Our guest this week is Dr. Stefan Buntrock , Consultant Urologist with post graduate qualifications in Sexual Medicine and Sports Medicine. He has a busy private practice in Göttingen, Germany specialising in men’s health conditions alongside standard urology care. He also owns and generates amazing content for the ever-popular Youtube channel – www.youtube.com/@UroChannel1A which covers everything from Peyronnies to CPPS in a bite size, easy to understand format for patient education. I thoroughly recommend it to all those working in this field.
Stefan talks us through his experience in Men’s Health, and how adopting ESWT transformed the way he deals with CPPS and ED, in particular. He has also recently added to his significant professional repertoire by providing education for therapists / clinicians through the excellent online portal – https://shockwavetherapist.com/shockwave-therapy-formens-health-conditions
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Episode Transcription
Welcome to the Ed Clinics podcast. My name is James Woledge. I’ll be your host for this series where we’ll be discussing everything to do with shockwave therapy and men’s health conditions. That’s everything from erectile dysfunction through to chronic pelvic pain syndrome, Peyronie’s disease, hard flacid syndrome amongst others. We’ll be talking to a host of experts from around the world to shed some light on these complex conditions. And we’ll also be talking to patients that have been through treatment journeys themselves, so you can get a greater understanding of how we can help a broad range of people with these conditions. So without further ado, enjoy this episode. Thanks for coming over. The last, I think probably couple of months before Thomas got hold of me, I was like, this guy’s everywhere. You had nearly like 250,000 on your YouTube channel, which I now tell patients about because I am not just saying this because you’re on my podcast, but they are, they’re like perfect little bite-sized bits that we tell patients about nitric oxide. That one that you did the eight sort of tactics for that,
Just exactly what patients are after. Yeah, I think that’s really good. And then I sort of digging around, usually I get patients to, sorry, I’ve been in clinical day guests to talk about themselves, but I can’t help but talk about him like Right, doctor? Doctor. Oh yeah, now I understand. So he’s got PhD, Scandinavian languages consultant, urologist, surgeon, sexologists, which we don’t have for those in the UK listening, we have urologists specialise in sexual medicine or andrologist. And then you have sports medicine qualifications as well. So two PhDs, sports med speak, several languages, a YouTube sensation that makes you pretty unique. Right.
Next month I’m going up for the exam for nutritional medicine. I’m kind of nervous.
Yeah, that’s impressive. Yeah, right. I don’t even want to go into the machinations of your mind, but clearly you are not one for sitting around and just resting at peace.
No, I mean I’m just a regular guy, so if you’re interested in stuff and you look around and you easily get interest in this and that and suddenly a few decades later you have accumulated a lot of stuff.
Yeah, it’s making me feel pretty bad because I might be a bit older than you. I’m 50 and you’ve managed to produce all of those things by the, how old are you? Do you mind me asking?
Oh, you’re looking pretty good. I’ll give you that.
So you currently have private practise in the middle of Germany?
Alright, and is that just you or do you work with a team of others or that’s your thing?
No, it’s just me. I made the experience that I’m quite good at doing things on myself, so I get lots of things done and the best thing about working alone is that you can make all your decisions yourself and you take credit for all the good things that you decided, but you also take the beating for all the bad things that came out of it. I don’t have to discuss any topics with anybody concerning my YouTube channel, so I just come up with a topic and then I just do it.
And I think I heard on another podcast that I listened to you on that you’ve done 110 videos just pretty much around the penis or men’s health,
Something like that. It’s around the penis.
And when I started, I never thought one could do so many videos, so many different videos about the penis. But it turns out it’s a pretty interesting organ and there are lots of nuances that you can explore in the penis. And I was most fascinated, I think about the fibro skeleton of the penis. Many species, they have a bone inside and we don’t. So the penis in principle feels soft, but it isn’t because it’s some of the miracles of nature. So when the penis feels with blood, it suddenly becomes rigid because of this fibro skeleton that expands
Of the pressure inside the penis. And I think this is just fabulous structure. If you look at it with all these pillars and connected to the odour surface, it’s very fascinating.
