PRP Penile Injection for erectile dysfunction

Marc Darrow, MD, JD

PRP Penile, the P-Shot®, or PRP Penis Injections are names to describe injections of platelet rich plasma into the penis to address concerns of erectile dysfunction. The injections are typically given into the corpora cavernosa (the two chambers of the shaft of the penis that fills with blood to maintain an erection) to help repair damage to arteries in the penis that may prevent erections because of blood flow impediment.

Platelet Rich Plasma Therapy or sometimes referred to as PRP is a regenerative (repairs and grows tissue) / biologic (from you) therapy that uses the healing factors of your blood to rebuild and repair damaged tissue. There is decades of research on PRP outcomes. In this article I will highlight new research into PRP use for erectile dysfunction.

  • PRP treatments are derived from you. For PRP Penile / the P-Shot®  injections we collect a small amount of your blood, similar to the blood taken for standard blood work, and then take it over to a centrifuge where the blood is spun. The spinning helps separate out the blood’s platelets from the red blood cells. The collected platelets and the healing factors within are then injected into the penis to stimulate healing and tissue regeneration.

The goal of the treatment is to help men achieve firmer erections with greater girth and length, not by injecting blood into the penis, but by injecting healing factors that can repair the blood vessels and the valves of the penis that make future erections possible. The concept is to provide regeneration and healing to tissue that supplies the blood that maintains erections.

The PRP Penile / the P-Shot®  injections  is the subject of new and intense research. We will cover this research below.

A November 2023 paper in the International journal of impotence research (1) summarized the latest evidence on platelet-rich plasma (PRP) intracavernosal injections effectiveness in men affected by primary organic erectile dysfunction (ED).

In this paper the researchers reviewed previously published research evaluating PRP alone or in combination (with other treatments) for erectile dysfunction (ED). The researchers identified data from seven studies for inclusion in their review. Three were randomized control trials which evaluated PRP vs. placebo, one study separately tested PRP and low-intensity shock wave therapy, three studies compared low-intensity shock wave therapy or low-intensity pulsed ultrasound alone with their combination with PRP. Of 641 included patients, 320 received PRP.

The researchers noted, as do many studies on PRP treatment for various ailments, that the studies tested various doses and timings, there was no one scepific method of treatment that is universally accepted. Despite this, they write: “Despite the heterogeneity among inclusion criteria, dose and protocol of PRP administration, and outcomes measured, most studies independently reported better sexual outcomes in patients who received PRP, without significant severe side effects.” In the analysis of the data from teh PRP vs placebo studies, the researchers found patients treated with PRP showed higher International Index of Erectile Function (erectile function domain) score compared to patients who received placebo.”

The paper concludes: “In men affected by primary organic erectile dysfunction (ED), PRP intracavernosal injections demonstrated an objective improvement or at least a tendency in erectile function recovery.” The paper also sites as limitation small patient numbers, and the short-term follow-up may limit the generalizability of these observations. Larger studies with longer follow-ups are needed.

In September 2023 a paper in the journal Sexual Medicine Reviews (2) found similar results. In reviewing four randomized clinical trials investigating the safety and efficacy of PRP for erectile dysfunction the authors suggest: “While intracavernosal PRP is considered safe, its efficacy for the management of ED remains unknown due to variability among clinical trials.” They too found many differences in the doses, timing and the way that the treatment was offered.”


Why are doctors interested in PRP for erectile dysfunction?


A September 2023 paper in the journal Minerva endocrinology (3) discusses the regenerative medicine aspect of PRP injections as a treatment that addresses the problems of the disease as opposed to treating just the symptoms. The authors write: “The vast majority of erectile dysfunction (ED) treatments are currently symptomatic and do not influence disease progression. Regenerative medicine may potentially reverse or stop the progression of complicated ED by restoring erectile capacity.”

The authors then reported on their evaluation of  potential safety and effectiveness and the clinical correlates of platelet function before platelet-rich plasma (PRP) injection in men with vascular ED unresponsive to phosphodiesterase-5 inhibitors (PDE-5is). These drugs work by increasing blood flow to the penis prior to sexual stimulation. They are  more commonly known as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra).

The study took 150 men with vascular ED:

  • Vascular erectile dysfunction is the most common form of ED. There is damage or blockage to the blood vessels that send blood to the penis needed for erection, and/or there is damage or dysfunction in the valves in the penis that hold the blood inside the penis that maintains the erection.

