LiSWT for postpartum pelvic pain: What evidence is still needed

Advancing low-intensity extracorporeal shock wave therapy from a promising case report to a guideline-supported intervention in postpartum care will require randomized controlled trial data with adequate sample sizes, long-term follow-up, and dedicated evidence in lactating patients, according to Sarina Hanfling, research coordinator for Rachel Rubin MD PLLC and a medical student at the University of Maryland School of Medicine.

Having previously addressed the clinical profile of the reported case and the question of patient selection and treatment timing, Hanfling turned to what the evidence base currently supports and what it will take to move the field forward.

Counseling patients on realistic expectations is a foundational starting point.

"Shock wave is not going to bring you from one hundred percent pain to 0% pain," Hanfling said. She noted that the literature in male chronic pelvic pain—the most developed evidence base for this modality—typically demonstrates 30% to 50% reductions in pain rather than complete resolution. For postpartum patients, functional improvement rather than cure should frame the treatment conversation. The patient in the reported case was an active athlete whose chronic pain had limited her ability to swim, bike, and run—and although her symptoms did not fully resolve, the treatment produced meaningful improvement in daily function, physical activity, and sexual health for the first time in over 2 decades.

Sexual function warrants explicit discussion in this population. Hanfling emphasized that episiotomy scar pain is one of multiple contributors to postpartum sexual dysfunction, and that LiSWT's effects on sexual function have been variable in existing studies.

"It's a multifaceted issue in a lot of these patients," she said, and that complexity should be acknowledged in counseling alongside the evidence gaps specific to postpartum populations.

On the research agenda, Hanfling identified several unanswered questions that will need to be addressed before LiSWT can move into formal postpartum care guidelines. Timing of intervention is among the most important unknowns—the reported patient was postmenopausal and had been symptomatic for more than 25 years, making it impossible to draw conclusions about early vs late postpartum use. Optimal session number, energy levels, and treatment intervals also remain undefined for this population. Robust safety data in lactating patients are a specific priority, given that breastfeeding populations are often excluded from device studies and that confirmation of safety in this group will be essential for clinical adoption.

Hanfling also identified a cost-effectiveness analysis as a practical next step. Understanding how LiSWT compares economically to current standard treatments—including pelvic floor physical therapy, pharmacologic management, and procedural interventions—would help clinicians and health systems evaluate its place in the care continuum.

"We certainly need good sample sizes and good long-term follow-up before we include it in any formal guidelines," she said. "But I'm definitely excited to see more research in shock wave in female patients and in postpartum patients in the future."

Reference:

1. Hanfling S, Macrae K; Twyford A; Wardrop F; Rubin R. Adjuvant low intensity shockwave therapy for the treatment of postpartum injury and dyspareunia. Presented at: International Society for the Study of Women’s Sexual Health Annual Meeting 2026. February 12-15, 2026. Long Beach, California. Abstract 055