madman
Super Moderator
INTRODUCTION
Despite major advances in the field of erectile dysfunction (ED) in the past decades, the current treatment paradigm is far from perfect and all available treatments have significant limitations.
Oral PDE-5 inhibitors are commonly offered as initial treatment. Although highly effective in many patients, they do not alter the underlying pathophysiology of the erectile mechanism, which may continue on its downward spiral [1]. In addition, select PDE-5 inhibitors may still be costly. Furthermore, PDE-5 inhibitors may have undesirable adverse effects such as dyspepsia, headache, flushing, and dizziness [1, 2].
Another effective treatment for ED is intracavernosal injections (ICI) which includes monotherapy or a combination of prostaglandin E1, papaverine, and phentolamine. Despite a response rate of up to 90%, the thought of inserting a needle to the penis is undesirable to many patients. Furthermore, ICI can lead to penile pain, priapism, and fibrosis [2], further leading to treatment discontinuation.
Intraurethral suppository is another non-invasive alternative with a moderate 43–60% success rate [2]. However, this option is often expensive and difficult to apply.
Vacuum constriction devices are the least expensive option, incurring only a one-time cost of $150–$450 for unlimited short-term erections of ~20–30 min [2]. Vacuum constriction devices are typically cumbersome to use and have numerous unpleasant side effects such as transient penile petechiae, ejaculatory difficulties, and numbness [2].
Finally, surgical insertion of a penile prosthesis is a very viable option for men with any stage of ED. While a penile prosthesis provides a high rate of patient satisfaction, it is an invasive surgical procedure [2]. Penile prostheses have multiple potential complications as well that are beyond the scope of this article.
In summary, all current treatment options for vasculogenic ED have multiple limitations, including decreased sexual spontaneity, local side effects, risk of priapism, compliance difficulties, and inability to reverse the underlying pathophysiology.
Low intensity extracorporeal shockwave therapy (LiESWT) is a novel treatment for ED that aims to reverse the pathophysiology of ED at the cellular level to provide longterm improvement and return of spontaneous erectile function [3]. Because Li-ESWT is minimally invasive, it is touted to be readily accepted and have minimal side effects.
Conclusion Despite the important progress made by various groups in investigating the utility of Li-ESWT as a minimally invasive treatment for vasculogenic ED, many questions remain unanswered. The sustainability of Li-ESWT is still unknown, as most of the evidence is limited to 6 months of follow-up. The optimal treatment protocol and patient population is also unknown. The AUA 2018 ED guidelines currently rated penile ESWT as conditional with Grade C evidence [1] and states that its use should only be in an experimental setting. Until these pressing questions discussed above can be answered this recommendation will likely remain in effect.
Despite major advances in the field of erectile dysfunction (ED) in the past decades, the current treatment paradigm is far from perfect and all available treatments have significant limitations.
Oral PDE-5 inhibitors are commonly offered as initial treatment. Although highly effective in many patients, they do not alter the underlying pathophysiology of the erectile mechanism, which may continue on its downward spiral [1]. In addition, select PDE-5 inhibitors may still be costly. Furthermore, PDE-5 inhibitors may have undesirable adverse effects such as dyspepsia, headache, flushing, and dizziness [1, 2].
Another effective treatment for ED is intracavernosal injections (ICI) which includes monotherapy or a combination of prostaglandin E1, papaverine, and phentolamine. Despite a response rate of up to 90%, the thought of inserting a needle to the penis is undesirable to many patients. Furthermore, ICI can lead to penile pain, priapism, and fibrosis [2], further leading to treatment discontinuation.
Intraurethral suppository is another non-invasive alternative with a moderate 43–60% success rate [2]. However, this option is often expensive and difficult to apply.
Vacuum constriction devices are the least expensive option, incurring only a one-time cost of $150–$450 for unlimited short-term erections of ~20–30 min [2]. Vacuum constriction devices are typically cumbersome to use and have numerous unpleasant side effects such as transient penile petechiae, ejaculatory difficulties, and numbness [2].
Finally, surgical insertion of a penile prosthesis is a very viable option for men with any stage of ED. While a penile prosthesis provides a high rate of patient satisfaction, it is an invasive surgical procedure [2]. Penile prostheses have multiple potential complications as well that are beyond the scope of this article.
In summary, all current treatment options for vasculogenic ED have multiple limitations, including decreased sexual spontaneity, local side effects, risk of priapism, compliance difficulties, and inability to reverse the underlying pathophysiology.
Low intensity extracorporeal shockwave therapy (LiESWT) is a novel treatment for ED that aims to reverse the pathophysiology of ED at the cellular level to provide longterm improvement and return of spontaneous erectile function [3]. Because Li-ESWT is minimally invasive, it is touted to be readily accepted and have minimal side effects.
Conclusion Despite the important progress made by various groups in investigating the utility of Li-ESWT as a minimally invasive treatment for vasculogenic ED, many questions remain unanswered. The sustainability of Li-ESWT is still unknown, as most of the evidence is limited to 6 months of follow-up. The optimal treatment protocol and patient population is also unknown. The AUA 2018 ED guidelines currently rated penile ESWT as conditional with Grade C evidence [1] and states that its use should only be in an experimental setting. Until these pressing questions discussed above can be answered this recommendation will likely remain in effect.
