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New Frontiers of Extracorporeal Shock Wave Medicine in Urology from Bench to Clinical Studies. Biomedicines 2022; 10:biomedicines10030675. [PMID: 35327477 PMCID: PMC8945448 DOI: 10.3390/biomedicines10030675] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/08/2022] [Accepted: 03/13/2022] [Indexed: 02/04/2023] Open
Abstract
A shock wave (SW), which carries energy and propagates through a medium, is a type of continuous transmitted sonic wave that can achieve rapid energy transformations. SWs have been applied for many fields of medical science in various treatment settings. In urology, high-energy extracorporeal SWs have been used to disintegrate urolithiasis for 30 years. However, at lower energy levels, SWs enhance the expression of vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), proliferating cell nuclear antigen (PCNA), chemoattractant factors, and the recruitment of progenitor cells, and inhibit inflammatory molecules. Low energy extracorporeal shock wave (LESW) therapy has been used in urology for treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, stress urinary incontinence, and erectile dysfunction through the mechanisms of anti-inflammation, neovascularization, and tissue regeneration. Additionally, LESW have been proven to temporarily increase tissue permeability and facilitate intravesical botulinum toxin delivery for treating overactive bladders in animal studies and in a human clinical trial. LESW assisted drug delivery was also suggested to have a synergistic effect in combination with cisplatin to improve the anti-cancer effect for treating urothelial cancer in an in vitro and in vivo study. LESW assisted drug delivery in uro-oncology is an interesting suggestion, but no comprehensive clinical trials have been conducted as of yet. Taken together, LESW is a promising method for the treatment of various diseases in urology. However, further investigation with a large scale of clinical studies is necessary to confirm the real role of LESW in clinical use. This article provides information on the basics of SW physics, mechanisms of action on biological systems, and new frontiers of SW medicine in urology.
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Kałka D, Biernikiewicz M, Gebala J, Sobieszczańska M, Jakima S, Pilecki W, Rusiecki L. Diagnosis of hypogonadism in patients treated with low energy shock wave therapy for erectile dysfunction: a narrative review. Transl Androl Urol 2021; 9:2786-2796. [PMID: 33457250 PMCID: PMC7807342 DOI: 10.21037/tau-20-796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Several methods of treatment of erectile dysfunction (ED) are offered with low energy shock-wave therapy (LESWT) gaining increasing attention. Reports have documented that LESWT stimulates tissue neovascularization, proliferation and differentiation of endothelial cells, and production of nitric oxide - all can improve the condition of erectile tissue. However, the overall and sexual condition of men deteriorates with age which is linked with a constant decrease in testosterone concentration. A higher risk of sexual health disorders and reduced physical fitness correlates with a testosterone concentration of <12 nmol/L. Such patients may require testosterone replacement therapy. We conducted a target literature review to investigate whether testosterone concentration is taken into account in studies on the use of LESWT in the treatment of ED. We found that most studies did not provide any information on testosterone status. Only 8 of 25 studies examined showed values of testosterone concentrations. Only one of these analyses checked the relationship between the efficacy of LESWT and testosterone concentration. As a result, meta-analyses published to date may not show the full value of LESWT in the treatment of ED. We conclude that in the light of the significant role testosterone plays in the process of an erection and the mechanism of LESWT action, it can be recommended to examine testosterone concentration and to diagnose hypogonadism during the qualification of patients to studies on LESWT efficacy. Moreover, the effectiveness of LESWT in relation to the current testosterone concentration should also be further investigated.
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Affiliation(s)
- Dariusz Kałka
- Cardiosexology Unit, Department of Pathophysiology, Wrocław Medical University, Wrocław, Poland.,Men's Health Centre in Wroclaw, Poland
| | | | - Jana Gebala
- Cardiosexology Students Club, Wrocław Medical University, Wrocław, Poland
| | | | | | - Witold Pilecki
- Cardiosexology Unit, Department of Pathophysiology, Wrocław Medical University, Wrocław, Poland
| | - Lesław Rusiecki
- Cardiosexology Unit, Department of Pathophysiology, Wrocław Medical University, Wrocław, Poland
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Lurz K, Dreher P, Levy J, McGreen B, Piraino J, Brevik A, Edwards D, Belkoff LH. Low-Intensity Shockwave Therapy in the Treatment of Erectile Dysfunction. Cureus 2020; 12:e11286. [PMID: 33274160 PMCID: PMC7707887 DOI: 10.7759/cureus.11286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Low-intensity shockwave therapy (LISWT) may improve erectile function in patients with mild to moderate erectile dysfunction (ED). Currently there is a paucity of research and prospective data on the utilization of LISWT in patients with ED. We present the results of our phase II clinical trial of LISWT with short-term follow-up in a cohort of patients with mild to moderate vasculogenic ED. Methods We obtained IRB approval and prospectively enrolled patients with mild to moderate vasculogenic ED. Baseline International Index of Erectile Function (IIEF) scores and peak systolic velocities (PSV) of cavernosal arteries measured on duplex penile ultrasound were obtained prior to treatment. Treatment included 6600 total shocks per session, for a total of six consecutive weekly treatment sessions. Baseline Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores were obtained at the completion of the treatment course. IIEF, EDITS and PSV were evaluated again at one-month follow-up. Clinical significance was defined as a median IIEF score increase of four points from baseline or an EDITS total score increase to greater than 65 or increase of greater than ten from baseline. Treatment success was evaluated on an individual basis and defined by a clinically significant improvement in questionnaire score. Results A total of 25 patients were enrolled in the trial, with 22 patients reporting for one-month follow-up. 68% (15/22) of patients demonstrated treatment success. In the cohort there was improvement in median EDITS from 61 (IQR 49-92) to 73 (IQR 43-49), which did meet criteria for clinical significance, but did not reach statistical significance (p = 0.74). IIEF improved from a median of 13 (IQR 12-19) to 18 (IQR 14-25), which did reach statistical significance (p = 0.011). On duplex ultrasound, mean cavernosal artery PSV increased from 34.3 cm/s (IQR 25.7-51.1) to 38.0 cm/s (IQR 31.6-45.1); however, these differences were statistically insignificant (p = 0.986). Of the 25 patients undergoing LISWT, two reported discomfort during treatment sessions, which subsided after repositioning the device without alterations in energy delivered. Conclusion LISWT may be a safe and potentially efficacious clinical modality for treatment of patients with mild to moderate vasculogenic ED demonstrating increases in cavernosal artery PSV and improvements in IIEF and EDITS scores in short-term follow-up. Longitudinal studies with increased power are needed to better evaluate the long-term efficacy and cost-efficiency of this therapy.
