Comparing Risk of Post Infection Erectile Dysfunction Following SARS Coronavirus 2 Stratified by Acute and Long COVID, Hospitalization Status, and Vasopressor Administration (preprint)

No study has yet assessed the risk of developing erectile dysfunction (ED) after a diagnosis of long COVID-19, especially when compared to those diagnosed with only acute COVID or cases in which more severe treatment is required. To assess these risks, we queried the TriNetX COVID-19 Research Network from December 1st 2020 through June 2023. Men aged ≥ 18 diagnosed with long COVID-19 were compared to those diagnosed with acute COVID-19 and analyses were performed to compare men who were/were not hospitalized within 1 month of acute COVID diagnosis and men who did/did not need vasopressors. Cohorts were propensity score matched and compared for differences in new ED diagnosis and/or prescription of phosphodiesterase-5 inhibitors (PDE5i). After propensity score matching, the long and acute COVID cohorts included 2839 men with an average age of 54.5±16.7 years and 55.1±17.1 respectively. Men with long COVID-19 were more likely to develop ED or be prescribed PDE5i (3.63%) when compared to men with only acute COVID-19 infections (2.61%) [RR 1.39; 95% CI 1.04, 1.87]. There was no statistically significant risk of developing ED or being prescribed PDE5i for individuals who received vasopressors [RR 0.922; 95% CI 0.774,1.098] or were hospitalized [RR 0.933; 95% CI 0.824,1.056].

Factors associated with anxiety and depression in patients with erectile dysfunction: a cross-sectional study.

BACKGROUND: Few studies have investigated factors associated with anxiety and depression among patients with erectile dysfunction (ED). This study aimed to investigate associated factors and the prevalence of anxiety and depression in this special group in China. METHODS: Data from 511 patients with ED aged 18-60 years were collected between July 2021 and April 2022. The 5-item International Index of Erectile Function (IIEF-5) questionnaire, self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to evaluate erectile function, anxiety and depression, respectively. Univariate analysis and multivariate linear regression analyses were used to explore the associated factors of depression and anxiety. RESULTS: The prevalence of anxiety and depression among ED patients was 38.16% and 64.97%, respectively. The mean anxiety index score was 47.37 ± 6.69 points, and the mean depression index was 54.72 ± 9.10 points. Multiple linear regression analysis showed that worse ED, low education level, and smoking were positively associated with increased risk of anxiety and depression. In addition, younger age, longer onset time, and irregular sleep were positively associated with high risk of anxiety, and irregular exercise was associated with severe depression. CONCLUSIONS: The prevalence of depression and anxiety in ED patients is high, and the severity of ED, age, education level, smoking, onset time, regular sleep, and exercise were associated with anxiety or depression. Reversible risk factors should be avoided and individualized psychological support services are necessary for ED patients.

Long COVID and risk of erectile dysfunction in recovered patients from mild to moderate COVID-19.

Patients with coronavirus disease 2019 (COVID-19) were shown to have reduced serum testosterone levels compared to healthy individuals. Low testosterone levels are linked with the development of erectile dysfunction (ED). In this case-controlled study, 20 healthy controls and 39 patients with ED 3 months after recovering from mild-to-moderate COVID-19 pneumonia were studied. The patients ranged in age from 31 to 47 years. To identify early and late COVID-19 infections, real-time polymerase-chain reaction (RT-PCR) and COVID-19 antibody testing were done. The levels of luteinizing hormone (LH), follicular stimulating hormone (FSH), total testosterone (TT), free testosterone (FT), free androgenic index (FAI), and sex hormone-binding globulin (SHBG) were measured. The sexual health inventory for patients (SHIM) score was used to measure the erectile function of the patients and controls. When compared to the controls, the TT serum level in long COVID-19 (LC) patients with ED was low (p = 0.01). In contrast to controls, FT and FAI were both lower in LC patients with ED. (p = 0.001). FSH serum levels did not significantly differ (p = 0.07), but in ED patients, LH serum levels were elevated. SHIM scores were associated with low TT (p = 0.30), FT (p = 0.09), and high LH (p = 0.76) in LC patients with ED. Male patients with decreased serum levels of LH and testosterone may have hypothalamic-pituitary-gonadal axis dysfunction, which could lead to the development of LC-induced ED. Therefore, an in-depth research is necessary to confirm the causal link between COVID-19 and ED in LC patients.

