ESWT (Penile Shock Wave Therapy)

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The concept of shockwaves has been present since the time the universe was created, but it was not until the 19th century that the concept of shock tarted to play a role in the medical field.

ESWT is a form of shockwave therapy using low-range acoustic waves to expose any part of the body, including soft and hard tissue, to exert a therapeutic effect. In the 1960s, it was discovered that ESWT could break kidney stones (>100kv), and further technology using an electrical capacitator to produce electromagnetic shockwaves was then produced.

On the other hand, the concept of ESWT is using needle electrodes which are placed directly in the stone to generate the shockwaves. With the advancement of piezo technology and the material used to create it, the focal point of ESWT advanced from focal to point alignment.

ESWT also produces low-frequency pulse energy and has a fast pulse rise time. In combination with the absence of significant energy absorption by the tissue, the pulse maximum pressure is generated at the front. When this pressure wave reaches a point where the fluid is under tension as a result of high tensile strength, cavitation occurs.

The negative pressure peak of shockwaves lasts only a few microseconds and has a maximum pressure of a few millibars. Due to this low pressure, no damage is thought to occur as a result of cavitation. With the enlargement of the focal point in the direction of the force, the created bubbles stretch and compress the surrounding tissue, thereby increasing the local microcirculation.

As the bubbles expand and then compress, the surrounding tissue is stretched and then compressed, producing tensile and compressive forces which increase local blood flow and tissue function.

Definition and Mechanism of ESWT

With the development of technology, particularly the advances in piezoelectrics, it has become possible to generate shock waves of different strengths and qualities. As of today, it is known that the shock wave has several tissue effects.

Extracorporeal shock wave therapy forces the diffusion of nitrogen oxide, and changes in the cellular membrane lead to positive acute effects: analgesia and neo-angiogenesis in the tissue. In the local production of nitrogen oxide due to the shear stress resulting from these bubbles, the inhibition of the Rho-A/Rho kinase pathways was identified as a factor responsible for alterations in cellular membrane permeability after the rapid firing of shockwaves.

The increased transportation of extracellular calcium and the transmission of genetic material to the nucleus. As a result of these changes occurring in tissue, changes in cellular protein expression producing the tissue healing, analgesic, anti-inflammatory, and fibrinolytic effects are achieved.

A cell cascade response initiates the therapy effects provided by hematoma and proinflammatory cytokine production after the rapid firing of shockwaves. Bioactive angiogenesis growth, recruitment of bone marrow endothelial and proangiogenic stem cells, and tissue remodeling arise with cytokine-induced regeneration.

As summarized in Table 1, ESWT can trigger a multitude of gross biological responses, as it acts on the main components of the natural vascular regeneration cascade, enhancing both proangiogenic and stem cell secretomes and guiding local macrophage repolarization. ESWT mainly addresses ischemic symptoms in the heart, kidneys, brain, and hind limbs. In recent years, it has become popular in urology, targeting mainly erectile function through the treatment of Peyronie disease (PD) and men with vasculogenic ED (VED/ED).

Applications of ESWT in Urology

The Application of ESWT in urology is versatile. It generally promotes neovascularization, homing of angiogenic effector cells, and tissue regeneration. Filippi et al. reported the successful effect of ESWT on chronic pelvic pain syndrome cases. Ozturk et al. and Yassin et al. tried ESWT on BPH and successfully found a compatible ESWL regimen with encouraging results.

Kalyvianakis et al. tried ESWT on chronic prostatitis with promising objective and subjective results. Kitrey et al. tried it on chronic pelvic pain syndrome cases and noticed a significant decrease in pain level and International Prostate Symptom Score. These drugs have limited efficacy, and all of them have a variety of concomitant adverse reactions, so there is a certain risk in clinical application.

This article is a comprehensive guide to ESWT in urology, and the aim is to summarize and analyze the research status of common urological diseases concerned with the application of ESWT, so as to comprehensively and systematically identify the clinical application value, safety, effectiveness, and prospects of ESWT.