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Affiliation(s)
- Kelly Lurz
- Urological Surgery, Mainline Health, Philadelphia, USA
| | | | - Jason Levy
- Urology, Mainline Health, Philadelphia, USA
| | | | | | - Andrew Brevik
- Urology, Kansas City University of Medicine and Biosciences, Kansas City, USA
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Grandez-Urbina JA, Rodríguez RP, Torres-Román JS, Saldaña-Gallo J, García-Perdomo HA. [Low-intensity extracorporeal shock wave treatment improves erectile function in non-responder PDEi5 patients: A systematic review]. Rev Int Androl 2020; 19:272-280. [PMID: 32605764 DOI: 10.1016/j.androl.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 03/06/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effectiveness and safety in the short, medium, and long term of LISWT in patients with Erectile Dysfunction who do not respond to PDE5 inhibitors. METHODOLOGY Clinical study, quasi-experimental cohort and systematic review following the guidelines of the Cochrane collaboration and the PRISMA writing guides. The measurement of the variables was determined as a primary outcome to the evaluation of erectile function, by means of a validated questionnaire. The baseline scale was evaluated, as well as the difference at 1, 3 and 6 months, evidenced by the possibility of maintaining an erection or responding to therapy with PDEi5. An information search was carried out from its beginning to the current date, in the databases: Medline, Embase, Central, Science Direct and Lilacs. RESULTS The studies found used different outcome variables to show efficacy in the follow-up: All the studies used the IIEF-EF as outcome variable in its different variations. CONCLUSION LISWT could be an effective and safe treatment in patients not responding to PDEi5. It is important to point out that the evidence is currently limited, randomized studies with greater methodological rigidity and follow-up longer than 12 months are needed in order to verify the medium and long-term effect of the application of shock waves in this group of patients.
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Affiliation(s)
| | - Rafael Pichardo Rodríguez
- Centro de Investigación, Clínica de Urología Avanzada UROZEN, Lima, Perú; Instituto de Investigación en Ciencias Biomédicas, Universidad Ricardo Palma, Lima, Perú
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Salter CA, Lue TF, Mulhall JP. What Is Shockwave Therapy? J Sex Med 2020; 17:565-569. [PMID: 32044257 DOI: 10.1016/j.jsxm.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/30/2019] [Accepted: 01/05/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Carolyn A Salter
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tom F Lue
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - John P Mulhall
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Capogrosso P, Frey A, Jensen CFS, Rastrelli G, Russo GI, Torremade J, Albersen M, Gruenwald I, Reisman Y, Corona G. Low-Intensity Shock Wave Therapy in Sexual Medicine-Clinical Recommendations from the European Society of Sexual Medicine (ESSM). J Sex Med 2019; 16:1490-1505. [PMID: 31447380 DOI: 10.1016/j.jsxm.2019.07.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 07/05/2019] [Accepted: 07/18/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Low-intensity shockwave therapy (LISWT) has been investigated for the treatment of uroandrological disorders including erectile dysfunction (ED), Peyronie's disease (PD) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) with controversial findings. AIM To review the evidence on LISWT for ED, PD, and CP/CPPS and provide clinical recommendations on behalf of the European Society of Sexual Medicine. METHODS Medline and Embase databases were searched for randomized clinical trials (RCTs), meta-analyses and open-label prospective or retrospective studies investigating the effect of LISWT on ED, PD, or CP/CPPS. OUTCOMES The panel provided statements on clinically relevant questions concerning LISWT: (i) treatment efficacy, (ii) treatment protocol, (iii) clinical indications, and (iv) safety. The level of evidence was provided according to the Oxford 2011 criteria and graded using the Oxford Centre for Evidence-Based Medicine recommendations. RESULTS 11 RCTs and 5 meta-analyses investigated LISWT for ED. RCTs provided controversial results on the efficacy of LISWT and were affected by high heterogeneity and the small number of patients included. Pooled-data analysis showed an overall positive effect in terms of erectile function improvement but reported small estimates and included a largely heterogeneous cohort of patients. 4 RCTs and 1 meta-analysis assessed LISWT for PD. All trials showed positive findings in terms of pain relief but no effect on penile curvature and plaque size. Inclusion criteria vary widely among studies, and further investigation is needed. 5 RCTs investigated LISWT for CP/CPPS. Data showed a possible effect on pain relief, although there is no evidence supporting that pain relief was maintained or any improvement in pain over time. CLINICAL IMPLICATIONS LISWT needs to be further investigated in the context of sexual medicine and is almost but not yet ready for clinical practice. STRENGTHS AND LIMITATIONS All studies have been evaluated by a panel of experts providing recommendations for clinical practice. CONCLUSIONS LISWT is a safe and well-tolerated procedure but its efficacy for the treatment of ED is doubtful and deserves more investigation. Patients reporting pain associated with PD may benefit from LISWT, although no effect is expected on disease progression. LISWT is not a primary treatment for CP/CPPS, but it may be considered as an option to relieve pain. Capogrosso P, Frey A, Jensen CFS, et al. Low-Intensity Shock Wave Therapy in Sexual Medicine-Clinical Recommendations from the European Society of Sexual Medicine (ESSM). J Sex Med 2019;16:1490-1505.
