The vicious circle of erectile dysfunction

Around 20% of all adult men suffer from erection problems and this figure rises to 50% in men aged 40 and above.

By far the most common cause of erectile dysfunction is a condition called endothelium dysfunction. In brief, so as not to overcomplicate things, the endothelium is a layer of cells that is found throughout the erection mechanism and these need to be healthy in order for the erection bodies to expand adequately so as to trap the blood flowing in the penis (the expanding erection bodies trap the blood by effectively becoming engorged and blocking the veins that take away the blood from the penis). If this mechanism, called the veno-occlusive mechanism, is damaged then it becomes difficult to get an erection, maintain it or the penis might not be rigid enough for penetration.

Once erectile dysfunction occurs it progressively gets worse due to persistence of the risk factors (aging, genetic and lifestyle factors)  which cause worsening endothelium/smooth muscle dysfunction, reduced night erections and eventually scarring and atrophy of the erectile tissue, creating a vicious circle.

Oral medication and other on-demand treatments for ED, such as penile injections, can help men achieve better erections by temporarily increasing blood flow to the penis but do not heal the damaged erection mechanism or improve the functioning of the endothelium and smooth muscle cells.

As such, most men suffering from ED will experience a gradual deterioration of their erections and will eventually become unresponsive to these types of treatments.

With that in mind, the holy grail of ED treatment has always been a therapy that rejuvenates the damaged erection mechanism and helps men restore their natural erections including the night ones, which are necessary so as to keep the erection mechanism healthy.  

Enter Shockwave Therapy.

Shockwave therapy: the new frontier in erectile dysfunction treatment

Shockwave therapy works by passing shock waves, an intense but short energy wave that travels faster than the speed of sound into the tissues. Originally it was used to treat kidney stones in the 1970’s  by using acoustic shockwaves to break up the stones without the need of surgery. Clinicians soon discovered that whilst patients were being treated for kidney stones they reported that other non-related medical conditions either improved or had disappeared entirely. This in turn lead to the discovery that shockwaves had a healing impact on pain and chronic conditions in the musculoskeletal system. Devices were then developed to treat a range of tissue injuries on all different parts of the body. Today Shockwave therapy is widely used to treat all kinds of indications from soft tissue injuries (tendinopathies) in humans and horses to diabetic foot ulcers to erectile dysfunction and even cellulite.

Shockwave treatment initiates a pro-inflamatory response in the tissue where it is applied. The body responds by increasing the blood circulation and metabolism in the impact area which in turn accelerates the body’s own healing processes.

In the specific case of ED, shockwave can improve erections via three potential mechanisms:

• Promote angio-genesis (development of new blood vessels) in the penis which means that the blood flow to the penis increases and hence stronger erections are achieved;

• Rejuvenate the endothelium and penis smooth muscle – Shockwave therapy has been shown to induce the body to repair the endothelium and smooth muscle in the penis and thus improve the function of the veno-occlusive mechanism; and

• There is some initial evidence to suggest that shockwave therapy can also improve the functioning of the penile nerves if these have been damaged following a radical prostatectomy or because of diabetes.

Backed by leading science and clinical experience with thousands of men

Shockwave therapy as a potential treatment for ED was first suggested in a seminal paper in 2010. Since then, thousands of men have been treated successfully and hundreds of clinical trials and research papers have validated both its safety and efficacy. The interested reader can find a list of all the published research regarding the application of shockwave therapy for erectile dysfunction below.

List of Publications

Low intensity extracorporeal shockwave Therapy shifts PDE5i non-responders to responders

Wang J, Luo L, Zhao S, Liu Y, Zhu Z, Zhao Z.

Brazilian Journal of Urology, November 2020

Penile low intensity shock wave treatment for PDE5I refractory erectile dysfunction: a randomized double-blind sham-controlled clinical trial

Vinay J, Moreno D, Rajmil O, Ruiz-Castañe E, Sanchez-Curbelo J.

World Journal of Urology, July 2020

Low intensity shock wave for Erectile Dysfunction (LED) Study Group. Low intensity shockwave therapy in combination with phosphodiesterase-5 inhibitors is an effective and safe treatment option in patients with vasculogenic ED who are PDE5i non-responders: a multicenter single-arm clinical trial

Palmieri A, Arcaniolo D, Palumbo F, Verze P, Liguori G, Mondaini N, Falcone M, Scroppo FI, Salonia A, Cai T

Journal of Impotence Research, July 2020

Review of the Current Status of Low Intensity Extracorporeal Shockwave Therapy (Li-ESWT) in Erectile Dysfunction (ED), Peyronie's Disease (PD), and Sexual Rehabilitation After Radical Prostatectomy With Special Focus on Technical Aspects of the Different Marketed ESWT Devices Including Personal Experiences in 350 Patients

Harmurt Porst

Sexual Medicine Reviews, June 2020

Long-term effectiveness and predictors of success of low-intensity shockwave therapy in phosphodiesterase type 5 inhibitors non-responders

Musa ZS, El-Assmy A, Shokry AM, Shokeir AA, Zween T, Al-Kenawy MR.

