Electrical Stimulation for Erectile dysfunction – Can Small Pulses Solve a Big Problem

When electricity meets medicine

Erectile dysfunction affects nearly half of all men between the ages of 40 and 70. That is millions of men worldwide. For most of them, the first line of treatment is a pill. PDE5 inhibitors like sildenafil, tadalafil, and vardenafil work well for about 70 percent of men who try them.

But what about the other 30 percent? And what about men who cannot take these pills because of side effects or other medical conditions?

This is why researchers keep looking for alternatives. One of the more unusual ideas to emerge in recent years is peripheral electrical stimulation or PES. The concept is simple. Small electrical pulses applied to nerves or muscles might improve blood flow and nerve function in the pelvis, leading to better erections.

It sounds like science fiction. But electrical stimulation has been used in medicine for decades. Physical therapists use it to treat muscle weakness. Pain specialists use it to block pain signals. Could the same technology work for erectile dysfunction?

A new systematic review and meta-analysis published in the journal Sexual Medicine Reviews tried to answer this question. The researchers gathered all available evidence on PES for ED, from the first studies in 1998 up to April 2024. They found 13 studies involving a variety of electrical stimulation techniques.

The results are not what you might expect. Unlike the promising data we have for shockwave therapy, the evidence for electrical stimulation is weak. Very weak.

Let me explain what the science actually says, so you can make an informed decision.

Here are the main reasons why a man might look beyond the pill to a treatment like PES.

• He has tried PDE5 inhibitors and they did not work for him. The pills either had no effect or stopped working over time.
• He experiences unpleasant side effects from medication, such as severe headaches, flushing, or indigestion that does not go away.
• He has a medical condition that makes PDE5 inhibitors unsafe, such as taking nitrate medications for heart disease.
• He simply wants a non drug option. He does not want to take a pill every time he wants to be intimate with his partner.

For these men, any safe alternative is worth exploring. But we have to be honest about what the evidence actually supports.

How does electrical stimulation work? The theory

Before we look at the data, let me explain why anyone thought electrical stimulation might help with erections in the first place. The theory is actually quite logical.

An erection requires three things to work together. Healthy blood vessels that can open wide enough to let blood flow in. Healthy nerves that can send the right signals from the brain to the penis. And healthy muscles in the pelvic floor that can support the whole process.

Electrical stimulation targets all three of these systems. Here are the proposed mechanisms.

• Increased blood flow. Electrical pulses cause blood vessels to dilate, or open wider. More blood flow to the penis means stronger and more reliable erections.
• Nerve stimulation. The pudendal nerve and cavernous nerves are directly involved in creating an erection. Electrical stimulation may wake up these nerves, especially in men who have nerve damage from surgery or diabetes.
• Pelvic floor muscle strengthening. The ischiocavernosus and bulbocavernosus muscles help trap blood in the penis once an erection occurs. Electrical stimulation can make these muscles stronger, similar to how a TENS unit can strengthen other muscles in the body.

The review authors note that PES aims to improve penile hemodynamics and neuromuscular function. In plain English, it tries to fix both the plumbing and the wiring. It is a clever idea. But clever ideas do not always work in practice. That is why we need clinical trials.

Four types of peripheral electrical stimulation

Not all electrical stimulation is the same. The review identifies four different techniques that have been tested for ED. Each one works a little differently.

The first is transcutaneous electrical nerve stimulation (TENS). This is the most common form. Small electrodes are placed on the skin, usually on the lower back, the abdomen, or the penis itself. The patient feels a tingling sensation. TENS is completely non invasive and can even be done at home with a portable device.

The second is PENS, or percutaneous electrical nerve stimulation. Instead of surface electrodes, PENS uses thin needles inserted through the skin. The needles are placed near specific nerves. This is similar to acupuncture but with the addition of electrical current. PENS is more invasive than TENS and requires a trained provider.

The third is FES, or functional electrical stimulation. This technique is designed to activate muscles directly. In the context of ED, FES targets the pelvic floor muscles. The goal is to strengthen these muscles so they can better support erectile function.

The fourth is transanal pelvic plexus stimulation (TPPS). This involves placing an electrode inside the rectum. The electrode sits close to the pelvic nerve plexus, which controls erectile function. This is the most invasive of the four techniques and the least comfortable for patients.

Here is a table comparing these four approaches.

As you can see, TENS is the simplest and most accessible option. It is also the most studied. The other techniques are more experimental and have much less evidence behind them.

What does the science say? Study methods and quality

Now we get to the most important question. How good is the evidence? The review authors searched five major medical databases: PubMed, Embase, Scopus, Web of Science, and Google Scholar. They looked for any study that tested any form of PES for ED in adult men.

They found 13 studies published between 1998 and 2024. Of these, 6 were randomized controlled trials, or RCTs. RCTs are the gold standard in medical research because they randomly assign patients to treatment or control groups, reducing bias. The other 7 were quasi experimental studies, which are less rigorous because they lack randomization.

All together, these 13 studies included several hundred patients. The main measurement tool was the International Index of Erectile Function, or IIEF, a standardized questionnaire that men complete to rate their erectile function.

