**6. ESWT in the treatment of erectile dysfunction (ED)**

Several trials studied the efficacy of ESWT in the treatment of ED. Clavijo et al published a systematic review and meta‐analysis of seven randomized clinical trials with 602 patients with vascular ED [15]. The seven studies used low‐intensity shockwave therapy (Li‐ESWT) for ED and used the erectile function domain of the International Index of Erectile Function (IIEF‐EF) to assess the response to treatment. The IIEF‐EF is a validated questionnaire that includes six questions about erectile frequency, firmness, penetration ability, frequency of maintenance, ability to maintain erection and erectile confidence on a scale of zero to five [28]. The difference in IIEF‐EF score pooled change was measured in patients with ED treated with Li‐ESWT and compared to that measured in patients treated with sham therapy. The IIEF‐EF score in ESWL group was 6.40 points compared to the sham group which was 1.65 [15].

Another systematic review and meta‐analysis by Fojecki et al. [16] included four studies that also used IIEF questionnaire, in addition to erectile hardness scale (EHS) to assess the success of treatment. One study of the four also examined the penile hemodialysis as an indicator for erectile dysfunction [29]. All of them compared ESWT to sham therapy. Three out of the four studies showed positive effect of ESWT on EHS scale compared to sham group. Only one study reported negative effect of ESWT on both EHS scale and IIEF score [30]. Hence, the effect of ESWT on ED is still inconclusive, although according to EHS scale, it is proven to have some potential in the treatment of ED [16].