Can anxiety and depression serve as primary factors associated with erectile dysfunction after coronavirus disease?

OBJECTIVE: We investigated the association between anxiety and depression and erectile dysfunction (ED) in patients who developed ED after coronavirus disease 2019 (COVID-19). PATIENTS AND METHODS: This study included 228 men who were hospitalized in pandemic wards between July 2021 and January 2022 with positive reverse transcription-polymerase chain reaction test results for the severe acute respiratory syndrome coronavirus 2 RNA. All patients responded to a Turkish version of the International Index of Erectile Function (IIEF) questionnaire to determine erectile status. Patients were administered the Turkish version of the Beck Depression Inventory (BDI) and Generalized Anxiety Disorder 7-item scale (GAD-7) questionnaires the day after hospitalization and also during the 1st month after diagnosis of COVID-19 to compare the COVID-19 situation with the previous situation. RESULTS: Patients' mean age was 49.66 ± 13.3 years. The mean pre-COVID-19 erectile function score of 28.65 ± 1.33 decreased to a mean post-COVID-19 score of 26.58 ± 4.23, which indicates a statistically significant difference (p=0.03). Post-COVID-19 ED occurred in 46 (20.1%) patients; 10 (4.3%) patients had mild, 23 (10.0%) had mild-to-moderate, 5 (2.1%) had moderate, and 8 (3.5%) patients had severe ED. The mean pre-COVID-19 BDI score (which indicates depression) of 1.79 ± 2.45 increased to a mean post-COVID-19 score of 2.42 ± 2.89 (p<0.01). Additionally, the mean pre-COVID-19 GAD-7 score of 4.79 ± 1.83 increased to a mean post-COVID-19 score of 6.79 ± 2.52, which indicates a statistically significant difference (p<0.01). We observed a negative correlation between the increase in BDI and GAD-7 scores and the decrease in IIEF scores (r=0.426, p<.001, r=0.568, p<.001, respectively). CONCLUSIONS: Our study highlights that COVID-19 can cause ED and that disease-induced anxiety and depression serve as primary contributors to ED.

Mental and Sexual Health of Men in Times of COVID-19 Lockdown.

Due to the worldwide spread of COVID-19, some restrictions were introduced which could lead to the development of distress and somatic symptoms. This survey aimed to study the mental and sexual health of men during the COVID-19 outbreak. An online questionnaire was conducted to collect data on contact with people suspected of infection/infected with the SARS-CoV-2 virus, use of stimulants, and perceived mental and sexual health during isolation among Polish men. They were also asked to answer the Beck Depression Inventory (BDI) and the International Index of Erectile Function (IIEF-15) questionnaire. In total, 606 men with a mean age of 28.46 ± 9.17 years took part in the survey. Fear of contracting the COVID-19 infection had a negative impact on the mental health of 132 men (21.8%). Fear of the health condition of loved ones caused stress and a depressed mood in 253 men (41.7%), and media reports worsened the mental health of 185 men (30.2%). In the BDI, 71.95% of the respondents did not suffer from depressive symptoms, 17.33% were diagnosed with mild depression, 6.11% with moderate depression, and 4.62% had severe depression. The mean score in the IIEF-15 questionnaire in the erectile function domain was 22.27, orgasm-7.63, desire-8.25, satisfaction-10.17, and general satisfaction-6.84. Depressive symptoms indicated more severe sexual functioning disorders (p < 0.001). Fear, following the media, and loneliness were associated with more severe depressive and sexual disorders (p < 0.001). The libido level (p = 0.002) and frequency of sexual activity (p < 0.001) were also lower during the pandemic than before the lockdown. These data showed that the COVID-19 pandemic had a significant impact on male mental and sexual health.