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Affiliation(s)
- Paolo Capogrosso
- Department of Urology; Ospedale San Raffaele, Vita-Salute University, Milano, Italy.
| | - Anders Frey
- Department of Urology, University of Southern Denmark, Esbjerg and Odense, Denmark
| | | | - Giulia Rastrelli
- Andrology, Female Endocrinology and Gender Incongruence Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | | | | | - Maarten Albersen
- Laboratory of Experimental Urology, Department of Development and Regeneration, University of Leuven, Leuven, Belgium; Department of Urology, University Hospitals of Leuven, Leuven, Belgium
| | - Ilan Gruenwald
- Neuro-urology Unit, Rambam Healthcare Campus, Haifa, Israel
| | - Yacov Reisman
- Men's Health Clinic, Amstelland Hospital, Amsterdam, The Netherlands
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
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Current guideline recommendations and analysis of evidence quality on low-intensity shockwave therapy for erectile dysfunction. Int J Impot Res 2019; 31:209-217. [PMID: 30911110 DOI: 10.1038/s41443-019-0132-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/09/2019] [Accepted: 02/21/2019] [Indexed: 11/08/2022]
Abstract
Erectile dysfunction (ED) is defined as the inability to attain and maintain erection of the penis sufficient to permit satisfactory sexual activity. ED most commonly affects men from 40 years of age with a clear age-associated increase in prevalence. The condition may have significant negative impact on quality of life for both the patients and their partners. Over recent years, low-intensity shockwave therapy (LIST) has gained popularity in the treatment of ED, based on the assumption that LIST application may result in neoangiogenesis and thus increased blood flow to the corpora cavernosa. The increasing usage of LIST is contrasting with current guidelines, with the EAU guideline on ED stating that LIST can be used in mild organic ED patients or poor responders to PDE5I's, but with a weak strength of recommendation. In the AUA guideline on ED, the panel makes a conditional recommendation of grade C that LIST should be considered investigational. In this review, we will briefly review practice patterns, and critically discuss the evidence based on which these guideline statements have been made.
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Brunckhorst O, Wells L, Teeling F, Muir G, Muneer A, Ahmed K. A systematic review of the long-term efficacy of low-intensity shockwave therapy for vasculogenic erectile dysfunction. Int Urol Nephrol 2019; 51:773-781. [PMID: 30903393 PMCID: PMC6499893 DOI: 10.1007/s11255-019-02127-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/07/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To look at the evidence base for LISWT as a treatment modality for vasculogenic erectile dysfunction, focusing on the long-term outcomes at over 6 months following treatment. METHODS A systematic literature search was conducted utilising MEDLINE and Scopus databases from 2010 to September 2018 by two independent reviewers. Outcome measures extracted for long-term efficacy included International Index of Erectile Function scores and Erection Hardness Scores. Subgroup analysis for LISWT effectiveness included age, PDE5i responsiveness, presence of vascular co-morbidities and smoking status. RESULTS The search identified eleven studies, representing a total of 799 patients. Nine studies found a significant improvement in erectile function after LISWT at 6-month follow-up (median IIEF-EF improvement in 5.3 at 6 months). However, of five studies assessing erectile function at 12 months; two identified a plateauing of results, with three a deterioration (IIEF-EF score changes of - 2 to 0.1 from 6 months). Erectile function did, however, remain above baseline results in all of these studies. Subgroup analysis revealed increasing age to reduce the response to LISWT treatment. Whilst ED severity, PDE5i responsiveness and co-morbidities potentially influence effectiveness, results are still inconsistent. CONCLUSIONS LISWT may be a safe and acceptable potential ED treatment with demonstrated benefits at 6 months. There is some question regarding efficacy deterioration beyond this, but there is still a demonstrated benefit seen even at 12 months post treatment. However, quality of evidence remains low with larger multiinstitutional studies required, standardising confounders such as shockwave administration and oral medication use.
