Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: A Systematic Review of Efficacy, Patient Selection, and Optimal Treatment Parameters

Abstract

Background: Erectile dysfunction (ED) is a prevalent condition affecting men across all age groups, with a significant impact on quality of life, self-esteem, and interpersonal relationships. Low-intensity extracorporeal shockwave therapy (Li-ESWT) has emerged as a promising non-invasive treatment modality demonstrating improvements in erectile function with a favourable safety profile. However, the evidence base remains heterogeneous, and consensus regarding patient selection, optimal treatment protocols, and long-term sustainability of effects is lacking.Objective: To provide a critical, clinician-oriented synthesis of the current evidence on the effectiveness, safety, optimal patient profile, and treatment parameters of Li-ESWT in the management of ED.Methods: A systematic literature search of PubMed, MEDLINE, Cochrane Library, EMBASE, and grey literature databases was conducted for articles published from 2016 to 2023. Following PRISMA 2020-guided screening of 1,302 titles, 164 abstracts, and 94 full-text articles, 20 studies were included. Quality assessment was performed using the Newcastle-Ottawa Scale, STROBE Checklist, and Cochrane Risk of Bias Tool (RoB 2). A narrative synthesis approach was employed in keeping with UK Economic and Social Research Council guidance.Results: All included studies reported post-treatment improvements in erectile function as measured by the International Index of Erectile Function (IIEF). Li-ESWT demonstrated statistically significant benefits for organic vasculogenic and diabetic ED, with minimal clinically important difference (MCID) rates ranging from 22% to 86.4%. Li-ESWT was comparable in efficacy to phosphodiesterase-5 (PDE5) inhibitors with a superior safety profile. Evidence did not support its use for post-radical prostatectomy ED. Twelve treatment sessions at 0.09 mJ/mm², delivered twice weekly in a 3+3+3-week schedule, constituted the most commonly reported effective protocol. Treatment benefits were sustained in up to 82.69% of respondents at 12 months, with gradual decline thereafter.Conclusion: Li-ESWT is a safe, well-tolerated, and effective treatment for organic erectile dysfunction, particularly in younger men with vasculogenic or diabetic aetiology and moderate severity. It is comparable to PDE5 inhibitors and may be a viable alternative or complementary option in clinical practice. Future high-quality, multi-centre randomised controlled trials with standardised protocols and longer follow-up periods are warranted.