Erectile dysfunction (ED, impotence, impotence, erectile dysfunction, erectile dysfunction) is a common urological problem. Although the causes and treatment modalities of ED in young and older men differ, the treatment principles are generally similar. ESWT has been used since 2005 in the treatment of erectile dysfunction. We have been using this treatment method successfully for a long time for our patients with erectile dysfunction. In this article, I will give general information about the Li-ESWT application used in the treatment of ED, taking into account our own experiences.

The frequency of erectile dysfunction in the world and in our country

Erectile dysfunction (ED) is the inability to achieve or maintain an erection (hardness) sufficient for satisfactory sexual intercourse. The incidence rate varies according to countries, lifestyle, systemic diseases or not.

• It is estimated that there are approximately 150 million patients with erectile dysfunction worldwide.
• The number of patients in the USA is over 18 million
• 70% of them are due to vascular disease and diabetes
• The rate of ED in Turkey is around 65%
• There are 300 thousand patients between the ages of 20-29, 1 million 400 thousand patients between the ages of 40-49, and 1 million patients between the ages of 50-59 years old.
• 50% of them are moderate, 33% are mild.
• ED is 4 times more common in heart patients, high blood pressure and diabetes patients.
• 44% of patients with myocardial infarction have ED
• 17% of untreated hypertension patients and 25% of those with ED have ED

What is penile ESWT?

ESWL (Extracorporeal Shock Wave Lithotripsy) was first used in the 1980s to break up kidney stones by giving ultrasonic shock waves from outside the body. In the following years, this technology was developed and started to be used in the treatment of other diseases.

In the last 10 years, similar shock waves have been used in the treatment of patients with erectile dysfunction (erectile dysfunction, ED). The treatment used for this purpose is ESWT (Extracorporeal Shock Wave Therapy), that is, a treatment method by giving shock waves from outside the body. Low-intensity ESWT (Li-ESWT, Low-intensity ESWT, Low-Intensity Extracorporeal Shock Wave Therapy) is applied to the penis of patients with erectile dysfunction, that is, erectile dysfunction.

Shock Waves have been applied in many centers around the world since 2005 for the treatment of ischemic tissues in the heart, resulting in neovascularization (new vessel formation) and new collateral vessel formation. Thanks to the formation of new vessels, blood flow to the tissue is accelerated. Based on a similar logic, Li-ESWT has been used in the treatment of patients with vascular erection problems since 2010.

What are the features of Li-ESWT used in the treatment of ED?

Li-ESWT, which we use in the treatment of ED, has some features. Some of the physical characteristics of the low-intensity shock wave, which contributes positively to the recovery of the erection, are as follows;

• It is the effect of acoustic energy that spreads supersonic rapidly in liquid or gaseous environments.
• A very short and rapid rise in positive peak pressure is typical characteristic.
• Speed ​​(in water) =1500m/sec

How does Li-ESWT work?

ESWT increases the blood supply of the tissues and ensures tissue regeneration without causing serious damage to the tissues to which it is applied. We can summarize these effects as follows:

• Neo-angiogenesis (new vessel formation)
• Improvement of penile blood flow
• Tissue repair
• Stem cell transfer to tissues
• Reduction of pain and inflammation

What are the complications or side effects of ESWT treatment?

ESWT has no known serious complications or side effects. Some of the negative effects that can be considered very insignificant are:

• There may be little pain during the application.
• There may be a slight stinging or itching sensation in the application area during the treatment.
• After the procedure, slight redness may be seen on the skin.

Scientifically proven effects of ESWT

ESWT is a scientifically accepted method in the treatment of ED

There are numerous experimental and clinical studies demonstrating its effectiveness.

• Has a success rate of over 75%
• Creates a long lasting effect
• It is the “gold standard” in shock wave therapy in the treatment guideline of the European Urology Association.
• How is ESWT applied to the penis in the treatment of erectile dysfunction?
• It has been reported that patients who do not respond to their PDE5i respond positively to ED1000 treatment.
• ESWT treatment has been shown to increase blood flow at 6-month follow-ups.
• Improvement in penile blood flow and improvement in IIEF scoring were observed in Doppler USG.
• Li-ESWT was effective in diabetic patients who did not respond to PDE5i
• A positive response was obtained after Li-ESWT in patients with erectile dysfunction who did not respond to their PDE5i.