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Affiliation(s)
- Oliver Brunckhorst
- MRC Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, SE1 9RT UK
| | - Lauren Wells
- MRC Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, SE1 9RT UK
| | - Fiona Teeling
- MRC Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, SE1 9RT UK
| | - Gordon Muir
- MRC Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, SE1 9RT UK
| | - Asif Muneer
- Department of Urology, University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kamran Ahmed
- MRC Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, SE1 9RT UK
- Department of Urology, University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Urology, King’s College Hospital, London, UK
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Clinical studies on low intensity extracorporeal shockwave therapy for erectile dysfunction: a systematic review and meta-analysis of randomised controlled trials. Int J Impot Res 2019; 31:177-194. [PMID: 30664671 DOI: 10.1038/s41443-019-0117-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 01/25/2023]
Abstract
The efficacy of low intensity extracorporeal shock wave therapy (LI-ESWT) for erectile dysfunction (ED) has received hard criticism and recently published meta-analyses were not able to provide further insights, nor specific recommendations. The aim of this systematic review and meta-analysis is to evaluate the efficacy of LI-ESWT for ED, identify the ideal treatment population and treatment protocol, and provide recommendations for future research in the field. A systematic research for relevant clinical studies published from January 2010 to September 2018 was performed, using the following databases: Medline, Embase, The Cochrane Library, Scopus, and Web of Science. Only clinical studies that investigated the efficacy of LI-ESWT for ED only, and reported primary outcomes using IIEF-EF scores/questionnaires were included. Both, randomised controlled trials (RCTs) and cohort studies were included, but the meta-analysis was performed only for sham-controlled RCTs. Ten RCTs including 873 patients were selected for the meta-analysis. Pooling data of these studies showed that LI-ESWT could significantly improve erectile function in men with ED regarding both patient-subjective outcomes (IIEF-EF: +3.97; 95% CI [2.09-5.84]; p < 0.0001, EHS ≥ 3: OR: 4.35; 95% CI [1.82-10.37]; p = 0.0009) and patient-objective outcomes (peak systolic velocity: +4.12; 95% CI [2.30-5.94]; p < 0.00001). In conclusion, the present meta-analysis provided results showing that LI-ESWT significantly improves erectile function in patients with vasculogenic ED.
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Fojecki GL, Tiessen S, Osther PJS. Effect of Linear Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction-12-Month Follow-Up of a Randomized, Double-Blinded, Sham-Controlled Study. Sex Med 2017; 6:1-7. [PMID: 29275957 PMCID: PMC5815970 DOI: 10.1016/j.esxm.2017.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/22/2017] [Accepted: 09/30/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Short-term data on the effect of low-intensity extracorporeal shockwave therapy (Li-ESWT) on erectile dysfunction (ED) have been inconsistent. The suggested mechanisms of action of Li-ESWT on ED include stimulation of cell proliferation, tissue regeneration, and angiogenesis, which can be processes with a long generation time. Therefore, long-term data on the effect of Li-ESWT on ED are strongly warranted. AIM To assess the outcome at 6 and 12 months of linear Li-ESWT on ED from a previously published randomized, double-blinded, sham-controlled trial. METHODS Subjects with ED (N = 126) who scored lower than 25 points in the erectile function domain of the International Index of Erectile Function (IIEF-EF) were eligible for the study. They were allocated to 1 of 2 groups: 5 weekly sessions of sham treatment (group A) or linear Li-ESWT (group B). After a 4-week break, the 2 groups received active treatment once a week for 5 weeks. At baseline and 6 and 12 months, subjects were evaluated by the IIEF-EF, the Erectile Hardness Scale (EHS), and the Sexual Quality of Life in Men. MAIN OUTCOME MEASURES The primary outcome measure was an increase of at least 5 points in the IIEF-EF (ΔIIEF-EF score). The secondary outcome measure was an increase in the EHS score to at least 3 in men with a score no higher than 2 at baseline. Data were analyzed by linear and logistic regressions. RESULTS Linear regression of the ΔIIEF-EF score from baseline to 12 months included 95 patients (dropout rate = 25%). Adjusted for the IIEF-EF score at baseline, the difference between groups B and A was -1.30 (95% CI = -4.37 to 1.77, P = .4). The success rate based on the main outcome parameter (ΔIIEF-EF score ≥ 5) was 54% in group A vs 47% in group B (odds ratio = 0.67, P = .28). Improvement based on changes in the EHS score in groups A and B was 34% and 24%, respectively (odds ratio = 0.47, P = .82). CONCLUSION Exposure to 2 cycles of linear Li-ESWT for ED is not superior to 1 cycle at 6- and 12-month follow-ups. Fojecki GL, Tiessen S, Osther PJS. Effect of Linear Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction-12-Month Follow-Up of a Randomized, Double-Blinded, Sham-Controlled Study. Sex Med 2018;6:1-7.
