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Low-intensity shockwave therapy for erectile dysfunction: is the evidence strong enough?

Key Points

  • Low-intensity extracorporeal shockwave therapy (Li-ESWT) has emerged and rapidly gained popularity as a treatment option for men with erectile dysfunction (ED)

  • The mechanisms by which this therapy enhances erectile function are unclear, but hypotheses include stimulation of neoangiogenesis, recruitment of stem cells and Schwann cell activation leading to nerve regeneration

  • Single-arm trials almost unanimously show beneficial effects in patients with vasculogenic ED, even in those who do not respond to phosphodiesterase-5 inhibitors

  • Randomized controlled trials (RCTs) have produced conflicting results, and have evaluated erectile function only a short time after treatment; several RCTs are highly biased

  • Meta-analyses and systematic reviews conclude that shockwave therapy has an effect, but these analyses are limited by the fact that biased RCTs have been included in these analyses, and some fail to recognize this limitation

  • Thus, no high-quality level 1a evidence is available and level 1b evidence is conflicting regarding the use of Li-ESWT for ED treatment

Abstract

Erectile dysfunction (ED) affects 30% of all men above the age of 40 years and its prevalence steadily increases with age. Current nonsurgical treatment options, including phosphodiesterase type 5 inhibitors (PDE5I), provide temporary relief but have failed to provide a permanent improvement of the condition. Low-intensity extracorporeal shockwave therapy (Li-ESWT) is noninvasive and uses acoustic waves, which can pass through tissue and be focussed to target specific areas or organs to induce the desired effects. The use of Li-ESWT has previously been described in other disease contexts, such as ischaemic heart disease, bone fractures, and burns, in which it improves neoangiogenesis; similar principles seem to apply in the erectile tissue. The major potential advantage of the treatment, therefore, is the possibility to restore natural erectile function. Thus, Li-ESWT is the only currently marketed treatment for ED that might offer a cure, which is the most desired outcome for most men with ED. Li-ESWT has also been suggested to improve the effect of PDE5I in nonresponders, reducing the need for more invasive treatments. Several single-arm trials have shown benefit of Li-ESWT on patient-reported erectile function scores, but data from randomized trials are conflicting, and many questions remain to be answered before we can routinely offer this treatment to patients. Thus, the search for the true clinical value of Li-ESWT for ED represents a dynamic and continuing field of enquiry.

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Figure 1: Schematic depiction of a shockwave as used in the treatment of erectile dysfunction.
Figure 2: Putative mechanisms of action of shockwave therapy for ED.
Figure 3: Focussed and linear shockwave therapy.

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All authors researched data for article, made substantial contributions to discussion of content, and wrote and edited the manuscript before submission.

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Correspondence to Maarten Albersen.

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Glossary

Electrohydraulic

Shockwaves are generated by high voltage discharging to a spark plug in an underwater source.

Electromagnetic

Electromagnetic shockwave generation is based on the physical principle of electromagnetic induction, as used, for example, in loudspeakers.

Piezoelectric

Piezo elements are arranged on a spherical surface and are synchronously excited by an electrical pulse to emit a pressure wave in the direction of the centre of the spherical surface.

Piezomagnetic

Analogous to the piezoelectric shockwave generator, but instead of an electrical pulse, physical deformation of the piezo elements is achieved by applying a magnetic field.

Energy flux density

(EFD). The energy delivered by the shockwave-generating source at the focussed point is called energy flux density and is normally recorded in energy per surface area units (mJ/mm2).

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Young Academic Urologists Men's Health Group. Low-intensity shockwave therapy for erectile dysfunction: is the evidence strong enough?. Nat Rev Urol 14, 593–606 (2017). https://doi.org/10.1038/nrurol.2017.119

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