Low-Intensity Shock Wave Therapy in Sexual Medicine-Clinical Recommendations from the European Society of Sexual Medicine (ESSM)

Variability in methodology of erectile dysfunction regenerative therapy trials on ClinicalTrials.gov

OBJECTIVES

To evaluate the variability in the criteria of erectile dysfunction (ED) regenerative therapy trials registered on ClinicalTrials.gov.

METHODS

Interventional trials on ClinicalTrials.gov with the keywords "erectile dysfunction" and variations of "shockwave," "platelet rich plasma," "stem cell," "regenerative," and "restorative" were examined. Inclusion/exclusion criteria and primary/secondary outcomes were compared between extracorporeal shockwave therapy (ESWT), platelet rich plasma and stem cell injections (PRP/SC), and other regenerative therapies (ORT) groups.

RESULTS

Of the 92 trials analyzed, International Index of Erectile Function (IIEF) score was the most common primary outcome (72%), with a higher prevalence in ESWT trials than PRP/SC or ORT trials (89% vs 44% and 58%, p<.001). Safety/tolerability was a primary outcome for 44% of PRP/SC trials and 25% of ORT trials but no ESWT trials (p<.001). ESWT trials more frequently had sexual/romantic relationship-based inclusion criteria and cancer treatment-related exclusion criteria than PRP/SC and ORT trials.

CONCLUSIONS

There is substantial variability in the inclusion/exclusion criteria and outcome measures among ED regenerative therapy trials. ESWT trials most frequently utilized IIEF and had the strictest inclusion/exclusion criteria, suggesting more rigorous and functional outcome-based studies. Conversely, PRP/SC and ORT trials, but not ESWT trials, had safety/tolerability as a primary outcome, likely due to the experimental nature of these therapies. The variability in inclusion/exclusion criteria and outcome measures limits comparison of the various ED regenerative therapies.

Novel emerging therapy for erectile dysfunction: efficacy and safety of flat magnetic stimulation

BACKGROUND

The erectile dysfunction (ED), which is the inability to achieve and/or sustain a penile erection sufficient to result in a satisfying sexual performance, represents a very common complaint. for men over forty years old. The aim of the study was to evaluate if Flat Magnetic Stimulation (FMS) technology could help individuals with symptomatic erectile dysfunction.

METHODS

Twenty patients with erectile dysfunction, underwent eight sessions of about 30 minutes each in a twice a week frequency with the study device. During treatments, every potential side effect was assessed. The International Index of Erectile Function (IIEF) was compiled by all patients at the beginning, after the eighth treatment and at 1 month from the end of the last treatment. The questionnaire scores were presented as median values along with the interquartile range (IQR) and we set the significance threshold at 0.01.

RESULTS

After the treatment and at 1-month follow-up, the increase in questionnaire scores was statistically significant compared to the baseline, thus supporting the clinical usefulness of this treatment. In particular, the result of the study indicates a statistically significant difference between IIEF score before treatment (Median = 34) and IIEF score after the end of treatment (Median = 45) and between IIEF score before treatment and IIEF score at 1-month follow-up (Median = 54).

CONCLUSIONS

The study findings showed that FMS represents a promising treatment option to individuals affected by symptomatic erectile dysfunction.

High prevalence of erectile dysfunction in men with hyperthyroidism: a meta-analysis

OBJECTIVE

The objective of this study was to evaluate the association between hyperthyroidism and the risk of developing erectile dysfunction (ED).

METHODS

A comprehensive search of multiple databases, including PubMed, Embase, Cochrane, and Web of Science, was conducted to identify relevant studies investigating the relationship between hyperthyroidism and ED in men. The quality of the included studies was assessed using the Newcastle‒Ottawa Quality Rating Scale, and a meta-analysis was performed using Stata 16.0 and RevMan 5.3 software.

RESULTS

A total of four papers encompassing 25,519 study subjects were included in the analysis. Among these, 6,429 individuals had hyperthyroidism, while 19,090 served as controls. The overall prevalence of ED in patients with hyperthyroidism was determined to be 31.1% (95% CI 0.06-0.56). In patients with uncomplicated hyperthyroidism, the incidence of ED was 21.9% (95% CI 0.05-0.38). The combined odds ratio (OR) for the four studies was 1.73 (OR: 1.73; 95% CI [1.46-2.04]; p < .00001).

CONCLUSION

Our findings demonstrate a higher incidence of ED in patients with hyperthyroidism. These results provide valuable information for healthcare professionals and can facilitate discussions surrounding appropriate treatment options for ED in patients with hyperthyroidism.

Variations in Low Intensity Shockwave Treatment Protocols for Erectile Dysfunction: A Review of the Literature and Guide to Offering Treatment

Low-intensity shockwave therapy (LiSWT) for erectile dysfunction (ED) continues to gain popularity in both clinical practice and the academic literature. The majority of trials and meta-analysis studies have shown LiSWT to be low risk with a trend toward positive improvements in International Index of Erectile Function (IIEF) scores. However, there is still debate over the clinical utility of LiSWT and there is no agreed upon optimal treatment protocol. In this review article we summarize published meta-analysis studies of LiSWT for ED, and review the treatment protocols from randomized sham-control trials published in the last 10 years. We found the most common device settings were an energy of 0.09 mJ/mm² and a frequency of 5 Hz. Shock number and location varied, but the most common protocol was 1,500 shocks per session, with 900 shocks to the penis (shaft, base, or hilum) and 600 shocks to the proximal corpora/crura. Protocols ranged from 4 to 12 treatment sessions. We also describe our institutional experience with LiSWT, including patient counseling and treatment protocol.

Impact of low-intensity extracorporeal shockwave therapy on vascular parameters and sexual function in patients with arteriogenic erectile dysfunction

ABSTRACT

Previous published studies have shown an improvement of penile hemodynamic parameters after low-intensity extracorporeal shockwave therapy (Li-ESWT). However, the clinical significance of these findings remains unclear, and definitive selection criteria for Li-ESWT based on preexisting comorbidities have yet to be established. This was an observational study of 113 patients with ED, evaluated between January 2019 and December 2021 in Andrology Unit at the Department of Urology and Renal Transplantation, University of Foggia (Foggia, Italy). Penile dynamic Doppler was performed to evaluate vascular parameters and 5-item version of the International Index of Erectile Dysfunction (IIEF-5) questionnaire was administered to assess the severity of ED. This was repeated 1 month after treatment. Patients with a peak systolic velocity (PSV) <30 cm s-1 were considered eligible for Li-ESWT. Our protocol consisted of 8 weekly sessions with 1500 strokes distributed in 5 different locations along the penis. After treatment, a significant mean (±standard deviation [s.d.]) PSV increase of 5.0 (±3.4) cm s-1 was recorded and 52/113 (46.0%) patients reached a PSV >30 cm s-1 at posttherapeutic penile dynamic Doppler. A clinically significant IIEF-5 score improvement was observed in 7 patients, 21 patients, and 2 patients with mild-to-moderate, moderate, and severe pretreatment ED, respectively. No different outcomes were assessed based on smoking habits, previous pelvic surgery, or use of oral phosphodiesterase-5 inhibitor (PDE5i). On the other side, only 1 (6.7%) in 15 patients with diabetes mellitus showed an IIEF-5 score improvement after Li-ESWT. Shockwave treatment determined a significant increase in PSV and correlated IIEF-5 improvement in ED patients. This advantage seemed particularly evident for moderate ED and was not affected by smoking habits, previous pelvic surgery, and use of PDE5i. Conversely, diabetic patients did not benefit from the treatment.

Assessment of the treatment effectiveness of men with mild and medium degree of erectile dysfunction

OBJECTIVE

. Aim: To assess the effectiveness of monotherapy and complex treatment of patients with erectile dysfunction depending on its severity.

PATIENTS AND METHODS

Materials and Methods: Men with moderate and mild erectile dysfunction took part in the study, who, in turn, were divided into groups, depending on the treatment, with the evaluation of the results of the International Index of Erectile Function (MIEF-15), the state of cavernous hemodynamics and the function of the vascular endothelium before and after treatment.

