Basic Information
Chinese name: impotence
Aliases: Erectile Dysfunction
Abbreviation: ED
Most common group: male
Historical records
1. The syndrome of impotence was first recorded in the "Neijing". The article "Lingshu·Evil Qi Zang-fu Diseases" refers to impotence as "yin impotence". ". It is believed that consumptive fatigue and evil heat are the main causes of impotence. "Lingshu Jingjin" pointed out: "When the heat is hot, the tendons will relax and not retract, and the impotence will not be used.
2. Physicians in the Sui, Tang and Song dynasties believed that the occurrence of impotence was caused by fatigue and kidney deficiency. For example, "On the Origin of Diseases: Condition of Constipation and Impotence" believes: "Exhaustion damages the kidney, and kidney deficiency cannot prosper in the genitals, so it is also impotence and weakness." Therefore, the treatment is also mainly based on warming the kidney and strengthening yang.
3. In the Ming Dynasty, the understanding of the causes of impotence was more in-depth, and it was proposed that stagnation of fire, damp heat, and emotional injuries could also cause impotence. As stated in "Mingyi Miscellaneous Works: Volume Three": "Men can't afford impotence. In ancient times, there were many clouds in the fire of the gate of life, and the essence and qi were deficient and cold. It is inherent. However, there are also those who are stagnant and even cause impotence." Another example is "Jingyue". Quanshu·Impotence thinks: "There is also hot and humid heat, so that the tendons relax."
4. In the Qing Dynasty, "The Origin of Miscellaneous Diseases Rhinoceros Candle: The Origin of the Front Yin and the Back Yin" also said: "People who have lost their minds, depression hurts the liver, and the liver wood can't be dredged, and it can also cause Yin atrophy."
Cause introduction
1. Organic diseases
(1) Vascular origin includes any disease that may reduce the blood flow of the cavernosal artery of the penis, such as atherosclerosis, arterial injury, arterial stenosis, pudendal artery shunt and abnormal cardiac function, etc., or hinder the venous return and closure mechanism. Penile venous leakage due to decreased smooth muscle in the tunica albuginea and cavernous sinus of the penis.
(2) Neurogenic central and peripheral nerve diseases or injuries can lead to impotence.
(3) Surgery and traumatic major vascular surgery, radical prostatectomy, radical surgery for abdominal, perineal, and rectal cancer, as well as pelvic fractures, lumbar vertebral compression fractures or riding injuries, can cause vascular and nerve damage related to penile erection, leading to impotence .
(4) Endocrine diseases Impotence is caused by many endocrine diseases, mainly in diabetes, hypothalamic-pituitary abnormalities and primary gonadal insufficiency. According to foreign reports, 23% to 60% of male diabetic patients develop impotence of varying degrees. Its mechanism is mainly related to autonomic nerve fiber lesions on the corpus cavernosum, penile vascular stenosis, endocrine abnormalities and mental factors.
2. The disease of the penis itself
Such as Peyronie's disease, penile curvature deformity, severe phimosis and prepuce balanitis.
3. Urogenital deformities
Congenital curvature of the penis, double penis, micropenis, displacement of the penis and scrotum, retroverted bladder, urethral fissure, congenital absence or dysplasia of the testis, scarring of the cavernosal fibers, varicocele, etc.
4. Urogenital diseases
Chronic urogenital inflammation secondary to impotence is more common, such as orchitis, epididymitis, urethritis, cystitis, prostatitis, etc. Among them, chronic prostatitis is the most common impotence. Urogenital surgery and certain injuries, such as benign prostatic hyperplasia, prostatectomy, rupture of the urethra, penis, testicular damage, etc. can cause impotence. Patients with chronic renal failure often suffer from impotence due to testicular atrophy and decreased testosterone.
5. Other factors
Radiation exposure, heavy metal poisoning, etc. Chronic diseases and long-term use of certain medications can also cause impotence.
6. Psychological causes
It refers to impotence caused by mental and psychological factors such as tension, stress, depression, anxiety and discord between husband and wife.
7. Mixed etiology
It refers to impotence caused by both mental and psychological factors and organic etiologies. In addition, because the organic impotence is not treated in time, the patient's psychological pressure increases, and the patient is afraid of failure of sexual intercourse, which makes the treatment of impotence more complicated.
clinical manifestations
Impotence is manifested as dyspareunia due to the inability of men to erect or erect but not hard when they have sexual desire. Those who cannot erect the penis at all are called complete impotence, and those who can erect the penis but do not have enough hardness for sexual intercourse are called incomplete impotence. The main symptoms of impotence are:
1. The penis cannot be fully erected or erection is not firm enough to carry out normal sexual life successfully.
2. Young people have anxiety and impotence accompanied by impotence due to insufficient emotional communication with their sexual partners or inconsistent sexual habits.
