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Erectile Dysfunction & Premature Ejaculation with Shockwave

What is Erectile Dysfunction?

Erectile Dysfunction is the inability of a man to maintain an erection sufficient for satisfying sexual activity. Shockwave can be used to treat erectile dysfunction but you need to understand more about erectile dysfunction and the process of erection.

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What makes a man feel like a man?

We always ask the question; What makes a man feel manly? Is it about being muscular? Or perhaps the size of his penis (phallus)? Or maybe his Testosterone makes him a man?

A man can have a gorgeous muscular body, a penis size of a tree trunk and pumped with testosterone, but in fact, he may be silently suffering from Erectile Dysfunction or Premature Ejaculation which can be embarrassing for every man.

We do not look at the mathematical values like the ideal golden waist to height ratio (eg.: 5 feet 10 inches and had a waist of 32 inches which is the body’s golden ratio) or the penile size of an impressive 8 to 10 inches long. The most important attribute is the functionality of a man or in this case his penis. What is the use if you have an impressive penis without good functional?

So that is the main issue we are going to discuss here.

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How does the Penis get an erection?

The penis is an elongated external organ used to transfer sperm. It is a spongious tissue which can be engorged with blood to increase its size and length.

We always say “this is a tip of the iceberg”, meaning that what we see can be minuscule but there is a huge unseen problem. Therefore, erectile dysfunction is a huge unseen iceberg of processes with a visible problem portrayed as with a small tip.













When a man is sexually stimulated; blood starts to get shunted to the deep artery of the cavernous body (Corpus Cavernosum). The Corpus Cavernosum looks like a dried sponge with a lot of caverns and as the caverns are filled with blood the penis will start to harden.

When the penis becomes stiff and the Corpus Cavernousum starts to get engorges with blood and it presses against the veins to prevent blood from the Corpus Cavernousum to return to the general circulation, which causes a sustained erection.

The veins have valves to prevent blood from exiting the Corpus Cavernosum, these valves are unidirectional and work as a gate to stop blood from leaving the Corpus Cavernosum.

Nitric oxide is a substance which helps the vessels to dilate. Nitric oxide is released by the deep vessels of the penis causing the calibre of the deep arteries to dilate more and results in better blood flow and blood volume. When more blood is shunted to the dilated vessels, then the penis becomes harder and more erect.

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What are the phases of reproduction?

Erectile dysfunction is a complex problem which requires a very holistic approach. There are 4 phases of an erection to ejaculation:

  1. Stimulation
    A man is stimulated via mental and physical stimulation. Mental stimulation is a sexual thought and physical stimulation is via touch (e.g. stroking the penis). The penis is stimulated via touch and it sends signals to the brain. It starts off from stroking or touching the penis and is received via the pudendal nerve and passes to the Sacral Nerves (S1-S4) to the Dorsal Root of the Spinal Cord and send it to the Brain as stimulation.


  2. Erection
    After stimulation, the Sacral Parasympathetic Nerves (S2-S4) relays stimuli to the Pelvic Splanchnic Nerves and to a congregation of Nerves called the Pre Aortic and Prostatic Plexus. These Plexuses tells the Vessels of the Penis to produce Nitrix Oxide which is a chemical compound used to increase the vessel’s capacity to accommodate more blood (dilates the blood vessels) in the penile vessels. When more blood is shunted to the penis, the caverns of the cavernous body gets filled up with blood in between the tissues. This process makes the penis hard and erected. The cavernous body becomes double or triple its current size and presses against the veins, therefore, obliterate the return of blood from the penis to the general circulation.If the blood in the penis is not returned to the general circulation because the outflow is obstructed by the mechanical force of the Cavernous Body and the blood remains in the Cavernous Body, thus causing a sustained erection.


  3. Emission
    During this Emission Phase, the genitals are prepared for ejaculation by stimulation of the testis to start contraction to expel the sperm. Sperm and semen are two different things. Sperm is produced by the testicles and seminal fluid is produced by the seminal vesicles but when sperm and seminal fluid are combined they are called semen. The stimulus is sent to from the sympathetic lateral horns of the spinal cord (T10-T2) and passed to the Pre-Aortic Plexus then to the Inferior Hypogastric Nerve and Spermatic tube which turns on NorEpinephrine (causing contraction of the spermatic tube). Seminal vesicles, prostatic vesicles and internal urethra start to contract. This ends the phase of emission followed by ejaculation.


