Male Sexual Dysfunction| Volume 119, P97-103, September 2018

Low-intensity Extracorporeal Shock Wave Therapy for Erectile Dysfunction: A Systematic Review and Meta-analysis

Published:September 26, 2017DOI:


      To assess the efficacy of low-energy extracorporeal shock wave therapy (LI-ESWT) for erectile dysfunction (ED), a systematic review and meta-analysis was undertaken.


      A comprehensive search of the PubMed, Cochrane Register, and Embase databases to March 2017 was performed for randomized controlled trials reporting on patients with ED treated with LI-ESWT. The International Index of Erectile Function (IIEF) and the Erection Hardness Score (EHS) were the most commonly used tools to evaluate the therapeutic efficacy of LI-ESWT.


      There were 9 studies including 637 patients from 2005 to 2017. The meta-analysis revealed that LI-ESWT could significantly improve IIEF (mean difference [MD]: 2.54; 95% confidence interval [CI], 0.83-4.25; P = .004) and EHS (risk difference [RD]: 0.16; 95% CI, 0.03-0.28; P = .01). Therapeutic efficacy could last at least 3 months (MD: 4.15; 95% CI, 1.40-6.90; P = .003). Lower energy density (0.09 mJ/mm2, MD: 4.14; 95% CI, 0.87-7.42; P = .01) increased the number of pulses (3000 pulses per treatment, MD: 5.11; 95% CI, 3.18-7.05, P < .0001) and shorter total treatment courses (<6 weeks, MD: 3.73; 95% CI, 0.54-6.93; P = .02) resulted in better therapeutic efficacy.