3. Impotence occasionally occurs, but it is completely normal in the next sexual intercourse. It may be caused by temporary tension or fatigue, and it is not a morbid state.
4. Although impotence occurs frequently, the penis can be erected in the early morning or during masturbation and can be maintained for a period of time, mostly caused by psychological factors.
5. Impotence persists and progresses, mostly caused by organic lesions.
Disease check
1. Examination of the cause of impotence
(1) Neurological examination to distinguish functional and organic impotence.
(2) Psychological examination Carry out psychological investigation and question-and-answer score to clarify whether it is functional impotence.
(3) Penile blood pressure measurement The normal penile blood pressure is lower than the cerebral arterial blood pressure, and the difference is 266kPa.
(4) Penile pulse volume measurement can be used to know whether there is vascular disease.
(5) Determination of penile blood flow in patients with impotence, the blood flow decreases when the penis is erect.
(6) The method of Doppler ultrasonography of penile artery to determine vascular impotence.
(7) Drug-induced penile erection test is used to identify vascular impotence.
(8) Penile arteriography to check the function of the internal pudendal artery.
(9) The corpus cavernosum radiography directly injects the contrast agent into the corpus cavernosum for radiography.
(10) EMG measurement of bulbocavernosus reflex to diagnose neurogenic impotence.
(11) Determination of bladder pressure volume Observe whether the bladder pressure volume curve is abnormal.
2. Physical examination
Each patient should undergo a comprehensive systematic examination, focusing on the reproductive system, the development of secondary sexual characteristics, and cardiovascular and neurological examinations. Abnormal development of reproductive system and secondary sexual characteristics often indicates primary or secondary hypogonadism and endocrine impotence caused by pituitary lesions. Lack of palpation of the dorsal pedis artery or loss of bulbocavernosus reflexes and perineal insensitivity suggest the possibility of vascular or neurogenic impotence.
3. Laboratory inspection
Routine hematuria, liver and kidney function are used as screening tests, focusing on the following items
(1) Blood sugar and urine sugar Diabetes can often cause damage to blood vessels and nerves, and about 1/2 of diabetic patients have impotence complications. When necessary, a glucose tolerance test should be performed to detect patients with latent diabetes.
(2) Special examination ① Psychological and psychological test Minnesota Multiple Personality Inventory (MMPI), Derogatis Sexual Function Inventory, California Personality Inventory, etc. have reference value for identifying psychological and organic impotence, but cannot be used as an important basis. ②The nocturnal penile enlargement test In 1970, Karacan first used the physiological phenomenon of natural penis erection at night to distinguish psychological and organic yang fistulas. The test is less affected by psychological factors and can more objectively reflect the erectile function of the penis. When a normal person is in REM sleep state, the penis erects 4 to 6 times a night for 25 to 40 minutes. The hardness monitored by the durometer is 65% to 70%, but this test still has 15% to 20% false negatives. ③ Listening and visual stimulation test The penis changes were monitored under the sexual stimulation of watching the video of sexual behavior. This is closer to the physiological state to understand the erection ability of the penis, but it is often necessary to perform comprehensive analysis and judgment in conjunction with NPT monitoring. ④ Penile blood flow detection Penile vascular disease is an important cause of organic impotence, that is, the disorder of arterial blood supply and venous occlusion mechanism.
(3) At present, papaverine, phentolamine or prostaglandin E are mostly used in vasoactive drug-induced erection test, alone or in combination. When the drug is injected into the cavernous body, the penis can achieve a hard erection, which can be maintained for more than 30 minutes, indicating that there is no significant vascular disease, but there is still a possibility of false negatives. Supplemented by sexual stimulation after injection, its reliability is higher. Complications such as ecchymosis, hematoma, and priapism may occur.
(4) The penile arterial blood pressure to brachial arterial blood pressure ratio (PBI) was measured by penile Doppler ultrasound monitoring. Less than 0.6 suggests penile arterial blood supply disorder. The absolute difference between the two systolic blood pressures should not exceed 4kPa (30mmHg).
(5) Penile blood flow index The radial artery, dorsal penile artery and cavernous artery were measured with Doppler ultrasound probe to calculate the penile blood flow index. PFI<6 indicates normal blood supply to the penis.
(6) The pulse volume of penile arterial blood flow recorded in normal penile blood flow pulse volume waveform showed a rapid rise to the top of the peak and then a slow decline, a double-wave pulse notch appeared. A rounded peak or a slow descent and the disappearance of the double wave notch suggest vascular disease.
