Li-ESWT (low intensity shock wave therapy) has been used for more than 10 years in the treatment of patients with erectile dysfunction. It is a non-invasive treatment method. It has been reported that 60-80% successful results are obtained when applied to appropriate patients. It is more effective in patients with mild to moderate erectile dysfunction (ED, erectile dysfunction, erectile dysfunction).

We have been applying ESWT treatment to our eligible patients for a long time. In this article, I will try to answer frequently asked questions (FAQs) about the use of ESWT in the treatment of erectile dysfunction in the light of the literature and my own experience.

ED treatment with Li-ESWT: Frequently asked questions (FAQs) and answers

What does erection problem mean?

Erectile dysfunction (ED, erectile dysfunction, erectile dysfunction, impotence) means that an erection is not enough for a normal relationship or an erection cannot be maintained during sexual intercourse. Erectile functions decline with age. Erectile dysfunction is common in some systemic diseases such as diabetes, obesity, high cholesterol, high blood pressure (hypertension).

What does ESWT/Li-ESWT mean?

Li-ESWT (Low intensity shock wave therapy, low intensity shock wave therapy) is the process of applying low intensity shock waves with a special cap to different parts of the penis in patients with erection problems. There are special devices developed for this purpose.

Is ESWT a scientific treatment method?

ESWT treatment is a scientific treatment method. There are many laboratory and clinical studies published in international journals on this subject. It is a method that has been included in the treatment protocols by the European and American Urology Associations (EAU, AUA). Appropriate patient selection is important for success.

How is ESWT applied?

While the patient is in the supine position, low-intensity shock waves are given to the root and body parts of the penis with a special cap. It is applied to the root part of both penis and the body part of the penis in the form of 300 shots on an average of 5 sages. The frequency of application is different. It is usually applied once or twice a week.

Is it possible to administer ESWT at home/self?

Recently, small, mobile forms of the ESWT device that can be used at home have also been developed. However, this process is a medical application and it gives healthier results if it is done by a doctor.

In which situations/to whom is ESWT not performed?

ESWT is not a safe and has severe application limitations. An experimental genital examination should be performed in patients who will undergo this procedure and should not be performed if there are any obstacles. ESWT should not be performed if:
• If there is an open wound in the application area (penis, genital area)
• If there is a penile prosthesis

What are the complications of ESWT?

Every procedure has some complications, albeit minor ones. ESWT is a treatment method with minimal side effects and complications. For this reason, it is known as “non-invasive” treatment methods in the treatment of erectile dysfunction. Very rare problems in patients undergoing ESWT include:
• Very mild pain, tingling sensation
• Bruising, redness on the skin

Is ESWT treatment painful?

ESWT treatment is not a painful procedure. Patients do not feel pain during the application. No anesthesia is required for the application. Local anesthesia is not required for patients. There is no need to give pain medication. In short, ESWT is a painless procedure.

How many sessions of ESWT are applied?

There are different protocols for ESWT implementation. It is usually applied twice a week. At least 6 sessions are applied. It can be done up to 12 sessions. Each session takes about 10-15 minutes on average.

Who should do ESWT treatment?

Patients who will undergo ESWT should be evaluated by a specialist Urologist. It can be applied to every patient with erectile dysfunction, but not every patient gets results. In this regard, the correct indication is very important. ESWT treatment is most effective in the patient group with mild to moderate erection problems. It is not or extremely effective in those with severe erectile dysfunction.

Is examination and examination necessary before ESWT treatment?

ESWT treatment is an erectile dysfunction treatment. In this respect, these patients should be asked to examine the cause of erectile dysfunction, and if there are problems, treatments should be applied to them. For this reason, it is best for this group of patients to be evaluated by a urologist and the procedure to be performed by a urologist.

What should be done to increase the effectiveness of ESWT?

ESWT treatment is not an effective, miraculous treatment method alone in erection problem. It is effective in those with mild to moderate erection problems. It is a form of supportive therapy. In order for these patients to gain more benefit from ESWT, the following should be considered:
• A healthy, balanced diet
• A life free from stress
• A regular exercise program, an active life
• If alcohol and smoking are used, quitting
• Obese patients reach their ideal weight.
• If cholesterol is high, it should return to normal
• Those with blood pressure problems must be treated
• If the testosterone hormone is low (hypogonadism) it should be treated

What is the ESWT effectiveness/success rate?

The effectiveness of shock wave therapy is not the same for every patient. Its effectiveness may differ from patient to patient. No effect can be achieved if the correct indication is not set. In the literature, when ESWT is applied to eligible patients, the average success rate is 70-80%.

How does ESWT work?