  4. Ejaculation
    The process of ejaculation starts off with the stimulus from the anterior column of the spinal cord (S2-S4) and passes to the Pudendal nerve which causes contraction of the Bulbospongious muscle and Ischiocavernous muscles. Contraction of the Bulbospongious muscle and Ischiocavernous muscles increases the pressure along the urethra and results in ejaculation.

Understanding ED.PNG

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Understanding ED 2.PNG

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What causes erectile dysfunction?

So what actually causes erectile dysfunction? When reviewing through the phases of reproduction you can see that the first two phases are directly related to erectile dysfunction. This diagram is a short mind map that will facilitate your understanding but it is very complex and every aspect needs to be considered.

Commonly erectile dysfunction is usually caused by:

  1. Poor blood flow
    When blood flow is bad this causes the penis to be unable to erect and we need to work-up a few etiologies like::

    • Diabetes causes narrowing of blood vessels and reduces the caliber of the vessels to transport blood

    • The reduction of nitric oxide may be multifactorial and is a diagnosis of exclusion. Once you have excluded all the other causes then you can shift your diagnosis to Nitric Oxide reduction.


    • Cholesterol also forms vessel cholesterol plugs (atherosclerosis) which narrows the vessels and reduces the blood flow to the penis.


  2. Psychological

    • This is another complicated condition that is difficult to treat as the problem of being unable to get a good erection is due to problems of the mind. Take for example: if my patient is stressed and constantly thinking about his work; then he will not be getting an erection with all the stress.


    • Low self-esteem. I had many patients who are indirectly affected by presumed erectile dysfunction. Many of my cases their partner commented something about their sexual performance, which cause the man to suffer insecurity about his manhood.
      Read more about the experience of low-self esteem causing erectile dysfunction: coming soon!


  3. Drugs

    • There are many drugs that can cause erectile dysfunction and some of them are so common that many people have forgotten that those medications can reduce blood flow to the penis, therefore indirectly affecting the hardness of the erection.

    • Common drugs causing erectile dysfunction:

      • Beta-blockers (nifedipine, atenolol, metoprolol, carvedilol, bisoprolol) usually can be associated with erectile dysfunction.

      • Calcium channel blockers

    • Illicit drugs causing erectile dysfunction:

      • Erection is caused by parasympathetic activation and penile flaccidity is caused by sympathetic activation. Drugs like Methamphetamine, Ketamine, and Ecstasy keep the body in a sympathetic state, which causes the blood flow to the penis to diminish therefore causing flaccidity of the penis.


  4. Nerve damage
    Nerves are like wires which bring impulses to the penis and thus evoke a response but, damaged nerves are different as they are unable to bring the impulses to hit a threshold as a response to get an erection. There are many causes of nerve damage such as diabetes, lumbar radiculopathy, pudendal neuralgia, or pudendal neuropathy. These are a few examples of nerve damage causing erectile dysfunction.


    • Diabetes is known to cause generalized nerve injury when glucose levels in cells are high. This glucose may bond with cell proteins and alter their structure and these glycosylated proteins have been implicated in diabetic neuropathy. A very similar occurrence was studied in animals where high glucose indirectly increases Protein Kinase C. High blood glucose levels increase the amount of intracellular diacylglycerol which activates protein kinase C. This protein kinase C reduces the speed of conduction in nerves and in turn reduces stimulation and blood flow.


    • Lumbar radiculopathy can also cause erectile dysfunction. There are new studies that look into lumbosacral radiculopathy which causes sexual dysfunction. This new study shows that L5-S1 disc herniation can cause erectile dysfunction and was not widely reported. With this new data is it safe to say that most men with disc herniation suffer from erectile dysfunction but the sexual dysfunction is masked by other more debilitating symptoms such as back pain, leg numbness and incontinence, therefore, the subjects did not highlight their erectile dysfunction as the main problem associated with disc herniation.

    • Pudendal neuralgia causes pain and this misfiring will reduce blood flow to the penis.