Arab Journal of Urology, November 2019

The Basic Physics of Waves, Soundwaves and Shockwaves for Erectile Dysfunction

Katz JE, Clavijo RI, Rizk P, Ramasamy R

Sexual Medicine Reviews, November 2019

Efficacy and safety of low-intensity shockwave therapy plus tadalafil 5 mg once daily in men with type 2 diabetes mellitus and erectile dysfunction: a matched-pair comparison study

P. Verze, M. Capece, M. Creta, RL. Rocca, F. Persico, L. Spirito, A. Cardi, V. Mirone

Asian Journal of Andrology, November 2019

Low-intensity shockwave therapy (LiST) for erectile dysfunction: a randomized clinical trial assessing the impact of energy flux density (EFD) and frequency of sessions

D.Kalyvianakis, I.Mykoniatis, E.Memmos, P.Kapoteli, D.Memmos & D.Hatzichristou

International Journal of Impotence Research, September 2019

Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction in Diabetic Patients

L.Spivak, T.Shultz, B.Appel, P/Verze, D.Yagudaev, A.Vinarov

Sexual Medicine Reviews, August 2019

Determinants of Early Response to Low-Intensity Extracorporeal Shockwaves for the Treatment of Vasculogenic Erectile Dysfunction: An Open-Label, Prospective Study

Vita, Roberto et al.

Journal of clinical medicine, July 2019

The beginning of a new era: treatment of erectile dysfunction by use of physical energies as an alternative to pharmaceuticals

Ilan Gruenwald, Avner Spector, Tamar Shultz, Daniel Lischinsky & Eitan Kimmel

International Journal of Impotence Research 31, 155–161 (2019), April 2019

Effect of Low-Intensity Extracorporeal Shock Wave on the Treatment of Erectile Dysfunction: A Systematic Review and Meta-Analysis

Dong L, Chang D, Zhang X, Li J, Yang F, Tan K, Yang Y, Yong S, Yu X.

Am J Mens Health, April 2019

Meta-analysis of randomized controlled trials that assess the efficacy of low-intensity shockwave therapy for the treatment of erectile dysfunction

Campbell JD, Trock BJ, Oppenheim AR, Anusionwu I, Gor RA, Burnett AL.

Therapeutic Advances in Urology, March 2019

A systematic review of the long-term efficacy of low-intensity shockwave therapy for vasculogenic erectile dysfunction

Brunckhorst, O., Wells, L., Teeling, F., Muir, G., Muneer, A., & Ahmed, K. (2019).

International urology and nephrology, March 2019

Current guideline recommendations and analysis of evidence quality on low-intensity shockwave therapy for erectile dysfunction

Esther Schoofs, Mikkel Fode, Paolo Capogrosso, Maarten Albersen

International Journal of Impotence Research 31, 209–217 (2019), March 2019

The Basic Science Behind Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: A Systematic Scoping Review of Pre-Clinical Studies

Sokolakis, Ioannis et al.

The Journal of Sexual Medicine, 2019 Feb, Volume 16 , Issue 2 , 168 - 194

Low-intensity extracorporeal shockwave therapy in the treatment of erectile dysfunction following radical prostatectomy: a critical review

Mustafa F. Usta, Andrew T. Gabrielson & Trinity J. Bivalacqua

International Journal of Impotence Research 31, 239–242 (2019), February 2019

Controversies in low intensity extracorporeal shockwave therapy for erectile dysfunction

Hailiu Yang & Allen D. Seftel

International Journal of Impotence Research 31, 231–238 (2019), February 2019

Cellular signaling pathways modulated by low-intensity extracorporeal shock wave therapy

Tianshu Liu, Alan W. Shindel, Guiting Lin & Tom F. Lue

International Journal of Impotence Research 31, 170–176 (2019), January 2019

Clinical trial update on shockwave therapy and future of erectile function restoration

Premal Patel, Chun Huang, Manuel Molina & Ranjith Ramasamy

International Journal of Impotence Research 31, 206–208 (2019), January 2019

Clinical studies on low intensity extracorporeal shockwave therapy for erectile dysfunction: a systematic review and meta-analysis of randomised controlled trials.

Sokolakis I, Hatzichristodoulou G.