The prevalence and severity of mental health problems and sexual dysfunction in hemodialysis patients before and during the COVID-19 pandemic.

INTRODUCTION: This study aimed to investigate the prevalence and severity of mental health problems and sexual dysfunction in hemodialysis patients before and during the COVID-19 pandemic. METHODS: A total of 84 hemodialysis patients were evaluated in terms of Pittsburgh Sleep Quality Index, Beck Depression Inventory, International Index of Erectile Function (IIEF-5), and Female Sexual Function Index (FSFI). RESULTS: Poor sleep quality (79.8%) and poor mental health status (62.7%) and higher likelihood of having depression (31.0 vs. 61.9%, p < 0.001) were noted. The IIEF-5 (10.5 [5-25] vs. 7.5 [5-23], p < 0.001) and FSFI (12 [4-78] vs. 6 [4-66], p < 0.001) scores were significantly decreased during the pandemic with an increase in the likelihood of having erectile dysfunction (p < 0.001). CONCLUSION: Our findings indicate high prevalence of mental health issues, an impaired quality of life and an increase in prevalence and severity of suspected depression during pandemic in hemodialysis patients along with deterioration in erectile dysfunction among males.

COVID-19 vaccination does not affect male sexual functions.

BACKGROUND: COVID-19 infection has been linked with erectile dysfunction, which has also raised apprehensions about the impact of COVID-19 vaccination on male sexual functions. The purpose of this study was to investigate the impact of COVID-19 vaccination on male sexual functions, such as erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. METHODS: We used International Index of Erectile Function (IIEF) questionnaire for data collection. Mixed methods were adopted for this study, which consisted of Google online form distribution and the distribution of hard copies of the form to those who were not internet friendly. All data were entered in a spreadsheet and scores were assigned to each response according to the standard scores given in the IIEF questionnaire. Fifteen questions, one corresponding to each question in the IIEF questionnaire, were included to assess the impact of COVID-19 vaccination on each sexual function. RESULTS: In the first part of analysis, we calculated sexual function scores and men reporting low sexual function scores (~ 15%) were excluded, providing us with 465 individuals for further analysis. Regarding the impact of COVID-19 vaccination on male sexual functions, 71% individuals reported no impact, 3% reported a decline, 2.7% reported an improvement, and 23.3% could not assess the impact. We also performed analysis on the basis of age-groups of the participants and the duration after vaccination, finding that there was no impact irrespective of the age of subjects or the length of period after vaccination. CONCLUSIONS: COVID-19 vaccination does not affect male sexual functions, including erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction.

Relationship between COVID-19 and Male Sexual Dysfunction; A Prospective, Multicentric Study.