RESULTS

Results: In patients with an average degree of severity, who received complex treatment including a course of low-energy shock wave therapy, against the background of taking sildenafil and L-arginine, the best results were obtained in the quality of erection and increased cavernous blood flow, which positively affected satisfaction with sexual intercourse and overall satisfaction. It has also been proven that the function of the endothelium was improved in patients receiving L-arginine, due to which there was a probable decrease in endothelin-1. A probable improvement of erectile function was obtained in the group of patients with a mild degree who received L-arginine, and there was no statistical difference from the indicators in the group who received sildenafil, which was confirmed by the data of dopplerography.

CONCLUSION

Conclusions: Patients with an average degree of erectile dysfunction require comprehensive treatment. The use of L-arginine can be an alternative to phosphodiesterase type 5 inhibitors in the treatment of mild erectile dysfunction.

Reviving intimacy: Penile rehabilitation strategies for men after prostate cancer treatment

There have been considerable advances in the field of penile rehabilitation for upwards of 90% of men adversely affected by either short-term or long-term erectile dysfunction after definitive prostate cancer treatment. Despite the evolving landscape of treatment modalities for penile rehabilitation, there is a lack of consensus in the urologic community on the best therapies due to the level of evidence and efficacies of the current and emerging offerings. This review of current and next-generation interventions provides a practical approach to the myriad of data to make a better-informed decision based on the pathophysiology and highest-quality evidence available.

News and future perspectives of non-surgical treatments for erectile dysfunction

The significant discontinuation rate of available therapies and the paucity of curative options promoted the research on potential novel treatments suitable for erectile dysfunction patients. The aim of this study was to provide a summary of available evidence regarding the news and future perspectives related to the non-surgical treatment of erectile dysfunction. A narrative review of the literature was performed. A comprehensive search in the MEDLINE, Embase, and Scopus databases was done. Papers in English-language, published until April 2022, were included. No chronological restriction was applied. Retrospective and prospective clinical studies, as well as meta-analyses, were considered. Oro-dispersible formulations of phosphodiesterase type 5 inhibitors are particularly indicated in patients who have difficulty in swallowing solid dosage form; in addition, they constitute a discrete route of administration not requiring water. Low-intensity extracorporeal shock wave therapy is indicated in mild vasculogenic erectile dysfunction and in patients with vasculogenic erectile dysfunction poorly responsive to phosphodiesterase type 5 inhibitors. Stem cell therapy, platelet-rich plasma injections, and gene therapy seem promising regenerative treatments for selected patients with erectile dysfunction. Novel oral formulations of drugs commonly used in erectile dysfunction patients have recently become part of standard clinical practice. Regenerative treatments have been emerging in recent years and could become routine curative options in the near future. Further well-designed randomized controlled trials are needed to provide conclusive evidence on this topic and guide appropriate recommendations.

The atherosclerotic cardiovascular disease risk score is a reliable tool to identify patients with arteriogenic erectile dysfunction

BACKGROUND

The atherosclerotic cardiovascular disease risk score is a validated algorithm predicting an individual's 10-year risk of developing acute cardiovascular events (cardiovascular disease). Patients who suffer from arteriogenic erectile dysfunction are susceptible to developing cardiovascular disease in the future.

OBJECTIVES

To apply the atherosclerotic cardiovascular disease score at a homogenous cohort of men with erectile dysfunction undergoing a dynamic penile colour Doppler duplex ultrasound and explore its predictive ability to identify patients with vasculogenic erectile dysfunction at colour Doppler duplex ultrasound.

MATERIALS AND METHODS

Complete data of 219 patients undergoing colour Doppler duplex ultrasound were analysed. All patients completed the International Index of Erectile Function. The atherosclerotic cardiovascular disease score and Charlson comorbidity index were applied to the entire cohort. Patients were divided into those with normal vs. pathological parameters at colour Doppler duplex ultrasound. Descriptive statistics were used to explore differences between the two groups. Logistic regression models tested the potential role of atherosclerotic cardiovascular disease to predict arteriogenic and/or venogenic erectile dysfunction. Local polynomial smoothing models graphically displayed the probability of pathological colour Doppler duplex ultrasound parameters at different atherosclerotic cardiovascular disease scores.

RESULTS

Overall, arteriogenic erectile dysfunction and venous leakage were diagnosed in 88 (40.2%) and 28 (12.8%) patients respectively. The median (interquartile range) atherosclerotic cardiovascular disease score was 7.7 (3.9-14). Patients with pathologic colour Doppler duplex ultrasound were older (59 vs. 54 years, p < 0.001), had higher Body Mass Index (26.5 vs. 25.6 kg/m2 , p = 0.04), more comorbidities (Charlson comorbidity index ≥ 1) (76.5% vs. 54.4%, p = 0.002) and higher median atherosclerotic cardiovascular disease scores (9.95 vs. 7, p = 0.005), respectively. At logistic regression analysis, a higher atherosclerotic cardiovascular disease risk score was independently associated with arteriogenic erectile dysfunction at colour Doppler duplex ultrasound (odds ratio: 1.03, 95% confidence interval: 1.01-1.08, p = 0.02) after adjusting for Body Mass Index, physical activity, alcohol consumption and severe erectile dysfunction.

DISCUSSION

As vasculogenic erectile dysfunction may precede by some years the onset of acute cardiovascular diseases, the rigorous identification of patients with deficient cavernosal arterial blood flow, would definitely allow the implementation of earlier and more effective cardiovascular prevention strategies in men with erectile dysfunction.

CONCLUSIONS

The atherosclerotic cardiovascular disease risk score represents a reliable tool to identify patients with arteriogenic erectile dysfunction in everyday clinical practice.

Ledderhose's Disease: An Up-to-Date Review of a Rare Non-Malignant Disorder

Plantar fibromatosis (or Ledderhose's disease) is a rare benign condition, difficult to treat, defined by gradual-growing nodules in the central medial part of the plantar fascia, with the possibility of sclerosis and shrinkage of the entire fascia or, rarely, contractures of the toes. From a histopathological point of view, it is linked to Dupuytren's contracture of the hand and Peyronie's disease of the penis, being part of a large group of fibromatoses, based on a proliferation of collagen and fibroblasts. Its etiology is still not fully understood, even though it has been associated with trauma, diabetes mellitus, use of anticonvulsants, frozen shoulder, alcohol consumption, and liver disease. Typically, ultrasound confirms the diagnosis, and magnetic resonance imaging is used for more aggressive and advanced types. Several conservative treatment techniques, such as steroid injections, verapamil, imatinib, radiation therapy, extracorporeal shock wave therapy, tamoxifen, sorafenib, mitomycin C, and collagenase, have been documented. When non-operative care fails, surgical measures may be considered, even though recurrence is expected. We attempted to provide a better understanding of this disease by covering all of the important aspects: its history, clinical and radiologic findings, diagnosis, pathophysiology features, conservative and surgical treatment, recurrence rate, and prognosis.

