Definition and Guideline Introduction Erectile dysfunction (ED) is a condition in which the penis is unable to achieve or maintain an erection sufficient for a satisfactory sexual life, and the condition lasts for more than three months. The first edition of the ED guidelines began in 2000, and in 2009 the term “premature ejaculation” was added and renamed “sexual dysfunction”. 2012 saw the separation of penile curvature into the “penile curvature” guideline. In 2012, penile curvature was separated and included in the “penile curvature” guideline. The 2015 edition is based on important full-text literature from October 2014 onwards. New drug added for ED: Avanafil (avanavil), the fourth drug in the phosphodiesterase 5 inhibitor (PDE5I) class. Principles of treatment Target the cause, correct poor lifestyle, treat the underlying disease, and try to adjust the medication for drug-induced ED. There are three types of ED that show promise for cure. 1. Hormone deficiency testosterone (replacement therapy: oral (testosterone undecanoate), intramuscular injections, skin patches. 2. psychogenic: psychological counseling and specialty care 3. vascular trauma: consider surgery in young patients Most patients can only be improved, not cured. Treatment decisions need to be made with the participation of both the patient and the doctor, taking into account factors such as its effectiveness and safety, patient and partner satisfaction, and quality of life. First-line treatment I. Oral phosphodiesterase 5 inhibitors (PDE5 inhibitors) Increase the concentration of cyclic guanosine monophosphate in the cavernous smooth muscle of the penis, leading to smooth muscle relaxation, arterial dilatation, and enhancement of penile erection. 1. The following 4 (serial numbers are from the English version of the guideline) are currently approved by the European Medicines Agency and are effective for all types of ED, including diabetes. The overall evidence-based level is 1 and the level of recommendation is A. 3.5.1.1 Sildenafil Introduced in 1998. Sildenafil is effective 30 to 60 minutes after administration. Absorption is affected by fatty meals. Doses of 25, 50 and 100 mg are available. The recommended starting dose is 50 mg. Adjust accordingly depending on patient response and side effects. Efficacy is maintained for up to 12 hours. Adverse events are mild and self-limiting. 3.5.1.2 Tadalafil Launched in February 2003, tadalafil has an onset of action of 30 minutes to 2 hours, lasts for 36 hours, and is not affected by food. Doses of 10 and 20 mg are used as needed. The recommended starting dose is 10 mg. Existing dosage forms are taken on time (5 mg daily). 3.5.1.3 Vardenafil Introduced in March 2003. It is effective 30 minutes after administration. Its effectiveness is affected by high-fat meals. Doses of 5, 10 and 20mg are taken as required. The recommended starting dose is 10mg. 3.5.1.4 Avanafil (avanafil, new) Entered the clinic in 2013. Highly selective PDE5 inhibitor. Higher selectivity for PDE5I than other PDE subtypes and lower side effects. On-demand (temporary) doses of 50, 100, and 200mg. 100mg is recommended as a starting dose, taken at least 30 minutes earlier. 47%, 58%, and 59% success rates for intercourse at 50, 100, and 200mg doses, respectively. Another group of data showed 64%, 67% and 71% respectively. The maximum daily dose is 200mg, and there is no need to adjust the dosage according to liver and kidney function, age. It can be taken with a meal, but the onset of action of the drug is delayed after eating. 2. Selection of different phosphodiesterase 5 inhibitors Individualization. According to the frequency of sexual life, regular or impromptu, occasional or regular treatment, as well as the patient’s understanding of the rapid onset of action of the drug, the use of the drug, side effects to decide. 3. Timed (small daily doses) long-term use of phosphodiesterase 5 inhibitors Research has shown that long-term use of phosphodiesterase 5 inhibitors can improve the structure of the cavernous body of the penis. 4. ED treatment after radical prostatectomy Studies have found that medication given early after surgery has a better chance of restoring erectile function. Currently, PDE5 inhibitors are preferred for postoperative ED in patients undergoing radical prostatectomy with preservation of the erectile nerve. The basis for postoperative recovery of erectile function is closely related to age and nerve preservation. Findings: Sildenafil had 35-75% success in intercourse. Tadanafil 5% improvement, intercourse success rate 52%. Avanafil had a 36.4% success rate in intercourse. 5. Contraindications to Cardiovascular Disease: Clinical studies have shown no increase in myocardial infarction rates with PDE5 inhibitors. However, PDE5 inhibitors are contraindicated in patients with the following concomitant cardiovascular disease: myocardial infarction within 6 months, severe arrhythmia; resting blood pressure < 90/50 mmHg) or hypertension > 170/100 mmHg; unstable angina pectoris, angina pectoris during sexual intercourse, or congestive heart failure, with a score of >=2 on the (New York Heart Association criteria) scale. 