BACKGROUND: Sexual function is an excellent marker of psychological, systemic, and specifically vascular performance. Endothelial dysfunction is the main determinant of coronavirus disease 2019 (COVID-19) symptoms. Considering the adverse effects of the COVID-19 pandemic on psychological and sexual functions, we hypothesized potential differences and underlying factors if there is any erectile function and premature ejaculation status of male patients with COVID-19 by comparing both with the control group. METHODS: Hospitalized male patients diagnosed with COVID-19 pneumonia were evaluated. Male patients who applied to the Urology outpatient clinic were the control group. All participants completed the International Index of Erectile Function Form-15 (IIEF-15) and gave information regarding their premature ejaculation (PE) status if present. COVID-19 patients were called by phone to fill in the IIEF-15. Their PE status was questioned on the 45th and 90th days after discharge. The following parameters were in the data records: Age, comorbidity, length of hospital stay, treatment, oxygen saturation, pulmonary involvement, white blood cell (WBC), C-reactive protein (CRP), ferritin, fibrinogen, D-dimer, and sedimentation values. RESULTS: The study had 253 participants, including 168 COVID-19 patients and 85 volunteers as the control group. The number of PE cases was less, whereas erectile dysfunction (ED) cases were more in the COVID-19 patient group in comparison to the control group in the pre-pandemic period (p = 0.00) (p = 0.00). In the post-pandemic period, PE developed in 13 more COVID-19 patients on the 45th and 90th days (p = 0.00). The IIEF-15 scores of COVID-19 patients decreased by 4-point in the short term and by 3-point in the long term (p = 0.002). Age and sedimentation were responsible for the difference in PE status. On the other hand, comorbidity, length of hospital stay, treatment type, WBC, D-dimer, ferritin, CRP levels, and pulmonary infiltration were responsible for the difference in ED. CONCLUSIONS: Based on our findings, we can say that we have enough evidence to suspect COVID-19 sequelae can affect male sexual health. After the pandemic, male patients with andrological problems should have enough time to feel more comfortable and their organic and psychogenic conditions should be optimized.

The Impact of COVID-19 Vaccination on the Sexual Health of Males (preprint)

The COVID-19 pandemic negatively affected the mental and sexual health of individuals, especially healthcare professionals. In this study, we aimed to investigate the changes in anxiety and sexual activity of male healthcare professionals following vaccination. This prospective cross-sectional and descriptive online survey study was conducted between July 1, 2021 and November 1, 2021, involving a total of 170 healthcare professionals. Socio-demographic characteristics, pre- and post-vaccination anxiety and sexual activity levels of the participants were compared. There was a significant increase in only intercourse times of the participants before and after vaccination (p=0.034). The Beck anxiety scale score decreased from (median: 19, min: 16, max: 47) before vaccination to (median: 17, min: 10, max: 43) after vaccination (p<0.001). Likewise, Arizona Sexual Experiences Scale scores decreased after vaccination (median: 10, min: 5, max: 20) compared to before vaccination (median: 12, min: 5, max: 18) (p<0.001). International Index of Erectile functon(IIEF) score also increased after vaccination (25.49±6.50) compared to before vaccination (24.71±7.10) (p<0.001). Orgasmic Function, Sexual Desire, Intercourse Satisfaction, Overall Satisfaction scores also improved (p=0.013, p<0.001, p=0.027, p<0.001). Mental and Sexual disorders increased with the COVID-19 pandemic. In addition to immunity, the vaccine also has positive effects on anxiety and sexual activity.

Isolation, bioassay and 3D-QSAR analysis of 8-isopentenyl flavonoids from Epimedium sagittatum Maxim. as PDE5A inhibitors (preprint)

Background: As known, inhibition of phosphodiesterase 5 (PDE5) has the therapeutic effect on male erectile dysfunction (ED), and the processed folium of Epimedium sagittatum Maxim. (PFES) characterized by 8-isopentenyl flavonoids is a famous herb for treating ED. However, the main flavonoids inhibitory activities, structure-activity relationship (SAR) and signaling pathway have been not systematically studied so that its pharmacodynamic mechanism is unclear.  Methods: We aimed to initially reveal the PFES efficacy mechanism for treating ED. For the first time, 6 main 8-isopentenyl flavonoids (1-6) from PFES were isolated and identified. Then based on HPLC detection, we proposed a novel method with superior applicability compared to traditional radioisotope assay to screen inhibitors among them. We further established three-dimensional quantitative structure-activity relationship (3D-QSAR) models through CoMFA and CoMSIA to analyze the SAR for those inhibitors.  Results: The results were verified by cellular effects of the screened flavonoids. Among 6 compounds, Icariin (1), 2-O"-rhamnosylicaridide II (2) and Baohuoside I (3) were identified with significant activities (IC50 = 8.275, 3.233, 5.473 mM). Then 3D-QSAR studies showed that the replacement of C8 with bulky steric groups as isopentenyl, C3 with positive charge groups and C4' with a hydrogen bond acceptor substituent could increase inhibitory effects. In contrast, the substitution of C7 with bulky steric groups or hydrophilic groups tended to decrease the efficacies. And compounds1, 2, 3 could increase cGMP level and decrease cytoplasmic Ca2+ of rat corpus cavernosum smooth muscle cells (CCSMCs)by activating PKG.  Conclusion: 8-isopentenyl flavonoids could be the main pharmacodynamic substances of PFES in the treatment for ED, and some had significant PDE5A1 inhibitory activities so as to activate cGMP/PKG/Ca2+ signaling pathway in CCSMCs, that was related to the substituents at the key sites such as C8, C3, C4' and C7 in the characteristic compounds.

