Erectile dysfunction, a kind of male sexual dysfunction, commonly known as impotence, or ED for short, refers to the inability of the penis to get an erection or a weak erection when there is a sexual desire, or although there is an erection and a certain degree of hardness, but can not maintain sexual intercourse for a sufficient time, thus preventing sexual intercourse or unable to complete sexual intercourse. Diagnostic methods: a. History taking As sexual ability involves both husband and wife, the patient’s sexual ability is judged by patiently listening to the accounts of both husband and wife. The main contents should include: ① the cause, duration and severity of erectile dysfunction; ② whether erection can occur at night, morning awakening, masturbation and visual stimulation; ③ whether changes in sexual position have an effect on erectile hardness; ④ changes in libido and ejaculation; ⑤ psychological and psychiatric trauma in society and family; ⑥ whether there are chronic diseases, medication and surgical trauma; ⑦ history of smoking, alcoholism, and sexual abuse. (6) history of chronic diseases, drug use and surgical trauma; (7) history of smoking, alcoholism and drug abuse. The information obtained from the medical history can give a preliminary impression to identify psychological or organic erectile dysfunction. Psychological erectile dysfunction is often seen in young adults, with a history of psychological trauma, manifested as sudden, intermittent or situational erectile dysfunction, normal erection at night or during masturbation, no change in libido sexual ejaculation function, no history of trauma, surgery, chronic disease or long-term medication. Physical examination Each patient should have a comprehensive system examination, focusing on the reproductive system, the development of secondary sexual characteristics and cardiovascular and neurological examination. 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 is absent, and the perineal sensation is dull indicates the possibility of vascular or neurogenic erectile dysfunction. Blood and urine routine, liver and kidney function as a screening test, focusing on the following items: blood glucose and urine glucose: diabetes can often cause vascular and nerve damage, about 1/2 of diabetic patients occur erectile dysfunction complications. If necessary, a glucose tolerance test should be performed to detect patients with occult diabetes. (4) Special examination (1) Psycho-psychological test: Minnesota 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. (2) Nocturnal penile tumescence (NPT): In 1970, Karacan first used the physiological phenomenon of natural erection of the penis at night to identify psychological and organic phallic fistula. The test is less influenced by psychological factors and is a more objective response to penile erectile function. In a normal person, penile erections occur 4 to 6 times per night during REM sleep and last 25 to 40 minutes. The hardness of the penis is monitored by rigiscan (65% to 70%), however, this test still has 15% to 20% false negatives. (3) Audiovisual sexual stimulation (ASS): The penis is monitored under the sexual stimulation of watching a video of a sexual act. This is closer to the physiological state, to understand the penile erectile capacity, but often need to be monitored in conjunction with NPT for comprehensive analysis and judgment. (4) Penile blood flow testing: Penile vascular lesions are an important cause of organic erectile dysfunction, i.e., dysfunction of the arterial blood supply and venous blocking mechanisms. Vasoactive drug-induced erection test: Currently, 30-60mg of poppy bases, 1-2mg of phentolac or 20μg of 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 no significant vascular lesions, but there is still a possibility of false negatives. The reliability is higher when the injection is supplemented with sexual stimulation. Complications such as ecchymosis, hematoma and abnormal penile erection may occur. Penile Doppler ultrasound monitoring: The penile artery blood pressure to brachial artery blood pressure ratio (PBI) is measured. A value less than 0.6 indicates impaired penile arterial blood supply. The absolute difference between the two systolic blood pressures should not exceed 4 kPa (30 mmHg). Penile flow index (PFI): The penile blood flow index is calculated by measuring the acceleration of the radial artery, dorsal penile artery and cavernous artery with a Doppler ultrasound probe; PFI <6 indicates normal penile blood supply. Penile artery blood flow pulse volume recording: normal penile blood flow pulse volume waveform is a rapid rise to the top of the spike and then slowly decline to appear double-wave pulse cut traces. Rounded peak or slow decline and disappearance of double-wave pulse traces suggest vascular lesions. Color Doppler ultrasonography: detects the structure of the cavernous body, the internal diameter of blood vessels, blood