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转载 阴茎勃起功能障碍怎么治?除了伟哥还有没有别的招?

杨勇 主任医师 解放军总医院第四医学中心(原304医院) 泌尿外科
2015-05-20

阴茎勃起功能障碍怎么治?除了伟哥还有没有别的招?

美国国立卫生研究院将阴茎勃起功能障碍(ED)定义为:阴茎持续不能达到和(或)维持足够的勃起以完成满意的性生活[1, 2]。美国马萨诸塞州男性老龄化研究(Massachusetts male aging study, MMAS)调查数据显示[3]40 ~ 70岁中老年男性ED患病率52%,其中轻、中、重度ED患者患病率分别是17.2%25.2%9.6%,其发病率表现随年龄增加而增高。除了心理因素外,半数以上ED患者的发病原因与糖尿病、高血压、高血脂、动脉硬化、神经病变、脑脊髓及生殖器官外伤等器质性病变有关。解放军总医院第四医学中心(原304医院)泌尿外科杨勇

1998年,口服选择性磷酸二酯酶5型抑制剂(PDE5i)开发上市,使ED治疗发生革命性变化,今天已成为治疗ED的第一线治疗方法。目前国内常用的此类药物主要有:万艾可、希爱力、艾力达。作为一次性诱导勃起药物,在足够性刺激下,PDE5i治疗ED有效率约80%,约有15%的患者在用药过程中出现一次性头痛、头晕及色觉异常等副作用 [4]。对于那些同时患有糖尿病、严重血管病变以及前列腺癌根治术后的ED患者,PDE5i疗效较差 [5, 6]。近年来,研究显示长程口服PDE5i(希爱力)可改善难治性ED患者的治疗反应 [7],其机制可能与改善血管内皮功能 [8]、防止海绵体纤维化和减轻阴茎海绵体平滑肌含量减少有关 [9]

新版欧洲泌尿外科学会男性性功能障碍指南中,已将真空勃起装置(VEDs)和低能量体外冲击波(LESW)纳入ED的第一线疗法中。VEDs可以促使阴茎海绵体被动充血,并可通过诱导勃起后在阴茎根部套扎缩窄环阻止血液回流以维持阴茎勃起。但是,这种方法并不是通过生理途径维持阴茎勃起,约30%患者出现不同程度阴茎疼痛、射精延迟、淤血、麻木等不良反应 [10]。短期内临床满意度27% ~ 94%,使用两年后满意度至50% ~ 64%,大部分患者难以长期坚持 [11, 12]。近年来, LESW作为治疗ED的新型治疗方式,受到广泛关注。动物实验研究结果显示,LESW可促进阴茎神经元型一氧化氮合酶(nNOS)神经、内皮细胞和海绵体平滑肌再生 [13],其机制可能与调节阴茎内源性干细胞招募有关 [14]

ED的第二线疗法是阴茎海绵体内药物注射疗法(intracavernosal injection therapy, ICI),如注射罂粟碱、酚妥拉明和前列腺素E1等,通常注射药物后5 ~ 10分钟可以诱导勃起,其临床有效率达85%左右,该疗法属于侵袭性疗法,可引起疼痛、异常勃起、阴茎海绵体纤维化等副作用,须在医生指导下,药物剂量个体化 [12, 15]。对于第一线及第二线疗法均无效的重度器质性ED患者或其它治疗方式无效的ED患者,可选择阴茎假体植入手术(Penile prosthesis implantation, PPI) [16]。人工阴茎假体利用现代科技,根据阴茎海绵体结构使用与人体组织相容性良好的硅橡胶圆柱体,通过手术安放到阴茎海绵体内,扶持阴茎勃起。阴茎假体植入后可作为半永久性最佳治疗方法,临床有效率95%左右,并不影响原有的阴茎感觉、排尿、射精功能和性快感,目前已成为治疗勃起功能障碍的第三线标准治疗方法。目前阴茎起勃器存在多种类型,大体可分为半硬性可屈性假体、机械膨胀性假体和液体充胀性假体,后者有单件套,双件套和三件套假体[17-19]。但由于价格昂贵,存在感染、糜烂、设备故障等风险,选择手术治疗的患者有限 [20]

 

参考文献

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