First, the direct etiological examination of impotence.
(1) nervous system examination, distinguish between functional and organic impotence.
(2) Psychological examination, psychological investigation and question-and-answer score to determine whether it is functional impotence.
(3) Determination of penis blood pressure Normal penis blood pressure is lower than cerebral artery blood pressure, with a difference of 266kPa.
(4) We can know whether there is vascular disease by measuring penis pulse.
(5) Measurement of penile blood flow The blood flow of impotence patients decreases when the penis is erect.
(6) Doppler ultrasound examination of penile artery to determine the examination method of vascular impotence.
(7) Drug-induced penile erection test is used to distinguish vascular impotence.
(8) penis arteriography to check the function of internal pudendal artery.
(9) The contrast agent is directly injected into the corpus cavernosum for contrast.
The application of (10) electromyography in the diagnosis of nervous impotence.
(1 1) Measure the bladder pressure volume to see if the bladder pressure volume curve is abnormal.
Second, the general physical examination
Every patient should have a comprehensive and systematic examination, focusing on reproductive system development, secondary sexual characteristics, cardiovascular and nervous system examination. Abnormal development of reproductive system and secondary sexual characteristics often suggest primary or secondary hypogonadism and endocrine impotence caused by pituitary lesions. Failure to touch the dorsal artery of the foot or the disappearance of the bulbocavernous muscle reflex and perineal insensitivity suggest the possibility of vascular or neurotic impotence.
Third, laboratory tests to see if there are any other diseases.
Routine hematuria, liver and kidney function as screening examination, focusing on the following contents.
(1) Diabetes with blood sugar and urine sugar can often cause damage to blood vessels and nerves, and about 1/2 diabetic patients have impotence complications. When necessary, glucose tolerance test should be carried out to find patients with occult diabetes.
(2) Special examination ① Psycho-psychological test Minnesota Multiphasic Personality Questionnaire (MMPI), Derogative Function Questionnaire and California Personality Questionnaire have reference value in distinguishing psychological impotence from organic impotence, but they cannot be used as an important basis. ② Nocturnal penis enlargement test 1970 Karakan used the physiological phenomenon of nocturnal penis natural erection to distinguish psychological and organic male fistula for the first time. This test is less influenced by psychological factors and can objectively reflect the erectile function of penis. When normal people are in REM sleep, the penis erects 4-6 times a night for 25-40 minutes. The hardness of the hardness tester is 65% ~ 70%, but there is still a false negative of 15% ~ 20% in this test. ③ Listen to the visual stimulation test and monitor the changes of penis under the sexual stimulation of watching the video of sexual behavior. This is closer to the physiological state, we can understand the erectile ability of penis, but we often need to monitor it with NPT and make a comprehensive analysis and judgment. ④ The detection of penile blood flow 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 commonly used alone or in combination in the erection test induced by vasoactive drugs. When the drug is injected into the cavernous body, the penis can achieve hard erection for more than 30 minutes, indicating that there is no obvious vascular disease, but there is still the possibility of false negative. It is more reliable to supplement sexual stimulation after injection. There may be complications such as ecchymosis, hematoma and abnormal erection of penis.
(4) The ratio of penile arterial blood pressure to brachial arterial blood pressure (PBI) was measured by penis Doppler ultrasound monitoring. Less than 0.6 indicates that the blood supply of penile artery is damaged. The absolute difference between two systolic blood pressures should not exceed 4 kPa (30 mm Hg).
(5) Penile blood flow index The acceleration of radial artery, dorsal penile artery and cavernous artery was measured by Doppler ultrasound probe, and the penile blood flow index was calculated. PFI< suggested that the blood supply of penis was normal.
(6) The pulse volume of penile artery recorded normal penile blood flow, and the pulse volume waveform quickly rose to the peak value and then slowly decreased, and a double-wave pulse notch appeared. The round peak may drop too slowly, and the double-wave pulse notch disappears, suggesting vascular disease.
