Low-intensity extracorporeal shockwave therapy (Li-ESWT) is a non-invasive treatment that uses acoustic waves to stimulate blood vessel growth in the penis, potentially improving erectile function in men with vascular causes of erectile dysfunction. Unlike established oral medications such as sildenafil (Viagra) or tadalafil (Cialis), which work acutely to facilitate erections, shockwave therapy aims to address underlying vascular factors. Whilst clinical evidence shows promise for men with mild to moderate vasculogenic ED, the treatment is not routinely commissioned by the NHS and remains an evolving option rather than a first-line intervention. This article examines the evidence, suitability criteria, treatment process, and realistic expectations for shockwave therapy in erectile dysfunction.

What Is Shockwave Therapy for Erectile Dysfunction?

Low-intensity extracorporeal shockwave therapy (Li-ESWT) is a non-invasive treatment that uses acoustic waves to stimulate blood vessel growth and improve blood flow to the penis. Unlike the high-energy shockwaves used to break up kidney stones, this therapy employs gentle, pulsed acoustic waves delivered through a handheld device applied to the penile shaft and crural regions.

The proposed mechanism of action centres on neovascularisation—the formation of new blood vessels. Shockwave therapy is thought to trigger the release of angiogenic factors, including vascular endothelial growth factor (VEGF), which promotes the development of new capillaries in penile tissue. This process may improve blood flow to the corpora cavernosa, the erectile chambers of the penis, potentially enhancing erectile function in men with vascular causes of erectile dysfunction (ED).

Erectile dysfunction affects a substantial number of men in the UK, with vascular causes being the most common, particularly in men over 40. Traditional first-line treatments include oral phosphodiesterase-5 (PDE5) inhibitors such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil. These medications work acutely to facilitate erections but do not modify the underlying vascular pathology.

Shockwave therapy represents a different approach—it aims to improve erectile function by addressing vascular factors, though long-term disease-modifying effects remain uncertain. The treatment is typically delivered over multiple sessions, usually 6–12 treatments spread over several weeks.

Important distinction: The evidence base primarily concerns focused Li-ESWT devices. Some UK clinics use radial pressure wave devices marketed as 'shockwave therapy', but these have a much weaker evidence base and should not be assumed equivalent.

Li-ESWT is not routinely commissioned by the NHS for erectile dysfunction, though it may be available in some research settings. It is offered primarily through private clinics. The devices used must carry UKCA or CE marking for the treatment of erectile dysfunction, and private providers should be registered with the Care Quality Commission (CQC). The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medical devices and oversees post-market safety but does not approve individual procedures. Practitioners should follow appropriate clinical governance standards and use devices approved for this indication.

Clinical Evidence: Does Shockwave Therapy Work?

The evidence base for focused low-intensity shockwave therapy in erectile dysfunction is evolving and shows promise, particularly for men with mild to moderate vasculogenic ED. A 2019 systematic review and meta-analysis published in European Urology examined 14 randomised controlled trials involving over 800 men. The analysis found that Li-ESWT produced statistically significant improvements in erectile function scores compared to sham treatment, with effects lasting up to 12 months in some studies.

Key findings from clinical research include:

• Improvements in the erectile function (EF) domain of the International Index of Erectile Function (IIEF-EF), the validated questionnaire used to assess ED severity. Typical mean differences versus sham range from 2 to 5 points on the 30-point IIEF-EF scale; the minimal clinically important difference is approximately 4 points, so benefits may be modest in many patients

• Enhanced response to PDE5 inhibitors in some men who previously had suboptimal results

• Potential restoration of spontaneous erections in selected patients with mild vasculogenic ED

• Minimal adverse effects, with most studies reporting only mild, transient penile discomfort or skin redness

However, the evidence has important limitations. Study protocols have varied considerably in terms of energy levels, number of pulses, treatment sites, and session frequency, making direct comparisons difficult. Crucially, most positive trials used focused Li-ESWT devices; evidence for radial pressure wave devices is limited or negative, and the two should not be conflated. The quality of some trials has been questioned, with concerns about small sample sizes, short follow-up periods, and potential bias.

NICE (National Institute for Health and Care Excellence) has not issued specific interventional procedures guidance on shockwave therapy for ED. The NICE Clinical Knowledge Summary on erectile dysfunction focuses on established treatments. The European Association of Urology (EAU) guidelines state that Li-ESWT may be offered to men with mild to moderate vasculogenic ED as an investigational or conditional treatment option, but emphasise that patients should be informed about the uncertain long-term efficacy and the need for further high-quality research.

Importantly, there is no established evidence that Li-ESWT permanently cures erectile dysfunction or provides long-term disease modification. Most studies show functional benefit lasting 6–12 months, with some men requiring repeat treatment courses. The therapy appears most effective when ED is primarily vascular in origin and less severe, rather than in cases with significant nerve damage, hormonal causes, or psychological factors.

Who Is Suitable for Shockwave Therapy?

Patient selection is crucial for optimising outcomes with shockwave therapy. The treatment appears most beneficial for specific subgroups of men with erectile dysfunction, whilst being less appropriate or ineffective for others.

