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Not All Shockwaves Are Created Equal: Radial vs Focus Shockwave Therapy for Erectile Dysfunction
Updated: Jul 1
What’s up everyone? It’s Rich here again, and I’m here to talk about some things anyone trying to learn more about shockwave therapy will come up against — the idea that “not all shockwaves are created equal”.
I’m sure you all have probably read this title on some men’s health clinic’s website. This statement has grown popular in the past few years, and some clinics have had their marketing teams scrape other content from different websites and often reword it without doing their own research behind it.
Seriously…I dare you to Google it, and you’ll find a handful of these sites with similar content or content that doesn’t make sense.
But are they right, or are they wrong?
After some digging in the past two plus years, they are right — to some degree.
What you should know about shockwave therapy is that there are different types of shock waves or “soundwaves”:
Focus shockwaves/pressure waves
Radial shockwaves/pressure waves
Today, we will dig deeper into this topic and compare focus and radial shockwave and their use in erectile dysfunction treatment. My hope is that this ongoing debate between the efficacy and use of radial shockwaves versus focus shockwave therapy will have a different painted picture once you read what I found in my research.
But first, READ my disclaimer.
Bdestyle.com, (We, I, Us) is a professional review site that tests men’s health products thoroughly and provides educational information that shouldn't be misconstrued as medical advice. We are independently owned, and the opinions expressed here are our own. We are NOT doctors. We can’t diagnose you. If you need a diagnosis, prognosis or medical advice, go to your doctor. Read more about our policies and disclosures here.
Is Shockwave Therapy Approved for Treatment of ED in the U.S.?
It’s important to point out from the start that shockwave therapy for erectile dysfunction (Li-ESWT) isn’t approved in the United States yet. At the moment, research is still ongoing.
That said, in 2021, it was approved in Europe; however, counseling after a full screening is required before administering treatment. Additionally, because there are often other ED factors at play, patients need to know that there’s no cast-iron guarantee of success. But rather, a multiple-approach strategy is needed to tackle this condition from multiple angles.
So far, data suggest that shockwave therapy can help guys with vasculogenic ED, early onset Peyronie’s disease, CPPS, and several other sexual health problems.
What Is a Shockwave?
Shockwaves are energy transmitted across air or water. The wave is generated by a device that emits intense energy bursts. Once the energy reaches an object, it’s reflected.
Extracorporeal shockwaves (ESW) are non-invasive. These acoustic pressure waves target body parts to reduce pain or repair damaged tissue.
Let’s discuss how that relates to Extracorporeal Shockwave Therapy (ESWT). This type of treatment uses low-energy waves that move through your skin using transducers. There’s no need for anesthetic, and the treatment is usually tolerable or pain-free. However, some clinics use anesthetics anyway to avoid patient discomfort.
What’s the Difference Between Shockwave Therapy and Acoustic Wave Therapy?
There’s so much scientific jargon associated with shockwave therapy it’s easy to get confused. But maybe that’s how some professionals in the industry want you to feel…Some people play off this confusion on purpose.
Acoustic wave therapy is a non-scientific term. One reason that it’s often used is that it sounds less scary than the term “shockwave”. Of course, shockwaves don’t actually shock you, but it’s understandable from a marketing point of view that a softer term is used.
If you read anywhere that shockwave and acoustic wave therapy are different, it’s time to call BS. They’re clearly spreading misleading information.
When it comes to medical studies, you’ll always hear talk of shockwaves - radial or focus shockwaves. But to add extra confusion to the mix, physicists use the term “pressure waves.”
The glossary above is the terminology used in scientific studies on shockwave therapy to help clear up some confusion:
What’s The Difference Between Focus Shockwaves And Radial Shockwaves?
If you go to a men’s health clinic’s website, you’ll often see some marketing related to whatever device is being used by their providers.
For instance, on one side, you’ll see clinics that only use focus shockwave devices and bash other clinics for using radial shockwave devices. You’ll often see them writing misinformation about radial shockwave "patient experiences" or the wrong specifications on the actual radial device when they have NEVER used it themselves.
On the same token, you’ll see clinics that use radial shockwave devices and have a plethora of reviews and positive anecdotal experiences. Lastly, there are clinics that use BOTH radial and focus shockwave devices in their clinic because they BOTH work!
It’s a matter of knowing the differences and seeing it for yourself by actually doing your own research. Here’s what I’ve discovered.
How do Focused Shockwaves Work?
