Extracorporeal shock wave therapy in patients with chronic prostatitis/chronic pelvic pain syndrome and erectile dysfunction: a systematic review and meta-analysis

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.