Definition Erectile dysfunction (ED) refers to the persistent inability of the penis to achieve or maintain an erection sufficient to accomplish a satisfactory sexual life for more than three months. The causes of ED are complex and usually multifactorial. Penile erection is a complex vascular activity under the regulation of neuroendocrine, this activity requires the close coordination of neurological, endocrine, vascular, penile corpus cavernosum and psychological factors, and is affected by systemic diseases, nutrition and medication and other factors, which may lead to abnormalities in any aspect of the ED. (1) Psychosomatic etiology: such as daily husband and wife relationship is not coordinated, lack of knowledge of sexuality, adverse sexual experiences, (2) Endocrine etiology: hypogonadism, thyroid disease, acromegaly, etc. due to abnormal secretion of testosterone, LH, FSH, etc.; (3) Metabolic etiology: diabetes mellitus and lipid metabolism abnormalities are most common, of which diabetes mellitus, can occur in varying degrees of autonomic, autonomic, and metabolic disorders. (3) Metabolic causes: diabetes mellitus and lipid metabolism abnormalities are the most common, in which diabetic patients, different degrees of autonomic nerves, somatic nerves and peripheral nerves functional, organic or neurotransmitter changes can occur. Diabetes mellitus can also cause abnormalities in the white membrane of the corpus cavernosum of the penis, which is mainly manifested in the increase of the thickness of the peritoneum, the disappearance of the wave-like structure of the collagen, and a large number of proliferating collagen fibers between the corpus cavernosum and the smooth muscle, resulting in a decrease in the cavernous body compliance, that is, the cavernous body is impaired in diastolic function. Dyslipidemia mainly affects penile arterial blood flow in two ways: one is to cause atherosclerosis of large vessels such as internal iliac arteries, internal pubic arteries and penile arteries, which reduces penile arterial blood flow; the other is to damage the vascular endothelial cells, which affects the vascular smooth muscle relaxation in the process of penile erection; (4) Vascular etiology: factors affecting the mechanism of penile arterial blood perfusion and venous closure, including: arterial atherosclerosis, Arterial injury, arterial stenosis, pubic artery shunt and cardiac function abnormalities, congenital venous insufficiency, various causes of impaired valve function (venous degeneration of the elderly, smoking, trauma, diabetes, etc. may make the veins damaged by occlusive dysfunction), thinning of the cavernous body leukomalacia, abnormal venous traffic branches and abnormal shunt caused by abnormal erection of the penis after surgical treatment, etc.; (5) Neurological etiology: the cerebral, spinal cord, cavernous body nerves and other factors that affect the perfusion of penile artery and the mechanism of closure. (5) Neurological etiology: the brain, spinal cord, cavernous nerve, pubic nerve and nerve endings, small arteries and cavernous receptors on the cavernous lesions and other factors (6) Drug etiology: including neuropsychiatric drugs, antihypertensive drugs, anti-androgenic drugs, drugs that cause hyperprolactinemia, etc.; (7) Other etiology: such as age, cavernous erectile tissue abnormalities, changes in cavernous smooth muscle tone and other factors. (1) Classification according to the time of onset Primary ED: refers to the inability to induce an erection and/or maintain an erection from the first sexual intercourse. It includes primary psychological ED and primary organic ED. Secondary ED: It refers to erectile dysfunction that occurs after the experience of normal erection or sexual intercourse, as opposed to primary ED. (2) Classification by degree Currently, there are various erectile function scales used to evaluate the degree of ED lesions. For example, IIEF, BMSFI, EDTIS and so on. However, the most widely used and convenient is the IIEF-5 scale. (a) Classification according to IIEF-5 score: Normal value: the sum of scores, ≥22 points for normal erectile function; 12-21 points for mild ED; 8-11 points for moderate ED; 5-7 points for severe ED (b) According to the hardness of erection grading: Grade Ⅰ, the penis is only distended, but not hard, for severe ED; Grade Ⅱ, the hardness is not enough to penetrate into the vagina, for moderate ED; Grade Ⅲ, can penetrate into the vagina but not firm, for mild ED; Grade Ⅲ, can penetrate into the vagina, but not firm, for mild ED; Grade Ⅲ, can penetrate into the vagina, but not firm, for mild ED; Grade Ⅲ, can penetrate into the vagina, but not firm, for mild ED. Grade III, can penetrate the vagina but not firm for mild ED; Grade IV, erectile firmness for normal erectile function. (3) Classification according to whether the combination of other sexual dysfunction (a) Simple ED: refers to the occurrence of ED without other sexual dysfunction, often only mild to moderate ED and ED history of short patients