The abundant distribution of nerves, blood vessels, stem cells, and other crucial regenerative components in the male genital region is of great significance to the occurrence, erection, ejaculation, and sexual satisfaction of the penis. In the clinical phenomenology, a variety of organic erectile dysfunctions can be seen in patients with organic ED.

Orgasmic dysfunctions are actually organic in nature, and failure of penile shrinkage after ejaculation is the main cause of these organic symptoms. Among these erectile dysfunctions, the main etiology is the penile vasculogenic etiology, and insufficient trabecular smooth muscle content and erectile dysfunction are closely related to the production of collagen deposits in the vascular wall.

Diseases Treated with ESWT in Urology

Low-intensity shock wave therapy (Li-ESWT or ESWT) has been used in the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), erectile dysfunction (ED), Peyronie’s disease (PD), and other urological diseases. Clinical effects are attributed to gene/protein expression, suppression of inflammatory response, and enhancement of growth factor signaling.

These treatments help to activate L-arginine/NO, VEGF, VEGF-R, NOS, VCL, and Vim signaling. This results in better hemodynamics, vascularization, better and healthier nerve growth, and suppression of inflammation. Low intensity shock wave therapy is a new degree of freedom in urological diseases, by treating the primary pathomechanism, offering good efficacy, and the chance to revert the histopathology to a non-diseased tissue or organ. In addition, Li-ESWT is low-risk and low-cost with no downtime.

Chronic pelvic pain syndrome is hard to treat, as its etiology is not well understood. Beneficial effects of Li-ESWT may be related to its activation of L-arginine and nitric oxide pathway, which in turn leads to NO-mediated anti-inflammatory and pain-relieving effects. Li-ESWT may also suppress pain signal transmission through nerve fibers in the treatment area.

Several animal studies using nerve staining or nitroxidergic nerve studies strongly support the findings of a significant improvement of Prostatitis/Intervention Score, National Institutes of Health chronic prostatitis symptom index, and pain decrease scores up to 6 months post-treatment. Improvements related to treatment were detected for erectile dysfunction (ED) and benign prostatic obstruction in some studies; however, improvements of overactive bladder symptoms were not noted.

Prospective patient and physician-reported outcome measures showed significant improvement both under double-blind and open-label settings. Across different diseases, therapy settings (e.g., pulse numbers, frequency) and outcome measures (e.g., IIEF, EHS), undisturbed sexual activity and erection, better overall well-being, and disease-specific quality of life improvements are often reported by 45% to 75% of patients according to patient-reported outcome measures and like 5 to 25% better than placebo in double-blind studies.

Advantages of ESWT Treatment

Several comparative studies have shown that only 44% of participants treated with phosphodiesterase type 5 inhibitors (PDE5i) experienced spontaneous penile erection, and 38% were unable to continue treatment due to side effect symptoms, leaving only 18% of patients who experienced some improvement in erection.

The requirement for continuous medication is the largest defect after treatment with PDE5i, but many other defects such as high cost, limited effect in the elderly population, limitation of administration in patients with cardiovascular disease, and cavernous system changes. ESWT is a non-invasive treatment without any side effects, which makes it an increasingly popular alternative therapy.

It is particularly advantageous to focus on the implementation of in-office care, which reduces the discomfort and potential risks of surgical treatment. It also reduces local complications after surgery, such as pain, infection, and bleeding, scarring, penile curvature, and ED. It can be used as a treatment option that is different from oral medication or injections for patient groups who are poorly compliant with recommended treatments.

It can be considered as a preventive treatment for ED in patients at high risk for further development of ED. ESWT can be combined with other ED therapies for a multifactorial and multimodal approach. This combination increases the advantages of the treatment options without increasing the potential negative complications.

Contraindications and Precautions for ESWT

  • Penile shockwave therapy should not be applied in children, adolescents, pregnant women, or nursing women.
  • Contraindications to ESWT should also be considered as local and/or general and should be assessed before initiating treatment.
  • In the local category, contraindications can include cellulitis, ulcers, and neoplasms at the application point.
  • In the broader category, the following contraindications are present: immune suppression, local or general infection at the application site, local or general inflammation, fever, adherence to coralalgic therapy, important cardiovascular pathologies when shock waves involve the field of their influence, including intracavitary thrombosis, stent, pacemakers, and multifocal tumor locations in the same session.

