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
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.
This is a preview of subscription content, access via your institution
Access Nature and 54 other Nature Portfolio journals
Get Nature+, our best-value online-access subscription
$29.99 per month
cancel any time
Subscribe to this journal
Receive 12 print issues and online access
$189.00 per year
only $15.75 per issue
Rent or buy this article
Get just this article for as long as you need it
Prices may be subject to local taxes which are calculated during checkout
Hatzimouratidis, K. et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur. Urol. 57, 804–814 (2010).
Latini, D. M. et al. Psychological impact of erectile dysfunction: validation of a new health related quality of life measure for patients with erectile dysfunction. J. Urol. 168, 2086–2091 (2002).
Hanson-Divers, C., Jackson, S. E., Lue, T. F., Crawford, S. Y. & Rosen, R. C. Health outcomes variables important to patients in the treatment of erectile dysfunction. J. Urol. 159, 1541–1547 (1998).
Vardi, Y., Appel, B., Jacob, G., Massarwi, O. & Gruenwald, I. Can low-intensity extracorporeal shockwave therapy improve erectile function? A 6-month follow-up pilot study in patients with organic erectile dysfunction. Eur. Urol. 58, 243–248 (2010).
Gruenwald, I., Kitrey, N. D., Appel, B. & Vardi, Y. Low-intensity extracorporeal shock wave therapy in vascular disease and erectile dysfunction: theory and outcomes. Sexual Med. Rev. 1, 83–90 (2013).
Assaly-Kaddoum, R. et al. Low intensity extracorporeal shock wave therapy improves erectile function in a model of type II diabetes independently of NO/cGMP pathway. J. Urol. 196, 950–956 (2016).
Gruenwald, I., Appel, B. & Vardi, Y. Low-intensity extracorporeal shock wave therapy — a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy. J. Sex. Med. 9, 259–264 (2012).
Kitrey, N. D. et al. Penile low intensity shock wave treatment is able to shift PDE5i nonresponders to responders: a double-blind, sham controlled study. J. Urol. 195, 1550–1555 (2016).
Cleveland, R. O. & McAteer, J. A. in Smith's Textbook of Endourology (eds Smith A. D., Preminger G., Badlani G. & Kavoussi L. R.) 527–558 (Wiley-Blackwell, 2012)
Bongrazio, M. et al. Shear stress modulates the expression of thrombospondin-1 and CD36 in endothelial cells in vitro and during shear stress-induced angiogenesis in vivo. Int. J. Immunopathol. Pharmacol. 19, 35–48 (2006).
Belik, D. et al. Endothelium-derived microparticles from chronically thromboembolic pulmonary hypertensive patients facilitate endothelial angiogenesis. J. Biomed. Sci. 23, 462 (2016).
Young, S. R. & Dyson, M. The effect of therapeutic ultrasound on angiogenesis. Ultrasound Med. Biol. 16, 261–269 (1990).
Goertz, O. et al. Extracorporeal shock waves improve angiogenesis after full thickness burn. Burns 38, 1010–1018 (2012).
Nishida, T. et al. Extracorporeal cardiac shock wave therapy markedly ameliorates ischemia-induced myocardial dysfunction in pigs in vivo. Circulation 110, 3055–3061 (2004).
Aicher, A. et al. Low-energy shock wave for enhancing recruitment of endothelial progenitor cells: a new modality to increase efficacy of cell therapy in chronic hind limb ischemia. Circulation 114, 2823–2830 (2006).
Wang, C.-J. et al. Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J. Orthop. Res. 21, 984–989 (2003).
Chen, Y.-J. et al. Recruitment of mesenchymal stem cells and expression of TGF-β1 and VEGF in the early stage of shock wave-promoted bone regeneration of segmental defect in rats. J. Orthop. Res. 22, 526–534 (2004).
Kucia, M. et al. CXCR4-SDF-1 signalling, locomotion, chemotaxis and adhesion. J. Mol. Histol. 35, 233–245 (2004).
