The correct understanding of abnormal penile erection is directly related to the decision making and prognosis of the treatment of this disease, and abnormal erection is often an emergency condition, and there is a lack of evidence-based medical evidence for its diagnosis and management. In this paper, we intend to consider the definition, classification, diagnosis, treatment principles, signs of successful treatment and emergency management process of abnormal penile erection in the hope of providing assistance in clinical decision-making. I. New thoughts on the definition Abnormal penile erection is defined as an erection that is not related to sexual desire and sexual stimulation and lasts for more than 4h. For this definition, we consider the following problems: 1, not comprehensive or exact, such as recurrent type of abnormal erection, painful nocturnal erection and tumor infiltrating abnormal erection are not included; 2, for high flow type, especially those caused by trauma, the 4-hour diagnostic time limit is not significant for treatment guidance; 3, for those who may be transformed into low flow (such as cavernous body active drug injection test, waiting for observation may The 4-hour time limit may delay the treatment of those who may be transformed into low flow (such as cavernous active drug injection test, which may be delayed by waiting for observation of local hypoxia and acidosis). To define “abnormal penile erection”, we should first define what is a normal erection and the physiological mechanism of erection, which includes: psychological erection (central), reflex erection (peripheral), nocturnal erection (central?), and artificially induced erection (central?). , artificially induced erections (mostly peripheral). Therefore, we believe that the definition of abnormal penile erection should be “non-sexual (according to our research, painful nocturnal erection is “abnormal perception of erection”, not related to “sexual dreams”), which has a psychological or/and physiological impact on the patient. physiologically adverse erections”. This definition has a broader meaning, lightens the time and strengthens the psychological impact, which is more in line with the clinical reality. Traditionally, abnormal penile erection is classified as low-flowpriapism (LFP) and high-flowpriapism (HFP), which can only reflect the condition of cavernous blood flow and blood oxygenation status, but fail to reveal the more harmful local metabolic disorder to cavernous tissue. It fails to reveal the local metabolic disorder which is more harmful to the cavernous tissue). The traditional view is that blood gas analysis of abnormal penile erections is beneficial for diagnostic classification: “Blood gas analysis of blood in the penile corpus cavernosum is currently the most reliable diagnostic method for differentiating between low-flow and high-flow abnormal penile erections. The typical performance of blood gas analysis of intracavernosal blood of the penis in patients with low-flow type abnormal penile erection is PaO2 below 60 mmHg and PaCO2 above 50 mmhg, while the results of blood gas analysis of high-flow type are similar to normal arterial blood. How exactly to type abnormal penile erection is actually a very complex and practical issue: hypoxic vs. non-hypoxic? Metabolically impaired versus metabolically normal? Arterial versus venous? Input versus outflow disorders? Psychological versus physiological? Which is more accurate? Easier to define? Is it more helpful for diagnosis and treatment? And can the different types be converted to each other? For example, high-flow to low-flow, non-ischemic to ischemic, or low-flow to high-flow, ischemic to non-ischemic. We know that the pathophysiological/pathological-histological changes in the penile corpus cavernosum during abnormal erection are a dynamic process of change, starting with high cavernous flow and gradually transitioning to low flow later on, which in turn leads to changes such as hypoxia, metabolic disorders, tissue damage and cavernous fibrosis, eventually leading to the development of ED. Based on the above analysis, we believe that: the different classification names of abnormal erection only reflect the characteristic changes of a certain stage (time period) of abnormal penile erection. We should treat and handle abnormal erections with a comprehensive and developmental perspective, and make it clear that interventions at different stages of abnormal erections will have different outcomes. There are various types of high-flow abnormal penile erections, among which it is common that those who may become low-flow abnormal erections, such as after cavernous injection and other drug-induced ones, are still of the high-flow type until hypoxia and acidosis occur. High-flow abnormal erections are also often caused by perineal injuries (jockeying injuries in a slightly more deviated position. Otherwise, it may lead to urethral bulb injury) caused by a ruptured cavernous artery as its main pathological change; the penis is often in a filled or erect state, with blood oxygen approximating arterial blood and no local hypoxia, but with a sense of