belong to this type. (b) Complex ED: ED that occurs in combination with other sexual dysfunctions is known as complex ED. Commonly occurring sexual dysfunctions include ejaculatory dysfunction and libido disorders. Other sexual dysfunctions can have common causative factors with ED and occur at the same time, such as prostate cancer debulking treatment can lead to both hypogonadism and ED; they can also occur sequentially, such as premature ejaculation patients with long-term lesions can cause psychological ED, and patients with severe ED can cause hypogonadism. (4) Classification according to the causes of ED, including psychosomatic, endocrine, metabolic, vascular, neurological, pharmacological, and other causes of ED IV. Diagnosis As in the diagnosis of other diseases, detailed collection of medical history, comprehensive and targeted physical examination and basic laboratory tests to diagnose the erectile function, analyze the causes of erectile dysfunction, as well as discussing the treatment method with the patient and his/her spouse. Basic conditions. The diagnosis of ED is mainly based on the patient’s complaints, so obtaining an objective and accurate history is the key to the diagnosis of the disease. The patient’s shyness, embarrassment and difficulty in speaking should be eliminated. The patient’s spouse should be encouraged to participate in the diagnosis of ED. （Whether the onset of the disease is sudden or slow; whether the degree is gradually increasing; whether it is related to sexual situations; whether there are nocturnal erections and morning erections. (b) Marital and sexual life status Whether married, with or without a regular sexual partner, what is the sexual desire; whether the penis can be erected under sexual stimulation, whether the hardness is sufficient for penetration; whether the erection can be maintained until the completion of sexual intercourse; whether there is ejaculation dysfunction, such as premature ejaculation; and whether there is any abnormalities of orgasm, etc. Occasional failure of sexual intercourse cannot be diagnosed easily. Occasional failure of sexual intercourse cannot be easily diagnosed as erectile dysfunction. (iii) Spiritual, psychological, social and family factors: whether there are negative influences and traumas in the development process; whether there are marital conflicts, sexual partner discord or lack of communication in adulthood; whether there are external difficulties, work pressure, economic embarrassment, tense interpersonal relationships, external interference during sexual intercourse; whether there are factors such as bad feelings, doubt about one’s own sexuality, low self-esteem, ignorance of sexuality, or erroneous sexual knowledge, religion and traditional concepts. factors such as the influence of religious and traditional concepts. (d) Penile erection during non-sexual intercourse: whether there are nocturnal erection and morning erection in the past; whether there is erection during sexual fantasy or visual, auditory, olfactory and tactile stimulation. (E) concomitant diseases, injuries, drugs and bad habits 1, concomitant diseases ① systemic diseases: cardiovascular disease, hypertension, hyperlipidemia, diabetes mellitus and hepatic and renal insufficiency, etc.; ② neurological disorders: multiple cirrhosis, myasthenia gravis, cerebral atrophy, and sleep disorders, etc.; ③ reproductive disorders: penile deformities, sclerodactyly, and prostatic disorders, etc.; ④ endocrine disorders: hypogonadotropic hypogonadism, endocrine disorders: hypogonadism, hyperprolactinemia, abnormal thyroid function, etc.; ⑤ psychological disorders: depression, anxiety, fear and guilt, etc. 2, injury ① neurological diseases and injuries: spinal cord injury, traumatic brain injury, sympathetic neurectomy; ② pelvic and perineal injuries: genital and pelvic trauma, urethra and prostate surgery, pelvic organ surgery, retroperitoneal lymph node dissection, and pelvic radiation therapy. (6) Patient’s expectation of treatment The patient’s knowledge of erectile dysfunction and expectation of treatment should be fully understood, which will help to implement an individualized treatment plan for the patient. Physical examination Physical examination focuses on the reproductive system, secondary sexual characteristics and local nerve sensation. men over 50 years old should routinely undergo rectal examination. Rectal examination should be performed routinely for men over 50 years of age. Blood pressure and heart rate should be measured if they have not been checked in the past 3-6 months. (I) Development of secondary sexual characteristics: pay attention to the patient’s skin, body shape, bone and muscle development, the presence or absence of laryngeal nodes, the distribution and density of beard and body hair, and the presence or absence of male mammary gland development. (ii) Reproductive system examination: pay attention to the size of the penis, whether there are deformities and hard nodules, and whether the testicles are