Ultrasound monitoring can increase the effectiveness and safety of ESWT. Clinical studies have reported that the addition of Doppler ultrasound monitoring to shock wave therapy for Peyronie’s disease compliance is associated with greater efficacy in plaque shrinkage and hemodynamics. 

In these studies, ultrasound assessments have reported increases in erectile dysfunction symptoms and penile curvature improvement early in the treatment process in patients undergoing combined treatment compared to shockwave monotherapy. 

However, it is necessary to verify these results in controlled trials. The parameters that could be useful, such as the identification of plaque in the acute phase, the optimal time points, or the optimal frequency of the Doppler ultrasound scans have not been accurately identified due to the lack of evidence.

Cost Considerations: Pricing of ESWT Treatment

The economics of having specialized personnel increase the price, and specialized personnel and high levels of technical expertise are geared to decrease patient dissatisfaction and increase patient wellness.

Creating a competitive market for ESWT should not only favor the quality of the offer but also the cost of the treatment if performed within the reasonable quality standards.

The revision of European directives on medical devices started almost a decade ago. The step ahead of the European Parliament in the recent approval of the Medical Devices Regulation (MDR) is evidenced.

There are no paradoxes in favoring the reclassification and re-evaluation of medical devices and in this same regulation, at the same time, using current and future technologies for treatment

 Instead of increasing the bureaucracy, regulations should use comprehensive standards in terms of wellness in patients. It is therefore important to increase education and monitoring of the application of ESWT and adapt them to a more transparent, safer, and less expensive approach that benefits patient care.

ESWT in Erectile Dysfunction

The mechanism of action of ESWT in ED is not well understood. Despite many theories, it seems that it works via angiogenesis and nerve regeneration. Since the discovery of the efficacy of low-intensity ESWT for vasculogenesis, many studies have shown the real improvement in the corporal tissue without histological changes.

Sufficient evidence confirms increased neoangiogenesis in the ED tissue secondary to injury, as has been proved in a few histological studies. The anatomic changes on how this occurs are the idea of the damage in the endothelium promoting adenosine triphosphate synthesis with subsequent activation of the adenosinergic system and release of local nitric oxide from the endothelium or possibly from the neurons by activating the stem cells.

Matrix metalloproteinases, as a reversible response in the fibrotic phase of tissue repair after micro rupture of the arteries, show a reduction in penile animal tissue resulting in increased elastin and collagen fibers because of a significant increase in transforming growth factor-beta-1 expression.

There is no consensus in the literature about the optimal scheme, except the fact that the results of the scheme with increased intervals are not positive in the same proportion as those with more intense and few shocks. The majority of the clinical studies are capable of demonstrating the efficacy of the shockwave in Erectile Dysfunction for the low-intensity therapy. In a time of significant psychological pressure, shock wave treatment can be a useful intervention that can modify the natural course of Erectile Dysfunction caused by vessel damage.

Mechanism of ESWT in Treating Erectile Dysfunction

Improvement of blood flow in the penis is a common target of all devices aimed at treating erectile dysfunction. However, the methods of increasing the blood flow in the penis and their physiological sequences differ quite substantially, posing theoretical problems in the use of ESWT or devices that are developed from the principle of treating chronic wounds with shock waves.

The physiological and subsequent biochemical sequences of angiogenesis involve many different steps, involving the release of growth factors triggered by the injury of the tissue. Out of several types of growth factors, vascular endothelial growth factors and fibroblast growth factors stand out.

For that reason, ESWT differs in intended use and mechanism of action from photobiomodulation. ESWT, by inducing shear stress and microtrauma (mechanotransduction), leads to angiogenesis in the target tissue by activating genes for different growth factors and promoting the release of said growth factors: endothelium-derived growth factor, β-fibroblast growth factor (β-FGF), vascular endothelial growth factor, and PDGF.

It increases the activity of endothelial nitric oxide synthase and therefore the synthesis of nitric oxide, increasing the blood flow and lowering the blood pressure in the other endothelial and eNOS-dependent systems within the body.

