Low intensity shock wave therapy for impotence –
is it another dream or reality?
I would like to share exciting news about the management of erectile dysfunction: we have something to offer to our patient besides pills, penile injection and penile implant surgery. This new management came from regenerative medicine that is now is getting wide acceptance in different medical and surgical specialties. Its name is Low intensity Shock Wave therapy (LIST). We are familiar with this technology in the management of kidney stones when high intensity shock wave is used. Low intensity shock wave does not break anything but causes a mild contusion or injury to the tissue that triggers the cascade of events, finally causing formation of new vascular channels in it or neovascularity.
It is widely accepted that one of the underlying functional causes of ED is poor cavernosal arterial blood flow, it has been suggested that induction of neovascularization by LIST could improve cavernosal arterial flow, which in turn would improve erectile function. The first clinical study of the efficacy of LIST for ED was conducted in 2010: Low Intensity Shock Wave Therapy was applied to 20 middle-aged men with mild to moderate vasculogenic Erectile Dysfunction who responded well to the use of PDE5i (medications like Viagra, Cialis, Levitra etc).. The treatment protocol was based on the described methodology used in patients with cardiovascular disease with modifications according to anatomical differences. The main challenge presented by the authors was to apply shock waves to the whole area of the corpora cavernosa, including the crus. Another challenge was to adapt the shock wave delivery probe to the anatomy of the penis because the corpora cavernosa lies immediately under the penile skin. The protocol consisted of two treatment sessions per week for 3 weeks, a 3-week no-treatment interval, and a second 3-week treatment period of two treatment sessions per week. Each session comprised the application of 300 shock waves (energy intensity of 0.09 mJ/mm2) to each of five different sites: three along the penile shaft and two at the crura.
The results showed that 1 month after treatment, erectile function improved in 15 men (75%). Furthermore, erectile function and penile blood flow were measured by using nocturnal penile tumescence (NPT) and flow-mediated dilation methodology (FMD) of the penis. In the 15 men who responded to LIST, all NPT parameters improved as recorded by significant increases in the duration of the erections and penile rigidity. Penile blood flow also improved significantly at the 1-month follow-up examination. At the 6-month follow-up visit, 10 men reported that they still had spontaneous erections and did not require PDE5i support.
Following these impressive preliminary clinical results, the effect of LIST on erectile function was examined in an animal model. Several groups investigated the effects of LIST on erectile function in diabetes mellitus rats, using the changes in the intracavernosal pressure following electrostimulation of the cavernous nerve to assess erectile function: they found that erectile function was significantly decreased in all diabetic rats, but this effect was less evident in the LIST group. Additionally, histological analysis revealed an abundant amount of functioning small nerves, endothelial and smooth muscle cells, and mesenchymal stem cells (MSCs) in the LIST group compared with untreated diabetic rats. Such findings support the idea that the underlying mechanism of the therapeutic action of LIST is the recruitment of steam cells in penile tissue. Two more groups have recently examined the effect of extracorporeal shock waves on nerve stimulation-induced erection in rats: it was demonstrated that shock wave energy improved erectile function as well as pathological changes in the erectile tissue of diabetic rats.
The clinical study was extended further in vasculogenic ED patients and examined LIST as a possible treatment for patients with severe ED who responded poorly to PDE5i therapy (Viagra, Cialis, Levitra etc). The aim of this second study was to investigate the ability of LIST to convert non responders to PDE5i therapy to PDE5i responders so that they were able to achieve satisfactory erections for vaginal penetration. This study showed that, overall, 72% of patients, not responding to oral medications for ED were converted to PDE5i responders. Most importantly, none of the men in either study reported treatment-associated pain or any adverse events during or after the treatment.
Further Clinical Studies
Another study recently evaluated the effect of LIST after 2 years of follow-up and reported that the beneficial response that was achieved immediately after therapy had not faded in about 50% of the patients. The success rate after 2 years was lower mainly in patients with severe ED and diabetes. The same group also reported their preliminary results regarding a second round of penile LIST. They aimed to discover whether an additional LIST protocol would be therapeutically beneficial in patients whose first round of treatment was unsuccessful. Thirty patients were included in this study, 22 of whom (73.3%) had severe ED: in the “second round” protocol, LIST was effective in approximately half the patients, demonstrating that there are patients who probably need additional exposure to shock wave energy in order to respond.
Looks like, Low Intensity Shock Wave therapy or Corewave therapy as it is called sometimes is not a dream anymore. It is a safe and efficient treatment of erectile dysfunction that is effective overall in about 70% of patients, could be safely repeated and carries a lot of hope for the patient with Impotence.
Do you have any questions?
Get in touch with Dr. Kotkin.
Low Intensity Shock Wave Therapy
Revolutionary procedure that can lead to a healthier