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

Abstract

Introduction: Low-intensity shockwave therapy (LISWT) has been investigated for the treatment of uroandrological disorders including erectile dysfunction (ED), Peyronie's disease (PD) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) with controversial findings. Aim: To review the evidence on LISWT for ED, PD, and CP/CPPS and provide clinical recommendations on behalf of the European Society of Sexual Medicine. Methods: Medline and Embase databases were searched for randomized clinical trials (RCTs), meta-analyses and open-label prospective or retrospective studies investigating the effect of LISWT on ED, PD, or CP/CPPS. Outcomes: The panel provided statements on clinically relevant questions concerning LISWT: (i) treatment efficacy, (ii) treatment protocol, (iii) clinical indications, and (iv) safety. The level of evidence was provided according to the Oxford 2011 criteria and graded using the Oxford Centre for Evidence-Based Medicine recommendations. Results: 11 RCTs and 5 meta-analyses investigated LISWT for ED. RCTs provided controversial results on the efficacy of LISWT and were affected by high heterogeneity and the small number of patients included. Pooleddata analysis showed an overall positive effect in terms of erectile function improvement but reported small estimates and included a largely heterogeneous cohort of patients. 4 RCTs and 1 meta-analysis assessed LISWT for PD. All trials showed positive findings in terms of pain relief but no effect on penile curvature and plaque size. Inclusion criteria vary widely among studies, and further investigation is needed. 5 RCTs investigated LISWT for CP/CPPS. Data showed a possible effect on pain relief, although there is no evidence supporting that pain relief was maintained or any improvement in pain over time. Clinical Implications: LISWT needs to be further investigated in the context of sexual medicine and is almost but not yet ready for clinical practice. Strengths and limitations: All studies have been evaluated by a panel of experts providing recommendations for clinical practice. Conclusions: LISWT is a safe and well-tolerated procedure but its efficacy for the treatment of ED is doubtful and deserves more investigation. Patients reporting pain associated with PD may benefit from LISWT, although no effect is expected on disease progression. LISWT is not a primary treatment for CP/CPPS, but it may be

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

“…There was no significant morphologic change in fibromas on ultrasonography, with the exception of reduced thickness, and there was no case in which the fibroma was completely resolved after ESWT. This result is similar to previous reports on penile fibromatosis, in which ESWT is unlikely to reduce the size of the fibroma [14,15,23]. There are only two reports that ESWT reduced size of penile fibroma and improved penile curvature [17,18].…”

“…Extracorporeal shock wave therapy (ESWT) has been used as a safe alternative treatment for chronic refractory musculoskeletal disease, such as plantar fasciitis Achilles tendinopathy and gluteal tendinopathy [10][11][12][13]. Previous studies have shown that ESWT also can be therapeutically applied to various forms of fibromatosis such as penile fibromatosis [14][15][16][17][18][19] and palmar fibromatosis [20][21][22] to reduce pain and soften nodules, although it did not affect the physical size of the nodules [3,15,16,19,23].…”

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

“…Most published studies did not extend beyond 2 years follow-up, and one study that reviewed patients at 4-year follow-up [43] showed that the observed clinical improvement is not sustained and deteriorates at 48 months after completion of LIESWT. The pooled data from meta-analyses including randomized controlled trials showed an overall positive effect in terms of IIEF-EF score improvement, although the estimates are small (ranging from about 2 to 4 points of the IIEF-EF) and the heterogeneity high [44]. Additionally, the combination of LIESWT and adjunctive therapy such as oral PDE5i appeared to be more effective than a single-agent therapy [45].…”

“…No patients reported significant penile pain or required analgesia during LIESWT session. To date, treatment-related adverse events have been reported in published clinical trials as well as systematic reviews and meta-analyses [31,32,34,[39][40][41][42]44]. Furthermore, there is no reported drop-out rate during LIESWT due to treatment-related adverse events.…”

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

“…There are several national and international organizations that have published guideline recommendations surrounding LiSWT including the AUA (2018), Asia-Pacific Society for Sexual Medicine (APSSM; 2020), European Society of Sexual medicine (ESSM; 2019), and European Association of Urology (EAU; 2020) (3,(58)(59)(60). All organizations acknowledge LiSWT as a potential treatment for ED with promising early clinical studies.…”