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

<b>Background/Objectives:</b> 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. <b>Methods:</b> 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). <b>Results:</b> 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. <b>Conclusions:</b> 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.