Dear Dr. G,

I am hoping you can help me with my bedroom dilemma.

I am in my late twenties and recently married.

My life couldn’t have been more wonderful when we first got married two years ago.

However, it is now a nightmare as I have a persistent inability to maintain an erection during intercourse.

My wife is very sad and has asked me to seek help from an urologist, and the shocking news is that I have been diagnosed with erectile dysfunction (ED) and have been put on the blue pills.

I initially didn’t believe him but went on trying the pills.

Indeed, the pills work and I am so shocked that I am completely dependent on the pills to have sex at the young age of 29.

I would like to put Dr. G on the spot to find out why I have such a problem.

First, can you explain how doctors diagnose ED?

I often consider this to be an old man’s disease, so how can it affect a young man like me?

What are the causes of ED amongst youth? Can it be stress?

Lastly, I understand the pills work for me and I should be grateful. However, I am looking for a curative solution.

I have heard that shockwave therapy is a new technology that can potentially cure ED.

Can you tell me what is the scientific basis of shockwave therapy, and whether this can be my long-term solution for a sex life without a pill?

Regards

Shocked Shaun

Erectile Dysfunction, more commonly known as ED, is defined as the inability to achieve or maintain erectile rigidity for satisfactory penetrative intercourse. The World Health organization (WHO) estimates ED to affect more than 500 million men in 2025. The Malaysia Health and Morbidity Survey 2019 revealed one in three men admitted having ED.

The more shocking news is that 36.9% of young men aged 18 to 29 also admitted to such sexual dysfunction. Although some may consider this to be over-reporting, the correction of ED with young men presenting with non-communicable diseases is also worrying.

ED can also be considered to be the precursor of many cardiovascular diseases. Non-communicable diseases such as diabetes, dyslipidemia, hypertension and obesity are well known to be associated with ED. Such risk factors are also recognized to affect younger generations in many countries.

Other predisposing factors for ED affecting the youth also include depression, smoking and excessive alcohol consumption. Therefore, it is not surprising ED can also be prevalent in young men.

Since their introduction in 1998, the first line treatment for ED are medications known as Phosphodiesterase 5 inhibitors (PDE5-I). These medications work by persistently dilating the vessels supplying blood to the penis after sexual stimulation. The medications are known to have an efficacy as high as 80%, especially amongst younger individuals with milder risk factors. Despite such success rates, it is not uncommon for men to look for more permanent solutions.

Shockwave treatment in medicine is a treatment modality that has been well established since the 1980’s. The therapy was initially introduced for urinary stone fragmentation and now becomes first line minimal invasive intervention. The utilization of such technologies has been replicated in various medical specialties, such as orthopedics and rheumatology. The principles of shockwaves have also been applied in cardiology.

The effects of the shockwaves have been observed to induce the long-term impact of vasodilation and formation of new capillaries in the treated tissues. This had led to the promising potential of such applications in patients with occlusions in the coronary arteries.

Low-intensity extracorporeal shock wave therapy (LI-ESWT) as a novel modality for the treatment of ED was first introduced in 2010, literally shocking the penis back to life. Unlike the current treatment modalities such as medications, LI- ESWT aims to restore the erectile mechanism in order to enable the natural and spontaneous erection with the formation of neovascularization. The intensity of the shock waves is one tenth of what is used in kidney stone fragmentation, and this has the impact of cellular micro trauma, which in turn stimulates the release of angiogenic factors for the formations of new blood vessels and perfusions.

In the first randomized, double blind, sham controlled study on ED patients demonstrated that LI-ESWT had a positive short-term clinical and physiological effect on erectile function of men who respond to medications. The treatment regime ranged between six to twelve courses, and was generally well-tolerated by the patients. Although the outcome of the therapy is promising, this is quite variable on the severity and etiology of ED.

Twelve years after the introduction of LI-ESWT as the treatment option for ED, there are newer generations of machines and different treatment regimens aimed at different demographics of patients were also rolled out. Sadly, many of the studies involve a small number of patients with only a short-term follow-up. Although all the studies have the common aim to fine-tune the ideal treatment strategy for men with ED, the heterogeneity of the studies really makes it impossible to make a meaningful analysis for shockwave treatment to be considered a long-term solution for the treatment of ED.

The shockwave treatment of the penis to “bring back the life” of sexual function has generated passion in enthusiastic clinicians and patients. Although the publications have been promising, the success of the treatment still depends on men to alter their lifestyle without causing further vascular compromises to the penis.

Enthusiastic men eager to have a shockwave bring back the sparks between the sheets often put Dr. G on the spot for opinion. His view is: “Without the passion of lifestyle changes, the shockwave treatment is a mere latent force and possibility!”

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