Liu X. et al., 2026: Extracorporeal shock wave therapy in patients with chronic prostatitis/chronic pelvic pain syndrome and erectile dysfunction: a systematic review and meta-analysis.

Liu X, Ren L, Huang W, Zhang J.
Sex Med Rev. 2026 Apr 2;14(2):qeag037. doi: 10.1093/sxmrev/qeag037

Abstract

Introduction: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) frequently coexists with erectile dysfunction (ED) and is associated with substantial impairment in quality of life (QoL). Although extracorporeal shock wave therapy (ESWT) has been investigated as a noninvasive treatment option, its efficacy in this comorbid population remains uncertain.

Objective: To assess the efficacy and safety of ESWT for improving erectile function and CP/CPPS-related symptoms in men with CP/CPPS and concomitant ED.

Methods: A systematic search was performed up to December 2025 across eight electronic sources (PubMed, Web of Science, Embase, Cochrane Library, CNKI, Wanfang, VIP, and SinoMed) to identify randomized controlled trials evaluating ESWT in men with CP/CPPS and comorbid ED. Risk of bias was assessed using the Cochrane Risk of Bias tool (RoB 1.0). Analyzes were conducted in RevMan 5.4, with continuous outcomes reported as standardized mean differences (SMDs) and 95% confidence intervals (CIs). Subgroup and sensitivity analyzes were performed to explore heterogeneity and assess robustness. The GRADE framework was used to rate the certainty of evidence for the primary outcomes.

Results: Nine RCTs were included. The pooled effect on erectile function was numerically larger in sham-controlled trials than in active-comparator studies, although the between-subgroup difference was not statistically significant. Overall, pooled analyzes suggested that ESWT was associated with improved erectile function (SMD 0.80, 95% CI 0.31-1.28) and reduced NIH-CPSI total scores (SMD -1.14, 95% CI -1.73 to -0.55). Subgroup analyzes were exploratory and showed no significant between-subgroup differences. Short-term safety reporting suggested that ESWT was generally well tolerated: six of seven RCTs reported no device-related adverse events, while one reported four cases of transient hematuria/hematospermia. GRADE certainty was low across efficacy outcomes and high for safety outcomes.

Conclusions: Across randomized trials, ESWT was associated with improvements in erectile function and CP/CPPS-related symptoms in men with CP/CPPS and concomitant ED. Sham-controlled trials may provide more internally valid estimates for erectile function outcomes than active-comparator studies. Improvements in erectile function were generally accompanied by favorable changes in pain, urinary symptoms, and QoL. Although some subgroup strata showed more numerically consistent estimates, no statistically significant between-subgroup differences were identified, and these findings should be considered exploratory. ESWT may represent a potential non-invasive adjunct to standard care, but further sham-controlled trials are needed to strengthen causal inference and clarify optimal treatment protocols.

Comment Jens Rassweiler

Objective

This systematic review and meta-analysis evaluates whether extracorporeal shock wave therapy (ESWT) improves  chronic prostatitis/chronic pelvic pain syndrome symptoms measured mainly by the NIH-CPSI, and. Erectile dysfunction measured by IIEF-5 or IIEF-EF in men who have CP/CPPS with concomitant ED.This is clinically relevant because CP/CPPS and ED frequently coexist, and current treatments often target either pelvic pain or erectile function rather than both.

Study design

The authors performed a systematic review of randomized controlled trials up to December 2025 including 9 randomized controlled trials with 531 men. Treatment duration ranged from 3 to 8 weeks. ESWT was compared with sham ESWT, pharmacotherapy or multimodal standard care.The review included both focused ESWT and radial ESWT, with variation in energy settings, number of shocks, frequency, and treatment duration.

Results

Erectile Dysfunction

ESWT was associated with improved erectile function (SMD 0.80; 95% CI 0.31 to 1.28; P = .001) suggesting a moderate-to-large statistical effect, but heterogeneity was high.The effect was numerically larger in sham-controlled trials than in active-comparator studies. However, the difference between these subgroups was not statistically significant.