Radiofrequency energy in the treatment of erectile dysfunction-a novel cohort pilot study on safety, applicability, and short-term efficacy

The erectile mechanism depends, in part on the intactness of the collagen components in the penis. As such, impaired collagen may have a deleterious effect on erectile function. Radiofrequency energy has been shown to renew and restore spatial structural arrangement of collagen fibers; therefore, treatment of erectile dysfunction with radiofrequency could lead to anatomical and physiological changes at the penile tissue level and could lead to improvement in the erectile mechanism. We conducted this study to assess the effect of radiofrequency treatment on erection quality. We evaluated the safety, applicability, and efficacy of a self-applied, handheld, low-intensity radiofrequency device (Vertica®) in men with moderate and mild-to-moderate organic erectile dysfunction. The treatment protocol consisted of 12 treatments (twice a week during the 1st month, and once a week during the 2nd month), and each participant treated himself individually. Treatment outcomes were evaluated using the International Index of Erectile Function, Erection Hardness Scale, Erectile Dysfunction Index of Treatment Satisfaction, Benefit, Satisfaction & Willingness to continue, Quality of Erection Questionnaire, Sexual Quality of Life questionnaires and specific questions addressing side effects and ease of use. Twenty-eight out of 32 men (mean age 59.5 ± 9.8, range: 41-78 years) completed a one-month follow-up after treatment. Mean International Index of Erectile Function (43.7. ± 7.8 vs. 60.9 ± 10.8, p < 0.01), International Index of Erectile Function -Erection Function domain (16.8 ± 3.1 vs. 24.4 ± 4.4, p < 0.001), and Erection Hardness Scores (2.2 ± 0.8 vs. 3.2 ± 0.5, p = 0.01) were all significantly improved. Fifty percent of patients achieved normal erectile function parameters according to the International Index of Erectile Function -Erection Function domain score >25. High mean scores were achieved in the Erectile Dysfunction Index of Treatment Satisfaction (76.8 ± 20.3), Benefit, Satisfaction & Willingness to continue (4.83 ± 1.1), Quality of Erection Questionnaire (73.4 ± 23.8), and Sexual Quality of Life (67 ± 29.4) questionnaires. No side effects were reported and participants rated the device as very comfortable, simple, and easy to operate.

The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction

PURPOSE

Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.

Advanced hydrogels: New expectation for the repair of organic erectile dysfunction

Organic erectile dysfunction (ED) is a type of sexual disorder in men that is usually associated with illness, surgical injury, normal aging and has a high incidence across the globe. And the essence of penile erection is a neurovascular event regulated by a combination of factors. Nerve and vascular injury are the main causes of erectile dysfunction. Currently, the main treatment options for ED include phosphodiesterase type 5 inhibitors (PDE5Is), intracorporeal injections and vacuum erection devices (VEDs), which are ineffective. Therefore, it is essential to find an emerging, non-invasive and effective treatment for ED. The histopathological damage causing ED can be improved or even reversed with hydrogels, in contrast to current therapies. Hydrogels have many advantages, they can be synthesized from various raw materials with different properties, possess a definite composition, and have good biocompatibility and biodegradability. These advantages make hydrogels an effective drug carrier. In this review, we began with an overview of the underlying mechanisms of organic erectile dysfunction, discussed the dilemmas of existing treatments for ED, and described the unique advantages of hydrogel over other approaches. Then emphasizing the progress of research on hydrogels in the treatment of ED.

Low-intensity shockwave treatment (LISWT) improves penile rigidity in eugonadal subjects with erectile dysfunction: a pilot study

BACKGROUND

Since low-intensity shockwave treatment (LISWT) has putative effects on penile hemodynamics remodeling, the aim of this study was to evaluate any improvement of penile vascular flows after LISWT treatment in patients with erectile dysfunction (ED) and poor response to PDE5i.

METHODS

Twenty-one eugonadal patients with different ED severity underwent 6 weekly LISWT sessions (1500-4000 pulses) after 2 weeks withdrawal from PDE5i assumption. Once daily Tadalafil (2.5 mg daily) was reintroduced 4 weeks apart from LISWT termination and patients were evaluated at 1, 2 and 6 months follow-up (T1, T2, T6) by the International Index of Erectile Function-15 items questionnaire (IIEF-15) erectile function (EF) domain, Erection Hardness Score (EHS) and Global Assessment Questionnaires (GAQ). Basal Penile Color-Doppler Ultrasound parameters in the flaccid state (B-PCDU) were evaluated before, during and after interventional protocol.

RESULTS

Mean EHS score improved in 35% of patients at T1, and in up to 50% of patients at T2 and T6 follow-up visits (P<0.05). We found 25% improvement of EF scores at T1 session, 43.75% at T2 and 62.5% at T6, respectively (P<0.05). No statistically significant differences in flow parameters, EF-domain and testosterone levels were found when baseline and last observation carried forward (LOCF) parameters were compared. The GAQ questionnaire scored higher satisfaction rates either at the end of the treatment (100%), or at LOCF (92.5%).

CONCLUSIONS

Despite the study limitations with respect to B-PCDU in this setting, our results confirm a trend toward improvement of erectile questionnaire scores after LISWT with higher overall satisfaction rates among patients with ED. We conclude that LISWT may be an effective option in some difficult-to-treat patients with ED by improving the erectile response to PDE5i.

Low-intensity extracorporeal shock wave therapy for erectile dysfunction: Myths and realities

To review the evidence of clinical efficacy of low-intensity extracorporeal shock wave therapy (Li-ESWT) for the treatment of erectile dysfunction (ED). A search on PubMed using Medical Subject Headings terms [((low intensity extracorporeal shockwave therapy) OR (Li-ESWT)) AND (erectile dysfunction)] was conducted in August 2022, to obtain studies on the use of Li-ESWT for the treatment of ED. Its success rate in terms of International Index of Erectile Function-5 (IIEF-5) score and Erection Hardness Score (EHS) improvement was recorded and analysed. A total of 139 articles were reviewed. Overall, 52 studies were included in the final review. 17 studies were on vasculogenic ED, 5 on post pelvic surgery ED, 4 specifically on ED in diabetic patients, 24 on non-specified origin ED and 2 on mixed pathophysiological origin ED. The mean age of patients was 55.87±7.91 (standard deviation) years and the duration of ED was 4.36±2.08 years. The mean IIEF-5 score went from 12.04±2.67 at baseline to 16.12±5.72, 16.30±3.26 and 16.85±1.63 respectively at 3, 6 and 12 months. The mean EHS went from 2.00±0.46 at baseline to 2.58±0.60, 2.75±0.46 and 2.87±0.16 respectively at 3, 6 and 12 months. Li-ESWT may be a safe and efficacy option for the treatment and cure of ED. Further studies are needed to assess which patients are more suitable for this procedure and which Li-ESWT protocol can lead to the best outcomes.

Penile Rehabilitation after Prostate Cancer Treatment: Which Is the Right Program?

The management of sexual complications after treatment of localized prostate cancer, such as erectile dysfunction, changes in the length of the penis, pain during sexual intercourse, and lack of orgasm, is still an unsolved problem with an important impact on patients’ quality of life. In this review, we summarize the current scientific literature about the rehabilitation of erectile dysfunction after prostate cancer treatment. The therapy for penile rehabilitation includes different types of treatments: the combination of phosphodiesterase type 5 inhibitors (PDE5-I) and the vacuum erectile device (VED) are considered first-line treatment options. When therapy begins, the duration of treatment, the dosage and the drug used all play very important roles in the treatment outcome. Intracavernous injection (ICI) therapy represents the second-line option for patients ineligible for PDE5-I therapy. Technological development has led to the emergence of devices for the stimulation of the penis without the use of drugs, such as penile vibratory stimulation (PVS) for stimulation of ejaculation in spinal cord injury and low-intensity extracorporeal shockwave therapy (LIESWT). The rapid diffusion of the latter, thanks to its easy use, attains good results without side effects. The panorama of penile rehabilitation after PC treatments is vast and many studies are needed, especially on new technologies, to find the best therapeutic regimen possible, personalized to the patient’s characteristics and the type of treatment for PC.

A Prospective, Randomized, Double-Blinded, Clinical Trial Using a Second-Generation Duolith SD1 Low-Intensity Shockwave Machine in Males with Vascular Erectile Dysfunction

PURPOSE

To evaluate the clinical efficacy and patient satisfaction rates of low-intensity extracorporeal shockwave therapy LIESWT) in men with vasculogenic erectile dysfunction (ED) using Duolith SD1 machine.

MATERIALS AND METHODS

This prospective, randomized, double-blinded clinical trial included 60 men who were randomly assigned to LIESWT (n=30, active group) or placebo (n=30) over 6 weeks. Patient demographics, change in International Index of Erectile Function (IIEF)-5, Erection Hardness Score (EHS) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, and an overall satisfaction score (on a 5-point scale), were recorded. All patients were reviewed at 1, 3, and 6 months after completion of therapy.