Int J Impot Res. 2019 Jan 21. doi: 10.1038/s41443-019-0117-z. [Epub ahead of print] Review.

Therapeutic areas of Li-ESWT in sexual medicine other than erectile dysfunction

Mikkel Fode, Giorgio I. Russo & Paolo Verze

International Journal of Impotence Research 31, 223–230 (2019), January 2019

Low-intensity shock wave therapy ameliorates erectile dysfunction in men with pelvic fractures associated with urethral injury

Chii-Jye Wang, Yen-Man Lu, Ching-Chia Li, Wen-Jeng Wu & Tsu-Ming Chien

International Journal of Impotence Research 31, 218–222 (2019), November 2018

Is low-intensity shockwave therapy for erectile dysfunction ready for clinical practice?

Fode M, Albersen M, Østergren PB.

Int J Impot Res. 2018 Sep 25. doi: 10.1038/s41443-018-0081-z. [Epub ahead of print] No abstract available.

Effects of low-intensity shock wave therapy (LiST) on the erectile tissue of naturally aged rats

I. Sokolakis, F. Dimitriadis, D. Psalla, G. Karakiulakis, D. Kalyvianakis & D. Hatzichristou

International Journal of Impotence Research (2018)

[Focused low-intensity extracorporeal shock wave therapy for erectile dysfunction: Preliminary observation of 32 cases].

Chen X, Huang HW, Zhu XB, Chen GX, Li PC, Song F, Xiang CJ, Guo YP, Zhang SL, Zhang XS.

Zhonghua Nan Ke Xue. 2018 Jun;24(6):529-532. Chinese.

[Low-intensity shock wave therapy for erectile dysfunction: Progression in application].

Cheng C, Dong ZL, Wang ZP.

Zhonghua Nan Ke Xue. 2018 Janurary;24(1):78-81. Review. Chinese.

Low-intensity shockwave therapy for erectile dysfunction in kidney transplant recipients. A prospective, randomized, double blinded, sham-controlled study with evaluation by penile Doppler ultrasonography.

Yamaçake KGR, Carneiro F, Cury J, Lourenço R, Françolin PC, Piovesan AC, Srougi M, Nahas WC, Antonopoulos IM.

Int J Impot Res. 2018 Aug 14. doi: 10.1038/s41443-018-0062-2. [Epub ahead of print]

A Phase 2 Randomized Trial To Evaluate Different Dose Regimens of Low-intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: Clinical Trial Update.

Katz JE, Molina ML, Clavijo R, Prakash NS, Ramasamy R.

Eur Urol Focus. 2018 Apr;4(3):336-337. doi: 10.1016/j.euf.2018.07.011. Epub 2018 Jul 17.

Low-Intensity Shockwave Therapy for Erectile Dysfunction.

Rizk PJ, Krieger JR, Kohn TP, Pastuszak AW.

Sex Med Rev. 2018 Oct;6(4):624-630. doi: 10.1016/j.sxmr.2018.01.002. Epub 2018 Mar 22. Review.

The effect of low-intensity extracorporeal shockwave therapy in an obesity-associated erectile dysfunction rat model.

Ruan Y, Zhou J, Kang N, Reed-Maldonado AB, Tamaddon A, Wang B, Wang HS, Wang G, Banie L, Lin G, Liu J, Lue TF.

BJU Int. 2018 Jul;122(1):133-142. doi: 10.1111/bju.14202. Epub 2018 Apr 17.

Low-Intensity Shockwave Therapy for Erectile Dysfunction: A Randomized Clinical Trial Comparing 2 Treatment Protocols and the Impact of Repeating Treatment.

Kalyvianakis D, Memmos E, Mykoniatis I, Kapoteli P, Memmos D, Hatzichristou D.

J Sex Med. 2018 Mar;15(3):334-345. doi: 10.1016/j.jsxm.2018.01.003. Epub 2018 Feb 1.

Effect of Linear Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction-12-Month Follow-Up of a Randomized, Double-Blinded, Sham-Controlled Study.

Fojecki GL, Tiessen S, Osther PJS.

Sex Med. 2018 Mar;6(1):1-7. doi: 10.1016/j.esxm.2017.09.002. Epub 2017 Dec 21.

Low-intensity extracorporeal shock wave therapy for erectile dysfunction after radical prostatectomy: a review of preclinical studies.

Zou ZJ, Liang JY, Liu ZH, Gao R, Lu YP.

Int J Impot Res. 2018 Feb;30(1):1-7. doi: 10.1038/s41443-017-0002-6. Epub 2017 Nov 27. Review.