      These studies suggest that LI-ESWT could significantly improve the IIEF and EHS of patients with ED. The publication of robust evidence from additional randomized controlled trials and longer-term follow-up would provide more confidence regarding the use of LI-ESWT for patients with ED.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hatzichristou D.
        • d'Anzeo G.
        • Porst H.
        • et al.
        Tadalafil 5 mg once daily for the treatment of erectile dysfunction during a 6-month observational study (EDATE): impact of patient characteristics and comorbidities.
        BMC Urol. 2015; 15: 111
        • Rubanyi G.M.
        • Freay A.D.
        • Kauser K.
        • Johns A.
        • Harder D.R.
        Mechanoreception by the endothelium: mediators and mechanisms of pressure- and flow-induced vascular responses.
        Blood Vessels. 1990; 27: 246-257
        • Nava E.
        • Llorens S.
        The paracrine control of vascular motion. A historical perspective.
        Pharmacol Res. 2016; 113: 125-145
        • Rassweiler J.J.
        • Knoll T.
        • Kohrmann K.U.
        • et al.
        Shock wave technology and application: an update.
        Eur Urol. 2011; 59: 784-796
        • Hazan-Molina H.
        • Reznick A.Z.
        • Kaufman H.
        • Aizenbud D.
        Periodontal cytokines profile under orthodontic force and extracorporeal shock wave stimuli in a rat model.
        J Periodontal Res. 2015; 50: 389-396
        • Becker M.
        • Goetzenich A.
        • Roehl A.B.
        • et al.
        Myocardial effects of local shock wave therapy in a Langendorff model.
        Ultrasonics. 2014; 54: 131-136
        • Hayashi D.
        • Kawakami K.
        • Ito K.
        • et al.
        Low-energy extracorporeal shock wave therapy enhances skin wound healing in diabetic mice: a critical role of endothelial nitric oxide synthase.
        Wound Repair Regen. 2012; 20: 887-895
        • Olsen A.B.
        • Persiani M.
        • Boie S.
        • et al.
        Can low-intensity extracorporeal shockwave therapy improve erectile dysfunction? A prospective, randomized, double-blind, placebo-controlled study.
        Scand J Urol. 2015; 49: 329-333
        • Srini V.S.
        • Reddy R.K.
        • Shultz T.
        • et al.
        Low intensity extracorporeal shockwave therapy for erectile dysfunction: a study in an Indian population.
        Can J Urol. 2015; 22: 7614-7622
        • Kitrey N.D.
        • Gruenwald I.
        • Appel B.
        • et al.
        Penile low intensity shock wave treatment is able to shift PDE5i nonresponders to responders: a double-blind, sham controlled study.
        J Urol. 2016; 195: 1550-1555
        • Fojecki G.L.
        • Tiessen S.
        • Osther P.J.
        Effect of low-energy linear shockwave therapy on erectile dysfunction—A double-blinded, sham-controlled, randomized clinical trial.
        J Sex Med. 2017; 14: 106-112
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151: 264-269
        • Poulakis V.
        • Skriapas K.
        • de Vries R.
        • et al.
        Extracorporeal shockwave therapy for Peyronie's disease: an alternative treatment?.
        Asian J Androl. 2006; 8: 361-366
        • Zimmermann R.
        • Cumpanas A.
        • Miclea F.
        • et al.
        Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-con- trolled study.
        Eur Urol. 2009; 56: 418-424
        • Chitale S.
        • Morsey M.
        • Swift L.
        • et al.
        Limited shock wave therapy vs sham treatment in men with Peyronie's disease: results of a prospective randomized controlled double-blind trial.
        BJU Int. 2010; 106: 1352-1356
        • Vardi Y.
        • Appel B.
        • Kilchevsky A.
        • et al.
        Does low intensity extracorporeal shock wave therapy have a physiological effect on erectile function? Short-term results of a randomized, double-blind, sham controlled study.
        J Urol. 2012; 187: 1769-1775
        • Yee C.H.
        • Chan E.S.
        • Hou S.S.
        • et al.
        Extracorporeal shock wave therapy in the treatment of erectile dysfunction: a prospective, randomized, double-blinded, placebo controlled study.
        Int J Urol. 2014; 21: 1041-1045
        • Wang C.J.
        • Wang F.S.
        • Yang K.D.
        • et al.
        Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits.
        J Orthop Res. 2003; 21: 984-989
        • Nurzynska D.
        • Di Meglio F.
        • Castaldo C.
        • et al.
        Shock waves activate in vitro cultured progenitors and precursors of cardiac cell lineages from the human heart.
        Ultrasound Med Biol. 2008; 34: 334-342
        • Gotte G.
        • Amelio E.
        • Russo S.
        • et al.
        Short-time non-enzymatic nitric oxide synthesis from l-arginine and hydrogen peroxide induced by shock waves treatment.
        FEBS Lett. 2002; 520: 153-155
        • Holfeld J.
        • Zimpfer D.
        • Albrecht-Schgoer K.
        • et al.
        Epicardial shock-wave therapy improves ventricular function in a porcine model of ischaemic heart disease.
        J Tissue Eng Regen Med. 2016; 10: 1057-1064
        • Yan X.
        • Zeng B.
        • Chai Y.
        • et al.
        Improvement of blood flow, expression of nitric oxide, and vascular endothelial growth factor by low-energy shockwave therapy in random-pattern skin flap model.
        Ann Plast Surg. 2008; 61: 646-653
        • Qiu X.
        • Lin G.
        • Xin Z.
        • et al.
        Effects of low-energy shockwave therapy on the erectile function and tissue of a diabetic rat model.
        J Sex Med. 2013; 10: 738-746
        • Liu J.
        • Zhou F.
        • Li G.Y.
        • et al.
        Evaluation of the effect of different doses of low energy shock wave therapy on the erectile function of strepto-zotocin (STZ)-induced diabetic rats.
        Int J Mol Sci. 2013; 14: 10661-10673
        • Gruenwald I.
        • Shenfeld O.
        • Chen J.
        • et al.
        Positive effect of counseling and dose adjustment in patients with erectile dysfunction who failed treatment with sildenafil.
        Eur Urol. 2006; 50: 134-140
        • Assaly-Kaddoum R.
        • Giuliano F.
        • Laurin M.
        • et al.
        Low intensity extracorporeal shockwave therapy (Li-ESWT) improves erectile function in a model of type II diabetes independently of NO/cGMP pathway.
        J Urol. 2016; 196: 950-956
        • Kim J.H.
        • Kim J.Y.
        • Choi C.M.
        • et al.
        The dose-related effects of extracorporeal shock wave therapy for knee osteoarthritis.
        Ann Rehabil Med. 2015; 39: 616-623
        • Zou Z.J.
        • Liu Z.H.
        • Tang L.Y.
        • et al.
        Is there a role for extracorporeal shock wave therapy for erectile dysfunction unresponsive to phosphodiesterase type 5 inhibitors?.
        World J Urol. 2017; 35: 167-171
        • Lu Z.
        • Lin G.
        • Reed-Maldonado A.
        • et al.
        Low-intensity extracorporeal shock wave treatment improves erectile function: a systematic review and meta-analysis.
        Eur Urol. 2017; 71: 223-233
        • Clavijo R.I.
        • Kohn T.P.
        • Kohn J.R.
        • et al.
        Effects of low-intensity extracorporeal shockwave therapy on erectile dysfunction: a systematic review and meta-analysis.
        J Sex Med. 2017; 14: 27-35
        • Gao P.
        • Shen F.
        • Gabriel R.A.
        • et al.
        Attenuation of brain response to vascular endothelial growth factor-mediated angiogenesis and neurogenesis in aged mice.
        Stroke. 2009; 40: 3596-3600