RESULTS

There were 21 (70%) patients in the LIESWT group and 3 (10%) patients in the placebo group who had a 5-point or greater increase in IIEF-5 score (p=0.018). At 6-month study period, the mean IIEF-5 score was 18.8 (standard deviation [SD], 3.8) in the LIESWT group versus 14.8 (SD, 3.6) in the placebo group, difference in means between groups was 4.0 (95% confidence interval, 2.1-5.9; p<0.001). The EHS scores were higher in the LIESWT group with a mean of greater than 1.2 across the 1, 3, and 6 months compared to the placebo group (p<0.05). All patients completed the treatment study and there was no adverse event reported in terms of penile pain, bruising or deformity. There was a positive correlation between men who reported improvement in EF and treatment satisfaction level with LiESWT (p=0.008).

CONCLUSIONS

LIESWT improves erectile function in the short-term especially in men with mild to moderate ED, and those without a cardiometabolic disease.

The Efficacy and Safety of Thrice vs Twice per Week Low-Intensity Pulsed Ultrasound Therapy for Erectile Dysfunction: A Randomized Clinical Trial

BACKGROUND

A recent sham-controlled clinical study has shown that low-intensity pulsed ultrasound twice per week can safely and effectively treat patients with mild-to-moderate erectile dysfunction (ED). However, large-scale clinical trials are needed to verify its efficacy and safety and determine a reasonable treatment interval.

AIM

To study whether low-intensity pulsed ultrasound therapy thrice per week is non-inferior to twice per week in patients with mild-to-moderate ED.

METHODS

A randomized, open-label, parallel-group, non-inferiority clinical trial was conducted in 7 hospitals in China. A total of 323 patients with mild-to-moderate ED were randomized (1:1) into thrice per week (3/W) and twice per week (2/W) groups. Low-intensity pulsed ultrasound was applied on each side of the penis for 16 sessions.

OUTCOMES

The primary outcome was response rate using the minimal clinically important difference in the International Index of Erectile Function (IIEF-EF) score at week 12. Secondary outcomes included Erection Hardness Score (EHS), Sexual Encounter Profile, Global Assessment Question, and Self Esteem and Relationship Questionnaire.

RESULTS

Response rates in 3/W and 2/W groups were 62.0% and 62.5%, respectively. Treatment effect in the 3/W group was noninferior to that of the 2/W group, with rate difference lower bound of -0.01% [95% confidence interval -0.11 to 0.10%] within the acceptable margin (-14.0%). No significant difference was found among secondary outcomes. IIEF-EF score showed a significant increase from baseline in the 3/W group (16.8 to 20.7) and 2/W group (17.8 to 21.7), and the percentage of patients with EHS ≥3 increased in the 3/W (54.9% to 84.0%) and 2/W (59.5% to 83.5%) groups. There was no significant difference in response rate between the 2 groups after controlling for strata factors and homogeneous tests. No treatment-related adverse events were reported.

CLINICAL IMPLICATIONS

Low-intensity pulsed ultrasound therapy displays similar efficacy and safety for mild-to-moderate ED when administered thrice or twice per week for 16 sessions. This study provides two options to suit patients' needs.

STRENGTHS & LIMITATIONS

This is a large-sample, randomized, controlled, noninferiority trial study. Short-term follow-up and mostly younger patients are the main limitations.

CONCLUSION

Low-intensity pulsed ultrasound therapy thrice and twice per week showed equivalent therapeutic effects and safety for mild-to-moderate ED in a young and generally healthy population. This therapy warrants further investigation of its potential value in rehabilitation of ED.

Dietary habits and lifestyle related to the effectiveness of low-intensity extracorporeal shock wave therapy for chronic prostatitis/chronic pelvic pain syndrome-like symptoms: Initial results

To identify factors that could influence the treatment outcomes of low-intensity extracorporeal shock wave therapy (Li-ESWT) on chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)-like symptoms and establish a predictive model based on these factors to precisely screen individuals who might be more suitable for Li-ESWT. This study enrolled 84 patients with CP/CPPS-like symptoms who received Li-ESWT. Patients were divided into an effective group and an ineffective group based on the reduction of their National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). A nomogram was established based on logistic regression analyses. Then, receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA) were used to evaluate the nomogram. Univariate and multivariate logistic regression analysis showed that a higher NIH-CPSI score, a habit of holding urine, alcohol consumption, and urination soon after intercourse were independent predictors of Li-ESWT efficacy (p < 0.05). The nomogram constructed based on these four indicators and the added age effectively predicted the probability of Li-ESWT effectiveness for CP/CPPS-like symptoms (0.809 [95% CI: 0.717-0.901]; Hosmer-Lemeshow: p = 0.936). This study established a predictive model for the efficacy of Li-ESWT in treating CP/CPPS-like symptoms patients and help improve the management of CP/CPPS-like symptoms.

Clinical application of the therapeutic ultrasound in urologic disease: Part II of the therapeutic ultrasound in urology

This article aimed to review the clinical application and evidence of the therapeutic ultrasound in detail for urological diseases such as prostate cancer, kidney tumor, erectile dysfunction, and urolithiasis. We searched for articles about high-intensity focused ultrasound (HIFU), extracorporeal shock wave therapy, ultrasound lithotripsy, and extracorporeal shockwave lithotripsy (ESWL) in the MEDLINE and Embase. HIFU may be indicated as a primary treatment for low- or intermediate-risk prostate cancer, and salvage therapy for local recurrence as a promising way to address the limitations of current standard therapies. The application of HIFU in treating kidney tumors has scarcely been reported with unsatisfactory results. Evidence indicates that low-intensity shockwave therapy improves subjective and objective erectile function in patients with erectile dysfunction. Regarding the application of ultrasound in stone management, the novel combination of ultrasound lithotripsy and other energy sources in a single probe promises to be a game-changer in efficiently disintegrating large kidney stones in percutaneous nephrolithotomy. ESWL is losing its role in managing upper urinary tract calculi worldwide. The burst-wave lithotripsy and ultrasound propulsion could be the new hope to regain its position in the lithotripsy field. According to our investigations and reviews, cavitation bubbles of the therapeutic ultrasound are actively being used in the field of urology. Although clinical evidence has been accumulated in urological diseases such as prostate cancer, kidney tumor, erectile dysfunction, and lithotripsy, further development is needed to be a game-changer in treating these diseases.

Efficacy of Penile Low-Intensity Shockwave Therapy and Determinants of Treatment Response in Taiwanese Patients with Erectile Dysfunction

Background: Erectile dysfunction (ED) remains an emotional wrench to patients and a therapeutic challenge to urologists in andrology clinics worldwide. This is, in part, related to refraction to, or transient effect of phosphodiesterase 5 inhibitors (PDE5i), coupled with patients’ dissatisfaction with this treatment modality. Low-intensity extracorporeal shockwave therapy (Li-ESWT) is an evolving treatment option, with promising curative potential. Current international guidelines are inconclusive, bear weak recommendation strength, and lack ethnogeographic consensus. Objectives: This study evaluated the safety, efficacy, and effect duration of Li-ESWT, as well as exploring disease-associated determinants of treatment success in Taiwanese males with ED. Methods: A cohort of 69 eligible cases treated with 12 sessions of Li-ESWT and followed up for at least 12 months after treatment, between January 2018 and December 2019 at our medical facility, was used. The present single-center, retrospective, non-randomized, single-arm study employed standardized erectile function evaluation indices, namely, the five-item International Index of Erectile Function (IIEF-5) and Erection Hardness Score (EHS). Clinicopathological analyses of selected variables and comparative analyses of time-phased changes in the EF indices relative to baseline values were performed. Evaluation of treatment success was based on minimal clinically important difference (MCID), using a binomial logistic regression model. Results: The median age and duration of ED for our Taiwanese cohort were 55 years and 12 months, respectively, and an average of 31.3% presented with co-morbidities. The mean improvement in IIEF-5, EHS, and quality of life (QoL) domain scores relative to the baseline values was statistically very significant (p < 0.001) at all indicated follow-up time-points. When stratified, Taiwanese patients with severe and moderate ED benefited more from Li-ESWT, compared with those in the mild or mild-to-moderate group. Patients’ pre-Li-ESWT PDE5i response status was not found to significantly influence Li-ESWT response. Univariate analysis showed that age > 45 years (p = 0.04), uncontrolled diabetes mellitus (p = 0.04), and uncontrolled hyperlipidemia (p = 0.01) were strongly associated with Li-ESWT efficacy; however, only age > 45 years (p = 0.04) and uncontrolled hyperlipidemia (p = 0.03) were found to be independent negative predictors of Li-ESWT success by the multivariate logistic model. Follow-up was uneventful, with no treatment-related adverse events or side effects reported. Of the treated patients, 86.1% indicated satisfaction with the treatment regimen, and over 90% indicated they would recommend the same therapy to others. Conclusions: Li-ESWT is a safe and efficacious therapeutic modality for Taiwanese patients with ED. Uncontrolled hyperlipidemia and age > 45 years are independent negative predictors of treatment success for this cohort.