normal. (iii) Local nerve sensation: perineal sensation, reflex of the levator ani muscle, etc. Laboratory tests should be individualized according to the patient’s other complaints and risk factors, including routine blood tests, blood biochemistry, luteinizing hormone (LH), prolactin (PRL), testosterone (T) and estradiol (E2). Prostate-specific antigen (PSA) should be tested for patients over 50 years old or suspected of prostate cancer. Nocturnal Penile Tumescence (NPT): Nocturnal penile tumescence is a physiological phenomenon in healthy men from infancy to adulthood, and it is an important method to identify psychological and organic ED in clinic.NPT is a method that can continuously record the degree of penile distension, hardness, number of times of erection, and the duration at night and can be monitored at home. can be monitored at home. Normal people have about 3-6 erections at night during 8h sleep, each lasting more than 15min. Erection hardness >70% is considered normal erection, 40% to 70% is considered ineffective erection, and <40% is considered non-hard erection. Since this monitoring method is also affected by the sleep state, it is usually necessary to observe 2 to 3 consecutive nights in order to more accurately understand the patient's nocturnal erection. 2.Video Stimulation Tumescence and Rigidity (VSTR): In recent years, some scholars have applied the VSTR method to diagnose and record patients' penile erection after taking PDE5 inhibitors, which is suitable for the rapid preliminary diagnosis of outpatients and evaluation of the patients' response to drug treatment. 3, penile cavernous injection vasoactive drug test (Intracavernous Injection, ICI) penile cavernous injection vasoactive drug test is mainly used to identify vascular, psychological and neurological ED. the dose of injected drugs often varies from person to person, usually about 10-20μg of prostaglandin E1, or popphenytoin 15-60mg (or add phentolamine 1-2mg). 1～2mg). Penile length, circumference and erectile hardness were measured within 10 min after injection. Erectile hardness ≥ grade III, lasting more than 30min was considered as positive erectile response; if erectile hardness ≤ grade II, it suggested vascular lesions; hardness grade II-III was considered as suspicious. Slow erection after 15 min of injection often indicates that the blood supply of the penile artery is incomplete. If the erection is fast but weakens quickly after injection, it suggests penile venous occlusion dysfunction. Since the mental psychology, test environment and drug dosage can affect the test results, poor erection can not be sure of vascular lesions, and further examination is needed.ICI test can occur hypotension, headache, hematoma, cavernous inflammation, urethral injury and abnormal erection and other adverse reactions. Standardized operation can reduce the occurrence of penile hematoma and urethral injury. Tying a tourniquet at the root of the penis can reduce the incidence of hypotension and headache. If the penile erection is more than 1h after injection, patients should go to the hospital in time to avoid abnormal erection that may cause penile injury to the patient. 4, penile color Doppler Duplex Ultrasonography (Color Doppler Duplex Ultrasonography, CDDU) CDDU is currently used for the diagnosis of vascular ED one of the most valuable methods. Commonly used parameters for evaluating vascular function in the penis include: cavernous artery diameter, peak systolic velocity (Peak Systolic Velocity, PSV), end-diastolic velocity (End-Diastolic Velocity, EDV) and resistance index (Resistance Index, RI). There are no standardized normal values for this method. It is generally believed that after injection of vasoactive drugs, the diameter of the cavernous artery of the penis is >0.7mm or enlarged by more than 75%, PSV≥30cm/s, EDV<5cm/s, and RI>0.8 is normal. PSV<30cm/s suggests insufficient arterial blood supply; EDV>5cm/s, and RI<0.8 suggests insufficient function of the venous occlusion of the penis. Neuro-evoked potentials examination includes a variety of tests, such as penile sensory threshold measurement, bulbocavernosus reflex latency, penile cavernous body electromyography, somatosensory evoked potentials and sphincter electromyography, etc. Currently, there are few relevant studies, and the application value of these studies is limited. Currently, there are few studies on this topic, and the value of this test needs to be verified clinically. Currently the more widely used test is Bulbocavernosus Reflex Latency (BCR), which is mainly used for indirect diagnosis and differential diagnosis of neurological ED. The test in the penile coronal groove and its proximal 3cm were placed in the ring stimulation electrode, while in the bilateral bulbocavernosus muscle inserted concentric needle electrodes to record the reflex signals; from the DC stimulator issued square wave stimulation, measurement and recording of stimulation to the onset of the latency of the response.BCR of the normal average value of 30ms ~ 