Written by Michael Irvine (Men’s Health Physio) Email: [email protected]
(ONLY available at Southside Physio Woden)
If you think shockwave therapy may be beneficial for your men’s health condition, contact Southside Physio Woden to book (assessment consult first to assess if shockwave appropriate). If you have any questions about the use of shockwave therapy, or if it may be the right for you, contact Michael Irvine directly (our men’s health shockwave physio
What is shockwave therapy?
Extracorporeal Shockwave Therapy (ESWT) involves the use of high pressure acoustic pulses (1,000x more powerful than ultrasound waves) to stimulate healing in tissues. The high positive pressure wave is immediately followed by a negative pressure wave, which produce direct mechanical pressure and gas bubble/cavitation within the tissue respectively. The cavitation/gas bubble then immediately implodes, creating secondary shockwaves(1).
These shockwaves have then been found to produce the following effects to promote healing(1):
- Neovascularization (formation of new blood vessels)
- Nitric oxide production:
- Vasodilation (expand the blood vessels)
- Autonomic nervous system neurotransmitter (regulates involuntary body processes)
- Mediator of erections (required for the penis to fill with blood)
- Modulate many immune functions
- Increase growth factor and protein synthesis: allowing collagen synthesis and tissue remodelling
- Analgesic response (depletion of substance P: neurotransmitter for pain signals)
- Other responses specific for joint, bone and tendon healing
From the above, there are many potential mechanisms for how shockwave therapy can help in men’s health. ESWT is still very new to men’s health, with some conditions having much more research conducted than others. However, in all conditions listed in this article, ESWT research indicates very promising positive results.
Peyronie’s disease (PD) is characterized by the formation of inelastic scar tissue, into plaques, in the tunica albuginea of the penis. The exact cause/mechanism of how the plaques form is unknown, however, there is an increased risk with genetically susceptible individuals (family history of PD or Dupuytren’s), diabetic patients, or after micro trauma in the region (radical prostatectomy, radiation therapy, pelvic surgery, buckling during sexual activity)(3,4). It affects around 9% of all men, but is likely under underestimated due to stigmatization and social barriers, with 22% of men at death having PD(3). It is most prevalent in men aged 55-60 years old, and 2 thirds of men with PD will have risk factors for arterial disease. There is a large mental health burden, with up to 81% of men with PD report emotional difficulties, 48% with clinical depression, and 54% with relationship difficulties(3).
PD is one of the leading causes of penile curvature, reductions in penile length, narrowing, hinging and deformity of the penis. There is a palpable plaque when flaccid, and often leads to pain with erections or erectile dysfunction (up to 80% of PD sufferers)(3,4). The “acute phase” of PD lasts anywhere from 6-18months, which is defined by the still progressing/growing of the plaque. Previously, surgery had been considered the most effective treatment, but is unable to be performed until the penis reaches the “chronic phase”, where the plaque stabilises. However, surgery itself has the risk of penile shortening and erectile dysfunction(4).
More recent evidence has looked into more conservative treatment options which are able to be applied in the acute phase.
- Dosage: 1 session/week for 6 weeks
- Significantly greater proportion of patients having pain relief (82%) or complete pain resolution (61%)
- Significantly greater reduction in plaque size
- Higher number of patients have reductions in plaque size
- No significant changes to penile deformity/curvature or sexual function with ESWT alone (combine with vacuum pump)
- May require ultrasound first to reduce pain and sensitivity
Therapeutic Ultrasound(3) (available at Southside Physio Tuggeranong and Woden)
- Dosage: 2 sessions/week for 6 weeks (or 3 sessions/week for 4 weeks)
- Lead to reduced curvature/deformity by 38% or 17o on average
- Significant reductions in pain
- Plaques with a calcification larger than 0.5mm did not respond (needs ESWT)
- Dosage: 10 mins x2/day, or 30 mins x3/day for 3-6 months
- Significantly reduced curvature when already less than 45o (minimal change larger than 45o when use vacuum alone)
- Helps to reduce plaques less than 2cm in size
- Unsure of the effect on pain (only a small number of trial participants had pain)
- Plaques were not assessed for calcification (unsure of the effects if plaque has calcification)
- Requires a narrower vacuum cylinder for lengthening, not just overall expansion
- Combine with ESWT, especially for larger plaques or calcified
- Traction therapy devices have similar outcomes, but they require use for more than 3hours/day
Erectile Dysfunction (vasculogenic)
Erectile dysfunction (ED) is the repeated inability to obtain or maintain an erection that is sufficient/firm enough for sexual function(8). It effects 30-65% of men over 40 years old, and is an indicator of endothelial dysfunction (a type coronary artery disease) that may precede a coronary incident within 1-3 years(8). Due to this, if you have recently had any changes to erectile function/dysfunction, then please see your GP to check on your overall cardiovascular health. Other than preventing potential heart disease, this may also help in fixing any underlying vasculogenic problems that may have led to the ED.