A review of regenerative therapies as penile rehabilitation in men following primary prostate cancer treatment: Evidence for erectile restoration and cavernous nerve regeneration

Objective

Methods

Results

Conclusion

Efficacy and safety evaluation of low-intensity extracorporeal shock wave therapy on prostatitis-like symptoms: An open-label, single-arm trial

The present work aims to evaluate the clinical efficacy and safety of low-intensity extracorporeal shock wave therapy (Li-ESWT) on patients with prostatitis-like symptoms (PLS). Patients with PLS were recruited and received four-week Li-ESWT (once per week), which was conducted at a frequency of 3 Hz with a preferred energy flow density of 0.25 mJ/mm² . The scores of the National Institute of Health Chronic Prostatitis Symptoms Index (NIH-CPSI), International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5), and Visual Analogue Scale (VAS) were recorded to assess the remission of disease in the 0, 1st, 2nd, 3rd, 4th, 5th, 8th and 16th weeks. A decrease of the NIH-CPSI score ≥6 was regarded as the effectiveness standard of Li-ESWT. Among 91 enrolled patients, the scores of all validated questionnaires presented significant improvements in the 4th week (p < .05) compared with that in baseline, except for IIEF-5. The treatment effective rates in the 1st, 2nd, 3rd, 4th, 5th, 8th and 16th weeks were 28.57%, 38.46%, 47.25%, 51.65%, 57.30%, 68.18% and 69.44%, respectively. No pronounced undesirable side effect has occurred. Li-ESWT is effective and safe in treating PLS. The efficacy can be maintained within three months.

Regenerative technology to restore and preserve erectile function in men following prostate cancer treatment: evidence for penile rehabilitation in the context of prostate cancer survivorship

Introduction

Erectile dysfunction (ED) following prostate cancer treatment is not uncommon and penile rehabilitation is considered the standard of care in prostate cancer survivorship (PCS), where both patient and his partner desire to maintain and/or recover pre-treatment erectile function (EF). There is a clinical interest in the role of regenerative therapy to restore EF, since existing ED treatments do not always achieve adequate results.

Aim

To review regenerative therapies for the treatment of ED in the context of PCS.

Materials and Methods

A review of the existing PubMed literature on low-intensity extracorporeal shockwave therapy (LIESWT), stem cell therapy (SCT), platelet-rich plasma (PRP), gene therapy, and nerve graft/neurorrhaphy in the treatment of ED and penile rehabilitation, was undertaken.

Results

IESWT promotes neovascularization and neuroprotection in men with ED. While several systematic reviews and meta-analyses showed positive benefits, there is limited published clinical data in men following radical prostatectomy. Cellular-based technology such as SCT and PRP promotes cellular proliferation and the secretion of various growth factors to repair damaged tissues, especially in preclinical studies. However, longer-term clinical outcomes and concerns regarding bioethical and regulatory frameworks need to be addressed. Data on gene therapy in post-prostatectomy ED men are lacking; further clinical studies are required to investigate the optimal use of growth factors and the safest vector delivery system. Conceptually interpositional cavernous nerve grafting and penile re-innervation technique using a somatic-to-autonomic neurorrhaphy are attractive, but issues relating to surgical technique and potential for neural 'regeneration' are questionable.

Conclusion

In contrast to the existing treatment regime, regenerative ED technology aspires to promote endothelial revascularization and neuro-regeneration. Nevertheless, there remain considerable issues related to these regenerative technologies and techniques, with limited data on longer-term efficacy and safety records. Further research is necessary to define the role of these alternative therapies in the treatment of ED in the context of penile rehabilitation and PCS.

Are Radial Pressure Waves Effective in Treating Erectile Dysfunction? A Systematic Review of Preclinical and Clinical Studies

Introduction

Radial waves are used to treat erectile dysfunction; however, they are different than focal waves, and their mechanism of action or effect on improving this condition is not known.

Aim

To evaluate the effect of radial waves at the cellular level and their effectiveness at the clinical level for the treatment of erectile dysfunction.

Methods

Systematic literature review. Electronic database searches and manual searches were performed to identify (i) clinical trials or cohort studies evaluating the effectiveness of radial waves in men with erectile dysfunction and (ii) preclinical trials in animal models or cell cultures in which the production of nitric oxide or endothelial growth factor was evaluated. Study quality was assessed, and data were extracted from each study. A narrative synthesis of the results was performed given the high heterogeneity between the selected studies.

Main outcomes measures

Nitric oxide production, endothelial growth factor expression, and changes in the Erection Hardness Score (EHS) and the International Index of Erectile Function (IIEF) Questionnaire score.

Results

Four studies in animal models and 1 randomized clinical trial in men with erectile dysfunction and kidney transplantation were identified that met the selection criteria. Preclinical studies in animals suggest that radial waves increase cellular apoptosis in penile tissue, while vascular endothelial growth factor expression increases in brain tissue. In men with erectile dysfunction, no differences were found between radial wave therapy and placebo therapy in the mean IIEF score (15.6 ± 6.1 vs 16.6 ± 5.4 at 1 month after treatment), EHS (2.5 ± 0.85 vs 2.4 ± 0.7 at 1 month after treatment), or penile Doppler parameters.

Conclusions

No quality evidence was found to support the use of radial waves in humans for the treatment of erectile dysfunction. In animal models and at the cellular level, the results are contradictory. More research is needed. Sandoval-Salinas C, Saffon JP, Corredor HA, et al. Are Radial Pressure Waves Effective in Treating Erectile Dysfunction? A Systematic Review of Preclinical and Clinical Studies. Sex Med 2021;9:100393.

The use of combination regenerative therapies for erectile dysfunction: rationale and current status

Erectile Dysfunction (ED) is defined as the inability to achieve and maintain an erection sufficient for sexual intercourse. Available treatments for ED provide only symptomatic relief, which is for the most part temporary. Regenerative therapies such as Low Intensity Shockwave, Platelet-Rich Plasma, and Stem Cell therapy can potentially provide a "cure" for ED by reversing the underlying pathology of ED rather than just treating the symptoms. Low Intensity Shockwave therapy is the most evidence based at this point and is thought to act by improving penile blood flow, repairing previous nerve damage, and activating stem cells. Stem Cell therapy takes advantage of the self-replicative potential of stem cells to create new corporal tissue, but also to recruit host cells and angiogenic factors to stimulate endogenous repair. Platelet-Rich Plasma therapy uses concentrated growth factors that already exist within the bloodstream to repair damaged nerves and increase penile blood flow. The use of combination restorative therapy may provide an additive or synergistic benefit greater than any one therapy alone because of its overlapping mechanisms of action on the penis but is a topic that remains to be studied.

European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction

CONTEXT

The present summary of the European Association of Urology (EAU) guidelines is based on the latest guidelines on male sexual health published in March 2021, with a last comprehensive update in January 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health.