It makes some of the words that are used around the penis somewhat difficult because as you will probably get, you still have patients thinking there’s a bone in there because of course there is still a diagnosis of a fractured penis. And so when people hear fractured penis, they think, well, there must be a bone in there to fracture. And you go, well actually no, it’s a fibro skeleton. That actually is the fracture in effect, the collagenous stuff that does it not a bone. Yeah, it’s definitely got some interesting anatomy as I’ve discovered over the last five or six years looking into this now, I mean you spend all of your life doing men’s health. I mean for us in the UK I’m part of a group of clinics called ed clinics.co uk. So we are a physiotherapist osteopaths. There are some medics involved in that as well. And it probably makes up only maybe 10, 15% of our working day. The rest is still for me, musculoskeletal, which is how I got into shockwave over 10 years ago. And your journey’s been slightly longer than that, about 15 years ago maybe, that you started
Seeing something like that? So I started out as a regular urologist, you go to med school and then in my time we had something which was called A IP, which is asked in practicum. So after I was done with med school, I had one year and a half that I was kind of a doctor for German standards, but I wasn’t fully licenced. They abandoned that. But back in the day they had it where I looked around in all kinds of specialties. So I was in gynaecology and cardiology, internal medicine. I think I also did some geriatrics stuff. And then I ended up in urology. And as every urologist I had a surgical training and it’s basically cancer. When you work in a hospital, most of the stuff that you see is about cancer. So I always regarded myself being an oncologist in a way, but relatively early in my career I thought, well, what we’re doing is maybe not the best of things because we’re leaving aside the sexual aspects.
And as you mentioned, I’ve also studied literature and if you look around and look at the world, sex is one of the main promoters of actions for people. So whenever there’s anything you can be pretty sure sex is involved. And if you read novels, it’s everywhere in the novels. So I was actually, when I was getting out of med school, I wasn’t quite sure if I wanted to become a doctor. So I was interested in becoming a consultant and I had a job interview at the Boston Consulting Group that was over 20 years ago. Then they were asking us, so the first branch was they opened in Boston and then they opened in Tokyo and they were asking us, so why do you think it was Tokyo? So everybody was speculating about the economy and it being so important. I was so stupid I didn’t speak up because I immediately thought, well, because there was some kind of woman in Tokyo that was the solution.
So he had a girlfriend in Tokyo, so he opened a new branch in Tokyo. So there’s sexual motives everywhere and this is what I thought was so important. So we rip out the prostates and for that matter also the bladders. And then we say, here you go, you will live for many decades, but we don’t care about your sex life because it’s your private life and farewell, this is how we do it and this is how we still do it today. And because of that, I got interested in sexual medicine and I started to do all this stuff with PD five inhibitors. But then I came to a point where I thought, well, it can’t be everything. So I was interested in becoming a sexologist and this is the psychologic part of things. So I learned sex therapy at the cite University hospital in Berlin. That was a course that went over many years, I think two years. And then I studied because you had to handle all these cases. It wasn’t just going into a course, you had to make your homework and have patients, see patients get supervised, do therapies, get supervision on the therapies was quite complicated and how it all started,
Right? I mean, that’s a hell of a journey. You can’t say that you lack commitment in this journey. I mean goes without saying. This podcast is principally set up. It was originally set up about five, six years ago for practitioners using shockwave. But actually as I’ve discovered, there are a lot of people that are now, particularly in men’s health, there’s some very well educated patients that go on a big journey of understanding and they often find the podcast and then come and see me or some of my colleagues as a consequence of that. So I am always aware of that now that I want as much from this podcast to be for patients necessarily as I would for practitioners. And on that note, I mean probably most of this is going to be about ed, but I like your point, which you made on the other podcast.