A clinically important point is that the authors estimate the weighted mean IIEF-5 improvement at about 2.29 points, which may be statistically significant but may not always reach a clearly meaningful clinical threshold, especially in men with mild ED.

CP/CPPS symptoms

ESWT also improved CP/CPPS-related symptoms: NIH-CPSI total score (SMD −1.14; 95% CI −1.73 to −0.55; P = .0002). This indicates improvement in overall CP/CPPS symptom burden. This was true for pain, urinary symptoms, and Quality of life.

The quality-of-life effect appears particularly strong, although again the certainty is limited by heterogeneity and study design issues.

Safety

Short-term safety appeared favorable.

• Six of seven RCTs reported no device-related adverse events.
• One trial reported four cases of transient hematuria or hematospermia.
• No serious adverse events were reported.

The authors rated safety evidence as high certainty, although in practice this should be interpreted carefully because adverse-event reporting was inconsistent and follow-up was generally short.

Discussion

The review suggests that ESWT may benefit men with CP/CPPS and coexisting ED, improving both pelvic symptoms and erectile function.The biological rationale is plausible. ESWT may:

• promote angiogenesis,
• improve endothelial function,
• reduce inflammatory mediators,
• modulate pain pathways,
• improve pelvic floor or myofascial dysfunction,
• enhance tissue repair.

This is especially relevant because CP/CPPS and ED may share mechanisms such as inflammation, endothelial dysfunction, pelvic floor dysfunction, pain sensitization, and autonomic dysregulation.

Strengths of the article

Only randomized controlled trials were included, which strengthens the methodological basis compared with reviews including observational studies.

Subgroup and sensitivity analyses

The authors explored:

• focused vs radial ESWT,
• sham vs active comparators,
• different energy settings,
• treatment duration,
• total shocks,
• and exclusion of non-peer-reviewed dissertations.

This adds transparency, even though most subgroup findings remained exploratory. Here a comparison of both techologies

The review included studies using both focused and radial ESWT, but the evidence was tooheterogeneous to confidently conclude that one is clearly superior.

The authors performed subgroup analyses comparing different ESWT modalities, but these results should be interpreted cautiously because:

• the number of trials was small,
• protocols varied substantially,
• energy levels differed,
• treatment sites differed,
• some studies used sham controls while others used active comparators,
• and CP/CPPS phenotypes were not consistently stratified.

So, while focused ESWT may appear more biologically plausible for combined CP/CPPS and ED, the meta-analysis does not provide definitive proof that focused ESWT is clinically superior to radial ESWT.

Main limitations of the article

Several outcomes had substantial heterogeneity: This means the included trials differed substantially, making the pooled effect estimates less certain. Despite statistically significant results, the GRADE certainty for efficacy outcomes was low. This means further high-quality trials could meaningfully change the estimated effect.

Clinical relevance

The findings support ESWT as a potential adjunctive therapy, not yet a definitive standard treatment, for men with CP/CPPS and ED.

It may be especially relevant for patients who:

• have persistent symptoms despite standard pharmacotherapy,
• prefer non-invasive treatment,
• have both pelvic pain and erectile dysfunction,
• or are being managed within a multimodal phenotype-based framework such as UPOINTS.

However, clinicians should be cautious. The evidence does not yet clearly define:

• the optimal ESWT protocol,
• best device type,
• ideal energy setting,
• number of sessions,
• retreatment schedule,
• durability of response,
• or which patients are most likely to benefit.

Conclusions

This is a useful and clinically relevant review, particularly because it focuses on the overlapping CP/CPPS–ED phenotype rather than CP/CPPS alone. Its main contribution is showing that ESWT may have dual benefits across sexual and pelvic symptom domains.

However, the conclusions should remain conservative. The evidence supports promise, not definitive efficacy. ESWT should currently be viewed as a possible non-invasive adjunct to multimodal care rather than a replacement for established phenotype-guided management.

The next step should be large, multicenter, sham-controlled RCTs with standardized ESWT protocols, longer follow-up, and stratification by CP/CPPS phenotype, ED severity, psychological comorbidity, and pelvic floor dysfunction.

Jens Rassweiler