Erectile dysfunction after COVID-19 recovery: A follow-up study.

OBJECTIVES: Several studies confirm multiple complications after COVID-19 infection, including men's sexual health, which is caused by both physical and psychological factors. However, studies focusing on long-term effects among recovered patients are still lacking. Therefore, we aimed to investigate the erectile function at three months after COVID-19 recovery along with its predicting factors. METHODS: We enrolled all COVID-19 male patients, who were hospitalized from May to July 2021, and declared to be sexually active within the previous two weeks. Demographic data, mental health status, and erectile function were collected at baseline and prospectively recollected three months after hospital discharge. To determine changes between baseline and the follow-up, a generalized linear mixed effect model (GLMM) was used. Also, logistic regression analysis was used to identify the associating factors of erectile dysfunction (ED) at three months. RESULTS: One hundred fifty-three men with COVID-19 participated. Using GLMM, ED prevalence at three months after recovery was 50.3%, which was significantly lower compared with ED prevalence at baseline (64.7%, P = 0.002). Declination of prevalence of major depression and anxiety disorder was found, but only major depression reached statistical significance (major depression 13.7% vs. 1.4%, P < 0.001, anxiety disorder 5.2% vs. 2.8% P = 0.22). Logistic regression, adjusted for BMI, medical comorbidities, and self-reported normal morning erection, showed a significant association between ED at three months and age above 40 years and diagnosis of major depression with adjusted OR of 2.65, 95% CI 1.17-6.01, P = 0.02 and 8.93, 95% CI 2.28-34.9, P = 0.002, respectively. CONCLUSION: Our study showed a high ED prevalence during the third month of recovery from COVID-19. The predicting factors of persistent ED were age over 40 years and diagnosis of major depression during acute infection.

Trend and co-occurrence network study of symptoms through social media: an example of COVID-19 (preprint)

