© 2017 Author(s). In shock wave lithotripsy (SWL), acoustic pulses with a leading compression wave followed by a tensile wave are delivered into the patient's body using a water-filled coupling cushion. Cavitation-related acoustic energy loss in the coupling unit depends critically on water conditions, e.g. dissolved gas concentration and exchange flow rate. We have systematically investigated the attenuation mechanism in the coupling water via pressure measurements and cavitation characterization. In non-degassed water the bubble cluster became progressively dense (i.e., proliferated because of gas diffusion into bubbles and splitting of bubbles into many daughter bubbles) in shock waves delivered at 1 Hz leading to reduction in the tensile wave duration from a nominal value of 4.6 to 1.8 μs. To reduce cavitation in the coupling water along the beam path, we have used a continuous jet flow to remove residual daughter bubbles between consecutive shocks. As a result, stone fragmentation efficiency was increased from 16±4% to 30±5% (p = 0.002) after 250 shocks. Such a hydrodynamic approach for tensile wave attenuation in the coupling water may be used to provide a flexible means for a novel treatment strategy with tissue protection.