There are experimental studies showing how ESWT treatment works at the molecular level. ESWT treatment is effective by making the following changes in the penis:
Increases neovascularization (new vessel formation in the penis occurs)
Differentiation and proliferation take place in endothelial cells
Increases nitric oxide production (NO) in the penis. (NO: an important molecule involved in erection).
• Reduces free radical formation (oxidative stress)
• Provides tissue regeneration
• Stem cell activation
• Prevents fibrosis
• Reduces inflammation
• Increases the secretion of penile vascular endothelial growth factor (VEGF)
• Prevents apoptosis
• Provides axonal regeneration (prevents and heals nerve damage)

When does ESWT treatment show its effect?

The onset of the effect of ESWT therapy is not the same for every patient. The maximum effect varies from patient to patient. The patient’s age, lifestyle, being obese or fit, blood pressure status and the degree of erectile dysfunction are very important in this regard. Usually the effect starts in a few weeks. However, it may take several months to achieve maximum benefit.

Is the ESWT effect permanent?

One of the misconceptions about this issue is that ESWT treatment is a “permanent treatment”. This is wrong. The effectiveness of any treatment is not permanent. This treatment method is effective in suitable patients. This efficacy can be increased with combined treatments and lifestyle changes. ESWT therapy needs to be repeated over time.

Does ESWT affect penis size?

Shock wave therapy is not a treatment method to increase penis size. In scientific studies, it has been reported that with the application of ESWT, there are regeneration and changes in the internal structure of the penis, the formation of new vessels increases, and as a result, the penile thickness increases. These changes are macroscopically visible in the penis diameter and do not constitute a serious change. In this respect, it is not correct to think of ESWT treatment as “penis enlargement surgery” or treatment. If patients have problems with penis size, more special surgical procedures should be performed for this.

Is ESWT applied to those who have penis enlargement/enlargement surgery?

There is no study in the literature on this subject. In penis lengthening surgeries, the suspensory ligament of the penis is partially cut and the fat in the pubic region is removed when necessary. Since there is no procedure related to the penis body, there is no obstacle to the application of ESWT in penile lengthening surgeries when necessary. Since oil is added to the body of the penis in the penis enlargement process, ESWT application may disrupt the integrity of the oils. For this reason, if ESWT will be applied to people who have undergone penile thickening surgery, this should be considered.

Can ESWT be repeated in later periods?

ESWT can be repeated in later periods. In some studies, it has been reported that the efficacy can last 2-3 years. This treatment is not a life-long application. The doctor may repeat the sessions in the following periods, depending on the patient’s condition. There is no exact time for this. Since ESWT application has no negative effects, sessions can be repeated for certain periods.

Testosterone deficiency and ESWT treatment

There are no studies on the efficacy of ESWT in the treatment of erectile dysfunction in patients with testosterone deficiency (hypogonadism). Testosterone is a hormone that has important effects on erection and libido. Therefore, in patients with erectile dysfunction who will be treated with ESWT, the testosterone level should be checked beforehand, and if it is missing, treatment should be performed. We see the testosterone level of our patients before ESWT and treat them if they are missing.

Use of ESWT in diabetics

There are many studies in the literature on the use of ESWT therapy in the treatment of erectile dysfunction due to diabetes. ESWT has been reported to be effective in diabetic patients in these studies. This effect was also seen in those who did not respond to PDE5i group drugs. However, penile prosthesis implantation is the most effective treatment in patients with long-term and poorly controlled and severe arterial insufficiency.

High blood pressure and use of ESWT

High blood pressure (hepertension) is one of the important diseases that cause erection problems. There are experimental and clinical studies that ESWT therapy is effective in the treatment of erectile dysfunction in patients with hypertension. ESWT is an effective and safe treatment method in the treatment of mild to moderate erectile dysfunction due to hypertension. We also apply ESWT to these patients. Control of hypertension is also very important.

Use of ESWT in obese patients

Obesity is one of the diseases that cause erection problems. In obesity, erectile dysfunction develops in the penis due to the following conditions in obese patients:
Atrophy (regression) of penile smooth muscles
• Damage to penile capillaries (endothelial cell)
• Fat cell accumulation in the penis
• Free radical (oxidative stress) increase
• Defect in NO production
It has been reported that ESWT treatment gives positive results in the treatment of erectile dysfunction in obese patients in both human and laboratory studies. We also achieved successful results with ESWT treatment in obese patients who do not have serious erection problems. The main problem, of course, is the treatment of obesity. We inform our patients about this.

Use of ESWT in polycystic kidney patients

Polycystic kidney disease is a familial disease that causes hypertension. Erectile dysfunction is seen in these patients due to high blood pressure. There is no study in the literature on the use of ESWT in polycystic patients. We have positive results as a result of ESWT treatment in this group of patients.

