Low-Intensity Shockwave Therapy for Erectile Dysfunction (ED)

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health, from end to end.

Dr. Scott Steele: Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery and the President of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I'm super excited to have a third time guest here on Butts and Guts, Dr. Petar Bajic, who's a Urologist and the Director of Center for Men's Health at the Glickman Urological and Kidney Institute here at the Cleveland Clinic. Petar, welcome back.

Dr. Petar Bajic: Thanks so much for having me.

Dr. Scott Steele: So, today we're going to talk a little bit about low-intensity shockwave therapy for erectile dysfunction. Something that when I think of shockwaves, I always think of kidney stones and stuff, so I'm super excited to get into this. But before we go there, for those who didn't listen to the previous two episodes, give us a little bit about your background.

Dr. Petar Bajic: Sure. So, I'm a Cleveland native. I grew up in the west side in North Royalton and did my undergraduate degree at Case Western Reserve University. And I did medical school at Toledo and then did my residency and fellowship in Chicago and then made my way back to Cleveland. I always say all roads lead back to Cleveland.

Dr. Scott Steele: That's fantastic. And before we get into the shockwave therapy, can you tell our listeners a little bit about what exactly is erectile dysfunction? We see a lot of these commercials on TV and on the radio and everything, but what does it really mean?

Dr. Petar Bajic: So, erectile dysfunction refers to either the inability to get an erection satisfactory for sexual activity or inability to maintain an erection. So, it really is kind of a spectrum.

Dr. Scott Steele: And so, we'll talk today about low-intensity shockwave therapy, so can you talk a little bit about what that is and then how can it be used to help treat erectile dysfunction?

Dr. Petar Bajic: Sure. So, urologists have used shockwave therapy for decades to crack kidney stones in a non-invasive way. So really, what it refers to is using focused sound waves that focus their energy on a single point and create a shockwave inside of the body that then achieves some goal. So, for kidney stones, it cracks a kidney stone.

Now, shockwave therapy is FDA approved in a low energy setting for certain conditions like plantar fasciitis and chronic non-healing wounds. It is not FDA approved for the treatment of erectile dysfunction, but in a number of recent studies performed all around the world, it has shown promise for treating men who have erectile dysfunction due to reduced blood flow, which is the most common cause of ED.

Dr. Scott Steele: So, "Truth or myth" Truth or myth: although the low-intensity shockwave therapy has a long track record of medicine, it's used for treating erectile dysfunction in the United States is relatively new within the last few years.

Dr. Petar Bajic: Yeah, I would say that's true. A lot of the literature on shockwave therapy for ED has been done internationally, but there are a number of centers including our own that are continuing to do research in this area. As far as use outside of studies and clinical trials, it is a relatively new treatment.

Dr. Scott Steele: "Truth or myth?" Truth or myth: Low-intensity, shockwave therapy for treatment of erectile dysfunction hurts?

Dr. Petar Bajic: Myth. It does not hurt. In fact, typically when we do these types of treatments, a lot of times men don't even realize what's happening. Sometimes they may feel it, and if there are any particular areas that we're treating that have increased discomfort, we can reduce the energy a little bit.

Shockwave therapy, like I said, is used for different applications. It tends to be associated with more pain when it's applied to a bone, and there are no bones in the penis, contrary to some popular belief. So, it is typically not painful.

Dr. Scott Steele: So, let's dig in this a little bit more. So, who qualifies for this and exactly how does it work?

Dr. Petar Bajic: So, low-intensity shockwave therapy for men who have ED, is most appropriate for men who have mild to moderate ED. So, I usually tell patients that if they get a really good response to a pill like Sildenafil, also known as Viagra, but maybe they don't like the side effects, or they don't want to have to rely on a pill, that would be somebody who would be a reasonable candidate. Or perhaps when they take the pill, they get a good initial erection, but they lose it too quickly, and that it's not due to premature ejaculation or something like that, but they just can't maintain. Somebody like that, if they had a little bit better blood flow, might be satisfied. So, that would be somebody that would be a candidate for shockwave therapy and the expectation would be that they'd still have to take the pill.

