阳痿（勃起功能障碍）可以怎么治？

上一期我们给大家分析了阳痿的定义和分类，这一期我们来聊聊阳痿（勃起功能障碍）的治疗手段。

国内治疗ED一直沿用的欧洲泌尿外科学会的分线方法，“分线”治疗的原则需要考虑三个要素：即微创性、有效性和经济性。

国内专家在综合以上因素的情况下，将勃起功能障碍的治疗分为以下三线。

一、一线治疗^[1～24]

(1)从建立良好生活方式开始，积极治疗全身疾病

(2)口服PDE5抑制剂

PDE5抑制剂具有显著的疗效、同时不良反应发生率低、且治疗费用不高，因此，为一线治疗中的***方法。常用的药物有：西地那非、他达拉非、伐地那非等。

(3)低强度脉冲超声(LIPUS)

***近的研究表明LIPUS具有激活阴茎内的干细胞，调控细胞信号通路，促进血管新生等生物学效应，对于ED治疗具有良好效果，且无任何严重的不良反应，故列入一线治疗。

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(4)低能量体外冲击波(Li-ESWT)

Li-ESWT是一种治疗ED的有效物理治疗方法。Li-ESWT首先在2010年治疗血管性ED取得临床疗效，后续的系列临床研究证实了其疗效和安全性，欧洲泌尿外科学会从2013年开始将该方法列为ED的一线治疗选择。尽管存在对于重度ED患者治疗后有效持续时间不够长、患者经济负担较大等问题，但是目前国内外普遍认为Li-ESWT对于ED治疗整体上具有良好的效果，故列入一线治疗。

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(5)真空负压装置

真空负压装置在***的指南中列为一线治疗，且在2018年国内泌尿外科学会指南中，评为中等推荐。真空负压装置对普通的ED患者以及糖尿病、脊髓损伤、前列腺切除术后的ED患者都是有效的治疗方案。且其副作用较小，治疗费用并不昂贵，因此也纳人一线治疗。

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二、二线治疗^[25～31]

       血管活性药物海绵体内注射：血管活性药物海绵体内注射是传统ED治疗方法之一，其有效性高，但是需要患者自行注射，有一定创伤，有引起异常勃起的风险。

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三、三线治疗^[32～27]

(1)阴茎支撑体植入手术

支撑体植入手术治疗的有效性高，但相对于一、二线治疗创伤较大且费用较高。因此，纳入三线治疗。但是如果患者要求尽早进行支撑体植入手术，在充分介绍收益、风险和负担的前提下，若患者坚持选择该治疗方案，也应充分考虑患者的诉求。

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（2)阴茎血管手术

阴茎血管手术相对一、二线治疗创伤较大，动脉重建手术仅对动脉损伤或动脉狭窄的特殊病人适用，而静脉手术的远期疗效不尽人意，因此，应在严格把握手术适应症的前提下谨慎开展阴茎血管手术。

目前仍然以口服药物应用***广泛，下一期我们聊聊常用的PDE5抑制剂有哪些及如何正确使用。

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