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Affiliation(s)
| | - Stefan Tiessen
- Department of Urology, Odense University Hospital, Odense, Denmark
| | - Palle Jørn Sloth Osther
- Urological Research Center, Department of Urology, Lillebaelt Hospital, University of Southern, Denmark
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Kałka D, Gebala J, Smoliński R, Rusiecki L, Pilecki W, Zdrojowy R. Low-energy Shock Wave Therapy—A Novel Treatment Option for Erectile Dysfunction in Men With Cardiovascular Disease. Urology 2017; 109:19-26. [DOI: 10.1016/j.urology.2017.05.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/08/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
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Qi T, Ye L, Wang B, Zhang B, Chen J. Comparison of the effects of extracorporeal shock wave therapy and a vacuum erectile device on penile erectile dysfunction: a randomized clinical trial. Medicine (Baltimore) 2017; 96:e8414. [PMID: 29095274 PMCID: PMC5682793 DOI: 10.1097/md.0000000000008414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This randomized clinical trial (October 2012-December 2013) compared extracorporeal shock wave therapy (ESWT) and a vacuum erectile device (VED) for management of erectile dysfunction (ED). METHODS Consecutive Chinese patients (20-55 years) with ED, abnormal nocturnal penile tumescence and rigidity (NPTR), and international index of erectile function-5 items (IIEF-5) score <22 were randomized to receive ESWT or VED (twice weekly, 4 weeks). Primary outcomes were treatment efficacy and success rate 4 weeks after completion of therapy. Secondary outcomes included changes in IIEF-5 score, sex encounter profile (SEP) score, erection hardness score (EHS) and NPTR assessments 4 weeks post-therapy. All enrolled patients (n = 30 per group) completed the study. At baseline, age, IIEF-5 score, SEP score, EHS, and NPTR assessments were similar between groups. RESULTS Four weeks post-therapy, IIEF-5 score increased in the ESWT (15.03 ± 3.00 vs. 11.60 ± 2.28) and VED (15.10 ± 3.06 vs. 11.53 ± 2.27) groups, as did SEP score, EHS, and NPTR measures (all P < .05). Efficacy in the ESWT and VED groups was excellent in 10% and 13.3%, respectively, and moderate in 63.3% and 53.3%, respectively. Treatment success rate in the ESWT and VED groups was 73.3% and 67.7%, respectively. CONCLUSION VED use and ESWT have comparable efficacies in the treatment of ED in Chinese patients.
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Angulo J, Arance I, de las Heras M, Meilán E, Esquinas C, Andrés E. Efficacy of low-intensity shock wave therapy for erectile dysfunction: A systematic review and meta-analysis. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.acuroe.2017.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Saldaña-Gallo J, Torres-Román JS, Grandez-Urbina JA. Shock wave therapy for erectile dysfunction: The lack of evidence at the Latin America and Caribbean level. Actas Urol Esp 2017; 41:540. [PMID: 28139338 DOI: 10.1016/j.acuro.2016.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 10/15/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
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Angulo JC, Arance I, de Las Heras MM, Meilán E, Esquinas C, Andrés EM. Efficacy of low-intensity shock wave therapy for erectile dysfunction: A systematic review and meta-analysis. Actas Urol Esp 2017; 41:479-490. [PMID: 27521134 DOI: 10.1016/j.acuro.2016.07.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 11/29/2022]
Abstract
CONTEXT The low-intensity shockwave (LISW) therapy is a recently developed modality for treating erectile dysfunction. OBJECTIVE To assess the efficacy of LISW therapy for treating erectile dysfunction as described in the literature. ACQUISITION OF EVIDENCE Two independent reviewers identified studies eligible for a systematic review and meta-analysis of various sources written in English and Spanish, using the databases of PubMed, EMBASE and Web of Science. We excluded studies on Peyronie's disease. We employed the DerSimonian-Laird method for defining heterogeneity, calculating the grouped standard deviation of the mean (SDM). The primary objective of this review is to assess efficacy based on the change in the International Index of Erectile Function (IIEF-EF) over baseline at 1 month from the start of treatment, both for the treatment arm and the placebo arm. The secondary objective is focused on analysing IIEF-EF at 3-6 months from the start of the therapy. SUMMARY OF THE EVIDENCE The pooled data of 636 patients from 12 studies showed that treatment with LISW resulted in a significant increase in IIEF-EF at 1 month with respect to baseline (SDM, -2.92; P=.000), to a greater degree than placebo (SDM, -.99; P=.000). The IIEF-EF at 3-6 months for the treated patients was significantly greater than baseline (SDM, -2.78; P=.000). Only one study compared the efficacy of placebo at 3-6 months versus baseline (SDM, -9.14). The comparison between LISW and placebo favours active treatment (SDM, 2.53; P=.000) at 1 month. There are insufficient data in the literature to assess the response over placebo at 3-6 months. CONCLUSIONS According to the literature, treatment with LISW for erectile dysfunction is effective, both in the short and medium term. LISW has been described as more effective than placebo in the short term. The long-term efficacy data are insufficient. More studies are needed to explain the role of this therapy according to specific causes of erectile dysfunction.