flow velocity and vasodilation function, and can dynamically detect the hemodynamic changes of penile arteries and veins during erection and the cavernous resistance index, which is one of the most valuable non-invasive screening methods for vascular erectile dysfunction. Dynamic infusion cavernosometry & cavernosography (DICC): usually monitors the induction flow (IF), the maintenance of erectile flow (MF), and the cessation of perfusion. Larger MF and PL values are indicative of venous leaky erectile dysfunction. The normal PL should be <3.3kPa (25mmHg) in 30 seconds, MF should be <20-40ml/min, and IF should be 80-120ml/min. cavernosography is the observation of abnormal venous reflux during erection by injecting contrast agent, and several abnormal refluxes are common: deep dorsal penile vein to prostatic plexus and internal pubic vein, cavernous vein to prostatic plexus and internal pubic veins, and intercavernous leakage between the cavernous body of the penis and the urethral cavernous body. Internal pubic arteriogram: In suspected cases of penile artery supply disorders, bilateral internal pubic arteriograms should be performed via the femoral artery to observe lesions of the dorsal penile artery and cavernous artery on both sides before performing penile artery reconstruction. (5) Erectile nerve testing: Nerves play an important role in the erection mechanism, so routine testing of the nervous system related to erection is crucial in the etiological diagnosis, especially in patients with a history of cranial, spinal, pelvic trauma and diabetes mellitus. Bulbocavernosus reflex latency time (BCRL): 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, which should be 27-42 ms. Urethroanal reflex latency time (UARL): to detect the conduction velocity of autonomic nerve, normal should be in the range of 46~75ms. Pudendal evoked potential (PEP): to detect the conduction velocity of penile nerve along the spinal cord to the cerebral cortex, normal range is 36~47ms. Porst found these neurological abnormalities in 66% of 130 patients with erectile dysfunction. In 53 patients with erectile dysfunction at the Institute of Urology, Beijing Medical University, the abnormalities accounted for 39.6% (21 cases). Single potential analysis of cavernous electrical activity (SPACE): The degree of autonomic nerve and smooth muscle degeneration can be understood by observing cavernous electromyographic activity. abnormalities. (6) Cavernous biopsy: It is still controversial. Some scholars believe that the atrophy and loss of smooth muscle structure leading to hypofunction is an important factor in erectile dysfunction, however, Mealeman and Jevtich believe that there are differences in the structure of the age difference, and there is no significant difference between normal people and patients. V. Detailed classification of organic ED: endocrine disorders, chronic diseases and long-term use of certain drugs can also cause erectile dysfunction. Diseases of the penis itself: such as penile sclerosis, penile curvature deformity, severe prepuce and glansitis of the foreskin. Vascular causes: including any disease that may cause a decrease in blood flow to the cavernous arteries of the penis. Neurological causes: Central and peripheral nerve disease or injury can lead to erectile dysfunction. Prostate disorders: Repeated episodes of prostatitis and prostatic hyperplasia that do not heal for a long time. Surgery and trauma: Surgery and trauma cause damage to the blood vessels and nerves related to the penis, leading to erectile dysfunction. Nerve disorders: such as spinal cord injury, spinal cord transection, spinal cord tumor, temporal lobe lesions, can cause impotence due to nerve disorders that conduct sexual excitement. Inadequate blood flow: Atherosclerosis or other vascular lesions can lead to inadequate blood flow. Atherosclerosis, if it occurs in the arteries supplying the penis or in the vessels governing nutrition, can also cause impotence in patients. [1] Psychological ED: Erectile dysfunction caused by psychosomatic factors such as tension, stress, depression, anxiety, and marital discord. Mixed ED: refers to erectile dysfunction caused by a combination of psychosomatic factors and organic etiology. Treatment measures Because of the complex factors causing penile erectile dysfunction, although erectile dysfunction treatment methods, but the effect is still not ideal. Therefore, a comprehensive analysis should be conducted before deciding on the treatment plan, and multiple ways of treatment can be used to obtain satisfactory results. Psychological and drug treatment Psychosexual treatment Any type of erectile dysfunction should emphasize psychological treatment, in order to achieve twice the effect with half the effort. The human brain can transmit reinforcing stimulus impulses to the erectile center of the spinal cord, but also can send inhibitory messages to prevent the excitement of the erectile