Is shockwave therapy effective for treating erectile dysfunction (ED)?

Shockwave Therapy for Erectile Dysfunction

Low-intensity shockwave therapy (LI-SWT) may be used in men with mild vasculogenic ED, though the evidence remains weak and benefits are modest. 1

Primary Recommendation Based on Current Guidelines

The 2025 European Association of Urology guidelines provide a weak recommendation for LI-SWT use specifically in men with mild vasculogenic ED. 1 This weak recommendation reflects the limited standardization of treatment protocols and modest clinical benefits that may not be perceived as significant by all patients. 1

When to Consider LI-SWT

LI-SWT stands out as the only marketed treatment potentially offering a cure for ED, distinguishing it from symptomatic treatments like PDE5 inhibitors. 1

Best Candidates:

• Men with mild vasculogenic ED who want a potentially disease-modifying treatment 1
• PDE5 inhibitor non-responders, where LI-SWT has shown particular benefit 1, 2, 3
• Patients seeking treatment that addresses underlying pathology rather than on-demand symptom management 4

Expected Outcomes and Efficacy

Magnitude of Benefit:

• Mean IIEF-EF improvement of approximately 4 points in pooled RCT data 1
• Effects diminish over time but remain detectable up to 5 years in some cases 1
• In PDE5i non-responders specifically, studies show mean IIEF-EF increases of 8.6 points when LI-SWT is combined with continued PDE5i use 2

Response Rates:

• 60-78% of patients achieve clinically meaningful improvement in studies of PDE5i non-responders 2, 4, 3
• 67.9% achieve erections sufficient for intercourse (EHS ≥3) after treatment 2
• Response rates maintained at 12 months in 91.7% of initial responders 3

Combination Therapy Approach

LI-SWT shows enhanced results when combined with other ED treatments, suggesting multimodal approaches may be superior to monotherapy. 1

Evidence-Based Combinations:

• LI-SWT + daily tadalafil demonstrates improved outcomes 1
• LI-SWT + vacuum erection devices shows enhanced results 1
• LI-SWT + continued PDE5i use in non-responders produces significant improvements 2, 3

Treatment Protocol Considerations

Critical Limitation:

A standardized treatment protocol is still lacking, which weakens the overall evidence base. 1 Different studies use varying protocols:

• Some protocols: 3000 shocks at 0.25 mJ/mm² twice weekly for 3 weeks 2
• Other protocols: 12 sessions total with different energy levels 4
• Alternative protocols: 6600 shocks per session for 6 consecutive weeks 5
• Yet another approach: 8 weekly sessions with either 3000 shocks at 0.09 mJ/mm² or 10,000 shocks at 90 mJ 6

Despite protocol variations, efficacy appears independent of generator type, shockwave source, or morphology. 6

Safety Profile

LI-SWT demonstrates excellent safety with no serious adverse events reported. 2, 4, 3, 5, 6

• Treatment is well-tolerated in outpatient settings 2
• Minimal discomfort reported, easily managed by device repositioning 5
• No treatment-related adverse events in multiple studies 2, 3

Common Pitfalls to Avoid

Critical Errors:

• Using LI-SWT in severe ED or non-vasculogenic ED where evidence is lacking 1
• Abandoning PDE5i therapy when combining with LI-SWT in non-responders—studies showing benefit maintained concurrent PDE5i use 2, 3
• Expecting immediate results—assessment should occur at 1-3 months post-treatment 4, 3, 5
• Declaring treatment failure without adequate follow-up—benefits may take time to manifest and can persist long-term 1, 3

Positioning in Treatment Algorithm

First-Line Therapy:

PDE5 inhibitors remain the recommended first-line treatment for ED unless contraindicated. 1 LI-SWT should not replace initial PDE5i trials.

When to Offer LI-SWT:

1. After establishing PDE5i non-response with proper dosing, timing, and sexual stimulation education 1
2. In mild vasculogenic ED confirmed by appropriate diagnostic testing 1
3. As adjunctive therapy to enhance PDE5i effectiveness in partial responders 1, 2
4. In motivated patients seeking disease-modifying rather than symptomatic treatment 1, 4

Hemodynamic Evidence

LI-SWT produces measurable improvements in penile hemodynamics:

• Significant increases in peak systolic velocity (PSV) from 27.79 to 41.66 cm/s 2
• Significant decreases in end-diastolic velocity (EDV) from 5.66 to 1.93 cm/s 2
• These vascular improvements correlate with clinical erectile function gains 2, 4

Quality of Life Impact

Beyond erectile function scores, LI-SWT improves sexual quality of life, with SQOL-M scores increasing from 45.56 to 55.31 (p<0.0001). 2 This suggests benefits extend beyond mechanical erectile improvement to overall sexual satisfaction and relationship quality.