45ms, exceeding the average value of three standard deviations or more is abnormal, suggesting that there is a neurogenic pathology. The normal mean value of BCR is 30ms～45ms. 6, penile cavernous perfusion manometry and imaging penile cavernous angiography, used to diagnose venous ED. injection of vasoactive drug prostaglandin E1 about 10 ~ 20μg (or popaverine 15 ~ 60mg/phentolamine 1 ~ 2mg) 5 ~ 10min spongiotic smooth muscle relaxation, 80 ~ 120ml/min flow rate of rapid injection of contrast medium. If the venous function is normal, when the intracorporeal pressure is 100mmHg, the maintenance perfusion rate should be less than 10ml/min, and the intracorporeal pressure should not drop more than 50mmHg within 30s after stopping perfusion.Observe the morphology of the penile corpus cavernosum, and the reflux of penile and pelvic veins. Anteroposterior views were taken at 30-60, 90, 120 and 900s after injection of contrast medium. X-ray manifestations of venous leakage: the deep dorsal penile veins and periprostatic venous plexus are visualized; the internal and external venous system of the pubic area is visualized; the superficial penile veins are visualized; the urethral corpus cavernosum is visualized; and the perineal plexus is visualized in a small number of patients. In patients with normal venous occlusion function, it is difficult to see contrast images outside the cavernous body. In congenital or traumatic venous leakage, venous leakage images may be demonstrated at the penile pedicle or injury, respectively. Cavernous or leukomalacia venous leakage is typically characterized by diffuse leakage of all venous channels of the penis. 7.Selective internal penile arteriography, main indications: ED after pelvic trauma; primary ED, suspected internal penile arterial vascular malformation; negative response to NPT and ICI test, need for further diagnosis; color Doppler examination shows that arterial blood supply is incomplete and ready for revascularization surgery. Selective penile arteriography can identify the location and extent of arterial lesions and can be accompanied by dilation or intervention. Since this technique is not absolutely safe and can cause complications such as bleeding or arterial endothelial stripping, it should be adopted with caution. V. Treatment 1, the principle of treatment before the treatment of ED should be clear about its underlying diseases, predisposing factors, risk factors and potential causes, should be a comprehensive medical examination of patients to determine the appropriate treatment program. In particular, we should differentiate between ED caused by psychological ED, drug factors or poor lifestyle. ED caused by the above reasons may be improved through psychological counseling or removal of related factors. Organic ED or mixed ED is usually treated with medication. As a chronic disease that affects both the physical and psychological aspects of the body, the goal of ED treatment should be full recovery: to achieve and maintain a firm erection and to resume a satisfying sex life. In the past, the goal of treatment was that the patient could achieve full erection and complete sexual intercourse, but now it is recognized that erection hardness is related to the patient's self-esteem, self-confidence and satisfaction with the treatment, etc. The treatment of ED involves not only the patient himself, but also the patient's partner, so it should be both the patient's own individual communication, but also the husband and wife to participate in the treatment together. 2.Psychosexual therapy Compared with normal people, ED patients are more likely to have psychological problems such as reduced sense of well-being, self-confidence and self-esteem. Patient education or counseling may enable them to regain good sexual function. If patients have significant psychological problems, they should be counseled or treated, and some may require adjunctive medication. When communicating with the patient, one should try to establish mutual trust and a good relationship so that the patient can make a frank statement about his or her condition. At the same time, we should be good at detecting the patient's emotional symptoms, and when there is obvious emotional abnormality and suspicion of depressive disorder or other mental illnesses, we should pacify the patient and suggest that the patient go to the psychiatry department for counseling. Counseling for newly married patients or patients who have just experienced sex can often yield very good results. Of course, some of these patients may do better with a period of adjunctive therapy with a PDE5 inhibitor. Elderly patients often have many complex factors, age, concomitant diseases, medication, partner relationship, physical condition, sexual life expectations, psychosocial factors, etc., which require coordinated diagnosis and treatment by several departments, such as urology, obstetrics and gynecology, internal medicine, and spermatology. 