Most of the patients who come to the office for Erectile Dysfunction (ED) They ask about the effectiveness of Low Intensity Focused Shock Wave Treatment (LIESWT). Although it is known that in medicine treatments can be guaranteed, but not results, it will be convenient to delve into some concepts that may clear up uncertainties in this regard.
Since ED can have multiple causes, a correct diagnosis is essentialsince not all of them can be treated with LIESWT, and sometimes, even if the treatment is effective, other concomitant causes may still cause the disorder.
First of all, medication intake should be taken into account such as beta-blockers, antiandrogens, certain psychoactive drugs, etc. In such cases, the medication should be replaced or discontinued.
should also be take into account psychological or psychiatric factors, as well as factors of neurological originsuch as lesions of the Central or Peripheral Nervous System, the most frequent being those that occur after Radical Prostatectomy, even with preservation of the vascular-nervous packages.
When a psychopathy is suspected, it will be recommended to initiate a specialized psychotherapy, and in neurological conditions, it will be necessary to evaluate the afferent and efferent pathways through Pudendo-Cortical Evoked Potentials or Electromyogram of the cavernous bodies with sensory and motor conduction velocity. In case of involvement of the cavernous nerves, the LIESWT may be applied with a differentiated protocol and its efficacy evaluated with the referred studies before and after treatment.
From a clinical point of view, metabolic syndrome with all its components and its consequences should be considered (Obesity, DBT, HTA, etc.), however, the objective of the LIESWT will not aim to treat the causes but the mechanisms, which are: 1°) The inability to fill the cavernous sinusoids with blood and 2°) The inability to retain blood in the cavernous sinusoids (“Venous Leak”).
Besides, although LIESWT does not present adverse effects, its use is contraindicated in patients with pacemakers or with uncontrolled cardiac arrhythmias, bleeding disorders, anticoagulated, with systemic cancer and infections or local prostheses.
In order to arrive at an accurate diagnosis of the main failures in the mechanisms of organic cause, it will be essential to use diagnostic imaging methods such as two-dimensional ultrasound, color Doppler echography and shear wave elastography (2D SWE).
Ultrasound will rule out the presence of hypoechoic and hyperechogenic cavernous areas and fibrous or calcified plaques, responsible for Peyronie’s disease (penile curvature), which can present with ED. In these latter cases, the treatment will not try to eliminate the plaques but to reduce the stiffness of the tissue that surrounds them, the true cause of the curvature and the accompanying ED.
Color Doppler echocardiography will rule out both arterial insufficiency and venous leakage. The study may be performed with or without intracavernous injection of vasoactive drugs (Trimix; papaverine, phentolamine and/or prostaglandin E1). As far as possible, it will be advisable to avoid said injection in order to prevent intracavernous hemorrhages and the subsequent sequelae of fibrosis, responsible for erection failure due to decreased “compliance” (expansive capacity of the sinusoids).
If performed with vasoactive drugs, Doppler spectrography may detect arterial, venous, or mixed insufficiency; and if it is performed without vasoactive drugs, a venous macro-leak with rapid loss of erection can be detected in a dissociated way when phlebectasias (“penile varicocele”) appear in the trunk or roots of the corpora cavernosa, with venous diameters greater than 1.5 mm, on the one hand, and on the other hand, mild arterial insufficiency secondary to vascular compression when tissue stiffness exceeds 25 kPa, or severe when it exceeds 50 kPa.
Venous macro-leak may be of pre-sinusoidal origin (due to increased cavernous rigidity), sinusoidal (due to aging of the venous walls) or post-sinusoidal (due to BPH, abdominal obesity or other causes that hinder venous return). In cases of venous macro-leakage, the LIESWT will attempt to embolize the dilated vessels in order to improve the veno-occlusive mechanism through recanalization and vascular redirection, as well as correcting the predisposing factors with appropriate medical treatment, plus venotonic medication.
Penile 2D SWE will be able to detect central (in the corpora cavernosa), peripheral (in the tunica albuginea) or mixed fibrosis. When the fibrosis is central (causing lack of erection due to loss of compliance or expansive capacity of the venous sinusoids), peripheral (causing little tumescence or slow loss of erection due to venous micro-leakage through the emissary and subalbugineous vessels ), or in the intercavernous septum (cause of penile retraction plus venous micro-leakage), the monitoring of the LIESWT sessions will be able to verify the average reduction (E. Media) of tissue rigidity, which according to our statistics was presented in the totality of the treated patients, being approximately 10 kPa (+-5) per session.
While the intensity of the shock waves will be in the order of 0.25 mmJoules/mm2, the number of sessions and number of waves per session will depend on the initial values.
The objective of the LIESWT will be to achieve values below 25 kPa through “mechano-transduction”, with which it will be possible to verify the clinical improvement of ED naturally or with IPDE5 (Sildenafil, Tadalafil, Vardenafil) at doses low.
Mechano-transduction, which is the mechanism by which a physical stimulus (such as a shock wave) generates a biological response, consists of stimulating the cell nuclei through signaling pathways so that they produce and release growth factors. , structural proteins and promote the differentiation and migration of stem cells, achieving tissue revascularization and the restitution of muscle cells or type III collagen in replacement of fibroblasts and type I collagen, allowing the recovery of tissue elasticity and erectile capacity.
We must highlight the importance of diagnostic imaging (fundamentally 2D SWE) prior to the intake of IPDE5, since increasing the dose without consulting it can increase the risk of vascular damage at the cardiac or brain level.
Finally, statistics about the effectiveness of treatments have shown a favorable response in 100% of patientswhich presented a different magnitude in each individual depending on the assessment of all the aforementioned variables added to their individual regenerative capacity.
* Dr. Cesar Eisner. MN: 64,575.