  5. Hormonal

    • Hormones are important in helping with erection. It is a very complex process to explain how testosterone can improve erection

  6. Structural anomaly

    • Peyronie's disease is the development of fibrous scar tissue inside the penis that causes curved, painful erections. Penises vary in shape and size, and having a curved erection isn't necessarily a cause for concern. But Peyronie's disease causes a significant bend or pain in some men. This can prevent you from having sex or might make it difficult to get or maintain an erection (erectile dysfunction).​


  7. Smoking

    • Smoking has always been associated with constriction of blood vessels and if frequently seen in Raynaud's disease (cold hands and feet). Raynaud's disease is an obvious example of the detrimental effects of smoking. Smoking causes the blood vessels to constrict and reduce blood flow to the extremities causing Raynaud's Disease and likewise to the penis. When blood flow is reduced to the penis, it can often become difficult to get an erection.

  8. Spinal cord diseases and spinal cord trauma

    • Spinal cord or spinal nerves-related problems will in turn affect the nerve supplying the penis which is important in the Stimulation and Erection phase. If there is any damage to the spinal cord or spinal nerves, then the impulses to stimulate the penis to reach the erection phase will be reduced. Basically, the damaged spinal cord and nerves are like short-circuit electrical wires which do not carry electricity well, therefore, causing dysfunction of the penis. 


  9. Brain trauma 

    • The brain is a complex structure with many functions. It is a center of converting intent into action (take for example: having the intention of lift your hand by changing electrical impulses of intent into action to lift the arm) and center of thought.

    • We have higher and primordial (primitive) brain function. The basic instinct to propagate is through sexual desires (a form of primordial brain function) and the process to translate the instinct into sexual activity is considered as higher brain function.

    • People with brain injury can either lose one or both brain functions (primordial or higher brain function). This can depress sexual stimulation and or sexual function, which, leads to erectile dysfunction. 


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Schedule online. It's easy, fast and secure.

Schedule online. It's easy, fast and secure.

How to evaluate a person with erectile dysfunction?

Evaluation of the treatment of erectile dysfunction is another important part to decide the best treatment options as certain risk and benefits need to be weighted properly in order to get the best outcome.

Evaluation and Diagnosis:​

  1. Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing.  (Clinical Principle)

  2. For the man with ED, validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management. (Expert Opinion)

  3. Men should be counseled that ED is a risk marker for underlying cardiovascular disease (CVD) and other health conditions that may warrant evaluation and treatment. (Clinical Principle)

  4. In men with ED, morning serum total testosterone levels should be measured. (Moderate Recommendation; Evidence Level: Grade C)

  5. For some men with ED, specialized testing and evaluation may be necessary to guide treatment. (Expert Opinion) 

  6. To ask about the history of prostate and testicular cancers.

  7. Assess the IIEF-5 score system


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How to treat erectile dysfunction?

Treatment of erectile dysfunction is a complex plan and we will have to identify the causes to treat according to the root cause. Due to the complex nature of treatments then you will need to consult and I will fix you up with the best possible treatments.

Treatments can range from:

  1. Hormonal therapy. The method is used to replace the low male hormones which cause the loss of libido

  2. Drugs like: Sildenafil & Tadalafil belong to a group of medicines called phosphodiesterase 5 (PDE5) inhibitors. These medicines increase blood flow to the penis and cause the penis to engorge in size. 

  3. Intraurethral (IU) alprostadil. Is a pessary form drug inserted into the urethra and needs to be taught properly with stringent aseptic techniques to prevent urinary tract infections and urethra damage.


  4. Intracavernosal injections (ICI). This method is used in special groups of people who do not respond to oral drugs like Sildenafil & Tadalafil.  

  5. Shockwave for erectile dysfunction: 
    Shockwave is a pulse-like therapy which has a large clinical study in regards to its efficacy to treat and manage erectile dysfunction.


  6. Low-intensity pulsed ultrasound ( LIPUS)
    LIPUS shows effectiveness in mild to moderate erectile dysfunction but has a small clinical study and requires more trials to show evidence that it is effective as a treatment alternative for erectile dysfunction.


  7. Penile prosthesis implantation is a surgical procedure to implant a pump into the penis which can be manually inflated to reach an erection. 


  8. Penile arterial reconstruction is a method to remove obstructions in the artery of the penis and increase blood flow to the penis.


penile prothesis.jpg

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