Janout H. et al., 2025: Use of Secondary Reflectors for Enhanced ESWT Treatment of the Penis.

Wednesday, 05 November 2025

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Hannah Janout 1 2 3, Jonas Flatscher 2, Stephan M Winkler 1 3, Paul Slezak 2, Cyrill Slezak 2 4
1Bioinformatics Research Group, University of Applied Sciences Upper Austria, 4232 Hagenberg, Austria.
2Ludwig Boltzmann Institute for Traumatology the Research Center in Cooperation with the AUVA, 1200 Vienna, Austria.
3Department of Computer Science, Johannes Kepler University, 4040 Linz, Austria.
4Department of Physics, Utah Valley University, Orem, UT 84058, USA.

Abstract

Background: This study aimed to optimize low-intensity extracorporeal shockwave therapy (Li-ESWT) for the treatment of penile indications through the addition of a secondary reflector. The therapeutic potential of Li-ESWT is well-established, but its efficiency is limited by uncontrolled wave propagation and reflection resulting in regions of increased tensile pressures. The objective is to manage and reduce high tensile pressure and enhance treatment efficacy by reflecting applied shockwaves back into the treatment zone using a novel reflector design. Methods: A comprehensive investigation, including numerical modeling and phantom measurements, exploring a range of improvements to traditional shockwave application by reflecting applied therapeutic shockwaves back into the treatment zone. Computational optimization was employed to identify the most suitable secondary reflector shape for potential future clinical use. Subsequent hydrophone phantom reference measurements were extended to volumetric fields using 3D simulations. Results: Traditional treatment resulted in high tensile pressures in the treatment zone, which was mitigated by introducing an impedance-matched layer (IML) while preserving the initial shockwave's therapeutic function. The addition of the secondary reflector enabled controlled refocusing of the therapeutic shockwave back into the initial focal zone, thus either increasing the treatment volume or achieving a rapid secondary application. Choice of the reflector's impedance allowed for the secondary refocusing of either a tensile or positive pressure wave. Conclusions: The combined modifications of employing an IML and secondary reflector eliminate uncontrolled tensile waves and reflections, provide better control over consecutive reflections, and enable repeated shockwave signals with a single applicator shot, potentially reducing the number of required shots per session.

Biomedicines. 2025 Aug 13;13(8):1967. doi: 10.3390/biomedicines13081967. PMID: 40868220; PMCID: PMC12383372

Comments 1

Jens Rassweiler on Wednesday, 05 November 2025 11:00

The article discusses a study focused on improving the efficacy of extracorporeal shockwave therapy (ESWT) for treating erectile dysfunction (ED) through the introduction of secondary reflectors and impedance-matched layers.

Background:
ED, a widespread condition affecting millions of men, can stem from various health issues including vascular problems, diabetes, and psychological factors. Traditional treatments, like Viagra and intracavernosal injections, often allow only temporary relief and do not address the root causes of ED. ESWT, originally developed for kidney stones, has emerged as a promising non-invasive treatment for ED, specifically for vasculogenic types. However, there is currently no standardized protocol for its application, leading to varying effectiveness.

Study Focus and Methodology:
The study aims to enhance shockwave treatment by focusing on two key innovations:
1. The use of a secondary reflector to reflect shockwaves back towards the treatment area, minimizing the risk of injuring surrounding tissues due to excessive tensile pressures.
2. The implementation of an impedance-matched layer (IML) to further reduce the intensity of negative pressures caused during shockwave therapy.
The research involved:
- Designing an optimized secondary reflector using an evolutionary strategy (i.e. a computational optimization method).
- Experimental validation through pressure measurements using a gelatin penis phantom to simulate therapy applications.
- 3D simulations to assess pressure distribution, volume, and intensity within the treatment zone, which are critical to improving clinical results.

