The etiology of erectile dysfunction can be divided into.
1.Psychological ED
Refers to erectile dysfunction caused by mental and psychological factors such as tension, stress, depression, anxiety and marital discord.
2, organic ED
(1) vascular causes include 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 shunts and abnormal cardiac function, or penile venous leakage due to reduced smooth muscle in the white membrane and cavernous sinus of the penis that hinders the closure mechanism of venous return.
(2) Neurological causes central and peripheral nerve disease or injury can lead to erectile dysfunction.
(3) Surgery and trauma large vessel surgery, radical prostate cancer surgery, radical abdominal perineal rectal cancer surgery and other surgeries and pelvic fractures, lumbar compression fractures or riding injuries can cause vascular and nerve damage related to penile erection, leading to erectile dysfunction.
(4) Endocrine disorders, chronic diseases and long-term use of certain drugs these factors can also cause erectile dysfunction.
(5) The penis itself diseases such as penile sclerosis, penile curvature deformity, severe circumcision and glansitis of the foreskin.
3, mixed ED
Refers to erectile dysfunction caused by a combination of psychosomatic factors and organic etiology. In addition, because the organic ED is not treated in a timely manner, the patient’s psychological pressure increased, fear of failure of sexual intercourse, so that ED treatment tends to be more complex.
Clinical presentation
In addition to a detailed medical history, especially the history of sexual life, physical examination is necessary for the diagnosis of ED. Focus on the examination and ED-related neurological, endocrine, cardiovascular system and reproductive organs defects and abnormalities.
1, general condition
Should pay attention to body shape, hair and subcutaneous fat distribution, muscle strength, secondary sexual characteristics, the presence of male breast feminization. This is relevant to suggest the presence of cortisolism, thyroid disease, hyperprolactinism, testicular and other gonadal function abnormalities.
2.Cardiovascular system
Measurement of blood pressure and pulses of the extremities, disappearance or weakening of the femoral and N arteries suggest possible embolism or stenosis of the abdominal aorta and iliac arteries.
3.Nervous system
Pay attention to the pain, touch and temperature sensation of the lower back, lower limbs, perineum and penis, the vibration sensation of the penis and toes, the ball cavernous reflex (when stimulating the glans penis, the finger inserted into the anus should feel the contraction of the anal sphincter) and other neurological changes.
4.External genitalia
(1) Penis size, shape and prepuce are abnormal. The penile corpus cavernosum should be carefully touched, if there is a fibrous plaque, suggesting a penile corpus cavernosum sclerosis. Circumcision, foreskin adhesion or foreskin tie is too short, can affect the normal erectile function;
(2) Testicular size and texture, presence of syringomyelia, epididymal cysts and varicocele, etc. Giant syringomyelia and hernia can also affect normal sexual intercourse;
(3) anal finger examination of the prostate size, texture, the presence of nodules and tenderness, anal sphincter tone, etc. More attention should be paid to anal finger examination in ED patients over 50 years of age.
Examination
1, laboratory tests
(1) blood, urine routine, biochemical and liver and kidney function determination fasting glucose, high and low density lipoprotein and liver and kidney function tests are necessary to detect diabetes, abnormal lipid metabolism and chronic liver and kidney disease.
(2) Whether hormone level measurement should be used as a routine examination is still debated.
2.Special examination
In a small number of patients with erectile dysfunction (about 15%), some of the following tests are needed to further understand the exact pathogenesis or mechanism of erectile dysfunction due to the ineffectiveness of non-invasive treatment.
(1) Nocturnal penile erection test (NPT) can clinically help distinguish between psychological or organic ED.
(2) Penile corpus cavernosum injection vasoactive drug test (ICI) penile corpus cavernosum injection vasoactive drug can induce penile erection in patients with psychogenic, neurogenic, hormonal and mild vascular ED, especially in patients with neurogenic ED.
(3) Color dual-function ultrasonography (CDU) This test is non-invasive and can be performed on an outpatient basis.
(4) Penile corpus cavernosum manometry (CM) This method is an effective way to diagnose venous erectile dysfunction.
(5)Penile cavernosographyIn 1981, Wespes et al. first used penile cavernosal perfusion angiography in clinical practice, which improved the understanding of venous ED and also provided a basis for the treatment of venous ED.
(6) Selective penile arteriography arteriography remains the main method for localizing and characterizing abnormalities in the blood supply to the penis.
(7) Nerve testing for erectile dysfunction The autonomic nervous system plays an important role in the nerve conduction process of the erectile response.
