Post Date December, 03 2023
（1） Medical treatment
Treatment of systemic diseases: for example, early patients with diabetes, if the diet is properly controlled, insulin or oral hypoglycemic drugs are used, the sexual function can be rapidly improved.
Discontinuation of drugs that affect sexual function: Many drugs, such as antihypertensive drugs, antipsychotics, diuretics, hormones, anticholinergics, cardiovascular system drugs, can cause impotence, so discontinuation of these drugs will be beneficial to the recovery of sexual function; However, before discontinuation, it is necessary to weigh the patient's general condition to decide whether to continue treatment of the primary disease, or to reduce the dose, change to other drugs or completely stop using drugs.
Endocrine therapy: including the following aspects:
a) Application of sex hormone or gonadotropin: for patients with primary testicular insufficiency, testosterone can be used as replacement therapy; Gonadotropin and luteinizing hormone releasing hormone (LH-RH) can be used for hypothalamic or pituitary diseases. Testosterone propionate has a half-life of 5-7 hours in plasma, so it needs frequent medication, which is troublesome. If the drug is intended to be used for a long time, long-acting testosterone such as testosterone Yu or cyclopentyl propionate can be selected.
b) Adrenocortical hormone or thyroid hormone: applicable to adrenal cortex or hypothyroidism.
c) Dopamine synergist or dopamine-like drugs: should be used in patients with hyperprolactinemia caused by hypothalamic or pituitary diseases. About 5-19% of impotence patients have hyperprolactinemia and can be treated with bromocriptine.
d) Correct metabolic disorder: such as diabetes ketosis and metabolic acidosis.
e) Endocrine gland surgery: such as thalamus, pituitary tumor, male and female hypercortisolosis or hyperthyroidism, surgical treatment can help restore sexual function.
Nonhormone drug treatment: α－ The adrenergic blocker Yohimbine, because it selectively blocks presynaptic α－ 2 receptors, but Wang interferes with postsynaptic α－ 1 receptor, which can enhance the release of norepinephrine from nerve endings and reduce the return of penis veins. The common dose is 6mg, t.i.d. If stomach or nerve symptoms occur and can not be tolerated, the dose should be reduced to 2mg, t.i.d., and gradually increased (double weekly) until it reaches 18mg per day, at least for 18 weeks. Other commonly used a-blockers, such as phentolamine, phenoxybenzylamine or prazosin, have no similar effect.
（2） Penile prosthesis implantation
Doctors have long been looking for an ideal surgical treatment for patients who cannot have an erection at all.
In 1973, Scott and others successfully developed a hollow prosthesis that can be filled and expanded by liquid. In 1975, Small and Carrion developed a semi-rigid silicone rubber rod prosthesis. These two kinds of penile prosthesis have become the most commonly used at present, and the implantation site is also agreed that it is the most ideal to implant the two main silicon columns in the sponge body on both sides.
In recent years, two new types of expandable prosthesis have come out. It is characterized by assembling the three components of the above-mentioned columnar silicon capsule, infusion pump and liquid reservoir into a prosthesis, which can reduce the occurrence rate of mechanical failure even if the operation is pressed. One of them is called FlexiFlate penis prosthesis. The other is called Hydroflex penis prosthesis.
Recently, there is a new prosthesis called OmniPhase, which can make the penis change from withered state to kidney hard position by adjusting the mechanical knob without filling and releasing the liquid. The prosthesis is composed of a bending area and a regulating device.
Although the penis prosthesis implanted in the cavernous body has been considered as an effective method for the treatment of impotence, after various improvements, the function is more perfect, but there is no perfect ideal prosthesis, which needs to be improved in the future.
（3） Intracavernous injection of vasoactive drugs
Papaverine is a powerful smooth muscle relaxant. Injecting it into the cavernous body can dilate the artery and relax the smooth muscle of the cavernous trabecula, thus increasing the inflow of blood into the penis and inducing erections. It is applicable to vascular, neurogenic, endocrine and stubborn mental impotence, with an effective rate of 70-97%.
