Shockwave Therapy for Penile Fibrosis from Intracavernosal Alprostadil
Low-intensity shockwave therapy (LI-SWT) is not established as a treatment for penile fibrosis caused by intracavernosal alprostadil injections, and current evidence supports watchful waiting as the primary approach since over half of cases improve spontaneously without intervention. 1, 2
Evidence for Shockwave Therapy in This Context
The 2025 European Association of Urology guidelines discuss LI-SWT exclusively for vasculogenic erectile dysfunction, not for penile fibrosis treatment. 3 The guidelines note that:
- LI-SWT may be used in men with mild vasculogenic ED as a weak recommendation 3
- LI-SWT can be combined with PDE5 inhibitors or vacuum devices for enhanced ED treatment results 3
- No mention is made of LI-SWT for treating established penile fibrosis from any cause 3
Natural History of Alprostadil-Related Penile Fibrosis
The most compelling evidence argues against immediate intervention:
- 52.3% of patients with penile fibrosis from intracavernosal PGE1 showed clinical improvement without any therapeutic intervention 2
- 25% had complete resolution with no longer detectable fibrosis 2
- Most patients (91.3%) continued their injection therapy during spontaneous improvement 2
- The presence of penile curvature or pain did not significantly affect the likelihood of spontaneous improvement 2
Recommended Management Algorithm
First-Line Approach: Observation
- Continue regular follow-up with penile examination at 3-month intervals 1
- Monitor for penile nodules, plaques, curvature, and induration at each visit 1
- Retrain proper injection technique to prevent further trauma 1
- Defer therapeutic intervention in anticipation of possible spontaneous improvement 2
Second-Line: Alternative Therapies
If fibrosis progresses or erectile function deteriorates:
- Transition to PDE5 inhibitors (sildenafil, tadalafil, vardenafil) if not previously failed 1
- Consider intraurethral alprostadil to avoid further corporal trauma 1
- Vacuum erection devices with vacuum limiters can be used to avoid additional penile trauma 1
Third-Line: Surgical Intervention
- Consider penile prosthesis implantation only if ED becomes refractory to medical management and fibrosis significantly impairs quality of life 1
Critical Pitfalls to Avoid
Do not pursue aggressive interventions for penile fibrosis from alprostadil injections without allowing adequate observation time. 2 The natural history strongly favors spontaneous improvement in the majority of cases, and premature intervention may expose patients to unnecessary risks and costs without proven benefit.
The incidence of penile fibrosis with intracavernosal alprostadil ranges from <1% to 23.3% depending on the study, with more rigorous examination protocols detecting higher rates. 4, 5 However, the high rate of spontaneous resolution makes conservative management the evidence-based first choice. 2