Focused shockwaves (FSW) are high-energy waves that target a specific area. The sound waves focus on a small spot, similar to how a magnifying glass focuses sunlight on one point.
There are three methods to how focus shockwaves are generated (FSWT).
Electrohydraulic
Electromagnetic (flat coil / cylindrical coil)
Piezoelectric
The only difference between the three is the moment at which the shockwave is formed and the device employed by a practitioner who offers shockwave treatment. At this time, 6 focus shockwave devices are still being questioned from the earlier studies on shockwave therapy from the 2005-2016 era.
These devices are registered as class 3 medical devices and are only operated by trained professionals. Why? Because these devices are very powerful and can potentially injure you at higher and unregulated intensities.
At the same time, different practitioners using focus shock wave devices may or may not use the same protocol. Treatment will vary by different energy flux densities (EFD) or different settings on their devices on a patient-by-patient basis.
These focused shockwaves have the ability to penetrate deep into tissue, delivering strength at the designated depth. If we look at available focus wave devices, some companies, like Storz Medical, state their focus shockwaves penetrate up to 12 cm deep with very little energy loss. Damage to skin and underlying tissue is minimal.
If we translate this to treating penile tissue, the "average" penis size isn’t that big, guys! The wave type easily penetrates penile tissues on one focal point or a singular treatment line.
From experience of getting this type of treatment, you’re laying on a table naked from the waist down and flaccid unless you accidentally get erect during treatment, which happens! This treatment will penetrate no matter the size or rigidity of your penis.
How Do Radial Shockwaves Work?
In the past, radial shockwaves were generated using a pneumatic system. Using compressed air, a projectile is accelerated to a high speed and then quickly slowed down by a transmitter.
The kinetic energy created is then sent to the tissue through waves. These waves are generated at the transmitter's surface, with the highest pressure and strongest energy density.
Currently, better-made radial shockwave devices use electromagnetic systems instead of pneumatic systems. In an electromagnetic system, there’s a bullet in a barrel accelerated using alternating magnetic fields. These fields cause the bullet to strike an end plate creating a shockwave.
Devices like these usually categorize their shockwaves in terms of actual energy instead of the pressure “bar”. They use milijoules to determine the difference in energy level.
However, most studies I’ve seen use both measurements and often have a conversion table or chart to determine a pressure bar of 1.0, all the way to a bar of 5.0 being 60 to 180 mj (milijoules).
Even at the highest “pressure bar” or “milijoule”, the “conversion” or calculation of energy flux density for a pressure bar of 3.0 or 120 mj is approximately around 0.12 mj/mm2, which is within the range we have seen focus devices use during the clinical trials when treating erectile dysfunction.
***The below is approximations based on the current data.
Compressed Air Bar | Magnetic mJ | Energy Per mm using 15mm head mJ/mm2 |
1 | 60 | |
2 | 90 | |
3 | 120 | 0.12 |
4 | 150 | |
5 | 180 | 0.38 |
Based on the setting of a radial device, this is an example of what each pressure bar/milijoule output looks like:
Characteristics of Radial Shockwaves Versus Focus Shockwaves
If we look at the profile of a radial shockwave, it is often mentioned in studies that it does not meet the characteristics of a focus shockwave because of the difference in speed, rise time and non linearity.
Focus shockwaves have been researched to show the characteristics of a “true shockwave”.
“Because it is not clear which wave characteristics generate therapeutic effects, it is difficult to relate physical differences between focused pressure waves and radial pressure waves to clinical effectiveness”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657080/
But, does this mean that radial shockwaves can’t penetrate the penis?
The Myth That Radial Shockwaves Can’t Penetrate A Penis Is Debunked!
Compared to focused shockwaves, radial shockwaves have a much wider dispersion pattern and weaker energy levels. The deeper the pressure waves go into the body, the less powerful they become.
It’s thought that radial shockwaves can travel up to 5-6 cm deep at a 5.0 bar (pressure/highest setting for some devices), and the therapeutic level is mid-level from the area the waves are propagated from the tip. So, the theory is that “up to” the halfway point (how deep the wave penetrates), these waves can cause a therapeutic response to the body, and then they lessen and grow weaker.
Depending on where you look, other studies suggest that radial shockwaves can only penetrate up to 40 mm, which is around 4 cm. The halfway point for therapeutic benefits would be 20 mm. But, if some of these radial devices can penetrate up to 6 cm, then we’re looking at up to 60 mm with a therapeutic zone of 30 mm as the halfway point.
