Long-term effectiveness and predictors of success of low-intensity shockwave therapy in phosphodiesterase type 5 inhibitors non-responders

Conservative Non-surgical Options for Erectile Dysfunction

PURPOSE OF REVIEW

This study aimed to review recent evidence on conservative non-surgical options for erectile dysfunction (ED) in men. A narrative review of the literature was performed. A comprehensive search in the MEDLINE, Embase, and Cochrane databases was done. Papers in English language, published from May 2017 until May 2022, were included. Papers reporting basic research or animal research were excluded, as long as reviews or meta-analyses. Congress reports, clinical cases, or clinical trials protocols with no results were also excluded.

RECENT FINDINGS

We found a multitude of different treatment modalities for ED. We must take into account the type of patient, their comorbidities, the origin of their ED, and its severity in order to reproduce effective results using these therapies. Some of the treatments show good results with a good level of evidence (new IPDE5 formulations, intracavernous injections, shock wave therapy, hormonal theraphy, psycho-sexual theraphy). However, others (some new molecules, stem cell theraphy, platelet-rich plasma injections, oxygenation-based therapy, nutraceuticals), although some of them present promising results, require randomized studies with a larger number of patients and a longer follow-up time to be able to establish firm recommendations. Regarding the conservative treatment of erectile dysfunction, in recent years, some therapies have been consolidated as effective and safe for certain types of patients. On the other hand, other treatment modalities, although promising, still lack the evidence and the necessary follow-up to be recommended in daily practice.

Diagnosis of hypogonadism in patients treated with low energy shock wave therapy for erectile dysfunction: a narrative review

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.

Low-Intensity Shockwave Therapy in the Treatment of Erectile Dysfunction

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.