The formation of an erection occurs when a nerve signal triggers the corpus cavernosa muscles to relax and blood is then allowed to flow into the tissue. This expanded pressure pushes against the rigid tunica albuginea to form a firm erect penis. Venous blood flow is also reduced by the expanded tissues to maintain the internal pressure. So any changes to localised neural tissue, or local/systemic vasculogenic function, can have an impact on your erectile function.
As explained earlier about the mechanisms of shockwave therapy on the body, there are multiple possible reasons as to why it can help in erectile dysfunction. These include, but are not limited to: neovascularisation (new blood vessel formation), vasodilation (expanding the blood vessels), and nitric oxide (relaxes the muscle to allow blood to fill up).
- Dosage: 1 session/week for 6 weeks
- The average score on the “sexual health inventory for men” (SHIM) questionnaire improved from 9.1 (moderate ED) to 16.1 (mild ED) (22 or more out of 25 is related to normal erectile function)
- 75% of the cohort were able to regain erectile function for sexual activity (42% with PDE5i medications, 33% without PDE5i medications)
- No adverse events/complications/side effects
Other treatment options for erectile dysfunction
The current first line medical intervention for ED, is the use of phosphodiesterase 5 inhibitors (PDE5i). These increase penile blood flow by via nitric oxide pathways, as well as increased cyclic guanosine monophosphate (cGMP) which mediates the calcium channels (calcium is what stimulates the contraction of muscle fibres)(11). PDE5i has a 60-80% success rate in regaining erections for sexual activity, however, 24% of people taking the medication, stopped within 1 year for various reasons(12). Regardless of other intervention, most men continue using PDE5i’s (keep taking when having ESWT).
Previously, physiotherapy interventions for erectile dysfunction centred on pelvic floor muscle training. The premise behind this, is that the muscles of the penis increase the pressure within the penis when they contract, influencing penile rigidity, as well as preventing blood flow out of the penis, by compressing the deep dorsal vein(13). By working on the pelvic floor daily for 6 months, as well as reducing other risk factors (smoking, weight, diet/alcohol, fitness), 40% of participants regained normal erectile function, with a further 34.5% still having improved erectile function(13).
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Nonbacterial Prostatitis / Chronic Pelvic Pain Syndrome
Nonbacterial prostatitis is the most common cause of chronic pelvic pain syndrome (CPPS), which affects 15% of all men(14). CPPS is defined as pelvic pain persisting for more than 3 months that does not involve an infection. The exact mechanism of CPPS is still unknown, with theories ranging from: inflammation, pelvic floor muscle dysfunction, and neural or neurobehavioral disorders. CPPS causes pain, usually in the pelvic or perianal region, as well as urinary symptoms: like increased urination frequency or post void dribble(14). ESWT has only been used in clinical trials for CPPS since 2008 (very recently in medical world). Since then there has been much better size and quality studies conducted to demonstrate the benefits of ESWT for CPPS.
- Dosage: 2 sessions/week for 4 weeks
- National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI): total score and subscales evaluated (pain, urinary symptoms, quality of life)
- After 2 sessions (1 week): significant improvements were already seen in pain, quality of life and total score (significantly greater than the control group)
- After 8 sessions (4 weeks): further significant increases in all areas (pain, urinary symptoms, quality of life, total score)
- All improvements were maintained 8 weeks after ESWT had finished
Benign Prostatic Hyperplasia (refractory)
Benign prostatic hyperplasia (BPH), also known as prostate gland enlargement, occurs naturally as men get older, but sometimes the prostate becomes so large that it impacts on urinary function(15). As the prostate grows, it leads to: squeezing of the urethra, thickening of the bladder walls, weakening of the bladder, and increased post void residual volume (urine left in the bladder after urination)(15). It is non-cancerous, and has not been linked to the risk of prostate cancer. From 50 years old, if affects 50% of men, and the prevalence increases by 10%/decade, with 80% of men in their 80’s affected(16).