ImportanceCOVID-19 is a multi-organ disease with broad-spectrum manifestations. Clinical data-driven research can be difficult because many patients do not receive prompt diagnoses, treatment, and follow-up studies. Social medias accessibility, promptness, and rich information provide an opportunity for large-scale and long-term analyses, enabling a comprehensive symptom investigation to complement clinical studies. ObjectivePresent an efficient workflow to identify and study the characteristics and co-occurrences of COVID-19 symptoms using social media. Design, Setting, and ParticipantsThis retrospective cohort study analyzed 471,553,966 COVID-19-related tweets from February 1, 2020, to April 30, 2022. A comprehensive lexicon of symptoms was used to filter tweets through rule-based methods. 948,478 tweets with self-reported symptoms from 689,551 Twitter users were identified for analysis. Main Outcomes and MeasuresThe overall trends of COVID-19 symptoms reported on Twitter were analyzed (separately by the Delta strain and the Omicron strain) using weekly new numbers, overall frequency, and temporal distribution of reported symptoms. A co-occurrence network was developed to investigate relationships between symptoms and affected organ systems. ResultsThe weekly quantity of self-reported symptoms has a high consistency (0.8528, P<0.0001) and one-week leading trend (0. 8802, P<0.0001) with new infections in four countries. We grouped 201 common symptoms (mentioned [≥] 10 times) into 10 affected systems. The frequency of symptoms showed dynamic changes as the pandemic progressed, from typical respiratory symptoms in the early stage to more musculoskeletal and nervous symptoms at later stages. When comparing symptoms reported during the Delta strain versus the Omicron variant, significant changes were observed, with dropped odd ratios of coma (95%CI 0.55-0.49, P<0.01) and anosmia (95%CI, 0.6-0.56), and more pain in the throat (95%CI, 1.86-1.96) and concentration problems (95%CI, 1.58-1.70). The co-occurrence network characterizes relationships among symptoms and affected systems, both intra-systemic, such as cough and sneezing (respiratory), and inter-systemic, such as alopecia (integumentary) and impotence (reproductive). Conclusions and RelevanceWe found dynamic COVID-19 symptom evolution through self-reporting on social media and identified 201 symptoms from 10 affected systems. This demonstrates that social medias prevalence trends and co-occurrence networks can efficiently identify and study public health problems, such as common symptoms during pandemics. Key pointsO_ST_ABSQuestionsC_ST_ABSWhat are the epidemic characteristics and relationships of COVID-19 symptoms that have been extensively reported on social media? FindingsThis retrospective cohort study of 948,478 related tweets (February 2020 to April 2022) from 689,551 users identified 201 self-reported COVID-19 symptoms from 10 affected systems, mitigating the potential missing information in hospital-based epidemiologic studies due to many patients not being timely diagnosed and treated. Coma, anosmia, taste sense altered, and dyspnea were less common in participants infected during Omicron prevalence than in Delta. Symptoms that affect the same system have high co-occurrence. Frequent co-occurrences occurred between symptoms and systems corresponding to specific disease progressions, such as palpitations and dyspnea, alopecia and impotence. MeaningTrend and network analysis in social media can mine dynamic epidemic characteristics and relationships between symptoms in emergent pandemics.

COVID-19 vaccination not associated with increased risk of erectile dysfunction.

Although mRNA COVID-19 vaccines have proven to be safe and effective against SARS-CoV-2, vaccination rates have slowed, with some individuals citing impotence as a concern. Therefore, we conducted a survey of the US males to evaluate the impact of COVID-19 vaccination on erectile function. We hypothesized that vaccinated men would not have a higher risk of ED compared to unvaccinated men. Amazon Mechanical Turk (MTurk) was utilized to survey the US adult male population between August 26 and September 2, 2021. Survey participation was open to 1000 males over the age of 18 and currently living in the United States regardless of vaccination status or the past medical history of COVID-19. Selection criteria included respondents ≥45 years old, no history of physician-diagnosed ED, biologically born, and identify as male. Participants completed an anonymous 16-question survey that included a multidimensional scale used to evaluate ED, the International Index of Erectile Function (IIEF-5). Among vaccinated men, the median IIEF-5 score was 20 [16-24] compared to 22 [17.5-25] in the unvaccinated group (p = 0.195). The multivariable-adjusted analysis demonstrated that vaccination against COVID-19 was not associated with increased risk of ED. Overall, this cross-sectional survey showed that COVID-19 vaccination was not associated with an increased risk of erectile dysfunction in males 45 years and older.

Sexual dysfunction among men with diabetes; a cross-sectional study at a specialised diabetes clinic in Sri Lanka.

