Efficacy of Low-Intensity Extracorporeal Shock Wave Therapy for the Treatment of Chronic Pelvic Pain Syndrome IIIb: A Prospective-Randomized, Double-Blind, Placebo-Controlled Study

Treatment of prostatitis with low-intensity extracorporeal shockwave therapy (LI-ESWT)

BACKGROUND

Prostatitis is known as the inflammation of the prostate. The treatments of prostatitis are either pharmacological or non-pharmacological treatment. However, some of the treatments are not effective and very invasive which can lead to side effects. Thus, low-intensity extracorporeal shockwave therapy (LI-ESWT) is used as an alternative treatment for prostatitis due to its convenient and non-invasive procedure. However, a definite protocol for this treatment is not available due to the variability of the treatment protocols and the lack of research comparing the efficacy of these protocols.

OBJECTIVE

To review and compare the efficacy of different LI-ESWT protocols in treating prostatitis.

METHODS

The study was performed by comparing the intensity, duration, frequency and combination with different types of pharmacotherapy drugs of the different LI-ESWT protocols from various studies. The finding from various studies which consist of disease improvement and quality of life (QoL) were also presented in this review.

RESULT

From the findings, the protocol can be categorized into three different intensities which are at 3000 pulses, < 3000 pulses and > 3000 pulses. Most studies reported that each protocol is very effective and safe to use and can improve CP symptoms, urinary symptoms, erectile function and QoL. It is also found that no complications or adverse effects occur to the patient.

CONCLUSION

Most of the LI-ESWT protocols described are safe and effective in treating CP through the absence of treatment-related adverse effects and maintenance of clinical effects.

Long-term efficacy and safety of extracorporeal shock wave therapy (Li-ESWT) protocols in the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients

AIM

This study aims to evaluate the long-term effectiveness of Li-ESWT in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients and to compare the effect of treatment protocol differences on success.

METHOD

Between December 2019 and January 2021, the data of male patients over the age of 18 who applied to the urology outpatient clinic with CP/CPPS symptoms were retrospectively analyzed. International Prostate Symptom Index (IPSS) and International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaires were filled in for the evaluation of erectile function. All patients received treatment with the Medispect Bold Li-ESWT. The treatment responses of the patients who received a total of 6 sessions from one session per week and 12 sessions from two sessions per week were compared.

RESULTS

A total of 129 patients were included in the study. Significant improvements were observed in the NIH-CPSI, IPSS, and IIEF-EF scores at the third month follow-ups of the patients after EWST (p < 0.001 for each). Improvements in scores were also found to be significant in NIH-CPSI, IPSS, and IIEF-EF at the 12th month evaluation. When the patients were evaluated according to the number of Li-ESWT sessions they received, the IPSS score average of the patient group who received 12 sessions of Li-ESWT was found to be lower than the patients who received 6 sessions of Li-ESWT (5.67 ± 2, 30 vs 4.51 ± 2.21; p = 0.005). There was no significant difference in the IIEF-EF and IPSS scores in the 12th month evaluations of the patients, but the mean NIH-CPSI score was found to be higher in the group that received 12 sessions of Li-ESWT (p = 0.003).

CONCLUSION

Li-ESWT in the treatment of CP/CPPS patients shows positive improvements in urinary symptoms, erectile function, and quality of life in patients unresponsive to other medical treatments. The increase in the number of sessions does not seem to influence the symptoms of the patients.

The efficacy and safety of low-intensity extracorporeal shock wave treatment combined with or without medications in Chronic prostatitis/chronic pelvic pain syndrome: a systematic review and meta-analysis

BACKGROUND

We performed this systematic review and meta-analysis to investigate the efficacy and safety of Li-ESWT combined with or without medications for patients with Chronic prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS).

METHODS

A comprehensive search was conducted of PUBMED, Cochrane Library, and Web of Science databases from inception to February 2022 for randomized controlled trials (RCTs) assessing the efficacy and safety of Li-ESWT with or without the combination of medications compared with the control group. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Visual Analogue Scale/Score (VAS), International Index of Erectile Function (IIEF), and International prostate symptom score (IPSS) were used to assess the improvements of symptoms in CP/CPPS patients.

RESULTS

651 patients from 12 randomized controlled studies were included in this study. The total NIH-CPSI scores, pain domain scores, and quality of life (QOL) scores were significantly lower in the Li-ESWT group than those in the control group at the termination of treatment, and 1, 4, 12, and 24 weeks after treatment. And these scores were significantly reduced in the Li-ESWT group than in baselines. In the subgroup analysis, reductions of these scores lasted longer and were greater in Li-ESWT combined with medications than in Li-ESWT alone. In the Li-ESWT group, the VAS score; IIEF score; and IPSS score were significant improvements than those in control group at the termination of treatment, and 1, 4, and 12 weeks after treatment; 4, 12, and 24 weeks after treatment; and 1, 4, and 12 weeks after treatment, respectively.

CONCLUSIONS

Li-ESWT is a safe, non-invasive, and effective option for patients with CP/CPPS, whether combined with medications or not, should be recommended for widespread use in clinical practice.