Results:
The study's workflow allowed for thorough investigation into reflector design, performance optimization, and simulations that enabled a better understanding of pressure dynamics during treatment. The findings suggest that the use of secondary reflectors can enhance the therapeutic effects of ESWT, targeting the treatment zone more effectively and potentially mitigating side effects associated with existing methods.

Discussion

The findings of this study demonstrate the potential of secondary reflectors and impedance-matched layers (IMLs) to significantly enhance the effectiveness of extracorporeal shockwave therapy (ESWT) for treating erectile dysfunction (ED). The authors think, that the optimization of a secondary reflector has shown promising results that could pave the way for improved treatment protocols. This concerns:

Enhanced Treatment Efficacy:The introduction of secondary reflectors aims to address one of the critical challenges in ESWT: ensuring that the shockwaves delivered into the treatment zone are effectively focused. In the experimental setups, the optimized reflector has shown an ability to redirect shockwaves back into the desired therapeutic area following their initial pass. This refocusing may lead to higher localized energy delivery, increasing the efficacy of the treatment. By maximizing the impact of shockwaves, one may enhance the regenerative processes associated with erectile function improvement, aligning with the fundamental principles of promoting angiogenesis and endothelial function.

Mitigating Side Effects: One of the notable concerns with current ESWT methods is the risk of side effects, such as bruising resulting from cavitation effects when shockwaves reach air interfaces. By integrating an impedance-matched layer and a secondary reflector into the treatment schema, we can minimize the intensity of negative pressures that contribute to these adverse effects. The results of the study indicate a reduction in tensile pressures in the treatment area, which may lead to a more comfortable experience for patients and reduce instances of bruising and discomfort. This enhancement in safety is crucial for patient compliance and the overall acceptance of ESWT as a treatment modality for ED.

However, here one has to mention, that the actual standardized Protocol for ED using 3000 shock waves at 4-5 Hz delivered to 6 defined areas of the penis with an Intensity of 0.25 mJ/mm2 is very well tolerated by the patients.

Standardization of Treatment Protocols: Currently, the lack of standardization regarding treatment protocols for Li-ESWT presents a challenge in achieving uniform clinical outcomes. By establishing a framework for the use of a secondary reflector and IML, future clinical implementations can build on our findings to develop consistent treatment protocols that integrate this technology. This standardization could involve identifying optimal distances, angles, and energy settings to maximize the reflectors' benefits, leading to replicable and reliable outcomes across different clinical settings.

Scepticism for the use of an innovative reflector design
Usually ESWT is performed by distributing 500 impulses over a defined area (ie. distal part of right corpus cavernosum). This is done by manually moving the probe over this area. The reflectors is a static system. This might be could to disintegrate stones or plaques of IPP, but plays only a minor role in case of ED.
The Role of Mechanotransduction as main biological mechanism

The effectiveness of ESWT in treating ED is heavily reliant on the biological response elicited by mechanical stimuli, specifically through a process called mechanotransduction. This biological mechanism involves the conversion of mechanical signals—such as shockwaves—into biochemical responses, stimulating various cellular processes, including the activation of stem cells and the promotion of angiogenesis.

While enhanced focusing of shockwaves through technological refinements like secondary reflectors may improve energy delivery, it is crucial to recognize that the core therapeutic action occurs at a cellular level. The optimal level of mechanical stimulation must align with the physiological thresholds that trigger beneficial cellular responses. If the energy levels are too high or poorly distributed, they may lead to non-ideal biological responses, potentially overshadowing the benefits of improved shockwave focus.

Application Technique Considerations for ESWT in ED

Uniform Energy Distribution:

- The standard practice of manually moving the probe to deliver 500 impulses over a defined area (e.g., the distal part of the corpus cavernosum) aims for even distribution. However, this approach can result in inconsistencies in energy delivery, potentially leading to uneven stimulation of tissue. Some areas may receive more impulses while others may not receive enough, which could compromise the mechanotransductive signaling necessary for effective treatment.