They discontinued the use phosphodiesterase-5 inhibitors and after a one month pharmacological washout from the drugs, they asked the patients to complete the 5-item International Index of Erectile Function (IIEF-5) questionnaire  and a dynamic penile duplex ultrasound (d-PDU) was performed. Patients then underwent intracavernous PRP injection.

One month after treatment, the patients were evaluated based on their follow up scores in the 5-item International Index of Erectile Function (IIEF-5) questionnaire.

  • Most patients (80%) had a significant improvement in ED symptoms and in PSV (peak systolic velocity . blood getting to the penis) after dynamic penile duplex ultrasound (d-PDU) evaluation.

The researchers concluded: “This study provides the first evidence that PRP could represent an effective and safe option for patients poorly responding to phosphodiesterase-5 inhibitors.” Further they concluded that patients who responded poorly to this treatment may benefit still from subsequent PRP treatments.

A May 2023 paper in the journal Urology (4) reported on a placebo-controlled study of 100 cases with mild to moderate erectile dysfunction. Participants were divided into 2 groups; the PRP group received 3 injections (3 mL each corpus) and the interval between injections was 15 days, while the Placebo (Saline) group received 6 mL saline injected intracavernous. Post-injection follow-up lasted 6 months.

Results:

  • When compared to the placebo group, the PRP treatment group demonstrated a significant improvement in their erection capabilities at the one and three months follow-up. They also reported a slight drop at the 6 months follow-up. (This would indicate exploring another round of treatments).
  • The improvement was seen in the duplex (ultrasound) parameters, (showing stronger and repaired tissue), and in self-reported patient surveys, the International Index of Erectile Function Erectile Function (IIEF-EF), Sexual Encounter Profile (Questionnaires) Q2 and Q3.
  • At 1-month post-treatment follow-up (76%) patients in the PRP group had an improved International Index of Erectile Function Erectile Function scores as they attained a minimal clinically important difference compared to (18%) in the saline group.
  • At the 3-months post-treatment follow-up, (72%) patients achieved a minimal clinically important difference in the PRP group vs (16%) in saline group then dropped to (70%) in the PRP group vs (16%) in saline group at the 6-months post-treatment follow up.
  • Patients’ overall and intercourse satisfaction levels were higher in the PRP group.

A May 2021 paper in the Journal of sexual medicine (8) reported on the first double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of PRP injections in patients with mild and moderate erectile dysfunction.

  • Sixty sexually active patients with mild and moderate erectile dysfunction were randomly assigned to two sessions, with a one-month difference, of 10 mL PRP  or placebo  intracavernosal injections.
  • Patients were evaluated at 1, 3 and 6 months after completion of the treatment protocol.

Results:

  • At 6 months, a minimal clinically important difference (MCID) was achieved by 20/29 (69%) patients in the PRP group compared to 7/26 (27%) in the placebo group. Patients receiving PRP reported being more satisfied with the treatment than the patients treated with placebo. No adverse events were observed during the study period.

PRP as alternative to current treatments


An April 2022 paper in the Frontiers in reproductive health (5) explains why PRP is being researched as an option for erectile dysfunction: “Current therapies to treat ED include oral PDE5i medications, (as mentioned above sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra], and avanafil [Stendra.]) Intracavernosal injection or intraurethral applications of vasodilators (e.g., alprostadil), vacuum erection device, and ultimately if the aforementioned fail, penile prosthesis implant.

However, these treatments offer only temporary symptomatic relief and do not influence disease progression—patients are potentially on lifelong treatment, with ED worsening over time. Side effects from oral medications affect more than 16% of men, and more than 50% of men stop using oral tablets due to adverse effects, interactions with other medication, and variability in effect. As ED progresses, fibrous tissue replaces smooth muscle in the penis, rendering it inelastic and unresponsive to medication.”


Better results when diabetes is controlled


A July 2022 study (7) conducted by Cairo University evaluated the effectiveness of intracavernosal platelet-rich plasma (PRP) injections in addition to daily oral tadalafil (Cialis) dose in diabetic erectile dysfunction (ED) patients non-responding to PDE5 inhibitors.

Forty-eight erectile dysfunction patients who were non-responding to PDE5 inhibitors were divided into 2 equal groups, diabetics and non-diabetics that were given a daily dose of 5 mg tadalafil plus vardenafil 20 mg (a vasodilator) and were given three doses of intracavernosal platelet-rich plasma (PRP) injections, 4 weeks apart.

Responses to on-demand PDE5 inhibitors, International index of erectile function-5 (self-reported erectile function survey) score, erection hardness scores (EHS) and pharmaco-dynamic duplex studies (the dose compared to teh response) were assessed.

