Dear Dr. G,

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

I am in my late thirties and have been married for nearly ten years.

My life could not be more wonderful when we first got married two years ago.

However, the nightmare started when I was having persistent inability to maintain erection during intercourse.

My wife was very sad and asked me to seek help from a urologist.

The shocking news is that I was diagnosed with Erectile Dysfunction and was put on the blue pills at such a young age.

I was very sceptical about the treatment but went ahead trying the pills.

Indeed, the pills work, and I am so shocked as I am completely dependent on the pills to have sex at such a young age.

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

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

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

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

I hear 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?


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 to 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, however the corrections of ED with young men presenting with non-communicable diseases also worrying.

Erectile Dysfunction can also be considered a 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.

The first line of treatment for ED is medications known as Phosphodiesterase 5 Inhibitors (PDE5-I) since the introduction in 1998. These medications work by persistently dilating the vessels supplying blood to the penis after sexual stimulation. The medications are known to have 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 1980s. The therapy was initially introduced for urinary stone fragmentation and now become first-line minimal invasive intervention. The utilisation of such technologies has been replicated in various medical specialities, such as orthopaedics and rheumatology. The principles of shockwaves have also been applied in cardiology. The effects of the shockwaves had been observed to induce the long-term impact of vasodilation and the formation of new capillaries in the treated tissues. This has 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 microtrauma, which in turn stimulates the release of angiogenic factors for the formation of new blood vessels and perfusions.

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 the erectile function of men who respond to medications. The treatment regime ranges between six to twelve courses and is 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 following the introduction of LI-ESWT as the treatment option for ED sees the development of newer generations of machines. Different treatment regimens aiming at different demographics of patients were also rolled out. Sadly, many of the studies involve a small number of patients with only 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 meaningful analysis for shockwave treatment to be considered a long-term solution for the treatment.

The professor of moral philosophy at the Academy of Geneva, Henri Federic Amiel once said: “Without passion man is a mere latent force and possibility, like the flint which awaits the shock of the iron before it can give forth its spark”. The shock wave treatment of penis to “bring back the life” of sexual function has generated passions in enthusiastic clinicians and patients. Although the publications have been promising, the success of the treatment is still dependent on men to alter their lifestyle without causing further vascular compromises to the penis. Enthusiastic men eager to have shockwaves bringing 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, therefore the real flint which awaits the shock of the healthier life before it can give the penis forth its spark!”. Let’s hope the shocks can prove to generate lasting sparks that will keep the fire of passion burning forever.

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