3, drug therapy I. PDE5 inhibitor therapy (on-demand, long course) Type 5 phosphodiesterase (PDE5) inhibitors are easy to use, safe, effective, easy to be accepted by the majority of patients, and is currently used as the first choice of treatment for ED. PDE5 is mainly distributed in the penile cavernous smooth muscle, and is able to specifically degrade the NO-induced synthesis of the second messenger cGMP in the penile cavernous smooth muscle cells, so as to reduce its concentration, inhibit the concentration of cGMP and inhibit the penile cavernous smooth muscle, and then reduce the concentration of cGMP in the penis. It can specifically degrade cGMP, the second messenger synthesized by NO-induced synthesis in the cavernous smooth muscle cells of the penis, reduce its concentration, inhibit the relaxation of the cavernous smooth muscle of the penis, and keep the penis in a weak state. Sexual stimulation induces the release of NO from the nerve endings and endothelial cells of the cavernous body of the penis, which increases the biosynthesis of cGMP. Oral PDE5 inhibitors inhibit the degradation of cGMP and increase its concentration, prompting cavernous smooth muscle relaxation, causing dilatation of the cavernous arteries, cavernous sinus distension and blood filling, and enhancing penile erection. Currently, the commonly used PDE5 inhibitors include sildenafil, vardenafil and tadalafil. 3 PDE5 inhibitors have the same pharmacological mechanism of action, and after oral intake, there is enough sexual stimulation to enhance the erectile function, and the overall effectiveness rate of the patients with ED is about 80%. In recent years, studies have shown that chronic administration can improve endothelial function and vascular elasticity, which can help promote the "normalization" of erectile function in patients. Sildenafil (sildenafil, trade name: Viagra) Sildenafil, launched in 1998, is the first PDE5 inhibitor on the market. Sildenafil is available in doses of 50mg and 100mg. Sildenafil is recommended to be started at full dosage and adjusted according to efficacy and adverse effects. Sildenafil was 77% and 84% effective at 50 mg and 100 mg, respectively, compared with 25% effective at placebo; sildenafil improved erectile function in diabetic patients by 66.6%, with a 63% success rate in sexual intercourse, compared with 28.6% and 33%, respectively, in the placebo control group. Sildenafil is effective 30-60 minutes after oral administration, and absorption may be affected by a high-fat diet. Diet has little effect on the efficacy of sildenafil, and alcohol has no significant effect on its pharmacokinetics. 2, tadalafil (tadalafil, trade name: cialis) tadalafil, February 2003 approved for clinical use. The structure of tadalafil is significantly different from that of sildenafil and vardenafil, and is characterized by a long half-life (17.5h). The effective concentration of tadalafil can be maintained for 36 hours. Diet has little effect on its efficacy and alcohol has no significant effect on pharmacokinetics. The efficacy of tadalafil was 67% and 81% in patients taking 10mg and 20mg of tadalafil, respectively, compared with 35% for placebo. Statistically, tadalafil significantly improved patients' IIEF, SEP2, SEP3, GAQ, and satisfaction scores. Tadalafil is recommended to be started at full dosage and the dose should be adjusted according to efficacy and adverse effects. Tadalafil improves erectile function in 64% of patients with diabetic ED; 25% in the control group[74] . The pharmacokinetics of tadalafil are shown in Table 5, and adverse effects are shown in Table 6. Vardenafil (vardenafil, trade name: Elidel) Vardenafil was launched in March 2003, and its structure is similar to that of cialis. The structure of vardenafil is slightly different from that of sildenafil, and its overall clinical efficacy is similar to that of sildenafil. Fatty meals can affect its absorption, and alcohol has no significant effect on its efficacy. The efficacy rates of vardenafil 10mg and 20mg were 76% and 80%, respectively. Clinical studies have shown that vardenafil significantly improves the International Index of Erectile Function (IIEF), Sex Life Diary (SEP)2 and 3, General Assessment Question (GAQ), and Satisfaction scores; vardenafil is recommended to be started at full dosage, and dosage should be adjusted based on efficacy and adverse effects. Vardenafil improves erectile function in 72% of diabetic patients, compared with 13% for placebo. Other drugs (1) Androgens Androgen deficiency can lead to a decrease or loss of libido, as well as a decrease in the frequency, amplitude, and duration of nocturnal penile erections. Patients with primary or secondary hypogonadism due to various reasons are often combined with ED, androgen therapy for such patients can not only enhance libido, but also improve erectile function. In ED patients with low testosterone levels, androgen supplementation improves erectile function in patients who do not initially respond to PDE5 inhibitors, and is potentiated by the combination of PDE5i. Androgen supplementation is