It is thought to be caused by changes in hormones, that trigger prostate cell growth, but this is not clear. To prevent the condition, it is advised to maintain a lifestyle that does not lead to increased hormone levels: less body fat, good diet of fruits/ vegetables, and staying active(15). Previous treatment options included: lifestyle modifications, medications (not great efficacy and side effects), or surgery when other management fails/prostate to large (but has a much greater risk of serious side effects)(16). ESWT has shown to have no serious side effects and provides the following benefits(16):
- Dosage: 1 session/week for 8 weeks
- Urinary symptoms, measured by the “international prostate symptom score” (IPSS): from 28.1 (severe symptoms) to 16.7 (moderate symptoms)
- Quality of life improved by 56%
- Erectile function, measured by the “international index of erectile function” (IIEF): from 11.9 (moderate ED) to 20.5 (mild ED)
- Urinary flow rate increased from 9.7ml/sec to 15.8ml/sec
- Post void residual urine volume reduced from 114.2ml to 34.1ml
- Subjectively: some participants reported smoother urination and improved urine waiting symptoms on the same day or next after ESWT
Hard Flaccid Syndrome
Hard flaccid syndrome (HFS) is a very new condition that is poorly understood, and does not have a formal evidence based definition. It is characterised as a painful chronic condition where the penis is semi-rigid in its flaccid state, and has a loss of rigidity when erect(18). Evidence on HFS has mostly been gathered from online forums of people discussing their presentations, as well as through very few case studies(18,19).
Most cases begin with a traumatic event (incident with vacuum erection device, rough masturbation, masturbation incident, sex incident, jelqing), with symptoms then beginning anywhere from minutes to weeks after the event. Along with emotional stress from the condition, sufferers also report: decreased sensitivity (cold/numb); erectile dysfunction with reduced nocturnal/morning erections; penile/perineal pain with urination or ejaculation; requiring excessive physical/visual stimulation to achieve erections; spasm/tightening in the pelvic floor musculature; and more uncommonly associated urinary symptoms(18). Prevalence of the condition has not been assessed yet, but most cases are from men in their second and third decades. Imaging and blood tests all appear normal.
Differential diagnoses to HFS that may appear similar are: high-flow priapism and non-erection erections. High flow priapism occurs when the arteriovenous fistula ruptures from penetrative or blunt trauma: confirmed by a doppler ultrasound scan. Non erection erections are usually a congenital condition, whereby there is a deficiency or absence of the penile suspensory ligament, leading to reduced elevation of the penis with erections(18).
Appropriate treatment for HFS is still being tested, with very few case study evidence available. 3 case studies utilised PDE5i medications, which all did not result in return to erectile function. However, 1 case study involving PDE5i medication with shockwave therapy demonstrated very promising results(19):
- Dosage: 1 session/week for 6 weeks, along with PDE5i medication
- Complete resolution of symptoms, back to normal erectile function
- Symptoms started to return at 6 months, and he was given another course of ESWT
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10. Wu SS, Ericson KJ, Shoskes DA. Retrospective comparison of focused shockwave therapy and radial wave therapy for men with erectile dysfunction. Transl Androl Urol. 2020 Oct;9(5):2122–8.
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12. Kim S-C, Lee Y-S, Seo K-K, Jung G-W, Kim T-H. Reasons and predictive factors for discontinuation of PDE-5 inhibitors despite successful intercourse in erectile dysfunction patients. Int J Impot Res. 2014 May;26(3):87–93.
13. Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J Gen Pract. 2004 Nov 1;54(508):819–25.
14. Salama AB, Abouelnaga WA. Effect of radial shock wave on chronic pelvic pain syndrome/chronic prostatitis. J Phys Ther Sci. 2018;30(9):1145–9.
15. Benign Prostatic Hyperplasia (BPH): Symptoms, Diagnosis & Treatment - Urology Care Foundation [Internet]. [cited 2021 Nov 11]. Available from: https://www.urologyhealth.org/urology-a-z/b/benign-prostatic-hyperplasia-(bph)
16. Zhang D, Wang Y-L, Gong D-X, Zhang Z-X, Yu X-T, Ma Y-W. Radial Extracorporeal Shock Wave Therapy as a Novel Agent for Benign Prostatic Hyperplasia Refractory to Current Medical Therapy. Am J Mens Health. 2019 Jan 1;13(1):1557988319831899.
17. Benign Prostatic Hyperplasia (BPH) [Internet]. Perth Urology Clinic. [cited 2021 Nov 11]. Available from: https://perthurologyclinic.com.au/what-we-do/general-urology/benign-pros...
18. Abdessater M, Kanbar A, Akakpo W, Beley S. Hard flaccid syndrome: state of current knowledge. Basic Clin Androl. 2020 Jun 4;30:7.
19. Gul M, Towe M, Yafi F, Serefoglu E. Hard flaccid syndrome: initial report of four cases. Int J Impot Res. 2020 Mar 1;32.