He X. et al., 2026: Comparative efficacy and safety of non-pharmacological interventions for erectile dysfunction:a systematic review and network meta-analysis.

He X, Li T, Huang W, Liu G, Yang T, Zhang X, Li X, Feng Q.
Sex Med Rev. 2026 Jan 2;14(1):qeag004. doi: 10.1093/sxmrev/qeag004

Abstract

Introduction: Many erectile dysfunction (ED) patients respond inadequately to phosphodiesterase type 5 inhibitors (PDE5is). Non-pharmacological interventions (NPIs) have emerged as potential alternative or adjunct treatments for improving erectile function.

Objectives: This study aimed to evaluate and compare the efficacy and safety of various NPIs for ED through a systematic review and network meta-analysis.

Methods: Registered in PROSPERO (CRD420251083286), this NMA followed PRISMA guidelines. Eight databases were searched for RCTs through December 2025. Evaluated NPIs included Electrical Stimulation (ES), Exercise, Low-intensity Extracorporeal Shockwave Therapy (Li-ESWT), Acupuncture-Based Therapies (ABT), and Hyperbaric Oxygen Therapy (HOT). Outcomes were the International Index of Erectile Function-5 (IIEF-5), Erection Hardness Score (EHS), Peak Systolic Velocity (PSV) and Adverse Events (AEs). Risk of bias (RoB 2.0) and evidence certainty (CINeMA) were independently assessed.

Results: 31 RCTs (1874 participants) were included. For IIEF-5, ES + Exercise indicated the most notable improvement versus Sham/Placebo (Mean Difference [MD] = 6.81, 95% CI 3.50-10.12; Surface Under the Cumulative Ranking Curve [SUCRA] 98.1%; high-certainty evidence).ES alone also showed significant gains (MD = 2.86, 95% CI 0.86-4.85; SUCRA 82.3%; high-certainty evidence). Li-ESWT offered modest benefits (MD = 0.65, 95% CI 0.00-1.29), while HOT and other modalities ranked lower in efficacy. Regarding secondary outcomes, ES was most associated with EHS improvement (MD = 3.38), and Li-ESWT+Exercise with PSV increase (MD = 7.33). No serious AEs occurred; minor events included transient muscle strain and headache. Evidence certainty ranged from low to high.

Conclusion: This network meta-analysis suggest that NPIs, especially ES-based therapies, can significantly improve ED. ES combined with Exercise showed the most consistent and clinically meaningful benefits. However, the overall quality of evidence remains low due to intervention variability and small sample sizes. Further large-scale, high-quality trials are necessary to confirm the long-term efficacy and safety of these interventions across diverse patient populations.

Comment Jens Rassweiler

This systematic review and network meta-analysis compared several non-drug treatments for erectile dysfunction, including:

• Electrical stimulation: Electrical stimulation for erectile dysfunction usually means applying mild electrical pulses to nerves and/or pelvic floor muscles involved in erection. The goal is to improve the nerve signaling, muscle function, and blood-flow regulation needed for erections.
• Exercise: Exercise interventions primarily involved aerobic training (30–60 minutes, 3–5 sessions/week) or structured pelvic floor muscle training (PFMT), with durations typically spanning 3 to 6 months.
• Low-intensity extracorporeal shockwave therapy : The intervention protocols across the 31 studies were categorized by modality. Li-ESWT protocols typically employed energy flux densities of 0.09–0.20 mJ/mm2 and 1500–5000 pulses per session, administered 1–2 times weekly over 3–10 weeks.
• Acupuncture-based therapies
• Hyperbaric oxygen therapy
• Combinations of these interventions

Results

The main finding was that electrical stimulation combined with exercise appeared to produce the largest improvement in erectile function, measured by the IIEF-5 score.

Main efficacy results

1. Electrical stimulation + exercise

• Mean Difference in IIEF-5 = 6.81 (95% CI: 3.50 to 10.12); SUCRA (Surface Under the Cumulative Ranking Curve): 98.1%, reported as high-certainty evidence

This suggests a fairly large improvement. Since the IIEF-5 scale ranges from 5 to 25, an improvement of around 6–7 points could be clinically meaningful for many patients.

2. Electrical stimulation alone

• MD = 2.86 (95% CI: 0.86 to 4.85); SUCRA: 82.3%; reported as high-certainty evidence

This also suggests benefit, though smaller than the combination of electrical stimulation plus exercise.

3. Li-ESWT

• MD = 0.65 (95% CI: 0.00 to 1.29)

This is a modest effect and may not be clinically meaningful. The confidence interval touching 0.00 also suggests the effect is borderline.

Secondary outcomes

Erection Hardness Score

Electrical stimulation was most associated with improvement in EHS:

• MD = 3.38

This result needs caution. The Erection Hardness Score is usually a 1–4 scale, so a mean difference of 3.38 would be extremely large and may even be implausible depending on how it was calculated. This is a point worth checking in the full paper.

Peak Systolic Velocity

Li-ESWT plus exercise had the greatest reported increase:

• MD = 7.33

This suggests possible improvement in penile blood-flow parameters, but the clinical relevance depends on baseline PSV values and patient severity.

Safety findings

No serious adverse events were reported. Minor adverse events included:

• Temporary muscle strain
• Headache

This suggests these interventions were generally well tolerated, but safety conclusions are limited because the total sample size was modest and follow-up may have been short.

Discussion

There are important limitations

1. Possible contradiction in certainty of evidence

The results section says some findings were supported by high-certainty evidence, especially for electrical stimulation plus exercise. But the conclusion says the overall quality of evidence remains low.

That is somewhat inconsistent. It may mean that some comparisons were high certainty, while the overall evidence base was limited by small studies, heterogeneity, and variation in interventions.

2. Small sample size

The analysis included:

• 31 RCTs
• 1874 participants

For a network meta-analysis with many different interventions and combinations, this is not very large. Some treatment comparisons may rely on few trials or indirect evidence.

3. Intervention variability

Electrical stimulation, exercise, acupuncture-based therapy, and Li-ESWT can vary greatly in:

• Device type, dose/intensity, frequency, duration, severity of ED treated and follow-up length

This makes it harder to know exactly which protocol works best.

4. Network meta-analysis ranking should be interpreted carefully

SUCRA rankings can make one treatment look “best,” but rankings can be unstable when evidence is sparse or heterogeneous. A high SUCRA value does not automatically mean the treatment is definitively superior in clinical practice.

The article suggests that electrical stimulation, especially when combined with exercise, may improve erectile function more than other non-pharmacological interventions. Electrical stimulation alone also appears beneficial. However, there are still uncertain issues with electorstimulation:  Electrical stimulation can be delivered in different ways:

• Transcutaneous electrical nerve stimulation, using skin electrodes
• Pelvic floor electrical stimulation, often via perineal or anal probes
• Penile or peripenile stimulation, depending on the protocol
• Sacral or tibial nerve stimulation, less commonly used in ED research

The exact effect depends heavily on electrode placement, intensity, frequency, duration, and treatment schedule. Thus, electrical stimulation is not one single standardized treatment. Different studies use different devices and protocols, so results from one trial may not apply to every commercial device or home-use product.

Li-ESWT showed only modest benefit for IIEF-5 but may improve blood-flow measures when combined with exercise.

Conclusions

However, all the findings should be interpreted cautiously because of small studies, variable treatment protocols, and possible inconsistencies in the reported certainty of evidence. The findings are promising but not definitive.

Jens Rassweiler