20 encouraging given how poorly this group often responds to oral therapy. Post-radical-prostatectomy ED. This is the weakest part of the evidence base and warrants explicit caution. ED after radical prostatectomy is predominantly neurogenic, arising from cavernous nerve injury, rather than the vasculogenic mechanism that the bulk of the literature addresses. The rst randomised trial of Li-ESWT for penile rehabilitation after prostatectomy did not reach its primary endpoint of a clinically signicant IIEF [11] difference , and pooled analyses suggest any benet appears at three to four months and does not reliably persist. The 2025 Cochrane review excluded prostatectomy patients altogether. In this population, Li-ESWT should be regarded as a biologically rational but unproven adjunct within a broader penile- [12] rehabilitation strategy , not as an established treatment. Safety and tolerability Li-ESWT is consistently well tolerated. Across the randomised literature, adverse events are minimal and typically limited to mild, transient discomfort or occasional petechiae, with no serious treatment-related events reported. Treatment has also been shown to be safe in men receiving antiplatelet or anticoagulant therapy, with no signicant bleeding events [13] observed . The principal contraindications are a malignancy within the treatment eld, severe coagulopathy and local active infection. This favourable safety prole is one of the therapy's genuine strengths: even where the efcacy ceiling is modest, the risk of harm is low. Protocols and the standardisation problem The single greatest methodological weakness across the evidence base is the absence of a standardised protocol. Trials differ widely in device type, energy ux density, number of pulses per session, total number of sessions, treatment frequency, anatomical application to the shaft and crura, and duration of followup. This heterogeneity complicates direct comparison between studies and is a major reason the pooled certainty of evidence remains low. Notably, the positive trial evidence derives almost entirely from focusedenergy devices, which deliver energy to a focal zone at depth within the corpora cavernosa rather than dissipating it at the surface (Figure 2); clinicians adopting the therapy should align their protocols with those used in the trials that demonstrated benet, and should document baseline and follow-up validated outcome measures (IIEF-EF and EHS) to track individual response. Figure 2. Focused low-intensity shockwave therapy delivered to the penis (transverse cross-section, approximately to scale). The focused beam converges to a focal zone within the corpus cavernosum, the erectile target, which lies approximately 1 cm beneath the surface. Original schematic, not for diagnostic use. Proportions approximate; depth values are indicative and device/energy-dependent. The focused beam converges to a focal zone within the corpus cavernosum — the erectile target sits only ~1 cm beneath the surface, and focal depth is adjustable, so focused devices deliver a therapeutic dose at depth rather than only at the skin. Skin / dartos / Buck's fascia ≈ 1 cm to corpus Urethra Corpus spongiosum Tunica albuginea Cavernosal (deep) artery Corpus cavernosum paired erectile bodies — primary target Median septum Dorsal neurovascular bundle deep dorsal vein, dorsal arteries & nerves Focused low-intensity shockwave therapy: penetration to the erectile target Transverse cross-section of the penis (approximately to scale; accid diameter ≈ 3 cm) Focused applicator Focused pressure prole Steep spike, high peak
RkJQdWJsaXNoZXIy NTIyOTQ=