distension. At this time, ultrasound examination shows that arteriovenous blood flow is accelerated, and there are blood pools in the cavernous body. This type has a good prognosis and can be treated conservatively, but the effect of continuous high blood flow and high oxygen on the smooth muscle of the cavernous body needs to be further explored, and no changes in the tissue structure of the cavernous body have been found yet. For abnormal erections of the high-flow type due to injury, internal pubic arteriography can reveal the injured cavernous artery, which can be treated with simultaneous embolization, and highly selective embolization with absorbable material (e.g., gelatin sponge) is recommended to reduce the occurrence of post-embolization complications. Erectile failure (evident on the affected side) may occur for several months after embolization of the cavernous artery. The low-flow type of abnormal erection is often due to a variety of causes, the main pathophysiological basis of which is paralysis of the smooth muscles of the penile corpus cavernosum, impaired contraction, and obstruction of cavernous blood return. In this type of abnormal erection, the patient’s penis is often in a tonic erect state with significant pain. The cavernous blood oxygenation approximates venous blood, with localized hypoxia and acidosis. Ultrasound examination shows slow or stagnant blood flow to the penile corpus cavernosum and its affiliated arteries and veins, with enhanced echogenicity in the corpus cavernosum. The low-flow type of abnormal penile erection is partly caused by vasoactive drugs: poppy bases and poppy bases + phentolamine are common and PGE1 is rare (the drug is mainly metabolized locally in the corpus cavernosum). Partly caused by ICI examination, early (at this time should not be 4 hours, otherwise treatment may be delayed, it is recommended that more than 1 hour to give treatment) treatment prognosis is good; sodium bisoprolide alginate, considered to be related to the local hypercoagulable state, and this hypercoagulable state is the cause or the result? There are no conclusive findings. Other drugs that may cause low-flow type abnormal erections are antihypertensive drugs, anticoagulants, psychiatric drugs, a-blockers, PDE5i, etc., and cocaine, marijuana, alcohol, etc., which are extremely rare. Other so-called unexplained cases are actually a result of our lack of awareness, not unknown causes. There are also some special types, such as abnormal erections caused by hematological diseases: slow granulation, sickle cell anemia, etc., which often manifest as recurrent type, and whose pathogenesis is mainly a disorder of the cavernous outflow channels. Treatment measures for this type of abnormal erection include the application of hydroxyurea, fluid transfusion (hydration and alkalinization) and blood transfusion (in cases of anemia or low platelets), etc. Cavernous decompression, cavernous injection and cavernous shunt are feasible in the presence of good coagulation function. This shows that routine blood tests are of special importance for patients with abnormal penile erection. There are also abnormal erections of the penis due to solid tumors. Of these, 77% originate from tumors of organs in the pelvic region, such as prostate (34%), bladder (30%), colorectum (13%) and kidney (8%). Venous and lymphatic reflux, arterial spread, direct tumor infiltration and implantation, and cavernous outflow tract obstruction are the pathological mechanisms. Approximately 2/3 present 18 months after the discovery of the primary tumor, and 1/3 present at the same time as the primary tumor. Common presentations of solid tumors presenting as penile infiltrates were penile swelling, hard nodes (51%) and abnormal erections (27%). Spongy biopsy, pelvic MRI, and cavernous CDU are the main tests for this. Treatment can be local, partial or total penile excision, and external radiation and chemotherapy are also treatment options, but the prognosis is poor. There is also a specific type of abnormal erection: painful nocturnal erection. This type of abnormal erection has a long onset and can last from months to years. Patients often wake up with a painful (or distended) penis during sleep, and the erection subsides upon waking or after urination, with single or several episodes per night. Most patients with painful nocturnal erections have ED manifestations and abnormal NPT tests (poor hardness and persistence). Sleep monitoring suggests that penile erection occurs in the non-REM phase in some patients. The etiology of this type of abnormal erection is complex and common causes include blood stasis, sleep disorders (disturbed sleep structure, often in a light sleep state, abnormal perception of erection), etc. Depending on the etiology, anti-androgen therapy (finasteride, hexestrol and androgen receptor antagonists), anticoagulant therapy (e.g. aspirin) and anti-anxiety drugs (e.g. chlorpromazine, which suppresses REM sleep and excessive dreaming) can be given. Pathophysiological and histological changes in low-flow type abnormal erections: after 4 h of erection persistence, cavernous hypoxia and acidosis