But if you were that first case that I mentioned where you get a really strong response to the pill but don't like the side effects, you might be able to get by without having to use the pill at all if you were to undergo shockwave therapy. But it's not perfect. I usually quote men who meet those criteria, as long as they don't have certain other things in their history like a history of radiation therapy or poorly controlled medical issues, I usually tell them there's probably about a 75 percent chance that they get a benefit that they'll be satisfied with that would last about a year or two.

Dr. Scott Steele: So, there's a couple of different types of wave therapy. We're talking about the low-intensity shockwave. What's the difference between that and radial wave therapy?

Dr. Petar Bajic: So, there's a lot of attention on this area of regenerative therapies and wave therapies right now. You see all these ads on TV, radio, all over the place. Many, if not most of those places that advertise in a direct-to-consumer fashion, actually offer a different type of treatment called radial wave therapy.

The difference is whether or not the sound waves are focused and create a shockwave inside of the body or not. So, if it's just a sound wave that's not focused, it doesn't create the same type of energy in the tissues that stimulates the healing response or the development of new blood supply, which is what we're trying to achieve with shockwave therapy.

So, if you look at what's published on radial wave therapy, as far as the higher quality studies that are available go, essentially all of them show that radial wave does not actually help this type of erectile dysfunction. Although the literature available is not perfect, and we need more high-quality studies with long-term follow-up, the data supporting shockwave therapy is much more promising.

So, I equate radial wave therapy to essentially the type of waves that are coming out of my mouth right now. So just sound waves, whereas shockwave therapy is really something different.

Dr. Scott Steele: And so, flash forward ahead. So, somebody goes through the treatment. How do you determine if it is successful or not?

Dr. Petar Bajic: Sure. So, sexual function and erectile function can be a difficult thing to have kind of a standardized assessment for. So, there's a couple of different things that we do. The first thing is that we rely on validated questionnaires, which are kind of questionnaires that have been shown to be useful mainly as research tools, but it allows us to kind of quantify the severity of the ED before the treatment and then after. And this, by the way, can take up to two months after completion of the six weekly sessions, to see the full benefit.

In addition to that, we simply ask men, "Did you experience an improvement that you're satisfied with?" And as a sexual medicine specialist, I'm in the business of satisfaction, so I tend to focus on that with my patients. "Did the treatment lead to a satisfactory result?" And typically, that's more important than the numbers on a piece of paper.

Dr. Scott Steele: Any downsides to this treatment?

Dr. Petar Bajic: The primary downside comes from the fact that it is not FDA approved for the treatment of ED, which means that insurance won't cover it at this stage, and the hope is that that'll change in the future. But for men who are looking to get this treatment outside of a clinical trial or a research study, unfortunately, it would be a cash pay type of procedure.

We offer this treatment at Cleveland Clinic for about 1,800 bucks, which on the spectrum of cost around the country is on the lower side. However, we do have a couple clinical trials going on right now that we are enrolling men for shockwave therapy for both erectile dysfunction and another indication which is pelvic pain. As part of a clinical trial, you can get this treatment for free. So, men who are interested in that can certainly take a look and see what types of studies are going on.

Dr. Scott Steele: So, these are difficult conversations, and sometimes, it's difficult to even bring up to anybody. So, when should somebody experiencing erectile dysfunction speak to their medical provider about that alone, or especially about what we're talking about today, the shockwave therapy.

Dr. Petar Bajic: I think the reality is that, at some point, there's going to be a time in every man's life where maybe things don't work exactly the way that you want them to. And if it's just a one-off thing, it's probably not critical that you'd be evaluated. But if it's a recurring problem that you notice, it's really important to discuss that with your doctor, and you can start that conversation with your primary care doctor or a urologist.