Fuchs, S., Dohle, E., Kolbe, M. & Kirkpatrick, C. J. Outgrowth endothelial cells: sources, characteristics and potential applications in tissue engineering and regenerative medicine. Adv. Biochem. Eng. Biotechnol. 123, 201–217 (2010).
Seemann, O., Rassweiler, J., Chvapil, M., Alken, P. & Drach, G. W. The effect of single shock waves on the vascular system of artificially perfused rabbit kidneys. J. Stone Dis. 5, 172–178 (1993).
Gotte, G. et al. Short-time non-enzymatic nitric oxide synthesis from L-arginine and hydrogen peroxide induced by shock waves treatment. FEBS Lett. 520, 153–155 (2002).
Huang, J.-J. et al. Angiogenesis effect of therapeutic ultrasound on HUVECs through activation of the PI3K-Akt-eNOS signal pathway. Am. J. Transl Res. 7, 1106–1115 (2015).
Ciampa, A. R. et al. Nitric oxide mediates anti-inflammatory action of extracorporeal shock waves. FEBS Lett. 579, 6839–6845 (2005).
Hausner, T. et al. Improved rate of peripheral nerve regeneration induced by extracorporeal shock wave treatment in the rat. Exp. Neurol. 236, 363–370 (2012).
Schuh, C., Hausner T. & Redl H. R. A therapeutic shock propels Schwann cells to proliferate in peripheral nerve injury. Brain Circul. 2, 138 (2016).
Castela, A. & Costa, C. Molecular mechanisms associated with diabetic endothelial–erectile dysfunction. Nat. Rev. Urol. 13, 266–274 (2016).
Qiu, X. et al. Effects of low-energy shockwave therapy on the erectile function and tissue of a diabetic rat model. J. Sex. Med. 10, 738–746 (2013).
Liu, J. et al. Evaluation of the effect of different doses of low energy shock wave therapy on the erectile function of streptozotocin (STZ)-induced diabetic rats. IJMS 14, 10661–10673 (2013).
Lei, H. et al. Low-intensity pulsed ultrasound improves erectile function in streptozotocin-induced type I diabetic rats. Urology 86, 1241.e11 (2015).
Wang, J. et al. Kinetics of label retaining cells in the developing rat kidneys. PLoS ONE 10, e0144734 (2015).
Bickenbach, J. R. Identification and behavior of label-retaining cells in oral mucosa and skin. J. Dent. Res. 60, 1611–1620 (1981).
Li, H. et al. Low-energy shock wave therapy ameliorates erectile dysfunction in a pelvic neurovascular injuries rat model. J. Sex. Med. 13, 22–32 (2016).
Humphreys, B. D. Cutting to the chase: taking the pulse of label-retaining cells in kidney. Am. J. Physiol. Renal Physiol. 308, F29–F30 (2015)
Lin, G. et al. Presence of stem/progenitor cells in the rat penis. Stem Cells Dev. 24, 264–270 (2015).
Lin, C.-S., Xin, Z.-C., Dai, J. & Lue, T. F. Commonly used mesenchymal stem cell markers and tracking labels: limitations and challenges. Histol. Histopathol. 28, 1109–1116 (2013).
Mulhall, J. P., Goldstein, I., Bushmakin, A. G., Cappelleri, J. C. & Hvidsten, K. Validation of the erection hardness score. J. Sex. Med. 4, 1626–1634 (2007).
Rosen R. C., Cappelleri J. C., Smith M. D., Lipsky J. & Peña B. M. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot. Res. 11, 319–326 (1999).
Rosen, R. C. et al. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 49, 822–830 (1997).
Vardi, Y., Appel, B., Kilchevsky, A. & Gruenwald, I. 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. 187, 1769–1775 (2012).