If we translate that to inches, that’s around .80 to 1.2 of an inch if we round up. Technically, the average circumference (girth) of an average flaccid penis is approximately 3.66 inches. The diameter of an average flaccid penis would be around 1.16 inches.
Since shockwave providers usually perform treatments on a flaccid penis that is usually held out or somewhat stretched, these radial shockwaves do have the ability to penetrate deep enough into the tissues to cause the biological effects needed that studies suggest.
It’s hard to rule this out as more studies on rSWT are starting to be published.
I can see why there’s a widespread use of radial wave devices for erectile dysfunction because they CAN penetrate the dimensions of a penis. After all, it’s not a large organ to begin with.
It’s also about the treatment lines a urologist or provider determines when treating a patient. This is also why I’m assuming more doctors prefer radial shockwave devices over focus shockwave devices because of maximum coverage (think…” circular” or treating around the penis to ensure the waves penetrate the necessary areas to cause the cavitation effect and the physiological benefits that come with Li-ESWT).
Lastly, some research suggests that only radial shockwaves are actually called “pressure waves” compared to focus shockwaves. However, other research contradicts this by calling focus shockwaves “pressure waves” as well.
From my understanding, “pressure waves” is a term used by physicists and not by doctors. In a medical setting, doctors refer to it as Li-ESWT, rESWT, or fESWT. So, we’re just going to stick to that.
Addressing The Inaccurate Claims About Shockwave Therapy
Certain medical groups and men’s health clinics throughout the U.S. use radial wave devices that were obviously not in beginning studies on Li-ESWT. This brings up many questions about the effectiveness and safety of these devices.
As some urologists seem to point fingers at who is wrong. My question to all of you is — if these clinics offer radial wave therapy and have been doing so for over 10 years, then why do men return for future treatments?
Clearly, there’s something we’re missing here in terms of effectiveness because these men continue to go back and claim success in their personal lives.
So, this, to me, is something that requires further investigation. I find that clinics marketing the notion “radial wave therapy is bad”, “they don’t penetrate at all”, and that focus waves are “better” have pessimistic mindsets or are just misinformed. Their view is the studies to date conclude the discussion on shockwave therapy — a stance that benefits them financially.
It’s unfortunate because I often come across consumers like myself being misled by this misinformation, which makes potential Li-ESWT candidates feel conflicted about whether or not they should get shockwave treatment.
And it even happens with name brands, too…
Popular brands like GAINSWave that offer shockwave treatment often get caught in the web of misinformation. I’ve had people ask me if GAINSWave was a type of shockwave when really it’s just a branding term.
Urologists, PAs, RNs and even physiotherapists wanting to offer shockwave treatment usually sign under GAINSWave for marketing purposes so that consumers can find their clinics.
In addition to this noise in the mainstream, men are also misled into believing that they only offer radial wave treatment when this is false.
Don’t believe me? Try calling around different centers and asking the name of the device they use, and you’ll find out that clinics are using either radial, or focus. Or they use BOTH in their clinic. It’s not just one device.
Lastly, if we address the other claims, like acoustic wave therapy and shockwave therapy being two different things, you’ll see that there are no differences at all. It's just a layman's term.
Shockwave Therapy In Clinics
As previously mentioned, shockwave treatment for ED In the United States hasn’t been approved by the FDA yet. That said, you could receive treatment if you’re part of a clinical trial or you can easily visit your local men’s health clinic for this “off label” treatment.
Currently, anecdotal evidence surrounding the treatment seems positive and more clinics will open, offering shockwave therapy for premium rates.
Typically, clinics charge more than $500 per treatment, with many clinics offering packages of 6-12 treatments for between $3000 and $6000.
What Do Urologists and Others In the Medical Community Say About Shockwave Therapy for ED?
In an article about shockwave therapy posted on The Philadelphia Inquirer in November 2021, Stacy Burling uncovered an excellent example of how the medical community continues to argue about the safety, efficacy and benefits of shockwave therapy for men of all communities.
I will make my own comments about this article so you can see my interpretations.
But first…Stacy, I want to thank you for actually writing this because it really showed both optimism and pessimism from different medical practitioners about shockwave therapy.
You have the optimism of doctors such as Stephen Borgese, who mentioned that he quit his job in emergency medicine to form a new practice in 2018 and help treat men with ED using shockwave therapy.
Although he uses the Storz D-Actor 100 (radial wave model), it was mentioned he treated over 700 patients from that time frame (2018-2021). And this doesn't even factor in how many more men could’ve seen a benefit in 2020 without COVID disruptions.
