–Trost Commentary and Key Take-Aways–
Shock wave therapy has recently become in vogue as an alternative treatment option for PD. However, patients need to recognize that there really are no consistent data demonstrating any benefits. The American Urological Association and the Sexual Medicine Society of North America both have position statements that indicate that shock wave therapy either doesn’t work at all to correct issues such as deformity / curvature or should be considered purely experimental at this time. In my clinical experience, I have seen more cases of PD activated by shockwave than I ever have heard from men who feel that it improved their condition in any way. So, at the present time, and pending new data, we strongly recommend against shockwave therapy in men with PD.
Low-intensity extracorporeal shockwave therapy (Li-ESWT) was first introduced as a treatment for Peyronie’s disease (PD) in 1989 by Bellorofonte and associates but ended up being rejected because of substandard results during trials. However, it has returned recently as a treatment for erectile dysfunction and a web search revealed that it is sometimes being used by practitioners to treat Peyronie’s disease as well. The purpose of this article is to explore the role of Li-ESWT in Peyronie’s disease and suggest future research.
Mechanism of Action
Peyronie’s disease is a tunica albuginea disorder from the formation of fibrous plaques that cause pain and penile deformity. When shockwave therapy was first attempted for the treatment of Peyronie’s disease, Bellorofonte et al anticipated that the shockwaves would break down plaques, but the trials suggested that its affects were more subtle by upregulating growth factors and recruiting progenitor cells. This may lead to neoangiogenesis and tissue regeneration to reverse fibrosis, but theoretically Li-ESWT also induces transforming growth factor-b, which could encourage plaque development possibly inducing or exacerbating Peyronie’s disease.
The initial case series showed positive results, including a reduction in curvature of up to 60% and pain reduction. However, the many limitations of these studies must be taken into account including, differentiation of treatment parameters, devices and settings, it was unblinded with a high risk of bias, evaluations were self-photographed and division of active and stable phase was misleading. Because of the unreliability, 3 randomized control trials were done with very disappointing results, including worsening of curvature in some.
Non-invasive treatment options are always an ideal choice for the patient, the high-quality studies had such discouraging results that it was abandoned as a treatment option. With many positive case studies and few negative randomized control trials, more well-designed trials are needed. But positive trials or not, Li-ESWT is making its way into clinical practice as a treatment for Peyronie’s disease. If offered, it should be limited to those with clinically significant and persistent pain who do not respond to over-the-counter medications. Some argue that a lack of documented side-effects determines it should be exempt from proven efficacy. But this is refuted with the possible induction of transforming growth factor-b, and the high cost and time commitment involved.
Time will tell if the revival of Li-ESWT for erectile dysfunction is supportable, but for Peyronie’s disease, there is little to no evidence that it provides benefit for curvature and should not be prescribed at this time. This is in accordance with the American Urological Association and the European Association of Urology guidelines. If new treatment protocols suggest other outcomes that previous trials, they should undergo rigorous evaluation in sham-controlled trials and should be limited to patients in active phase, when its effectiveness is most likely to occur.