Olsen, A. B., Persiani, M., Boie, S., Hanna, M. & Lund, L. Can low-intensity extracorporeal shockwave therapy improve erectile dysfunction? A prospective, randomized, double-blind, placebo-controlled study. Scand. J. Urol. 49, 329–333 (2015).
Yee, C.-H., Chan, E. S., Hou, S. S.-M. & Ng, C.-F. Extracorporeal shockwave therapy in the treatment of erectile dysfunction: a prospective, randomized, double-blinded, placebo controlled study. Int. J. Urol. 21, 1041–1045 (2014).
Reisman, Y., Hind, A., Varaneckas, A. & Motil, I. Initial experience with linear focused shockwave treatment for erectile dysfunction: a 6-month follow-up pilot study. Int. J. Impot. Res. 27, 108–112 (2015).
Chung, E. & Cartmill, R. Evaluation of clinical efficacy, safety and patient satisfaction rate after low-intensity extracorporeal shockwave therapy for the treatment of male erectile dysfunction: an Australian first open-label single-arm prospective clinical trial. BJU Int. 115 (Suppl. 5), 46–49 (2015).
Pelayo-Nieto, M. et al. Linear shock wave therapy in the treatment of erectile dysfunction. Actas Urol. Esp. 39, 456–459 (2015).
Srini, V. S., Reddy, R. K., Shultz, T. & Denes, B. Low intensity extracorporeal shockwave therapy for erectile dysfunction: a study in an Indian population. Can. J. Urol. 22, 7614–7622 (2015).
Ruffo, A. et al. Safety and efficacy of low intensity shockwave (LISW) treatment in patients with erectile dysfunction. Int. Braz. J. Urol. 41, 967–974 (2015).
Frey, A., Sønksen, J. & Fode, M. Low-intensity extracorporeal shockwave therapy in the treatment of postprostatectomy erectile dysfunction: a pilot study. Scand. J. Urol. 50, 123–127 (2015).
Bechara, A., Casabé, A., De Bonis, W. & Ciciclia, P. G. Twelve-month efficacy and safety of low-intensity shockwave therapy for erectile dysfunction in patients who do not respond to phosphodiesterase type 5 inhibitors. Sex. Med. 4, e225–e232 (2016).
Hisasue, S.-I. et al. Impact of aging and comorbidity on the efficacy of low-intensity shock wave therapy for erectile dysfunction. Int. J. Urol. 23, 80–84 (2015).
Fojecki, G. L., Tiessen, S. & Osther, P. J. S. Effect of low-energy linear shockwave therapy on erectile dysfunction—A double-blinded, sham-controlled, randomized clinical trial. J. Sex. Med. 14, 106–112 (2017).
Motil, I., Kubis, I. & Sramkova, T. Treatment of vasculogenic erectile dysfunction with Piezowave2 device. Application of low intensity shockwaves using novel linear shockwave tissue coverage (LSTC-ED®) technique. A prospective, multicentric, placebo-controlled study. Adv. Sexual Med. 6, 15–18 (2016).
Lu, Z. et al. Low-intensity extracorporeal shock wave treatment improves erectile function: a systematic review and meta-analysis. Eur. Urol. 71, 223–233 (2017).
Fojecki, G. L., Tiessen, S. & Osther, P. J. S. Extracorporeal shock wave therapy (ESWT) in urology: a systematic review of outcome in Peyronie's disease, erectile dysfunction and chronic pelvic pain. World J. Urol. 35, 1–9 (2016).
Angulo, J. C. et al. Efficacy of low-intensity shock wave therapy for erectile dysfunction: a systematic review and meta-analysis. Actas Urol. Esp. https://doi.org/10.1016/j.acuro.2016.07.005 (2016).
Clavijo, R. I., Kohn, T. P., Kohn, J. R. & Ramasamy, R. Effects of low-intensity extracorporeal shockwave therapy on erectile dysfunction: A systematic review and meta-analysis. J. Sex. Med. 14, 27–35 (2017).