EVIDENCE ACQUISITION

A literature review was performed up to January 2021. The guidelines were updated, and a strength rating for each recommendation was included based on either a systematic review of the evidence or a consensus opinion from the expert panel.

EVIDENCE SYNTHESIS

Late-onset hypogonadism is a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. A comprehensive diagnostic and therapeutic work-up, along with screening recommendations and contraindications, is provided. Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Along with a detailed basic and advanced diagnostic approach, a novel decision-making algorithm for treating ED in order to better tailor therapy to individual patients is provided. The EAU guidelines have adopted the definition of premature ejaculation (PE), which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient's expectations should be discussed thoroughly and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. Haemospermia is defined as the appearance of blood in the ejaculate. Several reasons of haemospermia have been acknowledged; the primary goal over the management work-up is to exclude malignant conditions and treat any other underlying cause.

CONCLUSIONS

The 2021 guidelines on sexual and reproductive health summarise the most recent findings, and advise in terms of diagnosis and treatment of male hypogonadism and sexual dysfunction for their use in clinical practice. These guidelines reflect the multidisciplinary nature of their management.

PATIENT SUMMARY

Updated European Association of Urology guidelines on sexual and reproductive health are presented, addressing the diagnosis and treatment of the most prevalent conditions in men. Patients must be fully informed of all relevant diagnostic and therapeutic options and, together with their treating physicians, decide on optimal personalised management strategies.

Evaluation of Long-Term Clinical Outcomes and Patient Satisfaction Rate Following Low Intensity Shock Wave Therapy in Men With Erectile Dysfunction: A Minimum 5-Year Follow-Up on a Prospective Open-Label Single-Arm Clinical Study

Introduction

Low intensity extracorporeal shock wave therapy (LIESWT) improves erectile function (EF) in men with vascular erectile dysfunction (ED) but longer-term outcomes remain unknown.

Aim

To evaluate the clinical outcomes of LIESWT at a minimum 5-year follow-up.

Methods

This is an open-label single-arm prospective study involved men with vascular ED who received LIESWT.

Main Outcome Measure

Changes in patient demographics, IIEF-5 and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, as well as overall satisfaction score (on a 5-point scale) were reviewed at 12, 24, 48, and 60 months after completion of LIESWT. A chi-square contingency analysis was used to examine the relationship between erectile function score and treatment satisfaction, with statistical significance set at 5%.

Results

The mean follow-up period was 69.9 (63–82; median 76) months. The mean IIEF-5 scores for pretreatment and after treatment at 12, 24, 48, and 60 months were 14.8, 17.6, 16.8, 16.5, and 16.5 while the percentages of patients who reported an improvement in IIEF-5 score by 5 points were 60%, 45%, 40%, and 40%; and EDITS scores >50% were recorded in 70%, 55%, 50%, and 48% of patients at 12, 24, 48, and 60 months post-LIESWT. Ten patients required medical therapy and 2 patients opted for penile prosthesis implantation. The overall satisfaction rate appeared sustained subsequent follow-up (score 4 out of 5; 68% vs 50% vs 40% vs 40% at 12, 24, 48, and 60 months). There were minor time-limited, but no significant adverse event reported.

Conclusion

This long-term study showed the observed clinical improvement in EF continues to deteriorate but appears to plateau at 40% clinical efficacy at 48–60 months after completion of LIESWT. The absence of penile pain and deformity at 5-year follow-up supports the long-term safety data of LIESWT in men with ED.

Chung E, Cartmill R. Evaluation of Long-Term Clinical Outcomes and Patient Satisfaction Rate Following Low Intensity Shock Wave Therapy in Men With Erectile Dysfunction: A Minimum 5-Year Follow-Up on a Prospective Open-Label Single-Arm Clinical Study. Sex Med 2021;9:100384.

Low-intensity shock wave therapy for the treatment of vasculogenic erectile dysfunction: a narrative review of technical considerations and treatment outcomes

Erectile dysfunction (ED) impacts a significant portion of the aging male population. Standard treatments such as oral medications, intracavernosal injections, intraurethral suppositories, vacuum erection aids, and penile prosthesis placement have stood the test of time. Recently, there has been a growing interest in the concept of regenerative medicine with the goal of restoring or renewing functional tissue. Low intensity shock wave therapy (LiSWT) is one example of a regenerative therapy. A strong body of basic science data suggests that shockwaves, when applied to local tissue, will encourage blood vessel and nerve regeneration. Clinical evidence supports the use of LiSWT to treat conditions ranging from ischemic heart disease, musculoskeletal injuries, and even chronic non-healing wounds. LiSWT is also being used to treat male sexual dysfunction conditions such as Peyronie's Disease and ED. The first studied application of LiSWT for ED was published in 2010. Since then multiple randomized, sham-controlled trials have sought to evaluate outcomes for this novel therapy in men with vasculogenic ED. Additionally, several meta-analyses are available with pooled data suggesting that LiSWT results in a significantly greater improvement in erectile function relative to sham-control. Despite these promising findings, the current body of literature is marred by significant heterogeneity relating to treatment protocols, patient populations, and follow-up duration. Further work is necessary to determine optimal device technologies, patient characteristics, and treatment duration prior to considering LiSWT as standard of care for men with ED.

Comparing two different low-intensity shockwave therapy frequency protocols for nonbacterial chronic prostatitis/chronic pelvic pain syndrome: A two-arm, parallel-group randomized controlled trial

BACKGROUND

Despite encouraging results, the optimal low-intensity shockwave therapy (LiST) protocol in patients with chronic prostatitis/chronic pelvic pain syndrome (CPPS) remains unknown. We conducted a two-arm, parallel-group, randomized controlled trial aiming to compare the efficacy and safety of six LiST sessions applied once or twice weekly.

METHODS

Fifty patients with CP/CPPS type IIIb were randomly assigned to six LiST sessions once (Group A, n = 25) or twice weekly (Group B, n = 25). Both groups followed the same treatment protocol in terms of LiST application, impulses (5000/session), energy flux density (0.096 mJ/mm² ) and frequency (5 Hz). Subsequently, all participants were evaluated at 1 and 3 months after completion of LiST protocol.

RESULTS

At the follow-up evaluations, LiST significantly improved the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) total, pain and quality of life scores, as well as the International Index of Erectile Function-Erectile Domain (IIEF-ED) in both groups (p < .001 for all measures). Comparing between the two groups, no significant differences were demonstrated in the NIH-CPSI total, pain, urinary and quality of life scores, as well as in the International Prostate Symptom Score, IIEF-ED, and LiST-induced pain at both follow-up evaluations. Accordingly, no adverse events and no dropouts were observed in both groups.

CONCLUSION

Six sessions of LiST applied once weekly for 6 weeks or twice weekly for 3 weeks seem to be equally safe and effective in patients with CP/CPPS. Nevertheless, further studies are necessary, since LiST gradually gains its place for the management of CP/CPPS.

Low-intensity shockwave therapy in Peyronie's disease: long-term results from a prospective, randomized, sham-controlled trial

Low-intensity shockwave therapy (LiST) is an effective treatment for pain reduction in patients with Peyronie's disease (PD). We aimed to report the long-term results of a previously published randomized, sham-controlled trial on LiST for PD management. For the initial study, 102 patients with stable PD were randomly assigned to six sessions of LiST (n = 51) or sham (n = 51) therapy. All participants were subsequently contacted for an additional evaluation at 3 years after completion of the initial treatment and 63 of them (LiST = 34 and sham therapy = 29) presented for the evaluation. Among them, improvement of pain was reported in 23 participants (LiST = 16, sham = 7, p = 0.005) at 4 weeks and in 22 (LiST = 15, sham = 7, p = 0.031) at 3 years. We detected a mean difference of 2.2 points (95%CI: 0.9-3.5, p = 0.002) in the visual analog pain scale at 4 weeks and a mean difference of 2.5 points (95%CI: 1-4, p = 0.002) at 3 years between the two groups. No treatment-related complications occurred during the sessions or the follow-up period. Regarding the improvement of penile curvature or sexual function, no significant differences between the two groups were observed. Overall, LiST constitutes a safe and effective therapeutic approach for pain management both in the short- and long term.