Smoking and alcohol use and ESWT

Smoking is one of the important factors that cause erectile dysfunction. ESWT was found to be an effective treatment in a study involving 425 patients, including patients with smoking-related ED. We have seen that ESWT is effective in our patients, especially in the young age group. These patients should also be advised to quit smoking.

Can ESWT and PDE5i group drugs be used at the same time?

PDE5i group drugs are widely used in the treatment of ED. It is known that some patients do not respond to these drugs. There are studies showing that those who do not respond to PDE5i group drugs with ESWT treatment also improve. Likewise, it has been shown that the combination of PDE5i group drugs and ESWT is more effective. We also apply this combination therapy to our patients and our results are more positive.

Is penile injection given to ESWT patients?

Penile injection is one of the treatment methods we perform in patients with ED problems. There is no harm in administering penile injection therapy to patients undergoing ESWT at the same time. It is better not to do it at the same time. In this way, hematoma formation is prevented.

Is supplementation/vitamin therapy with ESWT effective?

Vitamins have an important role in the mechanism of erection. Especially vitamins such as B12, vitamin D, vitamin K2 are important for erection. Vitamins are used for supplementation. There is no harm in taking vitamins together in patients treated with ESWT. On the contrary, it can be even more effective.

Is ESWT effective if there is no response to PDE5i group drugs?

There is information in the literature that patients with erectile dysfunction who do not respond well to PDE5i group drugs are successfully treated with ESWT. We recommend ESWT treatment to patients who do not benefit from these oral medications. In these patients, the cause of unresponsiveness to PDE5i group drugs should be investigated and this condition should be treated.

Can the vacuum device be used together with the ESWT?

Vacuum application is one of the treatment methods we use in erection treatment. EWST application has no negative effect on vacuum therapy. It has been reported in the literature that patients who do not respond to PDE5i group drugs respond better to ESWT and vacuum application together.

Can PRP and ESWT be used at the same time?

PRP (platelet rich plasma) is also tried in the treatment of erectile dysfunction, as in many areas. It is still in the experimental stage. ESWT and PRP treatment can be given at the same time. There are no contraindications.

Can stem cell therapy and ESWT be used together?

There are many studies on stem cell application in the treatment of patients with erectile dysfunction. Results from human studies are encouraging. It has been reported that the efficacy of stem cell therapy will be greater when stem cells are given to the penis with ESWT.

Does penile damage due to diabetes improve with ESWT?

Diabetes (DM, diabetes mellitus) is one of the important causes of erectile dysfunction. SEWT treatment is recommended in the literature in patients with diabetes and ED problems. We also give the same treatment to this group of patients. Outcomes are better in mild to moderate cases that are appropriate and do not develop serious complications related to diabetes.

Is ESWT effective in the treatment of venous insufficiency?

ESWT may not be effective in cases of severe venous insufficiency. There are no scientific studies on this subject. We observed improvement with the combination of ESWT and PDE5i in our own patients with mild to moderate ED complaints. There is information in the literature that the results are better in patients who underwent ESWT after deep vein ligation.

If there is ED due to Peyronie’s disease, is ESWT effective?

Peyronie’s disease is a disease characterized by fibrotic plaque formation in the tunica albuginea and bending of the penis during erection. Depending on the prevalence of these plaques, patients may experience erection problems in the future. ESWT therapy is effective in the treatment of ED associated with this disease.

Is ESWT used in patients with priapism?

Priapism is a prolonged and painful involuntary erection of the penis. If an effective treatment is not done in time, it results in permanent damage to the penis and ED. It’s an emergency. Its treatment is to terminate the erection with an emergency surgical procedure. It has been reported that there are serious improvements in erection in patients with priapism who underwent ESWT 4 weeks after surgery. ESWT probably does this by preventing tissue damage due to ischemia. In this regard, we recommend late ESWT treatment in suitable cases for priapism patients.

Is ESWT effective in elderly patients?

There is not much information in the literature about the use of ESWT in elderly men. In our experience, ESWT is an effective treatment for people who are appropriately selected and do not have serious systemic problems. However, in the elderly, the activity starts later and is less.

Does the use of ESWT have a place in penile rehabilitation?

In patients who have undergone radical surgery for prostate cancer, bladder cancer and rectum cancer, the nerve and vascular structures responsible for erection may be damaged and eventually erection problems are seen. The aim of penile rehabilitation is to prevent loss of penile function due to damage during these procedures. There are different methods for this purpose. One of them is the ESWT method. We do it especially after nerve-sparing radical prostatectomy operations. In recent publications, it has been reported that better results are obtained with ESWT applications applied 2 weeks before the surgery.