Static vs. Dynamic Systems:
- The introduction of reflectors can optimize energy focusing for applications such as breaking up calcifications or stones, where concentrated energy is crucial. For ED, however, the goal is not just to create localized effects but to activate broader biological processes like angiogenesis and stem cell mobilization. A static system that focuses energy might still encounter challenges in ensuring the desired therapeutic depth and breadth across the penile tissues.

Potential for Focused Treatment:
- If a more precise and focused delivery system can be developed, it might enhance treatment outcomes in ED. A static reflector system could potentially allow for the delivery of high-energy pulses in targeted areas, which could stimulate regenerative capabilities more effectively than a manual sweep of the probe. However, achieving this requires accurate mapping and understanding of the anatomy and physiological responses in the erectile tissues.
Optimization of Impulse Parameters:
- In addition to the delivery method, considerations around the frequency, energy level, and number of impulses per session are crucial. Research should focus on optimizing these parameters to maximize cellular response without causing tissue damage. Adjusting these elements, alongside the application technique, could lead to better treatment protocols.

Potential Development of Custom Devices:
- Considering the limitations of manual application, the development of devices with automated mechanisms designed to deliver a predetermined number of shockwaves in a more controlled manner could enhance treatment efficacy. Such devices could ensure uniform application across the desired treatment area, promoting more consistent biological responses.

Conclusion

In summary, while the use of secondary reflectors and impedance-matched layers presents a novel approach to optimizing shockwave therapies, it is vital to remain grounded in the functional biological principles that govern treatment efficacy. Some scepticism may help to reinforce the importance of intertwining technology improvements with a strong understanding of the mechanotransductive processes critical to successful outcomes in ED treatment. Future research should prioritize a comprehensive exploration of these dynamics, ensuring that advancements in delivery methods translate into real, beneficial changes in patient health.

Jens Rassweiler

Background:
ED, a widespread condition affecting millions of men, can stem from various health issues including vascular problems, diabetes, and psychological factors. Traditional treatments, like Viagra and intracavernosal injections, often allow only temporary relief and do not address the root causes of ED. ESWT, originally developed for kidney stones, has emerged as a promising non-invasive treatment for ED, specifically for vasculogenic types. However, there is currently no standardized protocol for its application, leading to varying effectiveness.

Study Focus and Methodology:
The study aims to enhance shockwave treatment by focusing on two key innovations:
1. The use of a secondary reflector to reflect shockwaves back towards the treatment area, minimizing the risk of injuring surrounding tissues due to excessive tensile pressures.
2. The implementation of an impedance-matched layer (IML) to further reduce the intensity of negative pressures caused during shockwave therapy.
The research involved:
- Designing an optimized secondary reflector using an evolutionary strategy (i.e. a computational optimization method).
- Experimental validation through pressure measurements using a gelatin penis phantom to simulate therapy applications.
- 3D simulations to assess pressure distribution, volume, and intensity within the treatment zone, which are critical to improving clinical results.

Results:
The study's workflow allowed for thorough investigation into reflector design, performance optimization, and simulations that enabled a better understanding of pressure dynamics during treatment. The findings suggest that the use of secondary reflectors can enhance the therapeutic effects of ESWT, targeting the treatment zone more effectively and potentially mitigating side effects associated with existing methods.

Discussion

The findings of this study demonstrate the potential of secondary reflectors and impedance-matched layers (IMLs) to significantly enhance the effectiveness of extracorporeal shockwave therapy (ESWT) for treating erectile dysfunction (ED). The authors think, that the  optimization of a secondary reflector has shown promising results that could pave the way for improved treatment protocols. This concerns:

Enhanced Treatment Efficacy:The introduction of secondary reflectors aims to address one of the critical challenges in ESWT: ensuring that the shockwaves delivered into the treatment zone are effectively focused. In the experimental setups, the optimized reflector has shown an ability to redirect shockwaves back into the desired therapeutic area following their initial pass. This refocusing may lead to higher localized energy delivery, increasing the efficacy of the treatment. By maximizing the impact of shockwaves, one may enhance the regenerative processes associated with erectile function improvement, aligning with the fundamental principles of promoting angiogenesis and endothelial function.

