Welcome to shockwave therapy for erectile dysfunction. I am dr. Judson Brandeis, board-certified, urologist, chief medical officer for a firm science and director of Clinical Excellence for Gaines wave. This 20 minute educational webinar will discuss the physics of shock waves and how shock wave therapy works at a cellular level. We will then review the literature on shock wave therapy for erectile dysfunction and addressed the safety of shock wave therapy. We will then discuss optimal patient selection and supplementation of shock, wave therapy and, finally, future directions. What is the difference between a sound wave and a shock? Wave sound waves are forms that push against particles in a medi. The source of the sound is a type of energy that causes a vibration, which then propagates away from the vibrating source in a linear, consistent wave-like fashion. Examples would be sonar from a dolphin music from a guitar or diagnostic sound waves from an ultrasound machine shock. Waves are different, they carry more energy, and so the waves rise more acutely and then drop more dramatically. Shock waves travel faster than sound waves. When we talk about shock waves, there are two types focused and radial focused waves aimed the energy at a point like breaking up kidney stones with extracorporeal shock wave lithotripsy radial sound waves deliver a wider path with more diffuse energy. The purpose of radial waves is to stimulate tissue not to destroy it. There are many medical applications of shock waves in orthopedics shock. Wave therapy is used to treat plantar, fasciitis, tendinitis and other ailments shock. Wave therapy is also being investigated as a treatment for peripheral artery disease and heart issues in urology. It is used to treat erectile function. Shock waves are generated through spark-gap technology to stimulate the blood vessels of the corpora cavernosa gains wave low intensity shock. Wave therapy is the brand most closely associated with low intensity shock. Wave therapy shock. Wave therapy produces a strong pulse of energy, which creates cavitation bubbles which expand and then collapse as these cavitation bubbles collapse, they break down calcific and other deposits. Cavitation bubbles affect tissues and create a shear force which generates increasing cell permeability and stimulates the microcirculation and metabolism. A variety of cells are stimulated to grow like stem cells, osteoblasts and fibroblasts. Also, Schwann nerve cells are activated and vascular. Endothelial growth factor is released, stimulating the growth of new blood vessels, Tom Liu, a researcher and urologist at UCSF, has done cutting-edge work on the possible biologic cellular mechanism of action of shock wave therapy. He found that shock wave therapy causes micro trauma which leads to the release of vascular, endothelial growth factor or veg F shock wave therapy also directly increases nitric oxide synthesis in penile tissues. Finally, shock wave therapy results in the stimulation of stem cell expansion. You can see from the immunofluorescence in both young and middle-aged rats. There was a polarization of stem cells in clinical studies on humans. How do we measure the outcome of shock wave therapy? One way is the aye-aye ef5 or the international index of erectile function or shim score, which is graded v 325. With questions that directly relate to the strength of a demands erection. The other way is through penile duplex ultrasound, which measures arterial blood flow. The problem with this is that it requires the direct injection of a vasoactive, calm pound, which is uncomfortable and sometimes has to be reversed. The first randomized sham controlled study on shockwave therapy for erectile dysfunction was performed 2012 on 67 men. The protocol used was two treatments per week for three weeks a three week rest followed by two treatments per week for another three weeks. The erectile function score increased six point, seven versus three point: zero for the Sham control group and the blood flow increased eight point, two milliliters per minute versus zero point, one for the Sham arm. Two meta-analyses were published in 2017. The first looked at 14 studies with a total of 833 patients showing improvement in erectile function, score of 2.0 with shockwave therapy. There seemed to be a better response in patients with mild IDI versus severe IDI. The other meta analyses looked at seven randomized controlled trials with 602 patients. There was an increase in erectile function, score of four point: one: seven: over control with high statistical significance, a fascinating paper came out in the Journal of Sexual Medicine in 2018. The data shows that six or 12 treatments over a period of six weeks are efficacious with long lasting effects out to six months. Twelve sessions yielded more significant improvement in erectile function, score and duplex ultrasound, with an increase of 5.0 additional treatments at six months added. Another two points to the increase in erectile function score. The point was that shockwave therapy is the only current available option that focuses on disease, modification and restoration of erectile function, as opposed to pills, pumps or shots which only have a temporary effect high responders to shockwave therapy tended to be younger and respond better to pde5, inhibitors and repeat treatment with regular maintenance is usable and beneficial. The other really interesting point was that shockwave therapy could be a preventable treatment for erectile dysfunction in high-risk patients like type 1 diabetics and younger patients with coronary and vascular disease. Dr. Brandeis presented this abstract at the sexual medicine Society of North America meeting in 2018. The protocol was Gaines wave, low intensity shock, wave therapy plus affirm nitric oxide booster with l-citrulline and red beetroot extract patients were treated once a week for six weeks. 