Fisher, W. A. et al. Standards for clinical trials in male and female sexual dysfunction: III. Unique aspects of clinical trials in male sexual dysfunction. J. Sex. Med. 14, 3–18 (2017).
Masterson, T. A., Serio, A. M., Mulhall, J. P., Vickers, A. J. & Eastham, J. A. Modified technique for neurovascular bundle preservation during radical prostatectomy: association between technique and recovery of erectile function. BJU Int. 101, 1217–1222 (2008).
Weyne, E., Castiglione, F., Van der Aa, F., Bivalacqua, T. J. & Albersen, M. Landmarks in erectile function recovery after radical prostatectomy. Nat. Rev. Urol. 12, 289–297 (2015).
Iacono, F. et al. Histological alterations in cavernous tissue after radical prostatectomy. J. Urol. 173, 1673–1676 (2005).
Miles, C. et al. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD005540.pub2 (2007).
Hatzimouratidis, K. et al. Phosphodiesterase type 5 inhibitors in postprostatectomy erectile dysfunction: a critical analysis of the basic science rationale and clinical application. Eur. Urol. 55, 334–347 (2009).
Kilminster, S. et al. Predicting erectile function outcome in men after radical prostatectomy for prostate cancer. BJU Int. 110, 422–426 (2011).
Bellorofonte, C. et al. [Possibility of using the piezoelectric lithotriptor in the treatment of severe cavernous fibrosis]. Arch. Ital. Urol. Nefrol Androl 61, 417–422 (1989).
Poulakis, V. et al. Extracorporeal shockwave therapy for Peyronie's disease: an alternative treatment? Asian J. Androl. 8, 361–366 (2006).
Claro, J. A. et al. An alternative non-invasive treatment for Peyronie's disease. Int. Braz. J. Urol. 30, 199–204 (2004).
Strebel, R. T., Suter, S., Sautter, T. & Hauri, D. Extracorporeal shockwave therapy for Peyronie's disease does not correct penile deformity. Int. J. Impot. Res. 16, 448–451 (2004).
Manikandan, R., Islam, W., Srinivasan, V. & Evans, C. M. Evaluation of extracorporeal shock wave therapy in Peyronie's disease. Urology 60, 795–800 (2002).
Lebret, T. et al. Extracorporeal shock wave therapy in the treatment of Peyronie's disease: experience with standard lithotriptor (siemens-multiline). Urology 59, 657–661 (2002).
Palmieri, A. et al. A first prospective, randomized, double-blind, placebo-controlled clinical trial evaluating extracorporeal shock wave therapy for the treatment of Peyronie's disease. Eur. Urol. 56, 363–369 (2009).
Hatzichristodoulou, G., Meisner, C., Gschwend, J. E., Stenzl, A. & Lahme, S. Extracorporeal shock wave therapy in Peyronie's disease: results of a placebo-controlled, prospective, randomized, single-blind study. J. Sex. Med. 10, 2815–2821 (2013).
Chitale, S., Morsey, M., Swift, L. & Sethia, K. Limited shock wave therapy versus sham treatment in men with Peyronie's disease: results of a prospective randomized controlled double-blind trial. - PubMed - NCBI. BJU Int. 106, 1352–1356 (2010).
Mulhall, J. P., Schiff, J. & Guhring, P. An analysis of the natural history of peyronie's disease. J. Urol. 175, 2115–2118 (2006).
Larsen, S. M. & Levine, L. A. Peyronie's disease: review of nonsurgical treatment options. Urol. Clin. North Amer. 38, 195–205 (2011).
Gelbard, M. et al. Phase 2b study of the clinical efficacy and safety of collagenase clostridium histolyticum in patients with peyronie disease. J. Urol. 187, 2268–2274 (2012).