(7) Color duplex Doppler ultrasound detection detects the structure of the corpus cavernosum, the inner diameter of the blood vessel, the blood flow velocity and the vasomotor function, and can dynamically detect the hemodynamic changes of the penile arteries and veins during the erection process, and the resistance index of the corpus cavernosum, etc. It is one of the most valuable non-invasive methods for screening vascular impotence.
(8) Cavernous perfusion test and cavernosography usually monitor the perfusion rate (IF) for inducing erection, the minimum flow rate for maintaining erection (MF), and the pressure drop gradient (PL) in the cavernosal body within 30 seconds after stopping perfusion. Larger values of MF and PL indicate venous leak impotence. Normal PL should be <3.3kPa (25mmHg) within 30 seconds, MF should be <20~40ml/min, and IF should be 80~120ml/min. Cavernous angiography is to observe whether there is abnormal venous return during erection by injecting contrast agent. Several common abnormal return include: deep dorsal vein of penis to prostate plexus and internal pudendal vein, cavernous vein to prostate plexus and internal pudendal vein, cavernous penis Leakage between the corpus cavernosum and the urethral corpus cavernosum.
(9) For patients with suspected penile arterial blood supply disorder on internal pudendal artery angiography, bilateral internal pudendal artery angiography should be performed through the femoral artery before reconstruction of the penile artery to observe the lesions of the dorsal penile arteries and cavernosal arteries on both sides.
(10) Erectile nerve detection Nerve plays an important role in the mechanism of erection, so routine detection of the nervous system related to erection is crucial in the diagnosis of etiology, especially in patients with a history of craniocerebral, spinal cord, pelvic trauma and diabetes.
(11) Bulbocavernosus reflex latency to detect the conduction velocity of the dorsal penile nerve (sensory afferent) to the sacral medulla, and then from the motor efferent nerve to the bulbocavernosus muscle, the sciatic cavernosus muscle and the anal sphincter. Normally, the conduction velocity should be 27 ~42ms.
(12) The autonomic nerve conduction velocity is detected by the urethro-anal reflex latency, which should normally be 46-75ms.
(13) The pudendal evoked potential detects the conduction velocity of the penile nerve along the spinal cord to the cerebral cortex, and the normal range is 36-47ms.
(14) Single-potential analysis of cavernosal electrical activity By observing the electrical activity of cavernosal myocardium, we can understand the degree of autonomic nerve and smooth muscle degeneration. Among the 112 cases of impotence determined by Stief, 49% (55 cases) showed abnormal SPACE.
(15) The biopsy of cavernous body is still controversial. Some scholars believe that the shrinkage and disappearance of smooth muscle structure lead to functional decline is an important factor causing impotence, however, Mealeman and Jevtich believe that the structure of the age difference is also different, there is no significant difference between the normal and the patient.
4. Inspection test
(1) Blood and urine routine fasting blood glucose, high and low density lipoprotein and liver and kidney function.
(2) Hormone measurement including serum testosterone, progesterone (LH), follicle stimulating hormone (FSH) and prolactin (PRL). If hyposecretion of testosterone is suspected, testosterone levels should be measured twice.
(3) Chromosome examination when necessary.
5. Angiographic examination
For those suspected of having venous fistula. First inject vasoactive substances to induce penile erection, and then quickly inject 30% meglumine 30-100ml into the cavernosus, and immediately take positive and lateral X-ray films of the penis. Those with venous fistulas may have significant changes.
Selective penile arteriography is the main method to evaluate the localization and characterization of abnormal penile blood supply. It is an invasive examination and is contraindicated in patients with severe hypertension, diabetes, myocardial infarction and vasculitis.
6. Neurological examination
(1) At present, there is no direct inspection method for autonomic nerve detection, and only indirectly through the functional status and nerve distribution of organs and systems involved in autonomic neuropathy and their relationship with autonomic nerves, and evaluate their neurological function. Exams include: heart rate control test, cardiovascular reflex detection test, sympathetic skin response, cavernous electromyography, temperature threshold test, uro-anal reflex.
(2) Somatic nervous system examination including penile biological threshold measurement test, sacral nerve stimulation response, pudendal nerve conduction velocity, and somatosensory nerve evoked potential.
7. Color Duplex Ultrasound (CDU)
It is a non-invasive examination. The high-frequency probe can observe whether there are pathological changes in the penis. The 4.5MHz pulse ranging probe can perform blood flow analysis and measure the blood flow rate. Combined with ICI, the penile blood flow before and after injection can be observed to understand the penile arteries. Blood supply and venous closure mechanisms.
8. Cavernous manometry (CM)
is an effective method for diagnosing venous impotence, in which the perfusion flow rate (MF) that maintains an erection is directly related to the venous fistula. Venous closure can be considered for MF>10ml/min.