70% of the patients responded with an average sim score increase at five weeks of 5.2. This is the first paper in the literature to look at shock wave therapy with a nitric oxide booster and shows more improvement in shimm score than with most studies. Looking at shock, wave therapy alone shock wave therapy as a restoration for erectile dysfunction, is still controversial. On one hand, the urology x is touting shock waves as the future of erectile dysfunction therapy. On the other hand, the sexual medicine Society of North America and the American urologic Association position statement says that the use of shock waves or stem cells or platelet-rich plasma is experimental and should be conducted under research protocols and compliance with institution review boards. So who is right? What the data seems to show about low intensity shock wave therapy is that it is a non-invasive treatment that semi-permanently improves blood flow to the penis. In about three-quarters of carefully selected men with mild to moderate edie, it is not uncomfortable and has no significant side effects. Patients with nerve related issues or severe edie are unlikely to respond. We can resurrect this classic Thunderbird, but not a rusted-out old Plymouth. The Gaines wave protocol usually starts with six treatments either once or twice a week or 12 treatments for patients with very low sim scores. We use numbing cream 30 minutes before treatment and the treatment lasts for about 15 to 20 minutes. Patients can resume normal activity afterwards and they are encouraged to have erections. Most patients do not start responding until the fifth week after the start of treatment. It is important for patients not to take any non-steroidal anti-inflammatories during treatment and that patients undergo long term maintenance in order to continue to have good results. Shockwave therapy treats the corpora distally and proximally and results in the growth of new blood vessels. Dr. Brandeis came up with the concept of triple therapy, which is a nitric oxide booster, a pde5, inhibitor and shock wave therapy. Patients tend to respond earlier to treatment and have a longer-lasting response. Besides, nitric oxide boosters have general health benefits, like naturally lowering blood pressure, improving cognition and athletic performance and reducing the risk of heart disease as men, age. Their endogenous production of nitric oxide declines, significantly think of a salt shaker with only 20% of the original amount of salt. A nitric oxide booster, like a firm, will fill the salt shaker back up, stimulated nerves, release a neurotransmitter called nitric oxide which crosses the synapse and stimulates a blood vessel. The other way to increase the amount of nitric oxide that crosses the synapse is to stimulate the blood vessel is to block the enzyme pde5 with a pde5 inhibitor like Viagra or Cialis. By blocking the pde5 inhibitor, more nitric oxide crosses the synapse to stimulate the blood vessels. The third part of triple therapy is encouraging: the growth of blood vessels with low intensity radial, sound wave therapy, other supplemental treatments, complementing shockwave therapy, our vacu erection devices, platelet-rich plasma, stem cells, nitric oxide, boosting supplements like a firm and pde5 inhibitors like Viagra and Cialis. What we have learned is that shockwave therapy is potentially a curative treatment for low blood flow to the penis, causing erectile dysfunction. Shockwave therapy is an FDA approved technology in orthopedics and investigational for erectile dysfunction treatment. However, there is a significant body of literature on the efficacy of treatment of erectile dysfunction. Furthermore, shockwave therapy is safe with minimal discomfort and does not interfere with physical or sexual activity. It is effective in more than 75% of men with mild to moderate edie, but does require long-term maintenance, as you would expect, given the aging process. Thank you for your attention. This webinar was sponsored by a firm science developers of a firm nitric oxide booster, the official nitric oxide, boosting supplement of Gaines wave, a firm science donates, a portion of profits to research and education on erectile dysfunction. If you are over 45 and liked the webinar, please consider purchasing a firm at a firm science comm to support additional educational and research activities. A firm has been shown to increase the effectiveness of Gaines wave therapy with no side effects to the patient.