6. Treatment of angina Nitrates Nitrates are completely contraindicated with PDE5 inhibitors. If a patient has an angina attack after taking a PDE5 inhibitor, treatment with nitrates is contraindicated for the following time periods, depending on the half-life of the PDE5 inhibitor: sildenafil, 24 hours; tadalafil, 48 hours; and avanafil, 12 hours. 7. Antihypertensive drugs Some antihypertensive drugs can be used in combination, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium antagonists, beta-blockers, and diuretics. 8. α-blockers (prostatic hyperplasia, prostatitis patients, and those taking appropriate medications) Certain medications may be more likely to cause postural hypotension. Sildenafil Postural hypotension is likely to occur within 4 hours of taking doxazosin. The recommended starting dose of sildenafil is 25mg and caution should be exercised when increasing the dose. Vardenafil should not be used in persons taking alpha-blockers until their blood pressure has stabilized. Hypotension was not observed with tamsulosin. Tadanafil Not recommended for patients taking doxazosin. Combination with tamsulosin has little effect. Avanafil should be considered when taking alpha-blockers when blood pressure is stable, starting at a low dose of 50 mg. 9. Adjust the dose when combining with drugs that affect their metabolism Reduce the dose when combining with CYP34A heparanase inhibitors. Includes ketoconazole, itraconazole, erythromycin, clarithromycin, HIV drugs (ritonavir, saquinavir). May increase the concentration of phosphodiesterase 5 inhibitors in the blood. Rifampicin, phenobarbital, phenytoin, and carbamazepine may induce CYP34A and increase phosphodiesterase 5 metabolism, and phosphodiesterase 5 inhibitors are increased in combination. Severe renal or hepatic dysfunction also requires dose adjustment or caution. 10. Phosphodiesterase 5 inhibitors ineffective reasons and countermeasures 1) the drug is indeed ineffective 2) incorrect use of drugs Possible reasons: ① whether the regular way to buy drugs, a large number of drugs in the black market efficacy can not be guaranteed; ② factors affecting the efficacy of the drug: insufficient dosage, the drug is not effective or has been metabolized when the failure to live, or diet, sexual stimulation is not enough intensity, and so on. Vacuum erection devices, (VED) VED treatment, often with a contraction ring placed at the root of the penis, blocking venous return to increase the strength of erection. The ring must be removed within 30 minutes to avoid tissue necrosis. VED has an effective rate of up to 90%. For any type of ED, satisfaction rates range from 27-94%. Common adverse reactions are pain, weak ejaculation, bruising, bruising or numbness. Contraindications are patients with coagulation disorders or anticoagulation therapy. It is more suitable for the elderly, those who can master the relevant operation, and those who have infrequent sexual life. Third, low-energy shock wave See (3.26 platform, Prof. Lv Futai EAU speech) Second-line treatment I. Penile cavernous injection Combination therapy is often used to take advantage of the advantages of various therapies and to reduce side effects, and to reduce the dosage of single drugs. Triple combination, e.g. opioid + phentolamine + prostaglandin, has the highest success rate of 92%. However, there is a 5-10% incidence of opioid-induced side effects such as penile fibrosis. In some studies, when the above three combinations are ineffective, then combined with sildenafil, 31% effective. Second, urethral topical treatment Prostaglandin. Adverse effects include erythematous burning sensation of the skin and glans. THIRD-LINE TREATMENT Penile prosthesis implantation Suitable for patients for whom medications are ineffective or not indicated and who expect to solve the problem with a single operation. There are two types of prosthesis: semi-rigid and expandable. Has the highest satisfaction rate. Surgical complications are mechanical failure and infection. ED Treatment Recommendations Note: Recommendations (Level of Evidence 1/2/3/4, Grade of Recommendation A/B/C) Adverse lifestyle changes and implementation of risk factor reduction measures must be implemented first.1b A Penile rehabilitation after radical prostate cancer should be implemented early.1b A The exact cause of ED should be treated first.1b A The exact cause of ED should be treated first.1b A The exact cause of ED should be treated first.1b A The exact cause of ED should be treated first.1b A The exact cause of ED should be treated first. 1b B PDE5 inhibitors are the first line of treatment 1a A The main reasons for ineffectiveness of PDE5 inhibitors are incorrect usage and dosage and inadequate patient understanding.3 B Vacuum erection devices can be used to treat patients with stable partnerships. 4 C Penile prosthesis implantation is third-line treatment 4 C