center. The anxiety and tension generated by the brain is often the cause of erectile dysfunction, and significant results were achieved in the 1960s with Masters and Johnson and in the 1970s with Kaplan's psychosexual therapy. Through a series of sexual concentration training to relieve the patient's tension, eliminate anxiety and fear, enhance the confidence of restoring erectile ability, together with physiological knowledge and behavioral methods of guidance, the improvement rate of patients with no choice of erectile dysfunction reached 30% to 55%. Pharmacological treatment Intracavernosal drug self-injection Initially, 30-60mg of poppy bases or 1-2mg of phentolamine alone or in combination were used to achieve more satisfactory results, but about 2%-6% will have abnormal erectile comorbidity is worrying. Recently, prostaglandin E1 (prostaglandin E120-60μg) has been widely adopted as the most ideal drug because it can be rapidly metabolized in the body and significantly reduce the incidence of abnormal erections. Shanghai reported 1500 patients, injected with poppy alkaloids and phentolamine, 86% could complete sexual intercourse, while abnormal erection, local pain, skin ecchymosis, foreskin edema, cavernous fibrosis all accounted for 2% each, and there is a drug increment phenomenon. Stief (1991) used a combination of PGE1 10μg and CGRP 5mg, which was significantly more effective than injection alone, but the lack of toxicological studies on CGRP has limited its application. Recently, linsidomine (SIN-1) has been applied as an NO donor. stief was first applied for intracavernosal injection; in 40 patients who did not respond to poppyrine and phentolamine or experienced persistent erection, SIN-1 was switched to SIN-1 and 33 cases achieved complete or almost complete erection. However, Turss concluded that SIN-1 was more complete but less effective than poppyine and phentolamine (except for neurogenic erectile dysfunction.) In Porst's 10-year experience of treating 4000 cases of erectile dysfunction, he observed that the efficiency of various drugs was only 17.3% for SIN-1 (13/75), 39% for poppyine (370/950), 61% for poppyine + phentolamine ( Melman reported forskolin to be a promising clinical drug in animal studies due to its ability to drive away activated adenylate cyclase, elevate intracellular cAMP levels, and cause smooth muscle diastole. Schmidt, Cavallini et al. reported the application of nitroglycerin, yohimbine, and long-pressin (minoxidil), which have a skin-penetrating effect and can achieve an erectile effect when applied to the penile surface. Transurethral administration In 1996, synthetic prostaglandin E1 125-1000 μg (alprostadil, prostil urethral suppository) was introduced for the treatment of erectile dysfunction by transurethral administration, with a one-time success rate of 65% (19% for placebo). There can be side effects such as penile pain, urethral pain, testicular pain, and dizziness. There are no reports on whether the drug has an effect on early pregnancy, so contraception needs to be used. Oral medications are divided into hormonal and non-hormonal: hormonal medications are indicated for endocrine erectile dysfunction. Primary hypogonadism, such as Klinefelter's syndrome, is treated with testosterone enanthate, testosterone dodecanoate, triolandren and other testosterone replacement therapy. For secondary hypogonadism such as Kallmann syndrome, chorionic gonadotropin and LHRH biological pump are used to promote the development of testicular mesenchymal cells and spermatogenic epithelium for therapeutic purposes. Non-hormonal drugs include yohimbine, an α2 adrenergic receptor antagonist that acts on the central and peripheral nervous system, but its efficacy is still controversial. The dopamine receptor agonist apomorphine, which Heaton used in oral form, improved 70% of non-organic erectile dysfunction. The phosphodiesterase type V (PDE3) inhibitor (Viagra), which was introduced in 1998, relaxes cavernous smooth muscle through the NO-cGMP pathway to induce erectile dysfunction in the penis, improving erectile dysfunction by 78% compared to 205 for placebo, but has side effects such as dizziness, headache, flushing, nasal congestion, gastrointestinal symptoms, and visual disturbances; it cannot be combined with NO agents such as nitroglycerin. It should be used with caution in people with heart disease. Phentolamine, an oral alpha-blocker, has been used inside and outside the office with an efficiency of 36% to 50%, compared with 13.4% to 26% for placebo, and is effective for mild to moderate erectile dysfunction. Other treatment methods Vacuum constriction device (VCD) was designed by Lederer in 1917 and improved and popularized by Osben in the 1970s. It uses negative pressure to distend the penis, and an elastic ring is placed at the root of the penis to stop the return of venous blood to maintain an erection. Nadig observed 196 patients, but 75% had penile numbness, 28% had decreased orgasmic ability (2.5% were unable to reach orgasm), 12% had difficulty ejaculating, and 3% to 11% had painful orgasm. Surgical treatment Applicable to both venous and arterial erectile dysfunction. 