Mitigating Side Effects: One of the notable concerns with current ESWT methods is the risk of side effects, such as bruising resulting from cavitation effects when shockwaves reach air interfaces. By integrating an impedance-matched layer and a secondary reflector into the treatment schema, we can minimize the intensity of negative pressures that contribute to these adverse effects. The results of the study indicate a reduction in tensile pressures in the treatment area, which may lead to a more comfortable experience for patients and reduce instances of bruising and discomfort. This enhancement in safety is crucial for patient compliance and the overall acceptance of ESWT as a treatment modality for ED.

However, here one has to mention, that the actual standardized Protocol for ED using 3000 shock waves at 4-5 Hz delivered to 6 defined areas of the penis with an Intensity of 0.25 mJ/mm2 is very well tolerated by the patients.

Standardization of Treatment Protocols: Currently, the lack of standardization regarding treatment protocols for Li-ESWT presents a challenge in achieving uniform clinical outcomes. By establishing a framework for the use of a secondary reflector and IML, future clinical implementations can build on our findings to develop consistent treatment protocols that integrate this technology. This standardization could involve identifying optimal distances, angles, and energy settings to maximize the reflectors' benefits, leading to replicable and reliable outcomes across different clinical settings.

Scepticism for the use of an innovative reflector design
Usually ESWT is performed by distributing 500 impulses over a defined area (ie. distal part of right corpus cavernosum). This is done by manually moving the probe over this area. The reflectors is a static system. This might be could to disintegrate stones or plaques of IPP, but plays only a minor role in case of ED.
The Role of Mechanotransduction as main biological mechanism

The effectiveness of ESWT in treating ED is heavily reliant on the biological response elicited by mechanical stimuli, specifically through a process called mechanotransduction. This biological mechanism involves the conversion of mechanical signals—such as shockwaves—into biochemical responses, stimulating various cellular processes, including the activation of stem cells and the promotion of angiogenesis.

While enhanced focusing of shockwaves through technological refinements like secondary reflectors may improve energy delivery, it is crucial to recognize that the core therapeutic action occurs at a cellular level. The optimal level of mechanical stimulation must align with the physiological thresholds that trigger beneficial cellular responses. If the energy levels are too high or poorly distributed, they may lead to non-ideal biological responses, potentially overshadowing the benefits of improved shockwave focus.

Application Technique Considerations for ESWT in ED

Uniform Energy Distribution:

- The standard practice of manually moving the probe to deliver 500 impulses over a defined area (e.g., the distal part of the corpus cavernosum) aims for even distribution. However, this approach can result in inconsistencies in energy delivery, potentially leading to uneven stimulation of tissue. Some areas may receive more impulses while others may not receive enough, which could compromise the mechanotransductive signaling necessary for effective treatment.

Static vs. Dynamic Systems:
   - The introduction of reflectors can optimize energy focusing for applications such as breaking up calcifications or stones, where concentrated energy is crucial. For ED, however, the goal is not just to create localized effects but to activate broader biological processes like angiogenesis and stem cell mobilization. A static system that focuses energy might still encounter challenges in ensuring the desired therapeutic depth and breadth across the penile tissues.

Potential for Focused Treatment:
   - If a more precise and focused delivery system can be developed, it might enhance treatment outcomes in ED. A static reflector system could potentially allow for the delivery of high-energy pulses in targeted areas, which could stimulate regenerative capabilities more effectively than a manual sweep of the probe. However, achieving this requires accurate mapping and understanding of the anatomy and physiological responses in the erectile tissues.
Optimization of Impulse Parameters:
   - In addition to the delivery method, considerations around the frequency, energy level, and number of impulses per session are crucial. Research should focus on optimizing these parameters to maximize cellular response without causing tissue damage. Adjusting these elements, alongside the application technique, could lead to better treatment protocols.