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Affiliation(s)
- J C Angulo
- Servicio de Urología, Hospital Universitario, Getafe, Madrid, España; Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Laureate Universities, Getafe, Madrid, España.
| | - I Arance
- Servicio de Urología, Hospital Universitario, Getafe, Madrid, España
| | - M M de Las Heras
- Servicio de Urología, Hospital Universitario, Getafe, Madrid, España
| | - E Meilán
- Servicio de Urología, Hospital Universitario, Getafe, Madrid, España
| | - C Esquinas
- Servicio de Urología, Hospital Universitario, Getafe, Madrid, España
| | - E M Andrés
- Análisis Estadísticos PerTICA, S. L., Madrid, España
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Zou ZJ, Tang LY, Liu ZH, Liang JY, Zhang RC, Wang YJ, Tang YQ, Gao R, Lu YP. Short-term efficacy and safety of low-intensity extracorporeal shock wave therapy in erectile dysfunction: a systematic review and meta-analysis. Int Braz J Urol 2017; 43:805-821. [PMID: 28379665 PMCID: PMC5678511 DOI: 10.1590/s1677-5538.ibju.2016.0245] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 01/22/2017] [Indexed: 02/05/2023] Open
Abstract
AIM The role of low-intensity extracorporeal shock wave therapy (LI-ESWT) in erectile dysfunction (ED) is not clearly determined. The purpose of this study is to investigate the short-term efficacy and safety of LI-ESWT for ED patients. MATERIALS AND METHODS Relevant studies were searched in Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), WANFANG and VIP databases. Effective rate in terms of International Index of Erectile Function-Erectile Function Domain (IIEF-EF) and Erectile Hardness Score (EHS) at about 1month after LI-ESWT was extracted from eligible studies for meta-analysis to calculate risk ratio (RR) of effective treatment in ED patients treated by LI-ESWT compared to those receiving sham-treatment. RESULTS Overall fifteen studies were included in the review, of which four randomized controlled trials (RCTs) were for meta-analysis. Effective treatment was 8.31 [95% confidence interval (CI): 3.88-17.78] times more effective in the LI-ESWT group (n=176) than in the sham-treatment group (n=101) at about 1 month after the intervention in terms of EHS, while it was 2.50 (95% CI: 0.74-8.45) times more in the treatment group (n=121) than in the control group (n=89) in terms of IIEF-EF. Nine-week protocol with energy density of 0.09mJ/mm2 and 1500 pluses seemed to have better therapeutic effect than five-week protocol. No significant adverse event was reported. CONCLUSION LI-ESWT, as a noninvasive treatment, has potential short-term therapeutic effect on patients with organic ED irrespective of sensitivity to PDE5is. Owing to the limited number and quality of the studies, more large-scale, well-designed and long-term follow-up time studies are needed to confirm our analysis.
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Affiliation(s)
- Zi-jun Zou
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Liang-you Tang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Zhi-hong Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Jia-yu Liang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Ruo-chen Zhang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yu-jie Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yong-quan Tang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Rui Gao
- Department of Urology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Yi-ping Lu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
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17
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Low-intensity shockwave therapy for erectile dysfunction: is the evidence strong enough? Nat Rev Urol 2017; 14:593-606. [DOI: 10.1038/nrurol.2017.119] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Fode M, Lowenstein L, Reisman Y. Low-Intensity Extracorporeal Shockwave Therapy in Sexual Medicine: A Questionnaire-Based Assessment of Knowledge, Clinical Practice Patterns, and Attitudes in Sexual Medicine Practitioners. Sex Med 2017; 5:e94-e98. [PMID: 28268167 PMCID: PMC5440640 DOI: 10.1016/j.esxm.2016.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/15/2016] [Accepted: 12/04/2016] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Low-intensity extracorporeal shockwave therapy (LI-ESWT) has emerged as a treatment option for male sexual dysfunction. However, results have been contradictory. AIM To investigate the knowledge, practice patterns, and attitudes regarding LI-ESWT among experts in sexual medicine. METHODS A study-specific questionnaire was handed out at the 18th Congress for the European Society for Sexual Medicine. Participants were queried on their knowledge about LI-ESWT and about their use of the equipment. MAIN OUTCOME MEASURES Descriptive data on the knowledge of LI-ESWT and perception of treatment effects. RESULTS One hundred ninety-two questionnaires were available for analysis. Most respondents were physicians (79.7%) and most of these specialized in urology (58.9%). Overall, 144 of 192 (75%) reported that they were familiar with LI-ESWT in sexual medicine. Twenty-seven (14.1%) had performed the treatment. Of the 117 non-users who were familiar with LI-ESWT, 37 sometimes referred patients for the treatment. Nevertheless, 103 of 144 (71.5%) stated that they considered LI-ESWT an effective treatment for erectile dysfunction (ED) and 10 of 144 (6.9%) considered it an effective treatment for Peyronie disease. Of participants who regarded LI-ESWT an effective ED treatment, 91.2% would consider the treatment specifically for vasculogenic ED and 81.6% would combine it with phosphodiesterase type 5 inhibitors. Most participants (83.7%) regarded LI-ESWT as safe. A urology background (odds ratio = 2.4; 95% CI = 1.3-4.8; P = .0093) and working in a private setting (odds ratio = 2.8; 95% CI = 1.5-5.3; P = .0084) were significant predictors of familiarity with LI-ESWT in sexual medicine and of being an LI-ESWT user. Likewise, urologists were significantly more likely than non-urologists to consider the treatment effective (odds ratio = 2.8; 95% CI = 1.1-7.1; P = .033). CONCLUSION LI-ESWT is well known among experts in sexual medicine and the treatment is perceived as safe and effective against vasculogenic ED when combined with phosphodiesterase type 5 inhibitors. The treatment is mainly offered by urologists. Fode M, Lowenstein L, Reisman Y. Low-Intensity Extracorporeal Shockwave Therapy in Sexual Medicine: A Questionnaire-Based Assessment of Knowledge, Clinical Practice Patterns, and Attitudes in Sexual Medicine Practitioners. Sex Med 2017;5:e94-e98.