I think about if you had a selection of patients with men’s health in for the day, you would be really enthusiastic and happy about patients with CPPS, which for most people they would’ve understand that being chronic sitis, which I also sort of completely agreed with your point on that, which is it is become a little bit of a throwaway term for when you’ve got pain down there and you’ve got no evidence of infection and then you get told you’ve got non bacterial prostatitis because they’re the ones that with shockwaves are brilliant. We all agree this now in the working groups that I’m in and then followed up with, that would be a reasonable chance that shockwave will help with your ED if you are good at picking the right patients. And then my experience a long way after that is the Peyronie’s aspect,
Which is really difficult to treat. And I think that presents to me the biggest challenge on a number of levels because you will know this, is that they are by far and away the most emotive group, partly because you so so much sympathise for them and they’re the most motivated to try and get better. The dysfunction can be enormous, the emotional toil it takes upon them. I think that unfortunately there’s one downside about shockwave, most of it’s brilliant, but lots of people have got shockwave devices now or what they would call shop devices, radio, otherwise. And I think lots of these patients when we’ve been doing it six or so years now, and we’re starting to see more and more patients see us from having seen other clinics where they’ve been promised quite a lot of good outcomes with Peyronie’s and spent a lot of money then and not being really assessed properly and told realistic expectations. I mean I guess you’re in the same boat with that are you must see lots of other people that have tried to see lots of other urologists and then come see you as a specialist. Can you give us your overview on those three, those sort of three?
I totally agree and I think you have a big advantage over doctors because you are a physiotherapist and we don’t learn the stuff that you learn about muscle, about how the body works. And I think this is a bit disadvantage for doctors because we don’t think in that terms in these terms. There’s one thing, this is kind of how I got into this. It’s because of golf. I play golf
And so I get all these injuries like everybody else and then I got interested, so how do I cure that stuff? And then I entered into the Titleist Performance Institute, which is a big company in the US and they teach people how to assess the golf swing and they have three paths that you can move down. This is a medical, golf and fitness. So I did the medical qualification and there was a big chunk of physiotherapy and physiotherapeutic thinking about the body, how the body works in patterns and when these patterns don’t work well because it’s a pattern of stable and mobile segments and if you have stable a mobile segment that is stable because you have some problem, then you get a problem in the whole body. And so I think this is something that I think very much when I think about the pelvic floor and we haven’t learned to think about this, so I think you’re much better at this than I am.
Well, I don’t know, but I mean it’s certainly one of those areas we’re always thinking about. And I think I listened to one of your other podcasts where you said something interesting. It got me thinking about how just treating the pelvic floor in some instances can improve erectile function.
And I’ve definitely seen patients that I was like, that may be the reasoning behind that. The younger males in their thirties, we’ve seen a few post covid with erectile dysfunction and it seemingly they’re very healthy and fit. They’re not really a great candidate for having a vascular erectile dysfunction and they get pretty good nighttime erections, morning erections, that’s unchanged. But when it comes to the actual performance itself and they would pretty much say yes, it has become a bit of an anxiety issue. So there’s no doubt that bit between the ears, but I wonder as part of that anxiety, it’s driving pelvic hypertension if you like in those. And then when we treat that area, that’s probably the bit that’s out of the sort of protocol we use, which is treating the crower as well as the penile shaft. They often say within two or three sessions are much better and I think it’s partly because they’re getting help and their anxiety improves. I think that’s part of it, but I think that there is probably, from what you say there is probably some releasing of tension in the pelvic floor that is then helping them move forward.
This is especially when there are trigger points and when you hit these trigger points and you have seen it as well, I’m sure you barely touch them with shock waves and they scream, it’s so painful you have adapted. I’m very happy if I have some of those patients because I know they’re going to be fine. If I can’t just put in a lot of power and they don’t say anything, then I’m kind of worried because I think maybe it’s not working. But starting with your three diseases that we treat with shockwaves, I totally agree and I say if you’re looking for a miracle, then treat somebody with pelvic pain, especially somebody who has been to other places. But problem is I can’t help everybody. So I would say maybe five or six out of 10 if you select them carefully, but I mean this is better than none.
