(768) Micro-Dose Intracavernosal Alprostadil Priming Before Low-Intensity Shockwave Therapy (LiESWT) for Vasculogenic Erectile Dysfunction: A Novel Synergistic Approach

Abstract Introduction Low-intensity extracorporeal shockwave therapy (LiESWT) is a recognized restorative treatment for vasculogenic erectile dysfunction (ED), promoting angiogenesis, endothelial repair, and cavernosal tissue regeneration. Effective energy transfer during LiESWT requires adequate penile expansion and microvascular perfusion. Mechanical vacuum preparation has been proposed to improve cavernosal distension, but is technically demanding and poorly tolerated. Recent cardiovascular research has shown that alprostadil (prostaglandin E₁) improves microvascular perfusion and reduces microcirculatory dysfunction after myocardial infarction and percutaneous coronary intervention. Both LiESWT and alprostadil pursue the same therapeutic goal - restoration of microcirculation and improvement of endothelial function. Objective This study evaluated a simple pharmacologic alternative, micro-dose intracavernosal alprostadil priming before LiESWT, to obtain mild tumescence and optimize shockwave propagation, and to assess its feasibility, tolerability and preliminary efficacy. Methods A prospective single-arm study was performed on 34 men aged 48–65 years (mean 57.6 ± 5.1) with mild-to-moderate vasculogenic ED confirmed by dynamic penile color-Doppler ultrasound. All patients underwent six consecutive daily LiESWT sessions using the Morenova® system (3000 shocks per session, energy flux density 0.09 mJ/mm2, frequency 2.5 Hz). Before each session, 4 μg alprostadil (PGE₁) was injected intracavernosally to induce stable partial erection (≈40–50% rigidity), allowing uniform energy coupling along the penile shaft. Outcomes included the International Index of Erectile Function – Erectile Function domain (IIEF-EF), Erection Hardness Score (EHS), patient-reported satisfaction, and penile color-Doppler parameters (peak systolic velocity, PSV; end-diastolic velocity, EDV) at baseline and 3 months. Paired t-tests were used; p 0.05 was considered significant. Results All 34 patients completed treatment and follow-up without priapism, pain, or injection-site complications. Target semierection was achieved rapidly and reproducibly before every session. Mean IIEF-EF increased from 15.8 ± 3.0 to 22.8 ± 3.6 (p 0.001), exceeding the improvement typically reported for standard LiESWT protocols. EHS improved from 2.4 ± 0.5 to 3.5 ± 0.6 (p 0.01). PSV rose from 26.5 ± 5.3 cm/s to 35.5 ± 5.9 cm/s (p 0.01), while EDV decreased from 5.0 ± 1.6 cm/s to 2.9 ± 1.4 cm/s (p 0.01), indicating both enhanced arterial inflow and better veno-occlusive function. A clinically meaningful IIEF-EF gain (≥4 points) was observed in 82% of patients, and 89% reported better erectile response and higher confidence during the treatment course. Conclusions Pharmacologic priming with micro-dose intracavernosal alprostadil before LiESWT is feasible, well tolerated, and appears to potentiate the functional and hemodynamic benefits of shockwave therapy in vasculogenic ED. By combining two interventions with a shared microcirculatory target, this approach improved energy delivery, erectile rigidity, and Doppler indices more than expected with LiESWT alone. The method represents a practical alternative to vacuum preconditioning and warrants confirmation in controlled comparative studies. Disclosure No