Here is the problem. When the researchers assessed the quality of these studies using the Joanna Briggs Institute checklists, the results were not good. Most studies were rated as low to moderate quality. The certainty of the evidence, meaning how confident we can be in the findings, was rated as weak.

Here are the main limitations of the current evidence.

• Small sample sizes. Many studies included only 20 to 40 patients. Small studies are more likely to show false positive results.
• No standardization. The studies used different types of electrical stimulation, different electrode placements, different frequencies, different durations, and different treatment schedules. It is impossible to know which protocol works best.
• Lack of blinding. In many studies, patients knew they were receiving active treatment. This can create a placebo effect, where patients report improvement simply because they expect to improve.
• Short follow up. Most studies only followed patients for a few weeks or months. We have no idea if any benefits last.

The review authors state this clearly. The current evidence on PES for ED is limited and of low quality. They explicitly say that the evidence is too weak to support routine administration of PES in clinical practice.

That is a strong statement from a scientific journal. It means that as of today, no responsible doctor should be recommending peripheral electrical stimulation as a standard treatment for erectile dysfunction.

Results: Does PES actually work?

After establishing the poor quality of the available studies, the researchers still performed a meta-analysis to see if any signal of effectiveness emerged. They combined the numerical results from multiple studies to get a more precise estimate.

They performed two main analyses. The first analysis looked at before and after results within the same group of patients. In other words, they measured IIEF scores before PES treatment and again after treatment, then calculated the difference.

The result was a mean improvement of 3.09 points on the IIEF scale. However, the confidence interval ranged from a decrease of 2.19 points to an increase of 8.38 points. Because this interval crossed zero, the result was not statistically significant. In plain English, we cannot be sure that the improvement was real and not just due to chance or natural variation.

The second analysis compared patients who received PES to patients in a control group. Control groups received either sham treatment, meaning fake electrical stimulation, or no treatment at all.

This analysis showed a mean difference of 6.27 points in favor of the PES group. The confidence interval ranged from 4.30 to 8.27, which did not cross zero. This result was statistically significant. On average, men who received PES improved more than men who did not.

Here is what these numbers mean for a patient considering PES.

• The before and after analysis showed improvement that could have been due to chance. We cannot trust this result.
• The comparison with control groups showed a significant difference, suggesting PES may have a real effect.
• However, both analyses had very high heterogeneity. Heterogeneity is a statistical measure of how much the results vary from study to study. An I squared value above 50 percent means high heterogeneity. This analysis had I squared values of 99 percent and 79 percent.
• High heterogeneity means the studies were too different from each other to combine their results reliably. Different types of PES, different treatment schedules, different patient populations. The average result may not apply to any specific patient.
• Even the positive result, 6.27 points of improvement, must be interpreted with caution because of the low quality of the included studies.

The bottom line is that the data is too messy to draw firm conclusions. PES looks promising in some studies but not in others. The overall picture is unclear.

Why is the evidence weak? Quality concerns

Let me go deeper into the quality issues because this is critical for patients to understand. When a treatment has weak evidence, it means we cannot be sure if it works, how well it works, or for whom it works best.

The researchers used the Joanna Briggs Institute checklists to assess study quality. These checklists evaluate things like randomization, blinding, follow up completeness, and outcome measurement.

Most of the 13 studies scored poorly. Here are the specific problems.

• Many studies did not use sham controls. A sham control is a fake treatment that looks and feels like the real one but delivers no electrical current. Without sham controls, patients know they are getting active treatment. This creates expectation bias. Patients who believe in the treatment are more likely to report improvement, regardless of whether any real physiological change occurred.
• Randomization was often inadequate. Some studies did not randomly assign patients at all. Others used simple randomization without concealment, meaning the person assigning patients knew which group they were going to. This can introduce selection bias.
• Sample sizes were too small. Several studies had fewer than 30 patients total. Small studies are statistically underpowered, meaning they cannot reliably detect moderate effects. They also have a higher risk of false positive findings.
• Follow up periods were short. Most studies measured outcomes immediately after treatment or within a few weeks. We have almost no data on whether any benefits of PES last for six months or a year. For a condition like ED, durability of effect is extremely important.
• There was no standardization of treatment protocols. One study used TENS on the lower back for 20 minutes twice a week. Another used PENS on the penis for 30 minutes daily. A third used TPPS for one hour weekly. With so much variation, it is impossible to know what works.

The review authors concluded that the certainty of the evidence was weak. That is the lowest rating on the GRADE scale, which is used to evaluate medical evidence. Weak certainty means future research is very likely to change our understanding of the treatment’s effectiveness.

Here is the honest takeaway. Based on current evidence, doctor should not be recommending PES as a routine treatment for erectile dysfunction. It remains an experimental approach that should only be offered in the context of clinical research.

Comparison with other non-drug treatments

To put PES in perspective, let me compare it briefly to other non-drug treatments for ED that have been studied more thoroughly.

The first is low intensity extracorporeal shockwave therapy, or LIESWT. As I discussed in a previous article, LIESWT has been tested in 32 randomized controlled trials involving nearly 2,000 men. The evidence shows clear, significant improvement in erectile function that lasts up to one year. The quality of the evidence is moderate to high. LIESWT is now offered in many urology clinics around the world.