The method is to stretch the penis along the inner side of the thigh, and use a 30 # needle to vertically puncture the root of the penis into the sponge to inject the liquid medicine. The drug used and the starting dose are determined according to the cause of impotence and the penile brachial artery index of the patient. Only papaverine (30mg/ml) is used for nervous and mental impotence, and the initial injection volume is 0.25mg; For other kinds of impotence, papaverine (25mg/ml) and phentolamine (0.83mg/ml) were mixed, and the initial dose was 0.25ml. The initial dose of vascular impotence with penile blood pressure index less than 0.85 is 0.5ml. After injection, gently massage the penis to evenly distribute the drug in the sponge. The patient can go home, encourage sexual activities, and monitor the reaction and side effects. If the effect is not obvious, the dose can be doubled until the functional erection is achieved. The dose per time is not more than 1.5ml. If the nerve or mental impotence is ineffective for the simple papaverine injection, the combined treatment can be tried again. If functional erections can be obtained after injection, self-injection can be tried later. Follow up the medication and physical examination every month, and use it for liver function examination every 3 days. Intracavernous injection of drugs to induce erection has been proved to be effective in restoring erectile function in many impotent patients. The patient can inject by himself under the guidance of the doctor, but it should be noted that the possibility of continuous and abnormal erection should be treated in time to avoid the risk of penile spongy fiber.
（4） Vascular surgery
With the development of diagnostic technology, it is found that many impotences are caused by vascular diseases. There are three common causes:
Insufficiency of arterial blood supply: atherosclerotic lesions of the aorta, iliac plexus, internal iliac, internal penis, dorsal penis or cavernous artery of the penis can narrow or embolize the vascular lumen; Pelvic fracture or injury caused by perineal surgery can cause impotence due to insufficient blood supply.
Venous abnormality: fistula between the cavernous body of the penis and the head of the penis, and venous malformation of the white membrane can cause impotence due to excessive venous drainage.
Carcassing venous fistula: arteriovenous fistula of internal vessels of the vulva can cause impotence due to shunt of arterial blood. Therefore, treatment should also be carried out for the above-mentioned causes. For patients with incomplete arterial blood supply, if the lesion is located above the level of iliac artery, intimal denudation of the artery, or percutaneous transluminal angioplasty, vascular resection and transplantation or bypass surgery may be performed. There are three methods for the operation of small artery lesions:
1. Vascular reconstruction of penis cavernous body.
2. Obvious surgical reconstruction of penile vessels.
3. Arterization of veins.
For impotence caused by venous abnormalities, operations such as deep dorsal vein, Lowlsey operation (ischiocavernous muscle folding and suspension of cavernous body to pubic bone) and direct treatment of venous fistula can be performed. The cause of arteriovenous fistula is that the fistula needs to be treated directly to improve the blood supply of the cavernous body of the penis.
In short, the vascular surgery for impotence is still in the process of further development and improvement. Before treatment, patients should be carefully selected. Attention should be paid not only to the inflow rate of arteries, but also to the resistance of veins. Sometimes the anastomosis is smooth and the hemodynamics is improved after the operation, but the expected effect is still not achieved. It may be affected by other neurovascular mechanisms, which is still unclear.
（5） Negative pressure passive erection method
In order to make the penis with organic impotence produce enough erectile rigidity, the penis can be placed in a negative pressure device, so that the cavernous body can be passively congested and reach the erectile state. Then use the rubber band to bind the root of the penis to keep it erect, and then have sex. Remove the rubber band within 30 minutes, and the penis can return to the wilted state.
Negative pressure robbed erection is caused by blood accumulation in the cavernous body, which is different from normal erection; Due to the restriction of rubber band, the blood flow into the penis is reduced, so the skin temperature of the penis is low; The penis tissue outside the sponge is also congested, so the circumference of the penis increases greatly (4.3cm on average). The average increase of penis circumference during normal erection was 2.8 cm; During ejaculation, the semen will stay at the proximal end of the urethra and will not flow out until the rubber band is relaxed.