Right? Yeah. So can you give a really good summary of trying as you’ve discovered in your journey, trying to select patients with peyronie? Just to clarify from a urological surgical point of view with your experience, because we try and teach this when we teach in this country that there are some candidates that might work and there are some candidates that won’t work pretty much might work. Can you just give your summary of trying to pick those Peyronie’s patients out and what those that you would take
On generally? After having cranked up my machines to the highest levels in pones disease, I can say it doesn’t affect curvature. This is my conclusion in neither of them. Neither with calcified or noncalcified plaques, that’s for sure. So I think there is not one single modality to treat pones disease. So I’m treating in a pattern where I combine several treatments for pones disease and when I get a patient I first determine whether it’s an acute phase or the stable phase. Mostly will get patients in the stable phase because they don’t know what’s going on and then many valuable months are lost until they finally come to us and get an examination. Then I look at it with the ultrasound and it’s very important whether there are calcified plaques or noncalcified plaques. As soon as I see calcifications, things become very complicated because up to now I’m not quite sure whether they can be helped with anything but surgery. So what you can try is maybe you can stop that that’s not getting this severe. Maybe you can have a curvature that’s still functional, but to reduce curvature, I don’t think it’s possible in calcified plaques, I’m doing my approach mainly in noncalcified plaques.
And would you, sorry, just to clarify, would you treat them in the acute phase at all or would you just not do any of the interventions in the acute phase?
In the acute phase, I would try to stop the inflammation. So there are some at least theoretical reason to think that tadalafil could do that
Because of its interaction with the TGF beta one I think it is so that this chronic inflammation that’s going on can be stopped because in theory today you have a 30 degree angulation and it can go up to 90 or even 100 degrees and we don’t really want that. And I give them also a arginine and citraline just to have some antioxidants to stop this inflammation. I have the impression it works in most of them, not in all, but it works in most. This is what I would do with a calcified plaque. I think one could try traction in this. Traction is a big part of my approach because I don’t think you can reduce curvature without traction and traction also gives the advantage that penile length is lost and when you apply traction, you can regain some of the length that has been lost.
Do you use a particular device? Do you use the rex?
Yes, I think it’s my favourite right now
For those who are listening, the Rex is a traction device that’s as simple as that. It’s one of many. So you almost in a way you probably trying to take those patients and say, look, actually this is probably not a good idea. And then you still get those patients to say, even though it’s a 1% chance, I’m still willing to go for it.
If we talk about shockwaves, we haven’t talked about shockwaves yet.
So what’s happening in these with the noncalcified plaques is that they get really soft. Have you seen this too?
No. Well, you palpate and you think you get a softer plaque, but the patients report that they feel less of a plaque and there is good evidence. I think now that the plaque there is plaque reduction with shockwave, it’s just sometimes it doesn’t go into curve reduction, which is the annoying thing.
No, but it’s immediate softening of the plaque. So the noncalcified plaques, I can’t really feel them anymore. So even during treatment I get the impression, okay, now I have to really search where is it almost feels like it is gone and this is what the patients also say. So after three to four days it gets hard again. So I have no explanation for this, but in theory if I would apply traction during these days, having a flexible and soft plaque, this is my argument for doing shock waves because I soften up it, soften it up, and then I apply traction and then I can reduce curvature and I had effects with that. So it’s possible to do that, but the chances are not very high I have to say.
I have some patients where it worked.
Okay, and what do you generally do because there’ll be people listening to this that are practitioners that want some takeaways as they always do from this, I mean is your general view that every Peyronie’s you see is roughly a dozen treatments? I mean it’s not two treatments right? There a sort of general kind of number that you tend to suggest to patients that you’re going to need to see me weekly for however many,
I have a tendency to say, okay, maybe between 10 to 15
On the patient and how far he has to travel. And we always have to think that if we are looking at research on peroni’s disease and on results, this is not one or two weeks apart, we’re talking about six months, 12 months. These are the timeframes that we have to look at our results. It takes forever and stretching, it’s a lifestyle almost because you have to stretch for up to eight hours a day, which would be an advantage of the restore X.
There has been lots of debate about the energy usage we should use in Peyronie’s disease one. I think one of the recent ones was better results with a lower energy and then there’s people that say you need to go beyond. I think Professor Lund I think is now using I think the C actor which is an electro mechanical device from Storz, which is beyond the 0.55 millijoules that my device goes to and he thinks that would be better, but I don’t think we have any evidence yet for any particular energy level. Nothing concrete. What’s your instinct on Peyronie’s in a normal plaque?