Treatment Protocol: Sessions and Application on the Penis

After a resting phase, the patient undergoes treatment identically to that during the initial phase with the same intensity and energy flow for another 6 weeks. The same exercises have to be performed during the treatment-free intervals that are without ESWT and shock wave exposure.

A total of 12 treatments over a period of 6 weeks resting time take place. Generally, according to the protocol, each patient is treated twice per week to provide an interval of 2–3 days between the individual treatments. An aggregate of 12 EDSWT treatments with a general duration of 15–20 min per session is given.

The interval of 2–3 days between individual treatments has been established as effective in professional practice and is appreciated by the treating institution and by the patients. The correct position of the decolleté electrode is of utmost importance. Published studies described mainly guidelines or original aspects of the protocol and the treatment regimens used.

Accordingly, they varied not only by device and diagnosis, but also, within penis indications, by type of erectile dysfunction, energy, number of pulses delivered and number of series, interval, degree of tumescence, anesthetics use, association with related interventions, and effectiveness and outcome measures.

In general, the clinical success rates are comparably low, and the diversity of the various results impairs hitherto definitive conclusions about the therapeutic effectiveness of EDSWT for enhancement of the sexual experience. Despite possible confound factors, the compiling review especially summarizes critical data and guiding instruments on the abovementioned treatment protocol.

The focused conservative therapeutic application of EDSWT on the erectile tissue of the penis using a well-defined release/release schedule composing a series of pneumatic shock waves with optimal parameters densely applied is referred to as penile low-intensity EDSWT. Established device and evidence of those mechanisms are essential for the safety and effectiveness of LIESWT employed in Urology. For this reason, the shockwave device introduced which confirms established principles is comprehensively analyzed in the docking validation experiments assessing an optimal propagation of low-intensity EDSWT in the human penis.

Advantageous may be the combination of LIESWT with actual assisted sexual medicine in the treatment of category III B CPP/CPPS patients of long-term duration. Although ESWT cannot be considered as first-line treatment modality for this complex problem, inhibition of IL-6 and improvement of NO/cyclic GMP balance along with enhanced penile VA and perfusion in ED enable the antifibrotic and anti-inflammatory action to be more generalized throughout the penis and independent of responsiveness.

Animal studies have provided molecular explanations of these mechanisms in penile tissue and correlated with the restorative effect. Additional to selective denervation during surgical revascularization, LIESWT now becomes a conservative medical treatment. The advantage is to increase the appropriate nNOS activity in cavernous tissues necessary for the potentiation of attenuated erectile potentials.

Currently for LIESWT, a fixed-prostate immersion technique is verified by the prostate-specific membrane antigen-based, prostate-specific labeled verteporfin. For an alternative knee-heel position, standardized penile treatment protocols employing shock-adapted coupling media, such as the OPT phallosan elongation device, can serve as technical preparations of the penis under optimal conditions.

To follow a standardized treatment protocol, select a low-pressure nonfocused shockwave device able to administer pneumatic shock waves of comparable efficacy and stimulation index in a consistent manner. Such a shockwave source enables treatment by up to twice weekly with a 50% to transducer movement to achieve site-specific energy care within the device treatment window characteristic of a physiological zone.

Tips for Maximizing Results in ESWT for Erectile Dysfunction

Before using ESWT for erectile dysfunction, a duplex ultrasound is recommended to confirm the presence of macrovascular etiology. Reduce carbonated beverages. Reduce all cofounding stimulants, including PDE5 inhibitors. Stop smoking.

Reduce alcohol intake. Given the limited data available, point the patient towards a low-fat diet, avoiding sugars and carbohydrates. PACS and it is recommended to avoid blood-thinning supplements such as garlic, ginkgo, horse chestnut, and vina. ESWT on the site of the root of the penis to maintain artery patency and stimulate artery wall growth. Avoiding penile weights that could deactivate the effects of ePulse and ESWT.

Avoiding an overly physical and stretching-oriented treatment to not lengthen the penis excessively. Injury is reduced with post-treatment cooling of the penis. One 15-minute treatment weekly for 4-6 weeks and then a 4-6 monthly maintenance treatment.

