16 Low-Intensity Shockwave Therapy for Erectile Dysfunction: What the Evidence Actually Shows Abstract Background: Erectile dysfunction (ED) is highly prevalent and rises with age. Phosphodiesterase type 5 inhibitors (PDE5i) remain effective but symptomatic, which has created interest in restorative therapies that target the underlying vascular pathology. Low-intensity extracorporeal shockwave therapy (Li-ESWT) is the most clinically advanced of these. Objective: To summarise the current evidence on Li-ESWT for ED, covering its proposed mechanism, efcacy, patient selection, safety and guideline status, and to clarify where the evidence is strong and where caution is warranted. Methods: Narrative review of randomised controlled trials, meta-analyses and current clinical practice guidelines. Findings: Meta-analyses consistently show statistically signicant but modest improvements in the International Index of Erectile Function and the Erection Hardness Score in men with mild-tomoderate vasculogenic ED, with the clearest benet in milder disease and in PDE5i poor responders; combining it with a daily PDE5i improves outcomes. The 2025 Cochrane review rated overall certainty low and cautioned that the effect may fall below the minimal clinically important difference. The positive evidence comes almost entirely from focused-energy devices. Data in neurogenic and post-prostatectomy ED remain immature. The safety prole is favourable, with only mild, transient adverse effects. Conclusion: Focused Li-ESWT is a reasonable, well-tolerated, non-invasive option for selected men with mild-to-moderate vasculogenic ED, particularly PDE5i poor responders, but it is not a rst-line therapy, its durability is uncertain, and protocol standardisation with longer, independently funded trials is needed. Cecilia Raath Physiotherapist BPhysT (Honours), University of Pretoria Postgraduate Certicate, Orthopaedic Manipulative Therapy (OMT/NMS) Postgraduate Certicate, Sport Physiotherapy (SPT) Postgraduate Certicate, Women's Health Physiotherapy (PWH) Cecilia has been a physiotherapist in private practice since 1999, specialising in the integration of neuromusculoskeletal (NMS) and pelvic health physiotherapy. She has been actively treating pelvic health patients since 2004, with a clinical approach that evaluates the pelvis as part of a three-dimensional, whole-body system — identifying and addressing the mechanical and orthopaedic drivers (previous sports injuries, minor trauma, habitual posture) that frequently underlie pelvic oor dysfunction and its co-morbidities. She treats both women's and men's health conditions, including pelvic pain, incontinence, sexual dysfunction, pregnancy-related pelvic girdle pain, and paediatric pelvic health. She is a partner at Raath & Spies Physiotherapists — Silver Lakes, Pretoria, a team member and supervisor at My Sexual Health (MSH) and is a senior lecturer for pre- and postgraduate physiotherapy programmes.
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