The second is pelvic floor physical therapy. This involves exercises to strengthen the muscles that support erectile function. Several studies have shown that pelvic floor exercises can improve ED, especially in men with venous leak or after prostate surgery. The evidence is decent, though not as strong as for shockwave therapy.

The third is lifestyle modification. Diet, exercise, weight loss, and smoking cessation all improve erectile function. These interventions have strong evidence from large studies, but they require significant effort and discipline from the patient.

Where does PES fit in? Currently, it does not. The evidence for PES is far weaker than for shockwave therapy or pelvic floor exercises.

Here are the situations where PES might theoretically have a role if better evidence emerges in the future.

• As a home based treatment for men who cannot easily come to a clinic for shockwave therapy. A TENS unit is small, portable, and relatively inexpensive.
• As an adjunct to pelvic floor exercises. Adding electrical stimulation might help men who have difficulty activating the correct muscles on their own.
• For men with neurogenic ED, such as after spinal cord injury or prostate surgery. These men have damaged nerves that might respond to electrical stimulation.
• For men who have failed all other treatments and want to try something experimental before considering more invasive options like penile implants.

But again, these are theoretical possibilities. They are not supported by current evidence.

Who should consider PES? Patient selection

Given the weak evidence, there are very few men who should consider PES for ED at this time. However, for completeness, let me discuss how a doctor might approach this if a patient insisted on trying it.

First, a thorough evaluation is essential. Before considering any treatment, a man with ED should have blood work to check testosterone, blood sugar, and cholesterol. He should have a cardiovascular risk assessment. He should discuss his medications and medical history with his doctor. Many cases of ED are caused by undiagnosed diabetes, low testosterone, or heart disease. Treating the underlying cause is more important than any electrical device.

If the evaluation is complete and the patient still wants to try PES, here are the factors to consider.

• Previous treatments. Has the patient already tried and failed PDE5 inhibitors? Has he tried lifestyle changes? Has he considered shockwave therapy? PES should be a last resort, not a first choice.
• Type of ED. PES might be more promising for neurogenic ED, where there is nerve damage to repair. For vasculogenic ED, shockwave therapy has much better evidence.
• Patient preferences. Some patients are attracted to the idea of a home based treatment they can control themselves. Others are uncomfortable with the idea of electrical stimulation near sensitive areas.
• Cost and availability. PES devices are not typically covered by insurance for ED. The patient would likely pay out of pocket. He should also consider whether a qualified provider is available to guide the treatment.

There are also important contraindications and precautions.

• Men with implanted electronic devices such as pacemakers or defibrillators should never use electrical stimulation without explicit approval from their cardiologist. The electrical current can interfere with these devices.
• Men with epilepsy or seizure disorders should avoid electrical stimulation. The pulses can trigger seizures in susceptible individuals.
• Men with active infection or open wounds in the treatment area should not use PES until the area heals.
• Men with bleeding disorders or those taking blood thinners should be cautious. Needle based techniques like PENS carry a risk of bleeding.

At APUMN (Adult & Pediatric Urology Medical), our approach to non-drug treatments is based on evidence first. We offer shockwave therapy because the data supports it. We recommend pelvic floor exercises because the data supports them. We do not currently offer PES for ED because the data is too weak. If a patient asks about it, we explain the evidence honestly and help them weigh the risks and benefits.

Summary and key takeaways for patients

Let me end with a clear, honest summary of what we know about peripheral electrical stimulation for erectile dysfunction. The idea is interesting. Using small electrical pulses to improve blood flow and nerve function in the pelvis makes sense in theory. Electrical stimulation has helped patients with other medical conditions like chronic pain and muscle weakness.

But the evidence for ED is not there yet. The 13 studies that exist are mostly small and poorly designed. The quality of the evidence is low to moderate at best. The certainty is weak, meaning future research is likely to change our understanding.

The meta-analysis showed mixed results. Before and after comparisons were not statistically significant. Comparisons with control groups showed a significant difference, but the studies were too different from each other to combine reliably.

Here are the key points to remember.

• Do not spend money on PES for ED without talking to a doctor first. The evidence is too weak to recommend it as a routine treatment.
• Standard treatments like PDE5 inhibitors, lifestyle changes, and shockwave therapy have much stronger evidence. Try those first.
• If you are still curious about PES, ask your doctor about clinical trials. Experimental treatments should be received in the context of research, not as paid commercial services.
• Be wary of clinics or online sellers offering electrical stimulation devices for ED with bold claims. If the evidence is weak, the claims are likely exaggerated.
• The most important step is a proper medical evaluation. Many men with ED have underlying health problems that need treatment regardless of which ED therapy they choose.

PES may eventually prove to be a useful tool for some men with ED. But that day has not arrived yet. The science is not there. For now, stick with what works.

Medical Disclaimer

The information provided in this article is for educational purposes only and does not substitute professional medical advice. Always consult a licensed healthcare provider for diagnosis and treatment recommendations specific to your situation.

Author

John K. Matsuura, M.D.