Is the use of ESWT effective after radical prostatectomy surgery?

Erectile dysfunction is seen in men after nerve-sparing radical prostate surgery (open, laparoscopic, robotic). In these patients, various treatment methods are applied to ensure the continuation of post-operative erection. One of them is ESWT application to the penis. There are clinical and animal studies showing that ESWT is used in these patients and has positive results. We also give this treatment to our patients for penile rehabilitation. The results are related to many factors such as the age of the patients, preoperative erection status, presence of other diseases, unilateral or bilateral preservation of the nerve. If combined treatments are performed with ESWT, the results are better.

Is ESWT effective before radical prostatectomy?

ESWT is usually performed after surgery for penile rehabilitation in radical prostatectomy patients. In recent studies, it has been reported that the results are more successful in patients who started ESWT 2 weeks before radical prostatectomy and continued after surgery. We also recommend this treatment to our patients.

Is ESWT effective in radical cystectomy patients?

In patients with bladder cancer, nerve-sparing radical cystectomy is performed in appropriate cases. Erectile dysfunction may develop in these patients after surgery. It has been reported that there was a 16% improvement in erection with penile ESWT applied to these patients postoperatively. We also provide ESWT treatment to our eligible patients.

Does ESWT treatment affect sperms and testicles?

ESWT is applied directly to the penis. Since it is not applied to the testicles, it does not have any positive or negative effect on sperm.

Is ESWT treatment effective on premature ejaculation?

There is no scientific study in the medical literature on the effectiveness of ESWT treatment on premature ejaculation. ESWT application is not a treatment method directly related to ejaculation.

Is ESWT effective in the treatment of erectile dysfunction due to metabolic syndrome?

Metabolic syndrome is not a disease on its own, but a phenomenon in which more than one clinical condition is present. Hypertension, obesity (increased waist circumference), high blood sugar, high triglyceride, low HDL cholesterol are the parameters used to diagnose metabolic syndrome. If at least 3 of these are present, this person has metabolic syndrome. Erectile dysfunction is associated with each of these parameters. The presence of even one of these negatively affects the erection. ESWT has been reported to be effective in studies on each of these parameters. Efficacy is related to the degree of erectile dysfunction.

Is ESWT effective in the treatment of psychological erectile dysfunction?

There is no consensus in the literature regarding the use of ESWT in patients with psychological erection problems. Well-planned studies are needed to be able to say anything about this. The most effective treatment in these patients is elimination of the cause.
I think that it can be useful in patients with appropriate psychological erection problems because it is a non-invasive treatment method.

Is ESWT effective in the treatment of ED in kidney failure, dialysis patients and kidney transplant patients?

Erectile dysfunction develops with different mechanisms in chronic renal failure, patients undergoing dialysis due to kidney failure and kidney transplant patients. Appropriate treatment should be given to the condition of these patients. There is no study in the literature on the use of ESWT in these diseases. ESWT can be performed in patients with appropriate mild and moderate ED complaints.

Is ESWT effective in patients with ED due to cardiovascular diseases?

Cardiovascular diseases adversely affect erectile functions. Cardiovascular diseases can be a harbinger of erectile dysfunction. Or patients with erectile function problems may have cardiovascular diseases. ESWT treatment is effective in appropriate cases in patients with erectile dysfunction due to cardiovascular system problems. The last option in patients with severe arterial insufficiency is to wear a penile prosthesis.

Is ESWT effective in the treatment of erectile dysfunction due to antidepressant drugs?

Antidepressants cause varying degrees of erectile dysfunction. There is no study in the literature on the effectiveness of ESWT in cases of erectile dysfunction due to antidepressant use. Some antidepressant drugs show their effects by reducing penile nitric oxide secretion. Since ESWT makes its effect by increasing penile NO, I think it may be effective in these patients as well. For definitive treatment, discontinuing this group of drugs or starting alternative drugs is the best approach.

Is penile ESWT used in patients taking anticoagulant drugs?

The effect of blood thinners was investigated in 2 clinical studies involving 138 patients who underwent penile ESWT for erectile dysfunction. As a result of the study, it was reported that no complications developed due to ESWT application in the penis in patients using blood thinners. We did not see any complications in our limited number of patients. In conclusion, we can say that penile ESWT application is safe in patients using diluents.

Does the effectiveness of ESWT change according to the brands used?

The ESWT brands used have different working principles according to their energy sources. These are mainly of electromagnetic, electrohydraulic and piezoelectric energy source. All of these devices have been used for ED, Peyronie and penile rehabilitation and effective results have been achieved. There may be changes in the doses and protocols used.

Prof. Dr. Emin ÖZBEK
Urology Specialist
Istanbul- TURKEY