Role of Li-ESWT therapy in ED treatment

In the treatment of erectile dysfunction, it is necessary to follow a path from simple to more advanced treatment options. ESWT application is among the first-line treatment options of ED treatment. If there is no response to these treatments, the last option is penile prosthesis surgery. treatment options for ED;

• Oral medications (PDE5i: viagra, cialis, levitra)
• Hormone therapy
• Li-ESWT (ED1000)
• Vacuum pump application
• Injection therapy into the penis
• Penile prosthesis surgery

What diseases is ESWT used for in urology?

In urology, LI-ESWT is used in some other diseases besides erectile dysfunction. These:

• Erectile dysfunction treatment
• Peyronie’s disease
• Chronic pelvic pain syndrome
• Penile rejuvenation (penis rejuvenation)

Why is penile Li-ESWT used?

There are scientific and realistic reasons why we prefer ESWT in the treatment of ED. These;

• It is a treatment method that is easily performed in the office environment without the need for anesthesia and operating room conditions for patients with erection problems.
• It is effective by increasing the blood flow in cases where the penile flow is disturbed.
• It has been recommended to be used as a non-invasive first-line treatment method since 2018 among the erectile dysfunction treatment options published by the European Association of Urology.

Li-ESWT is used in the following areas besides urological diseases

It is used by Orthopedics and Physical Therapy departments in diseases such as heel spur, tennis elbow, shoulder calcification. It is also used to stimulate new vessel formation (angiogenesis) in patients with ischemic heart disease. It is also used by dermatologists for cellulite and skin tightening.

Who is ESWT applied to?

Before starting ESWT treatment, patients with erectile dysfunction undergo a general urological evaluation and appropriate patients are included in the treatment program. Before starting ESWT treatment, the following should be considered;

• Patients with mild, moderate or severe erection problems
• There is no age limit for the procedure.
• The number of sessions can be increased according to the severity of the disease.
• If the patient has diabetes, high blood pressure or hormonal disorders, these should also be treated at the same time.
• Lifestyle changes: Exercise, weight loss, alcohol and smoking habits, if any, should be given to the patients.
• ESWT application is generally not recommended for performance purposes but without complaints of erectile dysfunction.

Situations in which ESWT should not be done

ESWT is generally a treatment method without serious risks and complications. Some patients need to be cautious or not used.

• If there is a bleeding disorder
• If there is penile cancer, it should not be applied to the cancerous area.
• Presence of large vessels and nerves in the area to be applied,
• Bone growth areas (epiphysis, spinal cord),
• Pacemaker area
• To the infection site
• It should not be used in pregnant women.
• Patients with a penile prosthesis

How to apply ESWT to the penis?

The area in which ESWT is widely used in urology is the application of ESWT to the penis in patients with erectile dysfunction (ED), that is, erectile dysfunction.

While the patient is in the supine position, it is applied to both sides of the penis and in the groin area, to the radix (root) part of the penis with a device similar to an ultrasound probe. A special gel is applied to the applied areas to facilitate the passage of ESWT waves into the penile tissue.

The original application was ESWT twice a week for 3 weeks, then repeated after a 3-week break. The most common use is 2 times a week and a total of 6 sessions or 8 sessions. At the end of the application, an improvement in the international erection questioning score (IIEF-5) and an increase in arterial blood flow were achieved. The efficacy of ESWT was confirmed in subsequent controlled studies. In some studies, it has been reported that positive results continue for up to 1 year with LiESWT treatment, unlike other optional ED treatments.

Is any preparation required before treatment?

No prior preparation is required for ESWT treatment. It is possible to apply when the patient is hungry or full. It can also be applied at any time of the day.

When to start daily life?

Immediately after the application, patients continue their daily activities and work. Since the procedure is not painful, there is no need for rest.