Potential Development of Custom Devices:
   - Considering the limitations of manual application, the development of devices with automated mechanisms designed to deliver a predetermined number of shockwaves in a more controlled manner could enhance treatment efficacy. Such devices could ensure uniform application across the desired treatment area, promoting more consistent biological responses.

Conclusion

In summary, while the use of secondary reflectors and impedance-matched layers presents a novel approach to optimizing shockwave therapies, it is vital to remain grounded in the functional biological principles that govern treatment efficacy. Some scepticism may help to reinforce the importance of intertwining technology improvements with a strong understanding of the mechanotransductive processes critical to successful outcomes in ED treatment. Future research should prioritize a comprehensive exploration of these dynamics, ensuring that advancements in delivery methods translate into real, beneficial changes in patient health.

Jens Rassweiler

The article discusses a study focused on improving the efficacy of extracorporeal shockwave therapy (ESWT) for treating erectile dysfunction (ED) through the introduction of secondary reflectors and impedance-matched layers. Background: ED, a widespread condition affecting millions of men, can stem from various health issues including vascular problems, diabetes, and psychological factors. Traditional treatments, like Viagra and intracavernosal injections, often allow only temporary relief and do not address the root causes of ED. ESWT, originally developed for kidney stones, has emerged as a promising non-invasive treatment for ED, specifically for vasculogenic types. However, there is currently no standardized protocol for its application, leading to varying effectiveness. Study Focus and Methodology: The study aims to enhance shockwave treatment by focusing on two key innovations: 1. The use of a secondary reflector to reflect shockwaves back towards the treatment area, minimizing the risk of injuring surrounding tissues due to excessive tensile pressures. 2. The implementation of an impedance-matched layer (IML) to further reduce the intensity of negative pressures caused during shockwave therapy. The research involved: - Designing an optimized secondary reflector using an evolutionary strategy (i.e. a computational optimization method). - Experimental validation through pressure measurements using a gelatin penis phantom to simulate therapy applications. - 3D simulations to assess pressure distribution, volume, and intensity within the treatment zone, which are critical to improving clinical results. Results: The study's workflow allowed for thorough investigation into reflector design, performance optimization, and simulations that enabled a better understanding of pressure dynamics during treatment. The findings suggest that the use of secondary reflectors can enhance the therapeutic effects of ESWT, targeting the treatment zone more effectively and potentially mitigating side effects associated with existing methods. Discussion The findings of this study demonstrate the potential of secondary reflectors and impedance-matched layers (IMLs) to significantly enhance the effectiveness of extracorporeal shockwave therapy (ESWT) for treating erectile dysfunction (ED). The authors think, that the optimization of a secondary reflector has shown promising results that could pave the way for improved treatment protocols. This concerns: Enhanced Treatment Efficacy:The introduction of secondary reflectors aims to address one of the critical challenges in ESWT: ensuring that the shockwaves delivered into the treatment zone are effectively focused. In the experimental setups, the optimized reflector has shown an ability to redirect shockwaves back into the desired therapeutic area following their initial pass. This refocusing may lead to higher localized energy delivery, increasing the efficacy of the treatment. By maximizing the impact of shockwaves, one may enhance the regenerative processes associated with erectile function improvement, aligning with the fundamental principles of promoting angiogenesis and endothelial function. Mitigating Side Effects: One of the notable concerns with current ESWT methods is the risk of side effects, such as bruising resulting from cavitation effects when shockwaves reach air interfaces. By integrating an impedance-matched layer and a secondary reflector into the treatment schema, we can minimize the intensity of negative pressures that contribute to these adverse effects. The results of the study indicate a reduction in tensile pressures in the treatment area, which may lead to a more comfortable experience for patients and reduce instances of bruising and discomfort. This enhancement in safety is crucial for patient compliance and the overall acceptance of ESWT as a treatment modality for ED. However, here one has to mention, that the actual standardized Protocol for ED using 3000 shock waves at 4-5 Hz delivered to 6 defined