(8) cavernous body biopsy pathological changes in cavernous smooth muscle cells and cavernous lumen such as decreased number of smooth muscle, cellular ultrastructural changes and massive fibrous tissue proliferation can reduce the compliance and elasticity of smooth muscle cells and cavernous sinuses, resulting in inadequate arterial filling and venous blockage, which in turn leads to erectile insecurity. Penile cavernosal biopsy allows direct evaluation of cavernous function and is necessary in the etiologic diagnosis of certain patients with impotence.
Diagnosis
The diagnosis is made based on the patient’s lack of erectile hardness or duration of erection during sexual intercourse that is insufficient to complete sexual intercourse for more than three months. The type can be further differentiated by taking a medical history, relevant laboratory tests and an erectile function rating scale.
Many questionnaires have been developed internationally to evaluate erectile dysfunction, the most authoritative of which is the international index of erectile function (IIEF), a 15-question questionnaire designed by Rosen et al. in 1997. The following year, Rosen et al. further simplified it to 5 questions (IIEF-5), which is widely used internationally. In addition, the Brief Sexual Function Questionnaire developed by O’Leary et al. and the Erectile Dysfunction Quality of Life Rating Scale by Wagner et al. can also reflect the erectile function status of patients from different aspects. These scales help to diagnose erectile dysfunction and its extent and allow for assessment of efficacy.
Treatment
1.Sexual psychotherapy
Since most patients with erectile dysfunction have psychological factors, psychotherapy is very necessary, and it is best for both husband and wife to participate in psychosexual treatment together. Sexual concentration training is currently the most important treatment method for psychological erectile dysfunction, applicable to the treatment of almost all sexual dysfunction, the purpose of which is to relieve anxiety, improve communication and communication between the couple, improve the skills from verbal communication to non-verbal communication, and gradually improve the relationship and sexual function of the couple. The improvement rate of this method for erectile dysfunction is in the range of 20% to 81%.
2.Medication
Oral medication is the simplest and most acceptable first-line treatment for erectile dysfunction.
(1) Non-hormonal drugs can be roughly divided into the following categories according to the site of drug action. (1) Oral drugs that act on the central system such as adrenoceptor antagonists; dopamines; 5-hydroxytryptamine receptor antagonists. ② oral drugs acting in the periphery PDE5 inhibitors (such as sildenafil, tadalafil, vardenafil, etc.) are specific phosphodiesterase inhibitors that inhibit cGMP degradation and increase cGMP concentration, thereby relaxing smooth muscle and causing penile erection. This class of drugs is currently the drug of choice for the treatment of ED, with an overall efficiency of more than 70%. (3) Topical drugs creams and ointments are the oldest methods in the treatment of erectile dysfunction, but the effect is not exact.
(2) Hormonal drugs androgen replacement therapy is mainly used for the treatment of endocrine erectile dysfunction, including ED caused by primary and secondary hypogonadism. ① Primary hypogonadism testicular tumors, Creutzfeldt-Jakob syndrome, trauma, surgery and other lesions can lead to a decrease in testosterone levels and an increase in FSH and LH levels in the body, such patients have the best effect with exogenous testosterone replacement therapy. Secondary hypogonadism is caused by hypothalamic and pituitary lesions. The lack of gonadotropin causes stagnation of gonadal development, and the levels of testosterone, FSH and LH in the body are reduced. After supplementation of gonadotropin or gonadotropin-releasing hormone, libido can be increased and erectile function can be improved.
3.Vacuum constriction device (VCD)
Vacuum constriction device (VCD) can be used for any cause of erectile dysfunction and is a second-line method for treating ED. However, the hemodynamics that cause erection are different from those of a normal erection, and it does not have active relaxation of the cavernous body and smooth muscle. Animal tests have shown that arterial blood flow is not increased with VCD, but venous return is significantly reduced, and blood filling of the cavernous body and penile skin leads to penile enlargement.
4.Cavernous body injection therapy (ICI)
Intracavernosal drug injection is the injection of vasodilating drugs into the cavernous body of the penis to fill the cavernous body with blood for the purpose of penile erection. At present, the most commonly used drugs for cavernosal injection to treat erectile dysfunction are poppy bases, phentolamine and prostaglandin E1, etc. The method has obvious effect and fast onset of action. With the widespread use of oral drugs, the method is less and less used in clinical practice because it is an invasive operation and has side effects such as causing pain, bleeding, abnormal penile erection and penile fibrosis.
5.Surgical treatment
With the introduction of new drugs and increased understanding of the pathogenesis of erectile dysfunction, surgical treatment is gradually decreasing, but there are still some patients with erectile dysfunction who need surgery to solve it, generally by various other treatments are ineffective. Surgical treatments include prosthetic implants, revascularization, and venous ligation.