[Low-intensity extracorporeal shock wave therapy for erectile dysfunction: A systematic review]

INTRODUCTION

Our purpose was to assess the efficacy of low intensity extracorporeal shock waves (SW) for the treatment of organic erectile dysfunction (ED).

METHODS

A systematic review of the literature published between 2000 and 2020 was conducted using the PRISMA methodology. We used Medline data with the following key words (MesH): "extracorporeal shock wave therapy"; "erectile dysfunction"; "sexuality".

RESULTS

Nineteen articles were selected: thirteen randomised controlled trial and six meta-analyses. Most of them studied vascular etiology. Low intensity SW is beneficial ED is evaluated by the IIEF, EHS scores and penile hemodynamic.

CONCLUSION

SW may have a theoretical impact on the vascular etiology of organic DE. Their use in this context is supported by the European Society of urology and the European Society of sexual medecine. However, there are discrepancies in current data to establish a protocol to follow in daily practice.

Focusing on sexual rehabilitation besides penile rehabilitation following radical prostatectomy is important

Erectile dysfunction is commonly reported after radical prostatectomy. Besides the loss of erections, sexual life after prostatectomy is impacted by urinary incontinence, orgasmic dysfunction, and psychological stress. In this review, we describe classical medical therapies used for erectile function rehabilitation such as PDE5 inhibitors and injection therapy. A vast amount of data support the idea of focusing on restoration of sexual function on top of erectile function after prostatectomy. The important strategies described to rehabilitate sexual function include pelvic floor muscle therapy, couple therapy, appropriate preoperative counseling, and focusing on non-penetrative alternatives. A multidisciplinary approach and including the partner is important. Erectile function alone is not sufficient for satisfactory sexual experience and may not be used as a proxy for sexual quality of life. Adding full-spectrum sexual rehabilitation to a standard penile rehabilitation regimen has the highest chances of obtaining satisfactory sexual outcomes in men and their partners after radical prostatectomy.

[French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]

INTRODUCTION

Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations.

MATERIALS AND METHODS

These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography.

RESULTS

The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered.

CONCLUSION

The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.

Sexual function in men undergoing androgen deprivation therapy

Androgen deprivation therapy (ADT) has a deleterious effect on sexual functions and general well-being in men. Despite this evidence, however, patient and couple knowledge about ADT side effects as well as their management is poor. Similar considerations can be made for physician endorsement of management strategies. In this paper, we summarize and critically discuss available evidence regarding the possible associations between ADT and sexual dysfunction as well as the best therapeutical options. Preclinical data show that ADT is associated with penile contractility impairment as well as lower response to phosphodiesterase type 5 inhibitors (PDE5i). Available data indicate that ADT resulted in a five to sixfold increased risk of reduced libido and in a threefold increased risk of ED confirming the main role of testosterone in regulating sexual desire. Despite this evidence, sexuality remains an important aspect of health and well-being for men and their partner. The best therapeutical options depend on patient and couple desires and needs. When nonpenetrative erections are still possible, nonpenetrative activities should be encouraged to maintain sexual intimacy. A combined and personal educational program including the collaboration of different professional figures (including general physicians, oncologists, andrologists, sexologists, and psychologists) trained in sexual medicine is advisable in order to provide the best support to subjects undergoing ADT.

Peyronie's disease: new paradigm for the treatment of a unique cause of erectile dysfunction

Peyronie's Disease is an incurable condition of the tunica albuginea of the penis associated with scarring, plaque formation, and penile deformity on erection. It is often associated with erectile dysfunction. Recent data have supported a familial and genetic predisposition to this chronic condition. The etiology of Peyronie's Disease is unknown, but is likely associated with multiple micro traumas to the erect penis in men who are susceptible to the scarring typical of Peyronie's Disease. The treatment of Peyronie's Disease has improved over the past decade as a result of animal studies and the approval of new medications. In the acute phase of the condition, phosphodiesterase type 5 inhibitors have been shown to have some benefit and are supported by animal studies demonstrating reduced fibrosis of the penis in animal models of Peyronie's Disease. In the stable phase of the disease, newer injectable agents have shown great promise. Collagenase clostridium histolyticum is approved for the treatment of Peyronie's plaques by direct injection into the scarred tissue with data showing satisfactory safety and efficacy. Surgical procedures for penile straightening have been refined with improved outcomes in the past decade. For those men with erectile dysfunction and Peyronie's Disease, penile implants can restore erectile function and form. As a result of the new understanding of the risk factors for Peyronie's Disease and recent advances in treatment options, the algorithm for the treatment of Peyronie's Disease has improved outcomes for patients and their partners.

Evaluation of a low-intensity shockwave therapy for chronic prostatitis type IIIb/chronic pelvic pain syndrome: a double-blind randomized sham-controlled clinical trial

BACKGROUND

Currently, there is no efficacious treatment method for chronic prostatitis type IIIb/chronic pelvic pain syndrome (CP/CPPS). Aim of the study was to investigate and compare the efficacy and safety of low-intensity shockwave therapy (LiST) vs. sham treatment in CP/CPPS patients.

METHODS

Patients with CP/CPPS diagnosis were randomized in this prospective, sham-controlled, double-blind study either to the active groups (Group B, C) who received 5000 shockwaves per session with energy flux density 0.1 mJ/mm² or to the sham group (Group A) who received 5000 shockwaves from a visually identical sham probe. All groups underwent six sessions (once/week). LiST effects on pain, micturition, quality of life (QoL), and erectile function were evaluated at 4, 12, and 24 weeks after treatment. The parameters were investigated using validated questionnaires. Uroflowmetry and post void residual calculation were performed at baseline and at 4- and 12-week FU visit. Prostate mpMRI and PSA measurement were performed at baseline and 12-week FU visit.

RESULTS

Overall, 45 men were randomized to the active (n = 30) and sham groups (n = 15). Regarding impact of LiST in National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) total, pain, and QoL subdomains scores a clear and persistent in all FU timepoints improvement was found compared to sham treatment. NIH-CPSI urinary subdomain, International Prostate Symptom Score [IPSS], PSA, and mpMRI-PIRADS scores did not differ between the two groups. The mean difference between the LiST and sham group in the change of the NIH-CPSI pain-domain score (Q1-4) from baseline to 12 weeks after final treatment which was 3.3 (95% CI, 1.8, 4.7). Perineal LiST was easy and safe to perform without anesthesia or any side-effects.

CONCLUSIONS

LiST seems to be a safe and effective treatment option for CP/CPPS, considerably improving pain and quality of life. Lack of any side-effects, and the potential for repetition make LiST a promising treatment choice for CP/CPPS patients.

Low-intensity extracorporeal shockwave therapy among urologist practitioners: how the opinion of urologists changed between 2016 and 2019

Over the past few years, an increase use of low-intensity shockwave therapy (LISWT) for the treatment of erectile dysfunction (ED) has been observed. However, many controversies in the scientific literature about its efficacy still exist. We aimed to investigate changes in the pattern of usage and attitudes toward LISWT for ED among experts over the last years. A dedicated online survey was sent to delegates at the Congress for the EAU Section of Andrological Urology (ESAU) in Prague from 31st October to 1st November 2019. The survey captured demographic data, professional background, and the experience and personal knowledge about LISWT. The results were compared with a previous survey conducted in 2016 and investigating the same topics in order to assess changes in the knowledge and opinion on LISWT over time. Overall, 172 and 192 questionnaires were available from 2019 and 2016, respectively. Participants in the 2019 survey were 80 (45.7%) urologists, 52 (29.7%) uro-andrologists, and 34 (19.4%) residents in urology, from 30 different countries. Compared to the past, we observed an increase of respondents who were familiar with LISWT (75 vs. 95%; p < 0.0001) and who performed LISWT in their routine practice (38% in 2019 vs. 14% in 2016; p < 0.0001). Conversely, no changes in terms of overall perception of treatment efficacy were registered over time (68% in 2019 vs. 72% in 2016 considered LISWT as an effective treatment, respectively (p = 0.5)). An increased proportion of physicians had suggested a wider application of LISWT, and some even advocated its use in nonvasculogenic ED (33% in 2019 vs. 5.9% in 2016; p < 0.0001). The awareness and clinical application of LISWT for ED have increased over time, despite the lack of robust evidence in terms of effectiveness. Further research on the benefit of LISWT is needed to guide physicians in the therapeutic management of ED patients.

