of impotence in thyroid patients is common. However, it is rare to see a clinical consultation for impotence. The reasons for this are, firstly, that other symptoms are heavy and mask the effects caused by impotence and the patient is not bothered about the state of sexual function. Secondly, due to the influence of traditional concepts, it is difficult for patients to talk about this aspect of their condition for fear of being laughed at. The third is the patient’s self-inhibition, believing that he should not consider and talk about it. Fourthly, the physician or surgeon does not recognize the condition at all and believes that no special care or treatment is needed. In fact physician consideration and guidance in this regard will produce results that will benefit the recovery of the disease. The diagnosis of thyroid disease is based on symptoms and the measurement of blood levels of T3 and T4 (T3 is triiodothyronine in the blood and T4 is thyroxine in the blood). The levels of these two hormones basically reflect the functional state of the thyroid gland and are an essential test. Treatment 1.Specialized testing, clear causes For the complex causes of impotence, the use of high-tech cutting-edge instruments, special testing of various items related to sexual dysfunction, accurately identify the causes of sexual dysfunction, take targeted treatment measures. 2.For the cause, psychological treatment Comprehensively understand the patient’s pathogenesis, look for the triggering causes, actively carry out psychological guidance, help the patient eliminate the obstacles of thought, increase the confidence of recovery. 3.Electronic circulation, acupuncture point treatment The use of cutting-edge sexual dysfunction diagnosis and treatment instrument, through the special apparatus applied to the human penis and the relevant acupuncture points, regulation of cerebral cortex function, excitation of the crestal medullary center activities, expansion of penile arteriovenous vessels, activation of the spongy body power, thickening the volume of the penis spongy body and other overall treatment. 4.Vacuum negative pressure, suction training Through vacuum negative pressure, suction training, excite the sexual function center of the crestal medulla, help the penis erection, enhance the penile cavernous body blood filling and reduce blood reflux, improve penile hardness and maintain erection time, increase penile muscle vitality to improve the active erection function of the penis. At the same time, the use of simulated vaginal temperature, Chinese medicine liquid massage and electrical impulses and other functions effectively regulate the passive erectile function of the penis. 5.Combination of Chinese and Western, diagnosis and treatment For sexual dysfunction caused by endocrine problems, inflammation of the reproductive system, insufficient blood supply, etc., diagnosis and treatment, classification and treatment. The combination of Chinese and Western, scientific formula, regulate the qi and blood, dredge the meridians, eliminate inflammation, improve immunity, and promote the recovery of the disease. 6.Rehab check, eliminate recurrence Through understanding the patient’s sexual life condition, timely solve the various psychological problems encountered in sexual life, so as to consolidate and enhance the patient’s confidence in sexual life. And according to the different conditions, regular rehabilitation checks are conducted for recovered patients to completely exclude the possibility of recurrence. 7, drug treatment Prostaglandin E1, poppies, phentolamine and other vasodilator drugs injected into the cavernous body of the penis can induce penile erection through the local vasodilator effect. Prevention 1, learning about sex Some unmarried men claim impotence (no sexual desire or can not get an erection), often just not enough stimulation to cause sexual desire, can not be considered pathological. Newlywed couples sex, male tension, excitement, female fear, shyness, with bad, resulting in failure of sexual intercourse is inexperienced, not pathological, to understand each other, comfort, with the passage of time most can be satisfied and harmonious. 2, understand the physiological fluctuations When the man in the fever, excessive fatigue, emotional conditions such as a momentary or a phase of impotence, mostly a normal inhibition and physiological fluctuations, the male party do not add to the burden of thought, the female party do not blame, blame because of it, so as not to make false, resulting in impotence. 3, careful with drugs Avoid taking or stop taking drugs that may cause impotence. If you have to take certain kinds of drugs because of illness, you should try to choose those that have no effect on sexual function. 4.Save your room. Long-term excessive sexual intercourse and indulgence in pornography is one of the causes of impotence. It has been proved that separating husband and wife from bed, stopping sexual life for a period of time, avoiding all types of sexual stimulation, allowing the central nervous system and sexual organs to get sufficient rest, is an effective measure to prevent impotence. 5, diet conditioning dog meat, mutton, sparrow, walnuts, cow whip, lamb kidney, etc., zinc-containing foods such as oysters, beef, chicken liver, eggs, peanut rice, pork, chicken, etc., arginine-containing foods such as yams, ginkgo, frozen tofu, eel, sea cucumber, cuttlefish, octopus, etc., all help to improve sexual function. 6, improve physical fitness physical weakness, excessive fatigue, lack of sleep, stressful and persistent mental labor, are pathogenic factors, should actively engage in physical exercise, enhance physical fitness, and pay attention to rest, prevent overwork, adjust the imbalance of the central nervous system function. 7, eliminate psychological factors to have a full understanding of sexual knowledge, fully understand the impact of mental factors on sexual function. To correctly treat the “sexual desire”, can not be seen as a shameful thing and disgust and fear, not because of one or two failed sexual intercourse and frustrated worry, lack of confidence. The two sides of the couple should increase emotional communication, eliminate discordant factors, tacit cooperation. The woman should care, caress, encourage her husband, try to avoid the flow of dissatisfaction, to avoid causing mental pressure on her husband. The idea should be concentrated during sexual intercourse, especially when reaching the peak of sexual pleasure, when ejaculation is imminent.