may occur; at 12 h cavernous interstitial edema and thickening will occur; at 24 h endothelial platelet adhesion in the cavernous sinus will occur; at 48 h necrosis of cavernous smooth muscle cells and proliferation of fibroblasts, leading to subsequent fibrosis and calcification [7]. Due to persistent hypoxemia and acidosis, the expression of transforming growth factor (TGF-β1) is increased in the cavernous tissue, leading to smooth muscle fibrosis and replacement of the penile cavernous tissue by collagen fibers (reduced elastic fibers), with the end result of restricted cavernous diastole and the occurrence of cavernous erectile dysfunction. Third, thinking about the diagnosis The basic items for the diagnosis of abnormal penile erection should include medical history, physical examination, blood routine, cavernous blood gas analysis and cavernous body ultrasound, among which blood routine is often neglected. Special items include coagulation analysis, blood viscosity, urinary tract and pelvic ultrasound, internal pubic arteriogram, MRI and CT, etc., which are chosen according to the patient’s condition. Which of the spongy blood gas analysis indexes is more important?PaO2, PaCO2, SaO2, or pH. We believe that pH is more reflective of the local metabolic status of the cavernous body, because the damage to the smooth muscle of the cavernous body by metabolic disorders (metabolic acidosis) is direct and obvious, while the cavernous blood oxygen indexes often applied in the traditional diagnosis can hardly reflect the local metabolic status, such as when the penis is weak, the arteriovenous blood flow is little, and the cavernous blood gas value resembles venous blood [8]. We believe that there are three principles in the management of abnormal penile erection: 1. try to avoid affecting the body circulation; 2. try to protect the cavernous tissue; 3. try to save the erectile function of the penis. V. New thinking about treatment choice Under what circumstances and when to apply cavernous injection? What drug should be used for injection, Neuflorin or Aramin? What dose should be used? What is the success rate of applying this treatment method? All need to be explored and considered. The duration of abnormal erection and the effect of the drug (i.e., the sensitivity of the drug to the cavernous smooth muscle) are the first issues to be considered, and the patient’s heart rate and blood pressure should be monitored at the same time. Because of the good response of cavernous smooth muscle within 4 hours of erection, we advocate cavernous injection therapy first. Choose Alamine 2-4mg (injection 0.1-0.2ml) directly into the cavernous body, massage the cavernous body while observing, if the erection does not subside, the injection can be repeated, but the total amount of Alamine should not exceed 10mg, to avoid the danger of sharp elevation of the drug on the body circulation after the opening of the cavernous blood flow. When the spongy body has been hypoxic, it is recommended to decompress first so that fresh blood can be instilled in time, and then use vasoconstrictive drugs if necessary. When the spongy decompression treatment, need to decompression puncture needle selection, puncture needle is not the thicker the better, we experience 9 needle can meet the requirements, can also reduce the occurrence of subcutaneous hematoma and ecchymosis of the penis. Is suction, drainage, or irrigation used after puncture? We know that massaging the cavernous body and draining the accumulated blood is sufficient without suction or irrigation. Local acupressure and dressing of the needle hole is recommended after the above treatment to reduce the occurrence of petechiae and hematomas. It is important to note that neither cavernous injection nor decompression is indicated for abnormal high-flow erections due to trauma (rupture of the cavernous artery). If decompression is still not effective, the next step requires a cavernous bypass. At this point, the question to consider is: to choose the proximal or distal end? Is a thick needle or a sharp knife used for the instrumentation? We have learned that it is safer and easier to do a shunt at the head of the penis first, using a 16-gauge thick needle or sharp knife to directly communicate with the urethra-cavernous body of the penis, which provides immediate relief of abnormalities in most patients. It also reduces the incidence of venous fistula ED. For the application of cavernous a-agonist continuous perfusion or cavernous heparin perfusion, we believe that the efficacy is doubtful. We believe that the following four conditions should be satisfied after treatment of abnormal penile erection in order to be regarded as successful: 1, penile softening (complete softening is difficult due to cavernous tissue edema and other factors); 2, pain relief; 3, blood flow restoration (cavernous blood flow is accelerated compared with that before treatment); 4, acidosis correction (the most critical, so that the pH of cavernous blood reaches or approaches normal). The first two items need to be satisfied for the high-flow type, and four items must be satisfied for the low-flow type.