(7) Color duplex Doppler ultrasound can detect the structure, blood vessel diameter, blood flow velocity and vasomotor function of penile cavernous body, and can dynamically detect the hemodynamic changes of penile arteries and veins and the resistance index of cavernous body during erection, which is one of the most valuable noninvasive methods for screening vascular impotence.
(8) Sponge perfusion test and cavernography usually monitor the perfusion rate (IF) to induce erection, maintain the minimum flow rate (MF) of erection, and the pressure gradient (PL) of cavernous body within 30 seconds after stopping perfusion. The greater the MF and PL values, the more incompetent they are. Normal PL should be
(9) If it is suspected that internal pudendal arteriography has blood supply disorder of penile artery, bilateral internal pudendal arteriography should be performed through femoral artery before reconstruction of penile artery to observe the pathological changes of bilateral dorsal penile artery and cavernous artery.
(10) The detection of erectile nerve plays an important role in the erection mechanism, so the routine detection of erection-related nervous system is very important in the etiological diagnosis, especially for patients with brain, spinal cord and pelvic trauma and diabetes.
(1 1) The normal conduction velocity from the dorsal penile nerve (sensory afferent) to the sacral pulp and then from the motor efferent nerve to the bulbocavernous muscle, ischiocavernous muscle and anal sphincter should be 27 ~ 42 ms.
The autonomic nerve conduction velocity was detected by (12) urethral anal reflex latency, which should be 46 ~ 75 ms normally.
(13) pudendal evoked potential was used to detect the conduction velocity of penile nerve along spinal cord to cerebral cortex, and the normal range was 36 ~ 47 ms
(14) Single potential analysis of electrical activity of cavernous body By observing the myoelectrical activity of cavernous body, we can know the degeneration degree of autonomic nerve and smooth muscle. In 1 12 impotence patients measured by Stief, 49%(55 cases) showed abnormal gaps.
(15) Sponge biopsy is still controversial. Some scholars believe that the atrophy and disappearance of smooth muscle structure leads to functional decline, which is an important factor causing impotence. However, Mealeman and Jevtich believe that the structure of smooth muscle also varies with age, and there is no obvious difference between normal people and patients.
Fourth, inspection and testing.
(1) Blood and urine routine fasting blood glucose, high and low density lipoprotein and liver and kidney function.
(2) Hormone determination includes serum testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH) and prolactin (PRL). If insufficient testosterone secretion is suspected, the testosterone level should be measured twice.
(3) Chromosome examination should be carried out when necessary.
5. Contrast examination
It is suitable for those who are suspected of having venous fistula. Inject vasoactive substances to induce penile erection, then inject 30 ~100 ml of 30% meglumine diatrizoate into the cavernous body quickly, and immediately take a positive X-ray film of the penis. Patients with venous fistula have obvious changes.
Selective arteriography of penis is the main method to evaluate the location and characteristics of abnormal blood supply of penis, and it is an invasive examination, which is taboo for patients with severe hypertension, diabetes, myocardial infarction and vasculitis.
6. Examination of nervous system
(1) At present, there is no direct examination method for autonomic nerve detection. Only through the functional state and nerve distribution of organs and systems involved in autonomic neuropathy and their relationship with autonomic nerves can we indirectly understand and evaluate its neurological function. The examination contents include: heart rate control test, cardiovascular reflex test, sympathetic skin reaction, cavernous electromyography, temperature threshold test and urethral reflex.
(2) The examination of somatic nervous system includes penile biological threshold measurement test, sacral nerve stimulation response, pudendal nerve conduction velocity and somatosensory nerve evoked potential.
7. Color duplex ultrasound (CDU)
This is a non-invasive examination. The high-frequency probe can observe whether the penis is diseased. 4.5MHz pulse ranging probe can analyze blood flow and determine blood flow velocity. Combined with ICI, we can observe the blood flow of penis before and after injection and understand the blood supply and vein closure mechanism of penis.
8. Penile cavernous pressure measurement (cm)
Venous impotence is an effective diagnostic method, in which the perfusion flow (MF) to maintain erection is directly related to venous fistula. MF> 10ml/ min can consider vein closure.