ESWT in Chronic Prostatitis

Qin AMD et al. applied ESWT to the perineum and pelvis of patients and proved its effect on chronic prostatitis. Yani-Zlodre et al. used ESWT on the perineum and pelvis of patients and used energy sequentially according to patient tolerance. After 4 times, the results showed that the NIHCPSI value of the ESWT group was 17.07 and 12.78 before and after treatment.

The control group was 16.94 and 13.34, and the difference was statistically significant before and after treatment. The difference between the two groups was statistically significant, indicating that ESWT can clinically and statistically improve the symptoms of chronic nonbacterial prostatitis in terms of pain and voiding symptoms. The ESWT by Yani-Zlodre is four times 1 week apart, with a pressure of 3-4 bars in the perineum and 2-4 bars in the lumbar.

ESWT is also used for chronic prostatitis and endothelial dysfunction caused by BPH. ESWT: 3000 shock waves with density of 300-500 shock waves/cm2 per session for 1 month, a follow-up session of ESWT after six months.

ESWT is also used in closely located tissues. In a study based on literature of 15 years and with a total of 30 patients with type III CP/CPPS, there was a decrease in pain and an increase in MHI-S. However, the improvement obtained was reported as relatively low compared to patient expectations and ESWT duration achieved in erectile function.

Moreover, the therapy’s non-invasive nature and adverse events’ limited number developed increased patient preference. Nevertheless, the patients’ previous experience who benefited from the gradual decrease of 11.9 in the improvement of NIH-CPSI scores just emphasize to be more mindful of the relatively early dissatisfaction of the presented success in the reflection of expectations to treatment in the study with a total of 40 patients with prostatitis.

Impact of ESWT on Chronic Prostatitis

Very few studies have been conducted concerning the impact of ESWT on CP/CPPS. In vitro data suggest that ESWT has pro-migratory and pro-survival effects when applied to certain prostatic cells (e.g. prostate-derived stromal cells and histiocytes) and could modulate neurogenic inflammation in prostatitis via neuropeptide and growth factor release.

In a 12-week analysis by Mariotto et al. reporting the results of a single ESWT application in CP/CPPS (n = 36), the patients documented improvements in NIH-CPSI quality of life (QoL), reduction of pain via VAS, voiding symptoms, and an increase in erectile function. The protocol used focused on 3500 pulses with a total kinetic energy of 0.09 mJ/mm2 on 8 points covering the perineum, the Achilles tendons, and the dorsal foot in order to activate mesenchymal stem cells.

Another study by Barbalias reported treatment of 10 patients with a specifically developed ultrasound-guided protocol right into the prostate. Over the course of 4 weeks, 9 patients demonstrated a significant improvement (P < 0.05) based on NIH-CPSI, uroflowmetry, maximum urine flow, PVR (each P < 0.01), and EBV (P < 0.02), TIGH-T (P < 0.001), and IPSS (P < 0.001). In this group, 2 further ESWT sessions were administered and after 4 weeks of follow-up all parameters had further improved: 8 patients had asymptomatic CP/CPPS and 5 patients had a significantly improved CP/CPPS (4 points better NIH-CPSI compared to controls). In order to make more reliable conclusions, several RCTs with higher case numbers need to be performed.

Recovery Criteria Post-ESWT

The post-ESWT recovery process may be compared to the recovery process of organ injuries. You can explain the recovery process and timeline to the patient, with the following clarifications provided.

  • Sexual activity may be limited. ESWT induces neovascularisation and neovascular endothelial dysfunction, which affords natural erectile function, and a retreatment may be necessary if sexual activity commences too soon. However, the patient should resume sexual activity as soon as possible; doing so may hasten the recovery process and effects.
  • A break for one or two days is enough to return to work or daily operations. However, the patient should rest as much as he feels, and avoiding heavy lifting is beneficial for the healing process. The patient may resume work directly.
  • Light bruising (from slight hematoma or petechiae) on the penis and hematoma on the scrotum is normal and these fade away in a week or two.

In cases of severe pain, hematoma, or edema, suturing has been recommended. Hematoma that does not resolve in normal conditions has been identified as hematocele; this is surgically resolved and the patient is cannulated to facilitate hematoma blood absorption with a small ascending hemiscrototomy and a cannula.