safe for the treatment of ED patients with low testosterone levels, but is contraindicated in patients with prostate cancer or suspected prostate cancer. Therefore, prostate rectal examination (DRE), PSA measurement, and liver function tests should be routinely performed prior to androgen supplementation. Patients receiving androgen supplementation therapy should undergo regular testing for liver function and prostate cancer indicators. The effect of androgen therapy to improve erectile function has a certain correlation with serum testosterone levels. For ED patients with normal testosterone levels, testosterone therapy is not recommended due to the lack of evidence-based medical evidence. Androgens used for ED treatment mainly include testosterone undecanoate pills, injections and patches. (2) Proprietary Chinese medicine treatment Chinese medicine has a history of thousands of years in treating impotence, and it is also the main medication used by the Chinese nation to treat impotence. At present, there are many kinds of proprietary Chinese medicines on the market for the treatment of impotence, which need to be applied on the basis of TCM disease identification and diagnosis, and are mainly targeted at patients with psychological and mild or moderate organic ED. The main treatment of proprietary Chinese medicines, such as: Right Angelica Pill (capsule), Left Angelica Pill, Zhi Bai Di Huang Pill, Liu Wei Di Huang Pill, Gui Spleen Pill, Free and Easy Pills, Liver Shoveling and Beneficial Yang Capsules, Gentian Liver Laxative Pills, Blood Preventing Blood Stasis Pills, etc. Intracavitary injections For patients with ED who have not been treated with oral medication, intracavitary injections can be used with an effective rate of up to 85%. Prostaglandin (prostaglandin E1, PGE1) is the first and only drug approved for intracorporeal injection treatment of ED, and is currently the most widely used drug for intracorporeal injection treatment. Its mechanism of action is to stimulate the production of adenylate cyclase through receptors on the surface of smooth muscle cells, which converts ATP to cAMP, thereby decreasing the concentration of calcium ions in penile cavernous smooth muscle cells, leading to smooth muscle relaxation. The effective therapeutic dose is 5-20 μg, and the time to onset of erection is 5-15 minutes, with maintenance time depending on the amount injected. The main adverse effect of prostaglandin is localized pain during or after injection. Papaverine: Papaverine is a non-specific phosphodiesterase inhibitor that causes relaxation of cavernous smooth muscle by blocking cGMP and cAMP degradation and decreasing intracellular calcium concentrations. The dose of opioid injection is 15-60 mg, and its adverse effects mainly include abnormal penile erection and cavernous fibrosis. Phentolamine (Phentolamine): applied alone does not significantly improve the effect of penile erectile function, often used in conjunction with poppycock and prostaglandin (PGE1). Apparatus (vacuum device) treatment (1) vacuum device on-demand treatment The vacuum device draws blood into the corpus cavernosum of the penis through negative pressure, and then puts a narrowing ring at the root of the penis to stop the blood from flowing back to maintain an erection. This method is suitable for patients who do not respond to PDE5 inhibitor therapy, or who cannot tolerate medication, and is particularly suitable for elderly patients who have occasional sexual intercourse. Adverse effects include penile pain, numbness, and delayed ejaculation. Patients should be advised that negative pressure should not be used for more than 30 minutes. Contraindications include spontaneous abnormal erections, intermittent abnormal erections, and patients with severe penile deformities. Patients with coagulation disorders or on anticoagulation therapy have a higher risk of petechiae, ecchymosis, and hematomas with the use of vacuum devices. Patients who are ineffective on PDE5 inhibitor or vacuum device therapy alone may be treated with combination therapy. (2) Vacuum Device Rehabilitation for Erectile Function After Surgery or Trauma ED is a common complication after radical prostatectomy (RP) for prostate cancer. Postoperative hypoxia, apoptosis and collagen deposition in the cavernous tissue, and eventually venous leakage, result from cavernous nerve injury and reduced arterial perfusion. Vacuum erection device (VED) can prevent apoptosis and fibrosis of penile cavernous tissue by dilating cavernous arteries and improving hypoxia. Early postoperative application of VED promotes recovery of erectile function and preservation of penile length.VED is usually initiated within 1 month postoperatively with 10 minutes of suction once daily or two consecutive 5-minute sessions of negative pressure suction with brief intervals of suction release for 3-12 months. The combination of a PDE5 inhibitor and a VED was more effective in rehabilitating erectile function than a PDE5 inhibitor alone after RP. Among the patients who still obtained natural insertion hardness 5 years after surgery, 60% of them used VED as early rehabilitation therapy for penile erection. 