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Erectile Dysfunction: A quick stop 101 guide

This article will highlight such causes of erectile dysfunction, as well as discuss the old and new in terms of treatment and symptom management.

Shockwave Therapy Urology Blog

Sometimes it’s challenging to ignore the stigma. Being able to engage with the issue and educate yourself on the various causes and treatment options available is important, yet overlooked. This article will highlight such causes of erectile dysfunction, as well as discuss the old and new in terms of treatment and symptom management.

What is Erectile Dysfunction?

Erectile dysfunction (better known as ED) is defined as the persistent inability to attain and maintain an erection sufficient to allow for satisfactory sexual performance. A multitude of studies that span China, the US, Germany, and Brazil demonstrate that erectile dysfunction affects 16-40% of the adult male population, with an astonishing approximation of 150 million new cases reported every year.

Yes, older men are more likely to develop ED. But surprisingly, the condition itself can develop at any age. For example, one Italian research project showed that one in every four patients seeking help for ED is under the age of 40.

Additional research also suggests that erectile dysfunction is only becoming more and more common, with scientists at The Boston University School of Medicine estimating there will be 322 million new cases per year by 2025 – an increase of nearly 170 million cases of ED per year. Therefore, as expected, prescriptions for oral PDE-5 inhibiting medications – such as sildenafil, tadalafil, and vardenafil – are too on the rise.

Medication is just one way to produce and maintain an erection, but you may also be able to tackle erectile dysfunction by making changes to your lifestyle, or interestingly, exploring some of the latest evidence-backed procedures such as linear focused shockwave.

Erectile dysfunction is a complex issue that may link to a number of different health conditions. Such being: cardiovascular disease, hypertension, or multiple sclerosis to name a few. BUT, a few of the more concerning causal influences are ones that WE can work on, i.e. overconsumption of alcohol, obesity, smoking, and drug use. Let’s look at this in more detail.

So, what causes ED?

Erections are complicated, a result of a complex synergy between blood vessels, the nervous system, hormones, and muscles. They develop as part of a multistage process that starts when mental or physical stimulation prompts your central nervous system to release nitrous oxide. Nitrous oxide encourages the widening of the arteries, allowing blood to infuse into the soft tissue lining.

Since it relies on the vascular, endocrine, and central nervous systems, many health conditions can impede this process, including:

  • Atherosclerosis, causing the narrowing and hardening of your arteries, limiting the amount of blood that can reach your penis.
  • Diabetes, affecting both the blood supply and the nerve endings.
  • High blood pressure, which can again damage the arteries.
  • Multiple sclerosis, which affects your central nervous system.
  • Parkinson’s disease, which affects your brain’s ability to release the necessary hormones.
  • Nerve or spinal injury.
  • Hormonal conditions, such as hyperthyroidism or Cushing’s syndrome.
  • Peyronie’s disease, affecting the penile tissues.

Certain medications are known to cause temporary erectile dysfunction in men, including antihypertensives, diuretics, antidepressants, antihistamines, and medications that contain steroids, among others.

Again, it is essential to stress that several modifiable lifestyle factors are also connected to erectile dysfunction, including:

  • Smoking
  • Obesity
  • Lack of exercise
  • Recreational drug use
  • Excessive alcohol consumption

Many risk factors are shared with cardiovascular disease (CVD), such as some of the above lifestyle factors (smoking, lack of exercise, obesity) as well as others, like diabetes mellitus, high cholesterol and hypertension. It is crucial to note that ED is often an early warning sign for cardiovascular disease. So, if you are struggling to get or maintain an erection, you should always see a doctor to rule out or treat any underlying conditions like cardiovascular disease prior to addressing the ED itself.

Psychological conditions, including: depression, anxiety, stress, and relationship issues are also linked to persistent problems with erectile dysfunction.

What treatments are available?

ED can be addressed at any age, and there are a number of medical and nonmedical treatment options out there to explore. Medications always carry a risk of side effects, so it’s important to work with a health care provider to understand your risks before starting any medical treatment. Let’s highlight a few of those currently available:

  • Oral medications, like Sildenafil (Viagra, Revatio), Tadalafil (Cialis, Adcirca), Vardenafil (Levitra, Staxyn), and Avanafil (Stendra). PDE-5 inhibitors enhance the effect of nitric oxide within the body, relaxing muscles and increasing blood flow. However, they will not automatically cause an erection – sexual stimulation is necessary to release such nitric oxide from penile nerves. It’s important to note that such medications can cause undesirable side effects.
  • Alpostadil self-injection, produces an erection that lasts about half an hour.
  • Alpostadil urethral suppository, involving the placement of a suppository within the penis via the urethra using a special applicator. This causes an erection that usually starts within 10 minutes and lasts between 3 to 60 minutes.
  • Testosterone replacement. If the ED is caused by low levels of testosterone, replacement is the recommended first step, and can be accomplished through topical gels, creams, patches, underarm applications, or injections.
  • Penis pumps. These are legitimate medical pumps that pull blood into the penis, using a tension ring around the base to keep the blood where it needs to be.
  • Penile implants, which involve surgically placing an inflatable device into both sides of the penis. This is only recommended after trying other available methods.
  • Psychological counselling can help address underlying mental issues.
  • Blood vessel surgery. Although it is a rare cause of ED, leaking or obstructed blood vessels can be repaired with surgery… at a cost.
  • Linear focused shockwave therapy. Let’s look at this in further detail.

What is Linear-Focused Shockwave Therapy?

Linear focused shockwave therapy is a non-invasive procedure for the treatment of vascular ED and other urological conditions, including Peyronie’s disease and chronic pelvic pain syndrome. It is a first-line therapy in the EAU guidelines, based on sufficient evidence.

The device delivers ‘acoustic shockwaves’ into the tissue. Acoustic shockwaves are characterised as a strong, acoustic pulse with an extremely short rise time of only a few nanoseconds. After a brief moment of negative pressure, the pressure returns to normal. The focused shockwaves used here reach their highest point of pressure precisely in the target trauma tissue.

How does it help?

The targeted mechanical stimulus promotes the biological self-healing processes. On closer inspection, improvement of the erectile function is the result of a number of shockwave effects. Mechanical stimuli influence cellular functioning in living tissue, e.g. cell growth, differentiation, migration, protein synthesis, physiological apoptosis, and tissue necrosis. Mechanical stressors are capable of inducing biochemical changes, affecting gene expression at a molecular level – exciting certain tissue reactions when selectively applied.

The term is often referred to as mechanotransduction.


  • Promotes angio-genesis (development of new blood vessels) in the penis which means that the blood flow to the penis increases, hence stronger erections are achieved.
  • Rejuvenation of penis smooth muscle – the majority of patients suffering from ED do so because the smooth muscle in their penile arteries has been damaged, inhibiting the functioning of the veno-occlusive mechanism. Shockwave therapy has been shown to induce the body to repair the smooth muscle in the penis and thus improve the function of the veno-occlusive mechanism.
  • Induced release of growth factors.
  • Stimulation of fibroblast proliferation.
  • Stimulation of local blood flow and suppression of pro-inflammatory processes.
  • Neovascularisation.
  • Antibacterial effect.
  • Stimulation of mesenchymal stem cell migration.

LSTC-ED (Linear) Technique

For the first time, a system named PiezoWave2 encompasses a new linear LSTC-ED (linear shockwave tissue coverage) technique. This has improved application, providing immediate and long-term results with research exhibiting effectiveness in 81.3% of patients.

Treatment of Erectile Dysfunction with PiezoWave2 Device. Application of Low-Intensity Shockwaves Using Novel Linear Shockwave Tissue Coverage (LSTC-ED®) technique. A Prospective, Multicentric, Placebo-controlled Study.

Dr. Motil I. 1, Dr.Kubis I. 2, Dr. Sramkova T. 3

Are results permanent?

The biological effects of shockwave therapy are permanent and have been established on a scientific level. However, erectile dysfunction depends on the lifestyle of patients and is usually a symptom of underlying health issues which lead to ED. Because ED usually gets worse in patients with comorbidities, this means that the improvements after the treatment might be reversed over time if the underlying conditions are not addressed.

Non-medical Treatment Options

Please note that medical treatments are not the only solution for ED. There are plenty of lifestyle modifications and alternative methods that can have huge positive impacts, including:

  • If you’re a smoker, quit now.
  • Monitor and maintain a healthy weight.
  • Exercise daily.
  • Get ample adequate sleep.
  • Try Kegel exercises to strengthen the pelvic muscles – they are not just for women. And stick with it. Exercises must be done consistently for several months in order to see benefits.
  • Seek help for alcohol or drug-related problems.
  • Consider relationship counseling for existing or underlying problems.
  • Talk to a specialist about nutritional supplements including amino acid arginine, bioflavonoids, zinc, vitamin C, vitamin E, and flaxseed meal, which have been used to improve erectile function.
  • Herbal remedies like Asian ginseng, Yohimbe bark, and Ginkgo biloba may also help, but it’s important to consult with a provider before taking them to ensure they’re safe, as supplements are not always properly regulated.
  • Acupuncture has also been shown to help.

Remember, occasional impotence is more common than many men realise, but chronic ED can be a sign of something serious. Talk to your provider about your symptoms and any treatment option you may be considering.

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