There has been debate on increasing the level of energy in Peyronie’s plaques. I think my colleague Post and Hamburg, he’s a promoter of this hypothesis and he does a lot of this. I’m personally also using the C actor for Crohn’s disease and I’m using it on the highest level because maybe it’s the urologic thinking about breaking stones with ESWL that I think we can, the more power I get into this, the better it is. But if this is true or not, I’m not quite sure the stores right now. Before that I had the areas too
And on the areas I was shooting at much lower frequency, lower energy levels and I think this is something that you have to consider as well. It’s the machine that you’re using and the focus length and the focus size on each of those machines. So with the areas, the focus point is quite near the surface of the applicator, which makes it almost feel like a radio shockwave device and if you increase the energy it really hurts the patient. And I’ve also seen at the higher energy levels some bruising of the skin. You have to constantly move it around, otherwise the skin gets bruised, which is not the case in the C actor handpiece. I can double the energy that I used at the S device and still the patient doesn’t feel anything. And even if you have your finger, I’m using a gauze swap on the other side and I really had to use it with the ER because it would really hurt my finger through the penis.
This is not happening in the same way in the shorts device, so I don’t really have to use a gauze swab for the CP handpiece.
Right. And that level goes up to, what is that the 0.55 or have you got the one that goes to 1.24? Just 0.55,
So just on moving on to the ED front, which is where most of our patients sit, I mean you would see patients between the ages of approximately 40 and 70 I think I heard you say, which is roughly us as well. Seeing that group, do you have a particular where you rub your hands together and say this is the right patient for me over here when we see patients, if they’re responding to PDI fives already, they’re getting morning erections, they’re relatively healthy, of course they’re good patients and you’re welcoming them into clinic. Have you got any other insights in your experience as to what patient selection looks like for you? With an ed,
I roughly say between 40 and 65. These are the ages where I can be pretty sure if it has worked before 40, then the psychogenic component is not that prevalent. So I will mostly get people with malfunctions of the body because of the age, the ageing process, something like that. And if it’s 70, 75, I think there’s lots of ageing that has been going on and it’s very hard to revert that process in people that old, but I usually do, I palate the penis. There was something,
This wheat bread thing I heard,
Well yeah, explain what that was. I got lost in translation with that.
If you buy a fresh loaf of bread and it’s mostly the bread that you buy in America or I think also in the UK wheat bread and it’s very fresh and you can squeeze the loaf like this and you catch this thin,
Is what I call the wheat bread penis because if there’s lots of tissue lost then you can easily squeeze this like a fresh loaf of bread and there’s no resistance. It’s very fluffy. This is what I call the wheat bread pre and I’ve bad experience with that.
So that’s age related penile atrophy in effect. Yeah, I mean it makes sense. What are you rejuvenating? If the tissue’s not there to rejuvenate then it’s not great. I was just interested to know how do you warm the patient up for that? I’m just going to give your penis a squeeze just to see how it feels.
I don’t think he notices it because I always palpate the penis for pones plaques because this is one of the differentials in ed. This is why I do ultrasound on all penises. Once in a while I see Peyronie’s plugs and then I know, okay, this is an ED because of that and they don’t have any deviation of any kind and they didn’t even know they had Peyronie’s disease. But that would be the diagnosis
I scan as well. Do you do the whole thing in short axis? Do you come the way up or do you do a long axis view as well? Just short axi both. Both.
The short axis is really easy to see, isn’t it? It’s just a quick scan through and you can see that. Yeah, it’s a bit of difficult one when you see those patients and I personally don’t treat those. I’ve sent a few back to their surgeons and that’s obviously what they want to hear, having their penis sliced open. So I mean moving on the ED concept point of view as you’re a sexologist, I mean do have, because we get this sometimes when we are teaching, how much do you place importance upon the lifestyle aspect when you are seeing these patients? Do you sort of say to the patients, look, unless you do this, this and this, the shock wave is not going to work that well. Or do you just hand them information to give and assume they’re doing it? I mean, how much of a hard line do you take with your patients? There are some practitioners know that say, well if you don’t lose the weight and get rid of the diabetes, this is a waste of time, whatever else.
What I really insist on is smoking.
This is so bad for your health and for everything.