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Affiliation(s)
- Mikkel Fode
- Department of Urology, Zealand University Hospital, Roskilde, Denmark; Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark.
| | - Lior Lowenstein
- Department of Family Medicine, Ruth and Bruce Rappaport Faculty of Medicine, Clalit Health Services and Neuro-urology Unit, Rambam Medical Center, Haifa, Israel
| | - Yacov Reisman
- Department of Urology, Amstelland Hospital, Amstelveen, The Netherlands
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Clavijo RI, Kohn TP, Kohn JR, Ramasamy R. Effects of Low-Intensity Extracorporeal Shockwave Therapy on Erectile Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2016; 14:27-35. [PMID: 27986492 DOI: 10.1016/j.jsxm.2016.11.001] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/29/2016] [Accepted: 11/01/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Low-intensity extracorporeal shock wave therapy (Li-ESWT) has been proposed as an effective non-invasive treatment option for erectile dysfunction (ED). AIM To use systematic review and meta-analysis to assess the efficacy of Li-ESWT by comparing change in erectile function as assessed by the erectile function domain of the International Index of Erectile Function (IIEF-EF) in men undergoing Li-ESWT vs sham therapy for the treatment of ED. METHODS Systematic search was conducted of MEDLINE, EMBASE, and ClinicalTrials.gov for randomized controlled trials that were published in peer-reviewed journals or presented in abstract form of Li-ESWT used for the treatment of ED from January 2010 through March 2016. Randomized controlled trials were eligible for inclusion if they were published in the peer-reviewed literature and assessed erectile function outcomes using the IIEF-EF score. Estimates were pooled using random-effects meta-analysis. MAIN OUTCOME MEASURES Change in IIEF-EF score after treatment with Li-ESWT in patients treated with active treatment vs sham Li-ESWT probes. RESULTS Data were extracted from seven trials involving 602 participants. The average age was 60.7 years and the average follow-up was 19.8 weeks. There was a statistically significant improvement in pooled change in IIEF-EF score from baseline to follow-up in men undergoing Li-ESWT vs those undergoing sham therapy (6.40 points; 95% CI = 1.78-11.02; I2 = 98.7%; P < .0001 vs 1.65 points; 95% CI = 0.92-2.39; I2 = 64.6%; P < .0001; between-group difference, P = .047). Significant between-group differences were found for total treatment shocks received by patients (P < .0001). CONCLUSION In this meta-analysis of seven randomized controlled trials, treatment of ED with Li-ESWT resulted in a significant increase in IIEF-EF scores.
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Affiliation(s)
- Raul I Clavijo
- Department of Urology, University of California, Los Angeles, CA, USA
| | | | | | - Ranjith Ramasamy
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA.