And the reason for that is because ED is often the first sign of more serious health issues, like cardiovascular disease. I always refer to it as the “canary in the coal mine.” So, men might experience ED five years before a heart attack.

So, particularly for those men out there who maybe haven't been as good about following up yearly with their primary care doctor for a routine physical, if you're experiencing ED, you need to bring that to your doctor's attention because it's not only about getting a pill or other treatment that may help strengthen your erections; it's about getting the necessary diagnostics to better understand what's causing that issue.

Dr. Scott Steele: And one of the things is, circling back, you talked about regenerative medicine, regenerative therapy. So, are there any advancements on the horizon when it comes to either this low-intensity shockwave therapy or other regenerative therapies for ED?

Dr. Petar Bajic: I think that this is an area that's really ripe for research, and there are a number of centers around the country, including our own, that are actively investigating in this area. In addition to shockwave therapy, there are other areas that are being investigated. For example, stem cell therapy, platelet-rich plasma injection, which commercially is known as the “P-Shot.”

Unfortunately, to date, those two have not had the same level of evidence to support their use. So, as far as our professional societies govern what types of things are ready for prime time and what are not, the general recommendation is that those should only be performed as part of a clinical trial.

So, the bottom line is, we're not quite there yet. But the hope is that in the next five to 10 years that as these therapies' kind of mature and more research is available that will have some new options to offer our men within the scope of what will be covered by insurance.

Dr. Scott Steele: Okay. So now, it's time to get to know you just a little bit better, and we're going to give you your quick hitters. So, first of all, salt or sweet?

Dr. Petar Bajic: Salt.

Dr. Scott Steele: Okay. But you find yourself, number two, in a service store on a road trip, and you go into the candy aisle. What are you first to grab there?

Dr. Petar Bajic: Twix.

Dr. Scott Steele: Grab a Twix bar. The left one or the right one?

Dr. Petar Bajic: Both.

Dr. Scott Steele: Fantastic. Good. And then finally, we talked about a little bit in the past about what you like about Northeast Ohio but take me through someplace that you have never been in your life that you really want to get to. What's a bucket list place for you?

Dr. Petar Bajic: Let me think. So, last time I got into it, our main trip that was canceled due to the COVID-19 pandemic, which was to Japan, so I won't belabor that one again. But the other one was Croatia. We had a wedding that we were going to go to, and we had done all the research about all the places we were going to check out, including all the spots where they filmed Game of Thrones and all this stuff, so I would say that's number two.

Dr. Scott Steele: And then finally, you got a nice Saturday night on a rainy day. Do you go horror, comedy, or rom com?

Dr. Petar Bajic: Rom-com.

Dr. Scott Steele: Alright then. So, final take home message for our listeners regarding the shockwave therapy and erectile dysfunction.

Dr. Petar Bajic: So, with erectile dysfunction, oftentimes men look for one solution that can fix all their problems. But the reality about it is that every case is different, and it's important to seek out care from an experienced provider, whether that's a urologist or a primary care doctor, who knows what's out there and they can inform you about what your options are.

And if you want to do your own research online, make sure you stick to reliable sources of information, like Cleveland Clinic's website, where we have a lot of information, including videos that you can watch to learn about the available treatment options for ED. There are newer things like shockwave therapy, but there's also things that have been around even since the 1970s and are covered by insurance. So, inform yourself, discuss these things with both your physicians when appropriate, and even with your loved ones, because sometimes just having that initial conversation with your spouse or a friend might help you feel more comfortable discussing it and bringing it up to your primary care doctor.

Dr. Scott Steele: That's fantastic. And so, for more information about men's health here at the Cleveland Clinic, please visit clevelandclinic.org/menshealth. That's Clevelandclinic.org/ menshealth. You can also call the Department of Urology at 216-444-5600. That's 216-444-5600. Petar, thanks so much for joining us again on Butts and Guts.

Dr. Petar Bajic: Thanks so much.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.