At the time of this article, Stacy mentioned that on clinicaltrials.gov:
“There are no trials of shockwave, the most widely used restorative therapy, within 300 miles of Pennsylvania or New Jersey.”
Businesses weren’t the only things to shut down during 2020; research was also on pause. Plus, this “search” was only 300 miles from New Jersey or Pennsylvania, which doesn’t encompass the remaining states or other countries conducting studies on this therapy.
Currently, as of November 2022, it appears that there are new studies recruiting participants. What’s interesting is there are even devices that were not a part of the “original studies”.
For example, the Dornier Aries, but some trials are currently in progress. There’s also another device in China being trialed.
This proves my argument that some of these doctors only consider the 2010-2016 era as the “be all” and “end all” discussions when there needs to be additional research on all devices, protocols and wave types.
On the other hand, Stacy also mentioned in her article the pessimistic side of shockwave therapy.
The FDA has not yet approved Li-ESWT as a treatment option in the U.S. because more research is needed. Stacy confirmed this by mentioning a few quotes in her article from a few members of the Sexual Medicine Society of North America about their recent position statement on shockwave therapy.
“low-intensity shock wave therapy, aka shockwave, and other “restorative” treatments are “promising” but are not yet ready for widespread clinical use.”
“… The doctors who are offering therapy are not charlatans,” he added “They’re not selling you snake oil, but, as a medical consumer, you have to be a little bit savvy.”
“None of them have been proved effective in an appropriately designed, randomized, controlled trial.”
Stacy’s article gets even more interesting and also highlights an argument about the position statement from the SMSNA.
“They are correct that there are not enough data from high-quality clinical trials, he said. But, he added, ”there will never be good clinical trials on this.” Such trials are too expensive for device makers, and their placebo arms are not attractive to men with ED, he said.”
Here is another doctor’s response to this statement:
“Borgese thinks it makes sense to offer something that might work to men who are suffering while they can still benefit. Many are old enough that they’ll have no hope of resuming their sex lives if they have to wait years for the results of clinical trials. Shockwave treatment does not have serious side effects, he said.”
I feel like no one recognizes that clinical trials cost a lot of money, and they also take a long time to conduct and write up because of the participant follow-ups. At the same time, it looks like it’s a pain in the ass to submit a clinical trial if you go on clinicaltrials.gov (or other clinical trial sites) and look at the submission process. It is an eyeful.
I also agree with Borgese’s statement. Some “older” men, in my opinion, may not see the benefits of “FDA approved” shockwave therapy because there’s still debate about clinical trials and getting more concrete research. If the current data already shows that it works, it’s safe, and doesn’t have serious side effects, then why not?
After all this, Stacy also brought attention to urologists who don’t think shockwave therapy should even see the light of day.
“Bryn Mawr urologist who does not use restorative therapies because he thinks there’s insufficient proof of their value.”
Lastly, Stacy discusses erectile dysfunction and how it can “slowly” strip away a man’s identity.
“Men tend to measure their entire self-worth on the functioning of their penis,” Masterson said. That, he said, is “why men are so willing to seek out these treatments and do whatever they can to get that function back.”
Some doctors argue that this is a simplistic way of viewing erectile dysfunction and that it’s more about self-confidence and relationships and not having your body betray you.
Stacy also shared a story from William Marsh, a massage therapist, who, at the age of 53, was seeing a decline in performance — despite being physically fit and healthy.
“The hardest part was the frustration of letting your partner down,” William said.
William’s wife suggested he go see Borgese at his clinic, where not only does he explain to patients that this therapy may not work, but he also suggests communication and working on your relationship are just as important. It takes “two to tango” when it comes to ED in a relationship.
As I’ve spoken about this in previous articles, ED is more than just physical, and can be mental and affect your partner, too!
In the article's conclusion, William says he thinks the success of his experience with shockwave therapy was ¾’s of the treatment and ¼ on rekindling his relationship with his wife. This is something that I will argue that shockwave treatment is not the only solution to having a better sex life. We all have to face the fact that other treatments and strategies are needed, too!
What’s The Verdict? Are Focus Or Radial Shockwaves Better for Treating ED?
Now, I don’t know about you guys, but the article I mentioned from The Philadelphia Inquirer was really insightful and offered different perspectives on shockwave therapy. But, after reading all of that, I’m sure you can understand my frustration with the current arguments on all sides.