  • After PRP injections, 33% (of diabetics) and 50% (of non-diabetics) of cases were satisfied with on-demand PDE5 inhibitors, whereas 41% (of diabetics) and 66% (of non-diabetics) showed improved erection hardness scores response.
  • Compared with baseline scores, the mean International index of erectile function-5  scores were significantly improved after PRP therapy in the diabetic ED group as well as in the non-diabetic ED group linked to pharmaco-penile duplex readings.
  • Both good and fair diabetic control exhibited significant responses to intracavernosal platelet-rich plasma (PRP) injections compared with bad controlled cases.

Extracorporeal shockwave therapy, stem cells, and PRP


A March 2021 paper in the journal Therapeutic advances in urology (9) suggests “There is clinical interest in employing regenerative therapies, including low-intensity extracorporeal shockwave therapy, platelet rich plasma (PRP), and stem cell therapy, in the treatment of erectile dysfunction as adjunct or alternative treatments. In this paper the authors present evidence for emerging shockwave- and cell-based regenerative therapies for the treatment of erectile dysfunction. They write “low-intensity extracorporeal shockwave causes microtrauma in tissue that hypothetically upregulates angiogenesis (formation of new blood vessels) and recruits stem cells (to begin a healing cascade). Several large-scale systematic reviews and meta-analyses have reported that low-intensity extracorporeal shockwave improved erectile dysfunction in humans. Additionally, evidence has commenced to show that erectile dysfunction may be effective against two recognized and complex etiologies of erectile dysfunction: diabetic and neurogenic.  In the treatment of erectile dysfunction, stem cell therapy has been used in the setting of diabetic and post-prostatectomy erectile dysfunction.

Summary

When considering treatments for PRP injections for erectile dysfunction, one should research the pros and cons of the treatment and to discuss with his clinicain, the realistic goals of the treatment  and one’s sex history and current sexual activity.

References

1 Panunzio A, Labate C, Zacheo F, Orlando R, Rizzo FL, Porcaro AB, Migliorini F, Pagliarulo V, Tafuri A. Platelet-rich plasma intracavernosal injections for the treatment of primary organic erectile dysfunction: a systematic review and meta-analysis of contemporary controlled studies. International Journal of Impotence Research. 2023 Nov 22:1-0.
2 Fazekas D, Campbell K, Ledesma B, Masterson T. Platelet-rich plasma for erectile dysfunction: a review of the current research landscape. Sexual Medicine Reviews. 2023 Oct;11(4):369-74.
3 Francomano D, Iuliano S, Dehò F, Capogrosso P, Tuzzolo P, Antonini G, Aversa A. Regenerative treatment with platelet-rich plasma in patients with refractory erectile dysfunction: short-term outcomes and predictive value of mean platelet volume. Minerva Endocrinology. 2023 Sep 15.
4 Shaher H, Fathi A, Elbashir S, Abdelbaki SA, Soliman T. Is Platelet Rich Plasma Safe and Effective in Treatment of Erectile Dysfunction? Randomized Controlled Study. Urology. 2023 May 1;175:114-9.
5 Anastasiadis E, Ahmed R, Khoja AK, Yap T. Erectile dysfunction: Is platelet-rich plasma the new frontier for treatment in patients with erectile dysfunction? A review of the existing evidence. Frontiers in Reproductive Health. 2022 Aug 16;4:944765.
6 Schirmann A, Boutin E, Faix A, Yiou R. Pilot study of intra-cavernous injections of platelet-rich plasma (P-shot®) in the treatment of vascular erectile dysfunction. Progrès en Urologie. 2022 Dec 1;32(16):1440-5.
7 Zaghloul AS, El‐Nashaar AM, Said SZ, Osman IA, Mostafa T. Assessment of the intracavernosal injection platelet‐rich plasma in addition to daily oral tadalafil intake in diabetic patients with erectile dysfunction non‐responding to on‐demand oral PDE5 inhibitors. Andrologia. 2022 Jul;54(6):e14421.
8 Poulios E, Mykoniatis I, Pyrgidis N, Zilotis F, Kapoteli P, Kotsiris D, Kalyvianakis D, Hatzichristou D. Platelet-rich plasma (PRP) improves erectile function: a double-blind, randomized, placebo-controlled clinical trial. The journal of sexual medicine. 2021 May;18(5):926-35.
9 Drury R, Natale C, Hellstrom WJ. Reviewing the evidence for shockwave-and cell-based regenerative therapies in the treatment of erectile dysfunction. Therapeutic Advances in Urology. 2021 Mar;13:17562872211002059.

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