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Behr-Roussel D, Giuliano F. Low-energy shock wave therapy ameliorates erectile dysfunction in a pelvic neurovascular injuries rat model. Transl Androl Urol 2016; 5:977-979. [PMID: 28078237 PMCID: PMC5182213 DOI: 10.21037/tau.2016.11.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Delphine Behr-Roussel
- Pelvipharm Laboratories, Montigny-le-Bretonneux, France;; UMR1179, University Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France
| | - François Giuliano
- UMR1179, University Versailles Saint Quentin en Yvelines, Montigny-le-Bretonneux, France;; Neuro-Uro-Andrology, Dept. of Physical Medicine and Rehabilitation, Raymond Poincaré Hospital, AP-HP, Garches, France
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Lu Z, Lin G, Reed-Maldonado A, Wang C, Lee YC, Lue TF. Low-intensity Extracorporeal Shock Wave Treatment Improves Erectile Function: A Systematic Review and Meta-analysis. Eur Urol 2016; 71:223-233. [PMID: 27321373 DOI: 10.1016/j.eururo.2016.05.050] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/31/2016] [Indexed: 01/22/2023]
Abstract
CONTEXT As a novel therapeutic method for erectile dysfunction (ED), low-intensity extracorporeal shock wave treatment (LI-ESWT) has been applied recently in the clinical setting. We feel that a summary of the current literature and a systematic review to evaluate the therapeutic efficacy of LI-ESWT for ED would be helpful for physicians who are interested in using this modality to treat patients with ED. OBJECTIVE A systematic review of the evidence regarding LI-ESWT for patients with ED was undertaken with a meta-analysis to identify the efficacy of the treatment modality. EVIDENCE ACQUISITION A comprehensive search of the PubMed and Embase databases to November 2015 was performed. Studies reporting on patients with ED treated with LI-ESWT were included. The International Index of Erectile Function (IIEF) and the Erection Hardness Score (EHS) were the most commonly used tools to evaluate the therapeutic efficacy of LI-ESWT. EVIDENCE SYNTHESIS There were 14 studies including 833 patients from 2005 to 2015. Seven studies were randomized controlled trials (RCTs); however, in these studies, the setup parameters of LI-ESWT and the protocols of treatment were variable. The meta-analysis revealed that LI-ESWT could significantly improve IIEF (mean difference: 2.00; 95% confidence interval [CI], 0.99-3.00; p<0.0001) and EHS (risk difference: 0.16; 95% CI, 0.04-0.29; p=0.01). Therapeutic efficacy could last at least 3 mo. The patients with mild-moderate ED had better therapeutic efficacy after treatment than patients with more severe ED or comorbidities. Energy flux density, number of shock waves per treatment, and duration of LI-ESWT treatment were closely related to clinical outcome, especially regarding IIEF improvement. CONCLUSIONS The number of studies of LI-ESWT for ED have increased dramatically in recent years. Most of these studies presented encouraging results, regardless of variation in LI-ESWT setup parameters or treatment protocols. These studies suggest that LI-ESWT could significantly improve the IIEF and EHS of ED patients. The publication of robust evidence from additional RCTs and longer-term follow-up would provide more confidence regarding use of LI-ESWT for ED patients. PATIENT SUMMARY We reviewed 14 studies of men who received low-intensity extracorporeal shock wave treatment (LI-ESWT) for erectile dysfunction (ED). There was evidence that these men experienced improvements in their ED following LI-ESWT.
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Affiliation(s)
- Zhihua Lu
- Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA; Department of Urology, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Guiting Lin
- Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA
| | - Amanda Reed-Maldonado
- Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA
| | - Chunxi Wang
- Department of Urology, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Yung-Chin Lee
- Department of Urology, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tom F Lue
- Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA.
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Kitrey ND, Gruenwald I, Appel B, Shechter A, Massarwa O, Vardi Y. Penile Low Intensity Shock Wave Treatment is Able to Shift PDE5i Nonresponders to Responders: A Double-Blind, Sham Controlled Study. J Urol 2015; 195:1550-1555. [PMID: 26694904 DOI: 10.1016/j.juro.2015.12.049] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 12/22/2022]
Abstract
PURPOSE We performed sham controlled evaluation of penile low intensity shock wave treatment effect in patients unable to achieve sexual intercourse using PDE5i (phosphodiesterase type 5 inhibitor). MATERIALS AND METHODS This prospective, randomized, double-blind, sham controlled study was done in patients with vasculogenic erectile dysfunction who stopped using PDE5i due to no efficacy. All patients had an erection hardness score of 2 or less with PDE5i. A total of 58 patients were randomized, including 37 treated with low intensity shock waves (12 sessions of 1,500 pulses of 0.09 mJ/mm(2) at 120 shock waves per minute) and 18 treated with a sham probe. In the sham group 16 patients underwent low intensity shock wave treatment 1 month after sham treatment. All patients were evaluated at baseline and 1 month after the end of treatment using validated erectile dysfunction questionnaires and the flow mediated dilatation technique for penile endothelial function. Erectile function was evaluated while patients were receiving PDE5i. RESULTS In the low intensity shock wave treatment group and the sham group 54.1% and 0% of patients, respectively, achieved erection hard enough for vaginal penetration, that is an EHS (Erection Hardness Score) of 3 (p <0.0001). According to changes in the IIEF-EF (International Index of Erectile Function-Erectile Function) score treatment was effective in 40.5% of men who received low intensity shock wave treatment but in none in the sham group (p = 0.001). Of patients treated with shock waves after sham treatment 56.3% achieved erection hard enough for penetration (p <0.005). CONCLUSIONS Low intensity shock wave treatment is effective even in patients with severe erectile dysfunction who are PDE5i nonresponders. After treatment about half of them were able to achieve erection hard enough for penetration with PDE5i. Longer followup is needed to establish the place of low intensity shock wave treatment in these challenging cases.
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Affiliation(s)
- Noam D Kitrey
- Urology Department, Sheba Medical Center, Tel-Hashomer, Israel.
| | - Ilan Gruenwald
- Neurourology Unit, Rambam Healthcare Campus, Haifa, Israel
| | - Boaz Appel
- Neurourology Unit, Rambam Healthcare Campus, Haifa, Israel
| | - Arik Shechter
- Department of Family Medicine, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Clalit Health Services, Haifa, Israel
| | - Omar Massarwa
- Neurourology Unit, Rambam Healthcare Campus, Haifa, Israel
| | - Yoram Vardi
- Urology Department, Sheba Medical Center, Tel-Hashomer, Israel
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