And I tell them, it says even on the package it says makes you impotent and people don’t believe it. But I think smoking is a big thing that one, if there is a problem with rectal function and you smoke, I think you have to quit smoking. This is more or less the only thing that I say, you have to meet people at the spot they are in so to speak and work around. And I am always asking about lifestyle because we know from research that if you are active and even if you are obese or overweight and you are active, you have a better chance that for example, PD five inhibitors will work.
Always promote some kind of regular physical exercise. And if they haven’t done it, I tell them, okay, pick a walk of your choice and pick a pace of your choice and just do it every evening and maybe after two months you will see suddenly you arrive 10 minutes earlier for some reason that you don’t know because you’re walking faster without knowing it and then you do a bigger round. This is how you start. Just do little changes, don’t change anything, all of it at all In the beginning.
Do you just ask about Cialis or fil, do you prescribe that quite often for peyronie and for EDI assume do you go for a low dose five, two and a half milligramme per day daily dose or do you go for a bigger dose with that?
Depends on where I start. If it’s just for checking whether it is working, which is the start of every kind of therapy that I apply, then I go for the maximum dose, which is 20 milligrammes. I think it’s easier on a psychologic level because if this is working, you can easily say, okay, now it’s working, just reduce it.
If it’s not working and they get the hot flushes and the stuff nose, then tell them, you double the dose now they wouldn’t do it.
That seems so obvious now you say it. Yeah, good point. I think that my view on all these podcasts unfortunately is I try to keep them as short as possible. What’s clear to me is that we’re going to have to have you back on for other topics including one more specific perhaps for patients because your educational stuff is great. I think that from our perspective in terms of users in this country, it’s great having someone like you on because I think you might be the, I’ve had consultant orthopaedic surgeons on talking about MSK stuff, but having a urologist with insight and with the confidence that you have in shockwave therapy, I think it gives us confidence that we’re not entirely losing our minds and we’re doing a good thing by trying to achieve change with shockwave. And just that point, I mean just to clarify for, I still get these questions come up, which is radial shockwave has got its place in superficial myofascial trigger point work, still get questions about true shockwave. And I’m like you with this, I think there is just shockwave and there is radial pressure wave and they’re very distinctly different things, but you just use shockwaves and Boca shockwaves for people that still think that
For men’s health conditions, right?
I mean yes, because the evidence that we have and the way shockwaves work as opposed to radio of pressure waves, there is a difference. And generally I believe in shockwaves more than in radio pressure waves when it comes to men’s health. But I’m a curious guy. I’m always open to new approaches because things change and what is hip today is out tomorrow and you never know where
Are moving. If radio pressure wave is on the surface, there is not much surface on a penis. So the penis is quite small. So I mean in theory, why wouldn’t it work or would it work, for example, would it work better, the true shock wave with combined with a radio pressure wave? I don’t know. Nobody knows. But these are interesting questions.
So I going to put, after this, I’m going to think that God, there’s another 15 questions I should have asked you, but I’m going to email you and organise a follow up to this. But I will put a link on after this to your Euro channel on YouTube, which I think is fantastic. I’ll also, the other thing that I was interested, which I might even be going on myself, is that you now do some specific men’s health shockwave training with a colleague, don’t you? I think in Germany, is that
Canada, that’s right. Are they online or are they all Yes, all online. So I’ll put a link to that after this as well with the Euro channel people that might want to take
On some of that training. I think that you’ll just in the right space and place to do that.
So in this course, I did it this summer during my summer vacation. So
Is that, I love shockwave, is that right?
Shockwaves. I love shockwaves.com. Right,
And everything I know about shockwaves and how I treat my treatment protocols, how I place my patients, how I hold the plaque when I do pones disease. And
That’s been a real missing link actually, because lots of people treat, and this is to some extent there is, I could really waffle on about this, some protectionism about how we all do our things and no one really wants to share that much. So it’s great that you’re doing. So I’m going to wrap this up and thank you very much for coming on the podcast.
We’re going to have you back. You don’t know it yet, but I’m going to do that. But thank you very much for your time, Stefan. Have a lovely evening. I’ll see you later. Thanks.
The post Episode 17. A Urologist’s perspective on shockwave therapy and men’s health with Dr Stefan Buntrock appeared first on The Abbeyfields Clinic.
