Extracorporeal Shockwave Therapy for Erectile Dysfunction

Key Message

What Is the Issue?

• Sexual dysfunction, including erectile dysfunction (ED) is a common problem for males starting in their early 40s and increases with age.
• ED may be caused by 1 or more reasons, including organic (e.g., vasculogenic, hormonal), psychogenic, or mixed psychogenic and organic reasons. ED is also common after pelvic trauma and penile fracture, surgery (e.g., prostatectomy), and radiation therapy (e.g., prostate cancer).
• There are many nonsurgical treatment options for ED, including oral phosphodiesterase type 5 (PDE5) inhibitors, penile self-injections with vasoactive drugs, and extracorporeal shockwave therapy (ESWT). A review of the clinical effectiveness of ESWT could help clarify the potential role in clinical practice, in which populations and with which treatment protocols.

What Did We Do?

• To inform decisions regarding the use of ESWT, we conducted a rapid review to identify and summarize evidence that compared the clinical effectiveness of ESWT to any comparators (e.g., sham or no treatment, pharmacological therapy, or platelet-rich plasma). We identified evidence-based guidelines that provided recommendations related to ESWT in males with ED.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2014. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

• We found 1 health technology assessment (HTA), 1 overview of systematic reviews (SRs), and 7 SRs that evaluated the clinical effectiveness of ESWT for ED. We found 4 evidence-based guidelines that provided recommendations on the use of ESWT for ED.
• Comparing ESWT to sham or no treatment, shockwave therapy (SWT) increases the mean International Index of Erectile Function – Erectile Function subscale (IIEF-EF) score and the proportion of males achieving a minimal clinically important difference (MCID) when compared to sham or no treatment. This differed when looking at subpopulations. Similarly, ESWT increases the mean Erectile Hardness Scale (EHS) score and the proportion of males with an improvement of 3 or more when compared to sham or no treatment. This differed when looking at subpopulations.
• Comparing ESWT to pharmacological therapy, there was no statistical difference between groups for the IIEF-EF subscale (when reported) and the EHS. One observational study in an SR reported a statistically significant difference in the number of males who had an improved EHS score of 3 or more after treatment.
• Comparing ESWT to platelet-rich plasma, there was no difference in any outcomes; however, this was poorly reported.
  Comparing ESWT protocols, there was no difference in any outcomes; however, this was poorly reported.
• One SR reported on treatment-related adverse effects, with few adverse effects reported. Two SRs reported on discontinuation from treatment, with no discontinuations.
• International guidelines varied on recommending ESWT for ED, with 2 recommending it in specific populations, 1 not recommending it, and 1 guideline (published in 2019) stating there was insufficient evidence to make a recommendation.

What Does This Mean?

• ESWT may improve clinical outcomes for males with ED when compared to sham or no treatment.
• There may be differences in the effectiveness of ESWT treatment for subpopulations.
• Data on the clinical effectiveness of different protocols of ESWT were limited.
• ESWT is safe, with few treatment-related adverse events.