BACKGROUND: Male sexual dysfunction in diabetes is often an unrevealed clinical issue. Though many publications report the prevalence, there is limited data on its associations, impact, and health-seeking behaviour. The objectives were to assess the prevalence of male sexual dysfunction, its associations, impact and treatment-seeking among men with diabetes in a selected tertiary care Diabetes Clinic. METHODS: A cross-sectional study was conducted at the Diabetes Clinic, National Hospital of Sri Lanka, from January to September 2020. Men with diabetes aged 18 to 70 years undergoing annual assessment were recruited consecutively. Socio-demographic and clinical information were collected using an interviewer-administered questionnaire. Erectile dysfunction (ED), premature ejaculation, mental health and quality of life were assessed using validated self-administered questionnaires. Cardiovascular autonomic reflex tests and total testosterone levels were performed. Penile colour Doppler ultrasonography was performed on consenting participants with erectile dysfunction. Associations were assessed using the chi-square test or Fisher's exact for dichotomous variables and independent sample t-test for continuous variables. RESULTS: Two hundred and twelve participants were recruited with a mean age of 54.1 (SD = 10.1) years. Erectile dysfunction was present in 168 (79.2%), (mild: 45, mild-moderate: 56, moderate: 26, severe: 41). Premature ejaculation was present in 26 (18.7%). Libido was low among 16%. Sexual dysfunction was not revealed to a health provider by 85.6% despite 60.5% experiencing psychological and/or relationship effects. Out of 18 who sought treatment, only 4 achieved a good response. Mean age (55.4 ± 9.5 vs 48.7 ± 10.6 years, p < 0.001) and duration of diabetes (10.9 ± 7.6 vs 5.8 ± 4.6 years, p < 0.001) were higher while eGFR was lower (73.9 ± 27.7 vs 100.51 ± 28.08 years, p < 0.008) among those with ED compared to those without. Diabetic retinopathy (4% vs 42%, p < 0.001), peripheral neuropathy (17.9% vs 38.4%, p = 0.041) and lower limb arterial disease (0% vs 12.2%, p = 0.04) were associated with ED. Arterial insufficiency was seen among 50% of the participants who underwent penile colour Doppler ultrasonography. CONCLUSIONS: Male sexual dysfunction is a pervasive yet underappreciated problem in diabetes care despite its effect on the individual. Patient and disease characteristics would guide the identification of high-risk individuals for targeted screening in clinical practice.

Linear Low-Intensity Extracorporeal Shockwave Therapy as a Method for Penile Rehabilitation in Erectile Dysfunction Patients after Radical Prostatectomy: A Randomized, Single-Blinded, Sham-Controlled Clinical Trial.

INTRODUCTION: The objective of this study was to investigate the effect and feasibility of linear low-intensity extracorporeal shockwave therapy (LI-LiESWT) as a penile rehabilitation method for erectile dysfunction (ED) after bilateral nerve-sparing (NS) radical prostatectomy (RP). METHODS: Patients who had undergone bilateral NS RP (either radical retropubic prostatectomy or robot-assisted laparoscopic RP), 3 or more months prior to the study, and who had no ED preoperatively and were suffering from mild to severe postoperative ED were included in the study. Four treatments were given over a 4-week period, using the PiezoWave2 device with a linear shockwave applicator and the linear shockwave tissue coverage (LSTC-ED®) technique. If the improvement in erectile function was still considered insufficient (less than an IIEF-5 score of 22-25) at 2 months after the start of LI-LiESWT, penile rehabilitation was supplemented by pharmacological penile rehabilitation. The final effect of treatment was evaluated after 12 months. The main outcome measure was changes in the five-item International Index of Erectile Function (IIEF-5) score. RESULTS: Between September 2019 and September 2020, a total of 40 patients were included in the study and randomly divided into 2 groups: treatment group and sham group. Eight patients were excluded from the study and were not evaluated due to other conditions which required additional treatment (COVID-19 disease, postoperative incontinence, urethral stricture, and ischemic stroke). Thirty-two patients were included in the final analysis: 16 in the control group and 16 in the intervention group. At 6 months from the end of treatment, patients in both the treatment and the sham group achieved physiological IIEF-5 values, and the beneficial effect persisted for 12 months after the end of treatment. CONCLUSIONS: LI-LiESWT using the LSTC-ED® technique is a suitable and safe method for penile rehabilitation in patients with ED after bilateral NS RP, not only because of the vasculogenic effect of LI-LiESWT but also because of its neuroprotective and/or regenerative effects.