Palmieri, A. et al. Tadalafil once daily and extracorporeal shock wave therapy in the management of patients with Peyronie's disease and erectile dysfunction: results from a prospective randomized trial. Int. J. Androl. 35, 190–195 (2011).
Hauck, E. W. et al. Extracorporeal shock wave therapy for Peyronie's disease: exploratory meta-analysis of clinical trials. J. Urol. 171, 740–745 (2004).
Furlan, A. D., Pennick, V., Bombardier, C. & van Tulder, M. 2009 updated method guidelines for systematic reviews in the cochrane back review group. Spine 34, 1929–1941 (2009).
Rosen, R. C., Allen, K. R., Ni, X. & Araujo, A. B. Minimal clinically important differences in the erectile function domain of the international index of erectile function scale. Eur. Urol. 60, 1010–1016 (2011).
Albersen, M. & Lue, T. F. Sexual dysfunction: MCID provides new perspective on erectile function research. Nat. Rev. Urol. 8, 591–592 (2011).
Fode, M. & Albersen, M. Re: Zhihua Lu, Guiting Lin, Amanda Reed-Maldonado, Chunxi Wang, Yung-Chin Lee, Tom F. Lue. Low-intensity extracorporeal shock wave treatment improves erectile function: a systematic review and meta-analysis. Eur Urol 2017;71:223–33. Eur. Urol. 71, e76–e77 (2017).
Hatzichristou, D. G. & Kalyvianakis D. E. Erectile dysfunction shock wave therapy (EDSWT) improves hemodynamic parameters in patients with vasculogenic erectile dysfunction (ED): a triplex-based sham-controlled trial. Eur. Urol. 14, e124 (2015).
Feldman, R. A., et al. The safety and efficacy of li-ESWT in 604 patients for erectile dysfunction: summary of current and evolving evidence. Medispec.com http://medispec.com/general/the-safety-and-efficacy-of-li-eswt-in-604-patients-for-erectile-dysfunction-summary-of-current-and-evolving-evidence/ (2015).
US National Library of Medicine. ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT02063061 (2016).
Hatzichristou, D. Low-intensity extracorporeal shock waves therapy (LI-ESWT) for the treatment of erectile dysfunction: where do we stand? Eur. Urol. 71, 234–236 (2017).
Hamilton M. Cricket legend Sir Ian Botham bravely reveals impotence treatment after having privates zapped. www.thesun.co.ukhttps://www.thesun.co.uk/sport/1606663/sir-ian-botham-has-privates-zapped-in-bid-to-cure-impotence1606663/ (2016).
Cappelleri, J. C., Rosen, R. C., Smith, M. D., Mishra, A. & Osterloh, I. H. Diagnostic evaluation of the erectile function domain of the International Index of Erectile Function. Urology 54, 346–351 (1999).
Zimmermann, R., Cumpanas, A., Miclea, F. & Janetschek, G. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study. Eur. Urol. 56, 418–424 (2009).
The author declare no competing financial interests.
Shockwaves are generated by high voltage discharging to a spark plug in an underwater source.
Electromagnetic shockwave generation is based on the physical principle of electromagnetic induction, as used, for example, in loudspeakers.
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.
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).
Rights and permissions
About this article
Cite this article
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
This article is cited by
The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction
Journal of Endocrinological Investigation (2023)
Low-intensity extracorporeal shockwave therapy among urologist practitioners: how the opinion of urologists changed between 2016 and 2019
International Journal of Impotence Research (2021)
Penile low intensity shock wave treatment for PDE5I refractory erectile dysfunction: a randomized double-blind sham-controlled clinical trial
World Journal of Urology (2021)
Low-intensity shockwave therapy (LiST) for erectile dysfunction: a randomized clinical trial assessing the impact of energy flux density (EFD) and frequency of sessions
International Journal of Impotence Research (2020)
Current guideline recommendations and analysis of evidence quality on low-intensity shockwave therapy for erectile dysfunction
International Journal of Impotence Research (2019)