Clinical necessity Treatment and management of erectile dysfunction

The etiology and pathogenesis of ED are complex, not only related to local lesions of the penis, but also closely
related to various chronic diseases.
The ultimate goal of ED treatment is to improve penile erectile function, increase sexual satisfaction and quality of life for both partners, while delaying the progression of ED and preventing the progression of
comorbid diseases.

While focusing on controlling the causes, reducing risk factors and symptomatic treatment, ED treatment should also follow overall health management, chronic disease management, and physical and mental treatment and the principle of
co-governance.

Basic treatment

ED may be a prodromal symptom and local manifestation of systemic diseases, and the effective management of underlying diseases, poor lifestyle and mental and psychological factors associated with ED patients, especially basic treatment, will inevitably be conducive to the rehabilitation
of ED.

1.
A good lifestyle is important for improving erectile function
.
Moderate exercise, reasonable diet, good sleep, weight control, etc.
can improve vascular function and erectile function, and can increase the effect of drug treatment, such as phosphodiesterase inhibitor type 5 (PDE5i) to improve
erectile function.

2.
For patients with clear underlying diseases, ED should be treated before or at the same time as ED, such as CVD, diabetes, hyperlipidemia, depression, etc.
, and attention should also be paid to some antihypertensive drugs, lipid-lowering drugs, and antidepressants that may cause ED
for the treatment of these underlying diseases.

3.
People with ED are more likely to have psychological problems
such as reduced happiness, self-confidence and self-esteem.
Sex education, counseling, psychological counseling and treatment for patients can help restore their sexual function
.

4.
People with ED should be made to understand that sex is an important part of quality of life and to face this problem
with their sexual partners.
Close sexual partner feelings (especially passion) is the first concern, appropriately mobilize the interest of patients and their partners in sexual life, and encourage them to appropriately increase the frequency of sexual life under psychological or drug treatment, and gradually learn sexual life skills
.

Oral drug therapy

Oral PDE5i has become the preferred treatment of ED, and is easy to accept by most patients because it is convenient, safe and effective
.
PDE5i has two modes
: on-demand use and regular use.

Androgen replacement therapy

Patients with primary or secondary male hypogonadism for various causes often have ED, and androgen therapy in such patients can not only enhance libido, but also improve erectile function
.
In patients with ED with low testosterone levels, androgen replacement therapy improves erectile function in people who do not respond to PDE5i for the first time, and may have a potentiating effect
when combined with PDE5i.

Antioxidants and drugs that improve microcirculation

With age, as well as some metabolic diseases such as diabetes, the body is mostly in a state of oxidative stress, resulting in a decrease in NO and an increase in vascular endothelin 1 (ET-1), causing a weakening of smooth muscle relaxation and contractility of the corpus cavernosum, and causing functional and organic damage to the blood endothelium of small blood vessels, thereby aggravating the degree of ED.

Other drugs

Other drugs such as apomorphine, trazodone and other drugs have been partially confirmed for ED, but their use is less
.

physiotherapy

Physiotherapy (such as negative pressure aspiration and micro-energy) is often used as an adjunct to ED therapy, and appropriate physiotherapy
may be selected or combined with patients who do not respond well to oral drugs alone.
Commonly used physiotherapy methods include vacuum erection device (VED), low-intensity extracorporeal shockwave therapy (LI-ESWT), low-intensity pulsed ultrasound (LIPUS), electrophysiological techniques, etc
.

Penile cavernous body injection (ICI) treatment

ICI therapy as a second-line regimen for ED may be considered
when oral medications are ineffective.
Commonly used drugs include prostaglandin E1, papaverine, phentolamine, etc.
, often using combination therapy, aiming to improve the efficacy while reducing the adverse reactions
of each drug.
At present, the combined application of papaverine, prostaglandin E1 and phentolamine has the highest effective rate, up to 92%.

Transurethral administration

Transurethral vasoactive drugs are mainly based on the consideration of reducing penile trauma, and the commonly used drug is alprostadil.

There are two different methods of administration: the first is a mixture made with a cream that promotes osmotic action, applied to the external urethral orifice to facilitate the absorption of alprostadil, the clinical use of which has very limited
data.
The second method of administration is to place the alprostadil preparation into the urethra, and 30% to 65.
9% of patients can obtain enough erection for sexual intercourse
.

Surgical treatment

Surgery is the third-line treatment for ED and is used in patients
with moderate to severe ED who do not respond to first- and second-line treatments.
Due to the poor long-term efficacy of penile vascular surgery, surgical indications should be strictly selected and adequate preoperative communication
should be carried out.
In the absence of contraindications, penile prosthesis surgery has good safety and efficacy, but attention should still be paid to prevent the occurrence
of intraoperative and postoperative complications.

Traditional Chinese medicine treatment

Traditional Chinese medicine calls the disease "Yin Hemorrhage", "Tendon Hemorrhage", "Yin Apparatus Not Used", and the name "Impotence" began at the end of the Ming Dynasty, which has been used to this day
.
Traditional Chinese medicine treats impotence, emphasizing the overall concept and dialectical treatment, according to different symptom types, while enhancing erectile function and improving systemic symptoms
.
Modern research on the mechanism of action of impotence in traditional Chinese medicine mainly focuses on regulating the hypothalamic-pituitary-gonadal axis, improving microcirculation, anti-aging, and antioxidant
.

Treatment of special types of ED

The consensus of the guidelines proposes detailed treatment options for the treatment of special types of ED, such as ED after pelvic surgery, ED after pelvic fracture, urethral injury (PFUI), ED after spinal cord injury (SCI), ED secondary to hyperprolactinemia, and ED after brain disease, as detailed in the original article
.

Figure 1 Treatment flow of ED