We applied negative pressure drainage near the hematoma to control hematocrit fluid collection. On each occasion, full symptomatic recovery was obtained with resolution of the hematocele.

ESWT in Peyronie’s Disease

Peyronie’s disease (PD) is a localized, fibrosing, and progressive connective tissue inflammation associated with the lesion. Penile curvature, pain on erection, and possibly erectile dysfunction (ED) are frequent clinical complaints.

The exact pathogenesis of PD is still unknown, although it is believed that trauma to the penis has an important etiological role. The rupture of the fibers present in the tunica albuginea exposes the cavernous sinus to the blood and therefore to inflammation. Subsequent hematoma reabsorption leads to disorganization of the damaged fibers and deposition of connective tissue in the affected area.

The overall frequency of penile curvature after surgery in the literature has been reported to range from 3 to 23%. The choice of treatment depends on many factors, including the type of penile curvature, the degree of penile deviation (patients with a stable and moderate deviation receive more conservative treatment), the presence of comorbidities, and the patient’s age and previous erectile function.

ESWT should be performed in an extracorporeal manner by a device located near the patient. This means that the equipment must be located in the same room where the patient is, and the person performing the treatment should not have to leave the room during treatment. Treatment guidelines and the use of energy and frequency settings for each specific condition are important factors affecting the outcome, whether positive or negative.

The current recommendation is that 3 to 5 sessions are performed with an interval of 5 to 7 days. Performing more than one session in a day could lead to muscle swelling and bruising. Local anesthesia is not necessary for any of the conditions treated with ESWT. However, it is a useful practice to suggest that the patient take a painkiller one hour before the session and avoid bowel movements as long as possible after the application. A slight discomfort is generally felt, but it is moderate.

The ESWT technique involves the delivery of 3,000 shockwave shots in a focused manner on the inflammatory point, and an additional 10 shockwave shots in radial mode on the distal partition, both bilaterally. The treated flaccid penis must have an indurative plaque and a sensitive point or deformity or erectile dysfunction.

The third session of ESWT treatment is carried out instrumentally to evaluate the patient’s response to the therapy. The patient is instructed to return to perform ESWT in a week and to undergo 3 sessions. The patient should return for a checkup after an average of one month from the last session. It is necessary to treat both patients whose condition is described as the first treatment and patients with an adamant penis.

SSS

What is ESWT?

Extracorporeal shockwave therapy is a widely known, noninvasive, and very well-tolerated method for treating chronic musculoskeletal conditions such as calcified tendinosis, epicondylitis, plantar fasciitis, nonunions, delayed union of bone fractures, and more recently, myofascial trigger points.

Since its appearance in the early 1970s as a treatment for kidney stones, an extensive amount of research has been performed in an attempt to confirm its microdamage concept for musculoskeletal tissue. However, although shockwaves are used frequently in the treatment of musculoskeletal disorders, the therapeutic mechanism behind this treatment has remained unclear.

This therapeutic technique has recently become more popular and its use has increased because of an advancing understanding of the potential molecular mechanisms that could occur in tissue following exposure to the shockwaves.

The accumulated research data have also improved the understanding of the shockwave and its related physics, the interaction between the shockwave and the biological tissues, and the expected responses from the biological tissues following exposure to the shockwaves. In this chapter, we review the basic physics and generation of ESWT and the possible biological mechanisms of its effect in the context of clinical applications.

How to Apply ESWT?

ESWT is a class of conductive medium extracorporeal shock wave generated by initiating seismic waves deeper within the human body, focusing on the extracorporeal shock source per the requirements of the focusing device and generating an O moves closer to the tissue of interest.

A potential difference is created between the tissue and the medium, causing an electric current to move away from the Geiger sensors, which is recorded again as an electrical signal by the transducer. The depth of the tissue at the focus of treatment is a function of the tactical distance between the transducer and the tissue, the material properties on the transmission path, and the design of the focusing mechanism.