How long is the treatment period?

The treatment takes 6 or 8 sessions in total. Approximately 1500 beats are applied in each session and it takes an average of 10-15 minutes. Ideally, the interval between two sessions should not be less than 5 days or more than 10 days. Depending on the severity of the disease, a total of 12 sessions can be performed. It is necessary to wait 3-4 weeks after the last session for the expected positive effects of ESWT to occur.

Can ESWT treatment be used in combination with other treatments?

It can be combined with other treatment options to achieve greater effects with ESWT. In studies, ESWT treatment was found to be more effective when applied with combined methods. These combinations are:

• Drugs used in the treatment of ED (Phosphodiesterase 5 inhibitor, PDE5i)
• PRP treatment
• Stem cell therapy
• Injection therapy into the penis
• Vacuum pump application to the penis

What is the success rate of ESWT treatment?

The success rate varies from patient to patient, the severity of the disease, the age and lifestyle of the patient. The average success rate varies between 60-80%. The patient group in which ESWT treatment is most effective are as follows;

• Young patients
• Normal weight patients
• Those who do sports regularly
• Those without cardiovascular disease
• Patients without diabetes
• Those who do not have high blood pressure
• Those who do not have alcohol, smoking habits

Is ESWT treatment also effective in diabetes-related erection problem?

Scientific studies have shown that ESWT is also effective in the treatment of erection problems due to diabetes (diabetes). What is important in these patients is the duration of the disease and how well the blood sugar is controlled. The effect is greater in patients who are not long-term and whose sugar is under control, who pay attention to a regular diet and who exercise regularly.

Other factors affecting the effectiveness of ESWT in diabetics are alcohol and cigarette use, stress and weight problems. We recommend patients to whom we apply ESWT to quit alcohol and smoking, reach their ideal weight and lead a stress-free life.

Does ESWT treatment show the same effect in every patient?

No, ESWT does not show the same effect in every patient. Elderly patients are less successful than younger patients. The success rate is lower in those who have another underlying disease than those who do not. The patient groups for which ESWT is less effective are;

• Hypertension patients
• Obese (overweight patients)
• Diabetics
• Those with a sedentary life
• Advanced age patients
• People who use excessive alcohol and cigarettes
• Those with testosterone deficiency
• People under extreme stress

Our recommendations to patients receiving ESWT treatment

ESWT treatment is effective, but if there are known conditions that cause erectile dysfunction, they should be considered and treated. If the patient is overweight, he should lose it, if he smokes, he should quit, if his cholesterol level is high, he should be treated, if he has high blood pressure and diabetes, he should be controlled. If the patient has a sedentary life, he should be advised to move.

Li-ESWT treatment is a near-ideal treatment method.

An “ideal” treatment should have the following characteristics. ESWT treatment is not yet an ideal treatment method in the treatment of erectile dysfunction, but it has a high success rate and almost no side effects in selected patients.

• It should be simple
• Non-invasive
• It should be painless
• Must have a high success rate
• Easy to apply
• Should have little or no side effects

What are the advantages of ESWT application?

ESWT has many advantages in the treatment of ED. These advantages are:

• It does not require any maintenance before or after the procedure,
• ESWT is not a surgical method, so it does not require anesthesia, incisions and stitches.
• Patients do not feel pain during or after the procedure.
• The process is completed in a short time like 15-20 minutes.
• It is possible to return to daily life on the same day after ESWT.
• Success rate and patient satisfaction are high in appropriately selected patients.
• It is a method without complications and side effects.

In conclusion: Penis Li-ESWT (low intensity shock wave therapy) is one of the available options in the treatment of erectile dysfunction. Its effectiveness and mechanism of action have been demonstrated in scientific studies and it has been presented as an option by important Urology institutions. The treatment must be done by a urologist, preferably by a related urologist. It is not right to expect a miracle from this treatment and to direct patients in this way. It is a treatment method that is recommended to be applied before prosthesis treatment in suitable patients, where positive results can be obtained with appropriate treatment with almost no side effects.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul – TURKEY