Optimizing the Use of Extracorporeal Shock Wave Therapy for CP/CPPS: A Modality-Based Systematic Review and Meta-Analysis Comparing Focused and Radial Devices.

Background/

Objectives

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a multifactorial condition often refractory to standard medical therapy. Low-intensity extracorporeal shock wave therapy (Li-ESWT) is a mechanism-oriented option; however, prior reviews reported substantial heterogeneity, potentially due to pooling different wave-generator modalities despite their distinct physical properties. This study synthesized randomized evidence on Li-ESWT for CP/CPPS and explored a wave-generator modality as a prespecified effect modifier.

Methods

PubMed, Embase, Web of Science, and the Cochrane Library were searched from January 2015 to 31 October 2025 (date of last search) for randomized controlled trials (INPLASY: 2025120064). Eligible studies compared Li-ESWT (focused, radial, or multifocal) with sham or standard medical therapy (SMT). The primary outcome was total NIH-CPSI at the follow-up closest to 12 weeks. Pooled effects were calculated as weighted mean differences (WMDs) with 95% confidence intervals (CIs). Prespecified subgroup analyses were performed by wave-generator modality and therapy strategy (monotherapy vs add-on to SMT).

Results

Eight RCTs (n = 455) were included. Li-ESWT significantly improved total NIH-CPSI versus the control (WMD -8.46; 95% CI -12.12 to -4.79; I2 = 94.8%). Benefits were observed in both monotherapy and the add-on to SMT trials. By modality, focused devices showed consistent effects (WMD -6.59; I2 = 0.0%), whereas radial devices showed an imprecise estimate with extreme heterogeneity (WMD -10.38; 95% CI -21.33 to +0.57; I2 = 98.2%). Multifocal devices showed a significant benefit (WMD -10.84; I2 = 81.0%). Improvements were mainly driven by pain-domain reduction.

Conclusions

Li-ESWT provides clinically meaningful symptom relief in CP/CPPS, predominantly through pain reduction. Modality- and strategy-based subgroup findings are exploratory given substantial heterogeneity, limited trials, and no head-to-head comparisons; focused devices showed consistent effects, whereas estimates for radial and multifocal devices warrant cautious interpretation.