The prostate is a gland of the male reproductive system. It is usually the size of a walnut. The prostate is located below the urinary bladder and surrounds the urethra. The prostatic urethra joins with two ejaculatory ducts. The prostate functions both in ejaculation and urination.
In ejaculation, the prostate secretes fluid which becomes part of the semen. This accounts for 30% of the semen. When the body emits sperm, they travel from the vas deferens into the male urethra via the ejaculatory duct within the prostate gland. Contractions of the smooth muscle of the vas deferens and seminal vesicles move the semen into the urethra.
Stimulation sends nerve signals via the internal pudendal nerves to the lumbar spine and these nerve signals cause contraction via the hypogastric nerves. The seminal fluid is then ejaculated by contraction of the bulbocavernosus muscle.
In urination, the prostate changes shape which facilitate the mechanical switch between urination and ejaculation. There are two muscle systems which facilitate this action. These are the urethral dilator on the front side of the urethra which contracts during urination and tilts the prostate causing the widening of the urethral tube and the muscle switching the urethra into the ejaculatory state which is located on the backside of the urethra and this muscle relaxes.
Damage to this system during surgery for benign prostatic hyperplasia or cancer can cause incontinence, erectile dysfunction or ejaculatory disorders.
Common Pathology in the Prostate
There are three commonly treated conditions of the prostate gland.
- Inflammation called Prostatitis.
- Benign Prostatic Hypertrophy
- Cancer
Inflammation
Prostatitis is inflammation of the prostate gland. Bacteria typically cause prostatitis, but there are also noninfectious etiologies. Antibiotics treat both acute and chronic prostatitis. Treat chronic prostatitis, a long-term illness, with drugs such as alpha blockers, antihistamines, NSAIDs, and anxiolytics. Nerve modulators, physical therapy, and surgery are also effective in chronic refractory cases.
Benign Prostatic Hypertrophy
BPH is an enlargement of the prostate gland from causes other than malignancy. The common symptom is difficulty with urination. As the prostate enlarges and becomes denser, it compresses the urethra, making urination very difficult and sometimes even completely obstructing it. Over time, there can be a backflow of urine into the kidneys causing kidney damage if not relieved. Medication is the initial treatment to reduce the tone of the smooth muscle found in the urethra as it passes through the prostate. However, over time, surgery is usually performed to relieve the prostatic tissue causing the urethral obstruction. Besides TURP surgery, other options currently used include transurethral needle ablation of the prostate and transurethral microwave thermotherapy.
How common is prostate cancer?
Statistics for 2024 estimate about 299,010 new cases of prostate cancer, with approximately 35,250 deaths attributed to this disease.
Since the screening recommendations changed in 2014, cases have increased by 3% per year, with 5% classified as advanced-stage prostate cancers.
About 1 in 8 men will develop prostate cancer during their lifetime.
6 in 10 prostate cancers are men who are 65 years of age or older. Prostate cancer is the second leading cause of cancer death in the US men, second only to lung cancers.
Prostate cancer is a serious disease but most men with this diagnosis do not die from it due to advanced treatment protocols. There are 3.3 million men with prostate cancer diagnosis, who are alive today in the US.
Treatment of Prostate Cancer depends on the staging at the time of diagnosis. Protocols range from active surveillance in very low-risk groups to radiation therapy, hormone therapies, and radical prostatectomy in high or very high-risk groups. They can also be modified based on age and other comorbidities.
Typical treatments include:
- Radiation therapies
- Brachytherapy- insertion of radioactive substance into the tumor area
- Cryotherapy
- High intensity focused ultrasound
- Hormone therapy
- Surgery and lymph node dissection
- Chemotherapy in very advanced cases
- Castration in resistant cases not responsive to other therapies including hormone therapy
However, as previous noted, more than 3 million men are living today in the US with the diagnosis of prostate cancer. Sexual dysfunction is a common problem post treatment. The incidence varies with the treatment protocol.
Chemotherapy, radiation, hormonal therapy and surgery can all cause sexual dysfunction.
- 24% brachytherapy
- 40% brachytherapy plus external beam radiation
- 45% Radiation therapy
- 66% nerve sparing radical prostatectomy
- 75% non-nerve sparing prostatectomy
- 87% cryosurgery
Despite newer advances in nerve sparing surgery, it can take up to 2 years post-surgery to heal from the bruising and trauma. During this period, men may have difficulty in achieving natural erections which can lead to degeneration of penile tissue and structural alterations.
