Shock wave therapy (ESWT) in Peyronie’s disease

Shock wave therapy in Peyronie's disease

Peyronie ‘s disease (or Induratio Penis Plastica , “ PPI ”) is a not too rare disease that involves the formation of a fibrous plaque in the tissue surrounding the corpora cavernosa of the penis. This tissue (which is called tunic albuginea ) normally has high elastic capacity and therefore allows the penis to change its size during erection without creating tension. The presence of fibrosis in a point of the tunic albuginea causes the loss of elasticity of this area with consequent retraction of the penis and the appearance of a curvature in erection .

The most frequent clinical manifestations of this disease are represented by:

  • pain in erection,
  • deviation of the penis in erection,
  • reduction in the length of the penis,
  • erectile deficit .

For more details on the alleged causes and anatomical changes related to this pathology, please refer to a previous article . Here we only recall the existence of two distinctly separate phases of Peyronie’s disease:

  1. A first inflammatory phase (or acute phase) – which can last several months – in which there is usually pain in erection and the curvature of the penis tends to progressively accentuate.
  2. A second fibrotic phase (or chronic phase) in which the inflammatory process is exhausted, the pain disappears, the plaque becomes very hard to the touch and the curve of the penis stabilizes without further deterioration.

The precise classification of the patient with PPI in relation to the clinical phase of the disease in progress is very important for the choice of treatment: in the chronic phase the therapy is in fact almost exclusively surgical; in the initial phase, conservative therapeutic solutions can be considered, including shock wave treatment .

Hints on shock waves and their mechanism of action:

Shock waves are mechanical waves (similar to acoustic ones) capable of propagating in a medium. Their interaction with the blood capillaries favors the release of particular substances (called “growth factors”) responsible for the formation of new blood vessels, with a consequent increase in local vascularization. This process of ” neo-angiogenesis ” and blood hyper-influx would involve a series of chemical modifications at the level of the PPI plaque that would ultimately lead to the inhibition of the inflammatory process in progress. The anti-inflammatory action of the shock is able to reduce the pain typical of the acute phase and would also seem effective in decreasing the size of the plaque itself and avoiding a worsening of the penile curvature in erection.

The neo-angiogenic mechanism of action of shock waves is at the basis of their therapeutic use even in patients with erectile deficit (or impotence): the increase in the capillary network at the level of the corpora cavernosa facilitates the vasodilation process which is at the basis of the phenomenon of erection itself.

Efficacy and Safety of Shockwaves in Peyronie’s Disease Therapy:

In the recent past, an analysis was conducted of the studies present in the urological scientific literature in which this method was evaluated in the therapy of Peyronie’s disease. This “meta-analysis” made it possible to verify the results obtained in over 400 patients present in 6 different scientific studies. Statistical analysis has shown how the use of shock waves in the initial phase of the disease has a real action in reducing the size of the fibrous plaque and penile pain . On the contrary, the use of shock waves in patients with stabilized PPI did not bring any benefit in terms of reduction of penile curvature. The study also confirmed the extreme safetyof this method: in none of the treated patients there were significant complications or particular side effects .

When to use shock waves:

On the basis of what has been said, it is very clear how shock wave treatment is to be used in the initial phase of Peyronie’s disease, during which the plaque is still in an evolutionary and progressive phase. In this stage, shock waves can play an important role in speeding up the exhaustion of the inflammatory processes that are underway within the plaque itself. This leads to the disappearance of pain and the reduction in size of the plaque.

In practice, the transition to the chronic phase of the disease is speeded up, favoring an early stabilization of the plaque and thus avoiding further worsening of the curvature of the penis in erection.

The efficacy in the acute phase of the disease seems to increase when the shock waves are used in the context of “multi-modal” therapeutic protocols together with other conservative treatments. These may include some oral drugs (such as vitamin E, carnitine, pentoxifylline and tadalafil) or locally acting (such as calcium channel blockers, interferon or hyaluronic acid). In some patients subjected to these multimodal treatments early, there have also been real reductions in the penile curvature itself. However, further scientific studies are needed to verify the real effectiveness of these composite treatments.

In contrast, in patients with chronic Peyronie’s disease and stabilized curvature, proposing shock wave therapy is only a waste of time and money. At this stage – to achieve a significant reduction in penile curvature in erection – surgical treatment should be considered. Until the end of 2019 there was a single alternative to surgery and it was represented by injection therapy based on collagenase (a drug called “Xiapex” – the subject of this previous article – capable of “dissolving” the fibrous plaque even in the stabilized phase). To date – unfortunately – this drug is no longer on the market.

How shock waves are applied:

The shock wave treatment is outpatient , lasts about twenty minutes and does not require any preparation or anesthesia (since it is completely painless ).

A particular handpiece is used – connected to the shock wave generator – which is placed on the surface of the penis near the IPP plate.

Depending on the generator used, the number of strokes applied can vary from 2000 to 3000 per session. Generally a complete cycle includes 6 applications at weekly intervals .

The costs of the treatment:

Unlike kidney stone shock wave treatment (ESWL), penile shock wave therapy for erectile deficit or Peyronie’s disease is not reimbursed by the National Health System. A complete cycle of 6 applications at our clinics has a total cost of 720 euros (120 euros per session). For more information, you can send an email to the address you find at the bottom of the page.

Conclusions:

Shockwave therapy can be used in patients with early stage Peyronie’s disease where it can reduce penile pain and plaque size. This leads to an early stabilization of the plaque and therefore avoids the progressive worsening of the penile curvature in erection, typical of this disease. The effectiveness of shock waves seems to increase when used in the context of multimodal therapeutic protocols. In these situations, ESWT – if used early – could in some cases also lead to a certain reduction in the curvature of the penis. It is an outpatient method, completely painless, without contraindications and side effects. It should not be used in patients with PPI in the stabilized phase, where it has no ability to reduce penile curvature.

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