Effects of Next-Generation Low-Energy Extracorporeal Shockwave Therapy on Erectile Dysfunction in an Animal Model of Diabetes.

Jeong HC, Jeon SH, Qun ZG, Kim KS, Choi SW, Bashraheel F, Bae WJ, Kim SJ, Cho HJ, Ha US, Hong SH, Lee JY, Moon DG, Kim SW.

World J Mens Health. 2017 Dec;35(3):186-195. doi: 10.5534/wjmh.17024. Epub 2017 Nov 20.

Comparison of the effects of extracorporeal shock wave therapy and a vacuum erectile device on penile erectile dysfunction: a randomized clinical trial.

Qi T, Ye L, Wang B, Zhang B, Chen J.

Medicine. 2017 Nov 3; 96(44): e8414

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

Man L, Li G.

Urology. 2018 Sep;119:97-103. doi: 10.1016/j.urology.2017.09.011. Epub 2017 Sep 27.

Low-Intensity Extracorporeal Shockwave Therapy Can Improve Erectile Function in Patients Who Failed to Respond to Phosphodiesterase Type 5 Inhibitors.

Tsai CC, Wang CJ, Lee YC, Kuo YT, Lin HH, Li CC, Wu WJ, Liu CC.

Am J Mens Health. 2017 Nov;11(6):1781-1790. doi: 10.1177/1557988317721643. Epub 2017 Sep 8.

Low-Intensity Extracorporeal Shockwave Therapy Can Improve Erectile Function in Patients Who Failed to Respond to Phosphodiesterase Type 5 Inhibitors.

Tsai CC, Wang CJ, Lee YC, Kuo YT, Lin HH, Li CC, Wu WJ, Liu CC.

American Journal of Men's Health. 2017 Sep 8; 11(6): 1781-1790

Short-term efficacy and safety of low-intensity extracorporeal shock wave therapy in erectile dysfunction: a systematic review and meta-analysis.

Zou ZJ, Tang LY, Liu ZH, Liang JY, Zhang RC, Wang YJ, Tang YQ, Gao R, Lu YP.

International Brazilian Journal of Urology : official journal of the Brazilian Society of Urology. 2017 Sep-Oct; 43(5): 805-821

Low-Intensity Shockwave Therapy Improves Hemodynamic Parameters in Patients With Vasculogenic Erectile Dysfunction: A Triplex Ultrasonography-Based Sham-Controlled Trial.

Kalyvianakis D, Hatzichristou D.

J Sex Med. 2017 Jul;14(7):891-897. doi: 10.1016/j.jsxm.2017.05.012. Erratum in: J Sex Med. 2018 Feb;15(2):270.

Low-Intensity Extracorporeal Shockwave Therapy in Sexual Medicine: A Questionnaire-Based Assessment of Knowledge, Clinical Practice Patterns, and Attitudes in Sexual Medicine Practitioners.

Fode M, Lowenstein L, Reisman Y.

Sex Med. 2017 Jun;5(2):e94-e98. doi: 10.1016/j.esxm.2016.12.002. Epub 2017 Mar 6.

Shock Wave Therapy Enhances Angiogenesis through VEGFR2 Activation and Recycling.

Huang TH, Sun CK, Chen YL, Wang CJ, Yin TC, Lee MS, Yip HK.

Molecular Medicine. 2016 Dec 6; 22: 850-862

Low-intensity Extracorporeal Shock Wave Treatment Improves Erectile Function: A Systematic Review and Meta-analysis.

Lu Z, Lin G, Reed-Maldonado A, Wang C, Lee YC, Lue TF.

Eur Urol. 2017 Feb;71(2):223-233. doi: 10.1016/j.eururo.2016.05.050. Epub 2016 Jun 16. Review.

Low Intensity Extracorporeal Shock Wave Therapy Improves Erectile Function in a Model of Type II Diabetes Independently of NO/cGMP Pathway.

Assaly-Kaddoum R, Giuliano F, Laurin M, Gorny D, Kergoat M, Bernabé J, Vardi Y, Alexandre L, Behr-Roussel D.

J Urol. 2016 Sep;196(3):950-6. doi: 10.1016/j.juro.2016.03.147. Epub 2016 Mar 30.

Shockwave treatment of erectile dysfunction.

Gruenwald I, Appel B, Kitrey ND, Vardi Y.

Therapeutic Advances in Urology. 2013 Apr; 5(2): 95-99

Low-intensity extracorporeal shock wave therapy--a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy.

Gruenwald I, Appel B, Vardi Y.

J Sex Med. 2012 Jan;9(1):259-64. doi: 10.1111/j.1743-6109.2011.02498.x. Epub 2011 Oct 18.