In my opinion, we should all be on the SAME team instead of bashing other centers for their own financial gain or being uptight because Europe was able to get Li-ESWT approved as a treatment option for men in 2021.
There is also a plethora of studies on the energy signatures of radial shockwave therapy that still needs more investigation because the penis is not a big organ, and the machines that are widely used do have the potential or “capability” to penetrate deep enough to cause the biological and physiological effects that focus waves do at a low setting.
It's just a matter of producing more studies at a higher bar/milijoule, increasing the number of pulses and frequency with these devices and trialing different approaches to treating around the penis instead of only a few treatment lines demonstrated in the focus shockwave studies.
But because of the current data and differences in protocols, you may get a different experience in a men’s health clinic than your cousin Jimmy experienced in another state or country.
What Should You Expect When Going To A Men’s Health Clinic
As mentioned earlier, you will find that if you choose to go to a men’s health clinic you will either run into an MD, PA, RN, or physiotherapist who will offer this type of treatment.
Urologists will point fingers saying not to go to a clinic that doesn’t have a Urologist on staff, or that their “job title” is the only role who should wield a shockwave device. It’s funny because oftentimes, they’re not the ones administering treatment and will usually have a tech person or RN do it for them.
After all, it’s not a one-patient-a-day business. Dozens or even hundreds of guys go in one day. It would be unrealistic to expect the head Urologist of a clinic to treat every guy that walks in. It’s also not a quick treatment either…
In my opinion, I would stay clear of physiotherapists offering this off-label treatment for erectile dysfunction. It just doesn’t make the most sense because it’s not their field. Ideally, you should go to a clinic where there is a Urologist offering this treatment. However, even PAs and RNs are more than equipped to administer this treatment granted they’re more in line with the education and know-how versus a physiotherapist performing treatment on a penis or the head Urologist who is too busy making "lifestyle" YouTube videos instead.
You might also find certain doctors referring to a “secret shop” survey/study for their own financial gain, stating that some clinics don’t even know what device their clinic offers.
But, let’s be realistic here. Since most marketing teams from these clinics are not looking up the research, or are writing the incorrect terminology on their websites, then how do you expect a front desk worker to answer “medical questions” over the phone when they’re not doctors themselves to answer these questions?
They are only there to get you an appointment for you to then see a medical professional for advice.
The point is, no one has their ducks in a row! No one is perfect. Even the research that I did on this is not 100% because there are still questions being asked, the data is not uniform/linear and the mechanisms behind shockwave therapy are still theorized and not 100% defined, etc.
Closing Thoughts On Focus Shockwave Therapy Versus Radial Shockwave Therapy
The verdict is in and yes, not all shockwaves are created equal. Whether you get radial shockwave therapy or focus shockwave therapy, it should not change the way you think about your erections moving forward.
Both will WORK!
Shockwave therapy is a longer-lasting treatment option that has over a decade worth of research showing efficacy on treating men with moderate ED and mild to moderate ED categories (and even a few with severe categories based on a few studies).
The point is, sexual health is important and there is a natural decline that can’t be fixed with just a pill. You need to wake up and actually do something about it so that you can maintain or resume an active sex life.
At the same time, no one is going to spoon feed you the answers either. This is why I ALWAYS encourage you to keep learning and to make your own conclusions. Just because someone in a lab coat tells you their input, doesn’t mean you can’t do your own research and learn more on your own. You have to be your very own advocate when it comes to improving your sexual health. Sometimes you're not going to get that friendly doctor who will help you. Sometimes they'll gaslight you into thinking it's all in your head.
If you do get shockwave treatment done at a clinic or you try an at-home shockwave device, do your research and take notes on what your experiences are.
The more variables you have going on in your life, such as psychogenic ED (stress, marriage issues, etc.), or health and hormonal issues, you might not be able to see success or be considered a candidate for shockwave therapy.
You need to tackle the root causes…all of them! Shockwave treament is only a "singular" solution for vasculogenic ED, not a "catch all" treatment.
Much love and thanks for always listening.
-Rich
More references used. For more information please contact info@bdestyle.com:
https://www.shockwavetherapy.education/index.php/theory/types-of-shockwave
https://www.shockwavetherapy.org/about-eswt/physical-principles-of-eswt/
https://www.science.gov/topicpages/s/shockwave+therapy+eswt
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657080/
https://www.storzmedical.com/us/physics-and-technology
https://urology.wisc.edu/wp-content/uploads/2018/11/meta_analysis_LI_ESWL.pdf