5. Penile prosthesis implantation With the introduction of new drugs and the increased understanding of the pathogenesis of erectile dysfunction, surgical treatment is gradually reduced, but there are still some patients with erectile dysfunction who need surgery to solve the problem, and they are usually those who are ineffective in other kinds of treatments. Prosthesis implantation is one of the more effective surgical treatments. Penile prostheses are generally categorized into 2 types, non-expandable and expandable. Non-expandable prostheses are also commonly referred to as semi-rigid rod-shaped posts. Non-expandable penile prostheses are suitable for people who are severely obese or who cannot maneuver with flexibility, or for people who have difficulty affording expandable prostheses, as well as for older people who have less frequent sexual intercourse. Expandable prostheses are suitable for younger patients who are socially active and sexually active, or for patients with sclerodactyly, secondary prosthesis implantation, and patients with comorbid neuropathy. Penile prostheses are usually implanted through three routes: subcoronal, subpubic, and penoscrotal junction. The choice of route is usually determined by the type of prosthesis, the patient's anatomical condition, the surgical history, and the operator's habits. Vascular Surgery (1) Surgical treatment of venous leakage of the penis The hemodynamics of venous occlusive dysfunction (venous leakage) in the ED are basically clear but it is difficult to distinguish between functional abnormalities (smooth muscle dysfunction) and anatomical structural defects (white membrane abnormality). Anatomical defects (leukomalacia). Currently, there is no clear standardized diagnostic procedure for venous occlusive dysfunction ED, and the results of randomized controlled clinical studies are insufficient to validate the efficacy of its surgery. (2) Surgical treatment of arterial ED Surgical treatment of vascular ED with penile artery reconstruction surgery has a history of more than 30 years, with a variety of surgical methods, but due to the selection criteria, the evaluation of efficacy is not standardized, its effectiveness is still controversial, and the application of microsurgical techniques has not been standardized, and is only one of the optional methods. Sixth, the prevention of penile erectile dysfunction ED prevention and treatment is a whole, should be based on the principle of individualization, take comprehensive measures. Emphasis should be placed on relevant education for the male population and ED patients, and early intervention should be taken for ED risk factors. Since most middle-aged and elderly men with ED are associated with atherosclerosis, hypertension, diabetes, etc., the prevention of ED and the prevention of cardiovascular and cerebrovascular diseases are unified and mutually beneficial. In addition, it is necessary to take into account the close relationship between erectile function and various factors such as psychosocial, neurological, endocrine, genitourinary diseases and trauma, etc. The goals and measures of ED prevention are: for men with ED risk factors but normal erectile function, control the risk factors to reduce the likelihood of ED; for men with diminished erectile function, early intervention to restore and protect erectile function; for men with erectile dysfunction, active treatment to achieve the goal of ED; and for men with erectile dysfunction, active treatment to achieve the goal of erectile dysfunction, early intervention to restore and protect the erectile function. For men with erectile dysfunction, active treatment is needed to rehabilitate erectile function and improve the quality of sexual life. among the preventive measures for ED, it is most important to identify and treat correctable causes, improve lifestyle habits, and control the risk factors associated with ED. the evidence supports the following preventive measures: 1) smoking cessation, physical exercise, and weight reduction, low-fat, high-fiber diet. 2) control of concomitant diseases, such as coronary artery disease, and other diseases. 3) control of the risk factors associated with ED. 2. Control of concomitant diseases, such as coronary heart disease, hypertension, diabetes mellitus, hyperlipidemia and metabolic syndrome. 3, Regular sexual life helps to improve erectile function. 4. Use PDE5 inhibitors such as sildenafil for early treatment of mild ED. ED prevention is of positive significance in patients who have undergone radical pelvic organ resection or radiotherapy for rectal cancer, prostate cancer, and so on. Retaining bilateral erectile nerves during radical prostatectomy and applying sildenafil or vacuum negative pressure device in small daily doses early after surgery or radical radiotherapy can effectively prevent ED and promote the improvement of erectile function.