areas of the penis with an Intensity of 0.25 mJ/mm2 is very well tolerated by the patients. Standardization of Treatment Protocols: Currently, the lack of standardization regarding treatment protocols for Li-ESWT presents a challenge in achieving uniform clinical outcomes. By establishing a framework for the use of a secondary reflector and IML, future clinical implementations can build on our findings to develop consistent treatment protocols that integrate this technology. This standardization could involve identifying optimal distances, angles, and energy settings to maximize the reflectors' benefits, leading to replicable and reliable outcomes across different clinical settings. Scepticism for the use of an innovative reflector design Usually ESWT is performed by distributing 500 impulses over a defined area (ie. distal part of right corpus cavernosum). This is done by manually moving the probe over this area. The reflectors is a static system. This might be could to disintegrate stones or plaques of IPP, but plays only a minor role in case of ED. The Role of Mechanotransduction as main biological mechanism The effectiveness of ESWT in treating ED is heavily reliant on the biological response elicited by mechanical stimuli, specifically through a process called mechanotransduction. This biological mechanism involves the conversion of mechanical signals—such as shockwaves—into biochemical responses, stimulating various cellular processes, including the activation of stem cells and the promotion of angiogenesis. While enhanced focusing of shockwaves through technological refinements like secondary reflectors may improve energy delivery, it is crucial to recognize that the core therapeutic action occurs at a cellular level. The optimal level of mechanical stimulation must align with the physiological thresholds that trigger beneficial cellular responses. If the energy levels are too high or poorly distributed, they may lead to non-ideal biological responses, potentially overshadowing the benefits of improved shockwave focus. Application Technique Considerations for ESWT in ED Uniform Energy Distribution: - The standard practice of manually moving the probe to deliver 500 impulses over a defined area (e.g., the distal part of the corpus cavernosum) aims for even distribution. However, this approach can result in inconsistencies in energy delivery, potentially leading to uneven stimulation of tissue. Some areas may receive more impulses while others may not receive enough, which could compromise the mechanotransductive signaling necessary for effective treatment. Static vs. Dynamic Systems: - The introduction of reflectors can optimize energy focusing for applications such as breaking up calcifications or stones, where concentrated energy is crucial. For ED, however, the goal is not just to create localized effects but to activate broader biological processes like angiogenesis and stem cell mobilization. A static system that focuses energy might still encounter challenges in ensuring the desired therapeutic depth and breadth across the penile tissues. Potential for Focused Treatment: - If a more precise and focused delivery system can be developed, it might enhance treatment outcomes in ED. A static reflector system could potentially allow for the delivery of high-energy pulses in targeted areas, which could stimulate regenerative capabilities more effectively than a manual sweep of the probe. However, achieving this requires accurate mapping and understanding of the anatomy and physiological responses in the erectile tissues. Optimization of Impulse Parameters: - In addition to the delivery method, considerations around the frequency, energy level, and number of impulses per session are crucial. Research should focus on optimizing these parameters to maximize cellular response without causing tissue damage. Adjusting these elements, alongside the application technique, could lead to better treatment protocols. Potential Development of Custom Devices: - Considering the limitations of manual application, the development of devices with automated mechanisms designed to deliver a predetermined number of shockwaves in a more controlled manner could enhance treatment efficacy. Such devices could ensure uniform application across the desired treatment area, promoting more consistent biological responses. Conclusion In summary, while the use of secondary reflectors and impedance-matched layers presents a novel approach to optimizing shockwave therapies, it is vital to remain grounded in the functional biological principles that govern treatment efficacy. Some scepticism may help to reinforce the importance of intertwining technology improvements with a strong understanding of the mechanotransductive processes critical to successful outcomes in ED treatment. Future research should prioritize a comprehensive exploration of these dynamics, ensuring that advancements in delivery methods translate into real, beneficial changes in patient health. Jens Rassweiler

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