The energy of the shock absorption produced by the original seismic waves during this process induces a non-destructive and non-invasive biological effect that causes tissue regeneration at the receptor, endocrine, and anesthetics. Low to medium level reactions are usually induced. The same principles would seem to apply to the realization of other painless forms.

The initiation of acoustic shock waves in water is essentially a non-electromagnetic effect that can be analyzed in terms of how seismic waves are formed in the ethereal tunnel. The very rapid acceleration of part of the pistol when the shock wave propagates through the focusing region and becomes tumorous and positive-pressure.

The rise of pressure that can be obtained depends on the power supply and the size of the fuel used. If the pressure of the shock waves is large enough, cells or molecules within the tissue at the focus of the treatment chamber are thought to respond to the course of the shock waves. Small, negative pressure components of the shock waves can wedge bubbles trapped in the extracellular matrix within the shock spread during propagation.

The deflections cause asymmetric disturbances to bubble equilibrium that can cause a rapid increase in gas density, the collapse of the microbubble, and the release of a large amount of chemical energy from the stored mechanical energy.

The pulse emitted from the bubble toward the inner cell layer, which drives near-field higher-cell tension with which the membrane is drawn, contributes to the motion of nearby membrane components and assists in the efficient transfer of energy.

What are the Advantages of ESWT?

Healing of tissue without scarring, which is produced outside highly complicated biochemical reactions, is the most important advantage of ESWT. As also mentioned in the preceding text, tissue repairs proceed in the following course: there is an effusion of blood if the (peri-) tendonitis or fasciitis process becomes a non-specific inflammatory process.

This effusion provides an optimum supply of nutrients and growth factors. New vessels are also formed. A process for the migration and pluripotent differentiation of the stem cells that are always present in tendons and ligaments is transposed, in which the arriving mesenchymal stem cells always engage and differentiate themselves along the collagen-producing pathway.

The less the demands of the length subtracting collagen forming cells therefore depend on metabolism through resorption of cell excreta, the better it is. After the extracorporally induced tissue repair runs its course, there is model-forming collagen remodelling. If this has been effected without starting a fibrosis process, the tissue heals leaving it behind as good as it was before.

What are the Disadvantages of ESWT?

During extracorporeal shockwave lithotripsy (ESWL), possible side effects that may arise are skin reddening, ecchymosis, petechia, hematomas, and bruises that subside in a couple of days. Yet, the real hazards of this technique are the pneumonitis that might be caused by the passage of pathogenic organisms through the bloodstream via capillaries and debris, and the infections caused by the contamination of Foley catheter. In addition, calyceal perforation should be contained because of the same foreign body that causes the infections.

A high number of shockwaves would reduce all of these side effects. These uses are similar for ESWT and ESWP. And also similar to ESWP, subfebrile temperature occurs in around 25-30% of the animals with ESWT.

Yet, from all these aspects, ESWT, which is more selective for the fountain of the tendinitis, is much more advantageous because the intensity of the shockwaves is higher and shear waves are more effective. The local reactions are quite limited in the focused area, and also equally absorbed systemic damage does not occur.

There are yet reports that analyzed only the kidney tissue around the tendinitis area, about the histopathological differences of ESWT and ESWP, but it has not been proven yet whether it is more harmful in the long term. Another advantage of ESWT is that it can be operated in office conditions and no anesthetic agent would be required.

It might not also be necessary to keep up a fluoroscopic control in ESWT if there is no bone pathology. The procedure can be comfortably performed by watching only the anatomic localizations of anatomy.

What are the ESWT Application Areas?

ESWT, which has been used in orthopedics and traumatology for quite a long time, has paved the way for the treatment of a large range of diseases with both clinical and experimental experiences. Approximately 80% of such applications are orthopedic diseases, although an expanding range of treatment is observed. It is now possible for ESWT to be applied in urological, cardiovascular, neurological diseases, and some cancer pain.

Through the shock wave, there is a formation of gene therapy and chromosomal abnormalities. The mechanism of ESWT is disturbing the cellular arrangement and integrity. It might be modeled according to the dosage of ESWT that will be provided. When the dosage of shock waves increases, the integrity of cellular structures may deteriorate.