Follow-up of clinical and sonographic features after extracorporeal shock wave therapy in painful plantar fibromatosis

Background

Extracorporeal shock wave therapy (ESWT) has been used as a safe alternative treatment for refractory musculoskeletal diseases, such as plantar fasciitis, Achilles tendinopathy and gluteal tendinopathy, and various forms of fibromatosis including palmar or penile fibromatosis. However, there is limited published data for clinical and sonographic features of plantar fibromatosis after ESWT. The purpose of this study was to evaluate the long-term clinical outcome of ESWT in ultrasonography-confirmed plantar fibromatosis and ultrasonographic changes of plantar fibroma after ESWT.

Methods

Medical charts of 26 patients (30 feet) with plantar fibromatosis confirmed by ultrasonography were reviewed. Finally, a total of 10 feet who underwent ESWT for “Poor” or “Fair” grade of Roles-Maudsley Score (RMS) and symptoms persisted for >6 months were included in this study. Short-term follow-up was conducted one week after ESWT and long-term follow-up time averaged 34.0 months. The Numerical Rating Scale (NRS) and RMS were collected for the evaluation of clinical features. Follow-up ultrasonography was conducted at long-term follow-up and changes of plantar fibroma was assessed. A greater than 50% reduction in the NRS and achievement of a “good” or “excellent” grade in the RMS were regarded as treatment success. Additionally, medical charts of 144 patients (168 feet) with plantar fasciitis confirmed by ultrasonography were reviewed and subsequently, 42 feet who underwent ESWT with the same protocol were included for the comparison of clinical features.

Results

In plantar fibromatosis, baseline NRS (6.2 ± 1.3) and RMS (3.5 ± 0.5) were significantly improved at short-term follow-up (NRS, 1.8 ± 1.0; RMS, 2.0 ± 0.8, P < .001, respectively) and long-term follow-up (NRS, 0.6 ± 1.1; RMS, 1.4 ± 0.8, P < .001, respectively). Treatment success was recorded in seven feet (70.0%) at short-term follow-up and 8 feet (80%) at long-term follow-up, which is comparable to that of the plantar fasciitis group (28 feet, 66.7%; 35 feet, 83.3%, respectively). In long-term follow-up ultrasonography, mean fibroma thickness was reduced from 4.4±1.0 to 2.6±0.8 mm (P = .003); however, length and width were not significantly changed. There were no serious adverse effects.

Conclusion

While these are preliminary findings, and must be confirmed in a randomized placebo control study, ESWT can have a beneficial long-term effect on pain relief and functional outcomes in painful plantar fibromatosis. However, ESWT is unlikely to affect the ultrasonographic morphology of plantar fibroma, with the exception of reducing the thickness.

Level of evidence

Level III, retrospective cohort study.

Management of erectile dysfunction following robot-assisted radical prostatectomy: a systematic review

INTRODUCTION

We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines were followed. Population consisted of patients with erectile disfunction after RARP (P), conservative and surgical intervention were considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of erectile function after conservative treatments and sexual function after surgical treatments (O).

EVIDENCE SYNTHESIS

Eleven studies were included. Seven studies focused on the use of phosphodiesterase-5 inhibitors (PDE5i) alone (five studies) or associated with other treatments (two studies). All the studies confirmed the efficacy of PDE5i, while the most promising association is with vacuum pump erectile devices. Two studies investigated topical treatments, namely low intensity extracorporeal shock wave therapy and alprostadil. Low intensity extracorporeal shock wave therapy may be a promising option in patients in whom nerve-sparing surgery was performed. The use of alprostadil could be an effective alternative to intracorporeal injection in those who underwent non-nerve-sparing surgery. One study focused and confirmed the efficacy of penile implants. Furthermore, one study reported the efficacy of a multi-modal treatment with preoperative medication, showing the benefits of a multimodal approach.

CONCLUSIONS

Penile rehabilitation with PDE5i is effective after nerve sparing RARP. The association of PDE5i with vacuum devices could led to a faster recovery. A multimodal approach with preoperative specific care seems to be effective to fasten erectile function recovery.

Penile low intensity shock wave treatment for PDE5I refractory erectile dysfunction: a randomized double-blind sham-controlled clinical trial

PURPOSE

Over the last decade, penile low-intensity extracorporeal shockwave therapy (LI-ESWT) has emerged as a promising alternative for the treatment of erectile dysfunction (ED). The aim of this trial is to assess the effect of electromagnetic LI-ESWT on the erectile function of vascular phosphodiesterase type 5 inhibitor (PDE5I) refractory ED patients.

METHODS

Randomized, double-blind, sham-controlled study. 76 patients with vascular PDE5I-refractory ED completed the study. 40 men were treated with LI-ESWT (1 session/week for 4 weeks, 5000 shocks/session, 0.09 mJ/mm² energy density) and 36 were treated with a sham probe. Baseline and post-treatment (1, 3 and 6 months) evaluations were performed using validated erectile function questionnaires (IIEF-EF, EHS, SEP2, SEP3 and GAQ1). The groups were compared using Mann-Whitney-Wilcoxon and chi-squared tests, with results considered statistically significant at p < 0.05.

RESULTS

At the 3-month follow-up, median change in IIEF-EF score for active and sham groups was 3.5 (IQR 0-10) and - 0.5 (IQR - 11 to 1), respectively (p < 0.05). Six months after treatment, 52.5% of patients (21/40) in the active group and 27.8% of patients (10/36) in the sham group presented an EHS > 2 (p < 0.05). At the same evaluation, 40.0% (16/40) and 13.9% (5/36) of patients had positive answers to GAQ-1, in the treated and sham groups, respectively (p < 0.05). No adverse events were observed during the study.

CONCLUSION

This study showed that penile electromagnetic shockwave therapy may improve erectile function, to a modest extent, on certain patients that do not respond to PDE5I; making it an alternative for vascular ED patients that reject more invasive therapies.

Clinical Practice Guideline Recommendation on the Use of Low Intensity Extracorporeal Shock Wave Therapy and Low Intensity Pulsed Ultrasound Shock Wave Therapy to Treat Erectile Dysfunction: The Asia-Pacific Society for Sexual Medicine Position Statement

Published literature shows low intensity extracorporeal shock wave therapy (LIESWT) and low intensity pulsed ultrasound (LIPUS) therapy to improve erectile function and penile hemodynamic by inducing neovascularisation and promoting tissue regeneration. Key opinion leaders across the Asia Pacific region attended the recent biennial meeting of the Asia Pacific Society for Sexual Medicine in Australia, and presented the current evidence on LIESWT and LIPUS for erectile dysfunction (ED). The clinical findings were internally discussed, and the quality of evidence was graded based on the Oxford Centre for Evidence-Based Medicine recommendations. Existing literature supports the use of LIESWT and LIPUS in men with ED, with many clinical studies reported encouraging results with improved erectile function, good safety profile and short-term durability. However, controversial exists due to sampling heterogeneity, non-standardised treatment protocol and lack of large multiinstitutional studies. There is a need to better define which subgroup of ED population is best-suited, and specific treatment protocol to optimise shock wave energy delivery. More stringent and larger multi-institutional randomised placebo-controlled trials are warranted before clinical adoption of LIESWT and LIPUS as the new standard of care for men with ED.