Management of Erectile Dysfunction
Phosphodiesterase 5 inhibitors are the most commonly used oral agents and the first line of therapy for ED today. Surgery or radiation injuries can lead to hypoxia in penile tissue. PDE-5 inhibitors increase the release of nitric oxide, resulting in smooth muscle relaxation and increased blood flow to the corpus cavernosum. The cavernous nerve initiates the required erectile pathway. However, the effectiveness of these drugs is limited by the severity of damage to the cavernous nerve during treatment.
Use alprostadil (the synthetic form of prostaglandin E1), phentolamine (a vasodilator), or papaverine (a smooth muscle dilator) for intracavernosal injection. Administer these drugs alone or in combination. Side effects include fibrosis at the injection site.
Intraurethral suppositories are inserted into the urethra. This is the same alprostadil as the above injection. It creates vasodilation of the blood vessels.
Vacuum erection devices create an erection by suction and causing increased blood flow into the penis. A constrictive band is then applied.
Penis prosthesis implants are inflatable or non-inflatable penile implants surgically placed into the penis.
Vascular surgery to reconstruct the arteries and veins to improve blow flow into the corpus cavernosa and thus helps in achieving and maintaining an erection. This procedure is normally reserved for those who do not respond to oral or injectable pharmacological therapy.
Low intensity extracorporeal shock wave therapy is a newer therapy for the treatment of erectile dysfunction. It acts by inducing localized angiogenesis and neogenesis. It is a safe alternative in men post treatment for prostate cancer.
This therapy is noninvasive with minimal potential side effects and could be a treatment of choice to stimulate nerve regeneration and new blood vessel formation. The low cost and lack of side effects make shockwave therapy an attractive modality.
Studies
Aim: To investigate penile rehabilitation of Li-ESWT in a randomized placebo-controlled trial in men with ED following robotic nerve sparing radical prostatectomy
Conclusion: This randomized study indicates that Li-ESWT in men undergone RP might be effective and safe. However, further and more robust research is needed.
Aim: The aim of the current study was to systematically review the literature to assess the role of Li-ESWT in the management of patients with postprostatectomy ED.
Conclusion: Currently, limited evidence exists on the use of Li-ESWT alone or with PDE5i in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow up show that Li-ESWT could potentially play a role in the management of postprostatectomy ED in the future.
Patient Summary: Despite limited reports in the literature, low intensity shockwave therapy after removal of the prostate is a promising noninvasive treatment for dealing with erectile dysfunction after surgery.
Aim: Low intensity shockwave therapy may improve erectile function in patients with moderate erectile dysfunction. We present the results of our phase 11 clinical trial of LiSWT with short term follow up in a cohort of patients with mild to moderate vasculogenic ED.
Discussion: Shockwave therapy in the treatment of ED relies on delayed outcomes from tissue response to the damage created by the shockwaves. The hypothesized response mechanism is centered on local neovascularization. Wang et al demonstrated substantially increased levels of endothelial nitric oxide synthase, vascular endothelial growth factor and proliferating cell nuclear antigen. Shockwave therapy may result in nerve regeneration and mesenchymal stem cell migration/proliferation.
Conclusion: LiSWT may be a reliable treatment option in patients experiencing mild to moderate ED.
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Juventix Regenerative Medical offers a range of services and devices, continuously striving to provide regenerative professionals with state-of-the-art, FDA-cleared, approved, or registered products.
Efficacy and cost are primary goals at Juventix.
The current collaboration between Juventix Regenerative Medical and Oceanus adds the EDX Shockwave Device to our expanding catalogue of products. The EDX is a handheld, home use, clinical strength shockwave device for erectile dysfunction. This system stimulates angiogenesis, neogenesis and recruits the bodies mesenchymal stem cells to regenerate the cause of erectile dysfunction at the source. There are no office visits or prescriptions required allowing personal, convenient, home treatment without harmful side effects of drugs. Multiple adjustments on the EDX permits tailored therapy settings for mild to severe cases of ED. Treatments are minutes in duration with little to no discomfort.
For information on the EDX device, contact Juventix Regenerative Medical by visiting our website or emailing hello@juventix.com
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Regenerative Regards,
Dr. Robert McGrath