The characteristic of ESWT may be lost in different application areas or disturb the cellular integrity and arrangement or ultra-structural of the cell may be damaged. In order to adjust the therapeutic effect of shock waves, it will be necessary to understand the biophysical interactions between the shock waves and tissue to be applied.

Extracorporeal shock wave therapy may induce unexpected consequences in case of use for specific purposes. Damage in nerve tissue, modulation on microtubular, damaging in axoplasmic flow, and axoplasmic impaired could be considered only among the concomitant response obtained from experiments in rats, although the clinical reports seem to point to no nerve damage for the usage of low energy levels obtained for clinical uses.

A recent pathophysiological study in which electro-neuro-physiological and morphological studies are combined performed on a damaged nerve showing clear axoplasmic flow and a concomitant increased permeability executed on the axon wall and leading to a cutoff neurotrophic sources after three days after the first ESWT.

In one week, the axon shows groundbreaking modifications and the axon-membrane breaks. Such treatments on nerves mostly produce secondary axonal damage because shock wave could not be dissipated by nerve tissue. However, nerve tissue was not found to be sensitive to the dynamic force exerted by the ESWT on tissue. In order to decrease the negative effects of ESWT on tissues, it may be beneficial to improve the resistance of the tissue before the application of the treatment.

There is important experimental and clinical experience about the ESWT in different anatomic regions, appliances, and effects. No significant complications were reported unless a very high dose of energy gives rise to clinical complications. Further studies seem to have to be accomplished in order to determine the optimal dosage for the new indications.

What Are The Effects Of ESWT On Peyronie And Erectile Dysfunction Disorders?

The penis can be bent to the left or right while having an erection from a position of 10° up to 90° from the base of the penis. If the curvature does not exceed 10°, it is accepted as normal. Curvatures greater than 10° cause serious problems related to sexual performance and penile pain.

Having such a difficult bent is called Peyronie’s Disease (PD). PD is named after the French Surgeon François Gigot de la Peyronie, who first described this condition in 1743. The indifferent connective tissue and the heart’s origins are the tunica albuginea encapsulated by the tunica albuginea that accumulates, causing the penis’s curvature, shortening, and plaque formation.

Penile cavitation is responsible for ED occurring in patients with PD. Approximately 40% of patients with ED have been diagnosed with PD. The role of PD in ED has been disregarded by many health care providers and many health professionals. ESWT, which is known to heal PD without surgery, also has a significant effect on the disease-related sexual dysfunctions. Intralesional injection therapies also have a place in PD’s treatment. However, it has side effects such as penile plaque calcification and penile curvature persisting anteriorly.

In light of such negative results, ESWT’s role in patients with PD has become essential. Both shockwave ESWT reveal their effects as a result of ESWT passing in another way, revealing their effects in part and together. According to a hypothesis, ESWT increases the secretion of therapeutic growth factors so that the plaque begins to shrink and disappear.

ESWT increases tumor suppression gene secretion or gene activity. Moreover, by revealing their anti-inflammatory sting, the reptile fibrotic transformation significantly improves the inflammation and tissue remodeling abnormalities, and the fibroblast proliferation is stopped.

How Long Does ESWT Take?

The session dose may change depending on different studies and dealers, but it is certain that the frequency is between three and once a week. found that the optimal application rate of ESWT is once a week for 3-6 weeks. found that weekly ESWT had good results. detected that the most efficient therapy is based on three sessions monthly. In addition, detected that the shock wave therapy sessions should be once a week for 4 weeks, for chronic elbow pain.

The recommended frequency of ESWT is five sessions in 1 month. Five sessions are performed to patients suffering from pain or a delayed healing process. The five sessions, performed in one month, are recommended because pain generally continues for 1 month after the first session. Treatment may be completed in one session only.

Overall, the best manner can be accepted as one month, five sessions. The total number of sessions and frequency can be determined according to response. Due to our clinic’s conditions, mostly three sessions are chosen, but before application, the number of sessions should be determined after evaluating risk factors. If a patient has many risk factors, an additional session can be decided at 1st and 4th week. Since corticosteroid injection affects shock wave therapy, inappropriate implants, and hygiene problems, the frequency and number of sessions should be determined after careful consideration.


      

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