LAUSR

Two decades have passed since the phosphodiesterase-5inhibitors (PDE5Is) revolutionized the management of erectile dysfunction (ED). However, the restoration of natural erection remains the ultimate goal of any treatment. During the last decade low intensity extracorporeal shockwave therapy (Li-ESWT) emerged showing in some cases very promising results, with a range of improvement in International Index of Erectile Function (IIEF) scores similar to the published data on PDE5Is clinical trials [1]. Furthermore, Li-ESWT seems to improve erectile function by inducing neoangiogenesis and reversing pathologic processes in erectile tissue and thus partially by restoring of natural erection [2, 3]. Such data were initially enthusiastically accepted by the scientific community, as ideally, ED therapy should be simple, non-invasive and non-painful with a high success rate and few minor side effects. The following years a research marathon began regarding the effectiveness of Li-ESWT for ED. Most of the studies showed acceptable effectiveness of Li-ESWT in patients with vasculogenic ED, PDE5I responders and nonresponders [4]. However, some well-designed randomized sham-controlled trials (RCT) failed to show this effectiveness [4]. This confused both the scientific community and the office urologists, and we also see this confusion to recent published guidelines and recommendations from scientific societies [5, 6]. Therefore, we could not really guess how the Li-ESWT was accepted in everyday clinical practise. In this recent article in International Journal of Impotence research, the authors, members of the European Association of Urology—Young Academic Urologists (EAU-YAU) group on men’s health, investigated the opinion of urologists on Li-ESWT [7]. The survey was conducted during the European Association of Urology (EAU) Section of Andrological Urology (ESAU) annual meeting in Prague, from 31st October to 1st November 2019. The results were compared with a similar survey conducted in 2016 [8]. The study concluded that the awareness and the clinical application of Li-ESWT in men with ED have increased, despite the lack of robust evidence supporting the effectiveness of this treatment [7]. This is a very interesting conclusion since it is somehow self-conflicting. Especially in the era of evidence-based medicine, it is rather unusual to observe medical practitioners increasing the application of a medical treatment that it is not supported by robust clinical evidence. This could be partially attributed to the confusing fact that even between international scientific societies there is not full agreement in terms of recommendations on Li-ESWT in ED patients [9]. In 2019 the European Society of Sexual Medicine (ESSM) published clinical recommendations for Li-ESWT in the context of ED stating that unambiguous evidence on the efficacy of Li-SWT is still currently lacking and evidence quality is low due to the small number of patients included in randomized clinical trials, the heterogeneity of treatment protocols and the controversial findings [6]. On the other hand, the current guidelines of the European Association of Urology (EAU) on sexual and reproductive health recommend the use of Li-ESWT in patients with mild vasculogenic ED as an alternative firstline therapy in well-informed patients who do not wish or are not suitable for oral vasoactive therapy or desire a curable option [10]. Furthermore, they recommend the use of Li-ESWT in vasculogenic ED patients who are poor responders to PDE5Is [10]. Taking it altogether we can say that EAU Guidelines are recommending the use of Li-SWT as a first-line therapy alternative to PDE5is in fully counseled patients. The previous version of the guideline was * Ioannis Sokolakis [email protected]