1. Penile vein surgery includes deep dorsal penile vein ligation, penile pedicle vein ligation, sciatic cavernosus muscle folding, urethral corpus cavernosum stripping, internal iliac vein ligation, etc. The results of 602 cases of various venous procedures were reported by 15 authors, and the success rate ranged from 0 to 88% with a mean of 37.4% at 1 to 72 months of follow-up. 20 cases were reported by Wespes in 1985, with a success rate of 80% at 3 to 24 months of follow-up, while 67 cases were reported again in 1990, with a success rate decreasing to 46% at 24 to 72 months of follow-up. The Institute of Urology of Beijing Medical University reported 57 cases with a success rate of 47.4% with a follow-up of 1 to 3 months and 28.1% with a follow-up of 6 to 24 months. Therefore, intravenous surgery is not the ideal treatment method, which may be related to the more complex etiology of erectile dysfunction, and patients are often not solely venous problems, but often related to other factors such as psychological, arterial, neurological, and penile tissue structure lesions. 2.Penile artery surgery is mostly performed by end-to-end or end-to-end anastomosis between the inferior abdominal wall artery and the dorsal penile artery; those with poor conditions of the dorsal penile artery can use the arterialized Virag I (without ligating the dorsal deep penile vein above the anastomosis), Virag II (ligating the dorsal deep penile vein above the anastomosis) and trigeminal anastomosis between the dorsal penile artery and the dorsal deep penile vein and the inferior abdominal wall artery (Hauri method). . Eight authors reported 884 cases of penile artery reconstruction with a success rate of 50% to 80%, with an average of 71.5%. The success rate was 75% in the recent period and 50% in the long term at follow-up. 3.Penile prosthesis is an effective method for treating erectile dysfunction, which is suitable for patients with organic and certain psychological erectile dysfunction whose treatment by other methods is ineffective. Prosthesis mainly have semi-rigid rod penile prosthesis (small-carrion, flexirod, silicon silver prosthesis), expandable three-part prosthesis (AMS 700CX), expandable two-part prosthesis (mentor GFS, uni-flate 1000), expandable single-part prosthesis (AMS hydroflex, flexi- flate II), surgical complications and mechanical failure accounted for about 7% to 25%, infection about 1% to 8%, perforation 1.6% to 6.7%, pain 0.4% to 5.7%, prosthesis size discomfort about 0.7% to 2%. Seven, the erectile dysfunction caused by bad habits: (1.) eat prohibited drugs: such as smoking marijuana, heroin, etc. (2.) Too much stress: stress and anxiety can affect the erotic response, thus occurring erectile dysfunction, this situation is called is psychological erectile dysfunction. (3.) Smoking: Smoking can be very harmful to the body and can cause cancer, emphysema and other diseases. Smoking also has a serious impact on blood circulation. So men who smoke are more likely to have erectile dysfunction than men who do not smoke. (4). Alcohol abuse: alcohol has a sedative effect on the nervous system, which can have an effect on the ability of the penis to get an erection. Prevention of erectile dysfunction: (1) Do not wantonly clear indulgence, greedy for sex without excess. (2) popularize sex knowledge education, correct treatment of the natural physiological function of sex, reduce the anxiety of intercourse, eliminate unnecessary ideological concerns, to avoid the occurrence of psychogenic impotence. (3) Avoid taking or stop taking drugs that may cause (or are proven to cause) impotence. (4) Avoid all types of sexual stimulation and stop sexual life for a period of time to ensure that the sexual center and sexual organs can be regulated and rested, which is conducive to the regulation of the will and the recovery of the disease. (5) Actively treat various diseases that may cause impotence. Both husband and wife are responsible for this. The woman should be considerate and understanding to the man, never blame or belittle the man, so that the patient can increase his confidence based on understanding and comprehension, in order to benefit the spiritual conditioning, which can promote the blood circulation of the spongy body. (6) When impotence occurs, the doctor should be introduced to the full disease and its development and changes to help early treatment, do not hide the condition. (7) Be emotionally cheerful, clear your mind, pay attention to life regulation and strengthen physical exercise to enhance physical fitness and improve resistance to disease. Once impotence occurs, both men and women should treat it correctly, investigate the cause seriously and treat it actively.