Ideal candidates typically include:

• Men with mild to moderate vasculogenic ED (IIEF-EF scores of 11–25), where impaired blood flow is the primary cause

• Those with relatively recent-onset ED and shorter duration of symptoms

• Men who respond partially to PDE5 inhibitors but wish to reduce medication dependence

• Individuals with fewer cardiovascular comorbidities and better-preserved penile vascular health

• Men seeking non-pharmacological treatment options due to medication side effects or contraindications

Shockwave therapy is generally not recommended for:

• Men with severe ED (IIEF-EF scores below 11), where vascular damage may be too advanced

• Those with primarily psychological or neurological causes of ED

• Men with untreated hormonal deficiencies, particularly low testosterone (hypogonadism)

• Patients with Peyronie's disease seeking treatment for penile curvature (Li-ESWT may help reduce pain in the active inflammatory phase but does not reliably improve curvature or plaque and is not a primary ED treatment)

• Those with active genital infection, open penile wounds, penile malignancy, severe coagulopathy, or penile prosthesis in situ

• Men taking anticoagulants or with bleeding disorders should discuss the treatment with their clinician, as there is a small risk of bruising, though this is not usually an absolute contraindication

Before considering shockwave therapy, men should undergo proper clinical assessment by their GP or a specialist. According to NICE Clinical Knowledge Summary guidance on erectile dysfunction, this should include a detailed medical and sexual history, physical examination, and appropriate investigations. Your GP can arrange:

• Blood tests: HbA1c or fasting glucose (to identify diabetes), lipid profile, blood pressure measurement, and morning total testosterone (with repeat if low, plus further endocrine tests if confirmed)

• Cardiovascular risk assessment using QRISK or equivalent tools

• Referral to urology or sexual medicine for specialist investigations such as penile Doppler ultrasound to assess blood flow, if indicated

It's essential to address modifiable risk factors first, including smoking cessation, weight management, regular physical activity, blood pressure control, and optimising diabetes management. NICE guidance emphasises that lifestyle modification and treatment of underlying conditions should form the foundation of ED management. Shockwave therapy should be viewed as a potential adjunct rather than a replacement for these fundamental interventions.

Treatment Process and What to Expect

Typical shockwave therapy protocols involve multiple sessions delivered over several weeks, though specific regimens vary between clinics and devices. Most evidence-based protocols for focused Li-ESWT consist of 6–12 treatment sessions, with two sessions per week for 3–6 weeks, sometimes followed by a treatment-free interval and a second course. The parameters below are illustrative; real-world protocols vary and should follow evidence-based, device-specific guidelines.

During each session, which usually lasts 15–20 minutes, a handheld probe delivers low-intensity acoustic pulses to specific areas of the penis. Treatment sites typically include five locations along the penile shaft and two at the crural regions (where the penis attaches to the pelvic bone). Each site may receive 300–500 shockwave pulses at a defined energy level, usually 0.09–0.15 mJ/mm².

The procedure itself:

• Requires no anaesthesia—most men report only mild tingling or tapping sensations

• Involves no needles, incisions, or medication administration

• Allows immediate return to normal activities, including sexual activity

• Produces minimal side effects, most commonly mild penile skin redness or minor discomfort lasting a few hours

Realistic expectations are important. Improvements, when they occur, typically develop gradually over 4–12 weeks following treatment completion, as new blood vessel formation takes time. Some men notice enhanced erectile rigidity, improved spontaneous morning erections, or better response to oral medications. However, not all men respond, and current evidence suggests approximately 60–70% of appropriately selected patients experience some benefit, which may be modest and time-limited.

Before committing to treatment:

• Verify the device type: Confirm you are receiving focused Li-ESWT with a UKCA- or CE-marked device approved for erectile dysfunction, not a radial pressure wave device

• Check provider credentials: Ensure treatment is delivered by suitably trained clinicians (ideally urologists or sexual medicine specialists) within a CQC-registered service

• Obtain a written treatment plan detailing the device, protocol, number of sessions, and expected outcomes

Cost considerations are significant, as the treatment is not NHS-funded. Private clinic charges typically range from £1,500 to £3,000 for a complete course, with considerable variation. These figures are indicative; costs depend on location, device, and provider.

When to contact your GP:

• If ED persists or worsens despite treatment

• If you develop new symptoms such as penile pain, curvature, or lumps

• If you experience sudden loss of erections, which may indicate cardiovascular issues requiring urgent assessment

• Before pursuing private treatment, to ensure proper investigation of underlying causes (including cardiovascular risk assessment) and discussion of evidence-based alternatives

Reporting side effects or device problems:

If you experience unexpected side effects or suspect a problem with the device, you can report this via the MHRA Yellow Card scheme for medical devices at www.mhra.gov.uk/yellowcard or through the Yellow Card app.

Men considering shockwave therapy should have a thorough discussion with their healthcare provider about realistic outcomes, alternative treatments, and the current evidence limitations. Whilst the therapy shows promise and appears safe in appropriately selected patients, it remains an evolving treatment option rather than an established first-line intervention for erectile dysfunction.

Frequently Asked Questions