Efficacy and Safety of Extracorporeal Shock Wave Therapy in the Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Acquired Premature Ejaculation Patients

INTRODUCTION

The aim of this study was to evaluate the efficacy and safety of extracorporeal shock wave therapy (ESWT) in patients with acquired premature ejaculation (APE) due to chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHOD

Patients with APE due to CP/CPPS between January 2020 and June 2022 were included in the study. Demographic data of the patients were recorded, and the degree of their symptoms was evaluated with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), premature ejaculation diagnostic tool (PEDT), and Premature Ejaculation Profile (PEP). The international prostate symptom index (IPSS) was also used for lower urinary tract symptoms (LUTS), and the international erectile function index-erectile function (IIEF-EF) was used to evaluate erectile functions. All patients received treatment with the Medispec Bold Li-ESWT device without using any anesthesia method (12 sessions). The changes in the symptom scores of the patients were evaluated before the treatment and at the 3rd month after the treatment.

RESULTS

A total of 42 patients were included in the study. The mean age of the patients was 43.75 ± 12.03 (20-55), and the mean BMI was 23.58 ± 7.61 (18.03-35.98) kg/m2. The patients' estimated mean intravaginal ejaculation latency time (IELT) before ESWT was 37.98 ± 21.87 s. After a total of 12 sessions of ESWT, the IIEF-EF, IPSS, NIH-CPSI, and PEP index scores of the patients showed significant improvements (p < 0.001 for each). The IELT mean increased to 74.81 ± 46.79 s (p < 0.001). Posttreatment IELT fold increase was determined as 3.25 ± 1.72 fold. A highly significant positive correlation (p = 0.032; r = 0.839) was found between the CPSI score difference and the posttreatment PEP index score.

CONCLUSION

Li-ESWT treatment is an effective and safe treatment with positive effects on both LUTS and premature ejaculation in patients with APE symptoms due to CP/CPPS. Patients who benefit from CP treatment also have longer IELT times.

Extracorporeal shock wave therapy in association with bromelain and escin for the management of patients affected by chronic prostatitis/chronic pelvic pain syndrome

Extracorporeal shock wave therapy (ESWT) has been purposed for the management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) with encouraging results. Phytotherapeutic compounds have been used in everyday clinical practice for patients with CP/CPSS due to their anti-inflammatory properties. The present study aimed to investigate the effects of ESWT in association with the use of bromelain and escin extracts in patients with CP/CPSS. For this purpose, 95 patients with a clinical diagnosis of CP/CPSS were enrolled in the study. The patients were randomly allocated to either the ESWT plus bromelain and escin group (group A; n=48) or the ESWT only group (group B; n=47). A total of five weekly ESWT treatment sessions were administered alone or in combination with bromelain and escin. Each session consisted of 3,000 focused shock waves. Doses of 160 and 500 mg/day bromelain and escin were administered respectively for 5 weeks. The changes in urinary symptoms, pain and quality of life were considered the main outcome measures and were assessed at baseline, and at 4, 12 and 24 weeks of follow-up. Urinary symptoms, pain and quality of life were evaluated using the international prostatic symptoms score (IPSS), visual analog scale (VAS) and the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI). After 4 weeks, the mean VAS score, mean IPSS and mean satisfaction rate score had significantly improved in patients receiving ESWT plus bromelain and escin. After 12 weeks, the mean IPSS and mean satisfaction rate score were stable in the ESWT plus bromelain and escin group, while the mean VAS score was significantly lower when compared with the baseline values in both groups. On the whole, the present study demonstrates that in patients affected by CP/CPPS, treatment with ESWT plus bromelain and escin leads to pain resolution, and both treatments improve the IPSS, VAS and NIH-CPSI results.

Clinical Review of Neuromusculoskeletal Complementary and Alternative Approaches for the Treatment of Chronic Pelvic Pain Syndrome

Chronic pelvic pain syndrome (CPPS) is a functional pain disorder characterized by ongoing pain in the apparent absence of clinically identifiable causes. The prevalence of functional pain disorders demonstrates the importance of adequate management of ongoing symptomatology, but due to the uncertain etiology and myriad patient presentation phenotypes, reliable treatment options are difficult to implement. New interventions involving non-pharmacological approaches to pain management have been investigated across a spectrum of clinical and pre-clinical studies. Given that conservative care such as exercise, counseling, and musculoskeletal therapy is widely recommended as first-line treatment for CPPS, an updated review of these and related methodologies are needed. Familiarizing physicians and the public with the newest evidence for complementary and alternative medicine (CAM) and other conservative care treatments will assist with the promotion of evidence-based practices in a safe and reliable manner. This review aimed to summarize the current evidence and proposed mechanisms for non-pharmacological treatment specific to CAM and management of chronic pelvic pain centered on neuromusculoskeletal focused intervention such as acupuncture, auriculotherapy, manipulation, manual therapy, myofascial release, and phototherapy. The discussion suggests that reported improvements in pelvic pain or related symptomatology may be attributed to changes in the peripheral inflammasome and somatic origins of peripheral sensitization. Robustness of the included clinical studies is discussed throughout the review, and attention is paid to delineating inclusion criteria of formally diagnosed CPPS compared to general pelvic or abdominal pain. Overall, this review consolidates the current state of evidence regarding the utilization of non-traditional interventions using CAM techniques for the management of chronic pelvic pain and recommends a future direction for the field.

Metabolomics Analysis Reveals the Differential Metabolites and Establishes the Therapeutic Effect Prediction Nomogram Among CP/CPPS Patients Who Respond or Do Not Respond to LiST

Objective

Low-intensity shockwave therapy (LiST) has been applied in the clinical treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), but few studies have focused on the prediction of its therapeutic effect before treatment.

Methods

Seventy-five CP/CPPS patients from our institute between July 2020 and May 2021 were enrolled and received 3 Hz, 0.25 mJ/mm² LiST once a week over the course of four weeks. The scores of the NIH-CPSI, IPSS questionnaire and demographic features before treatment were recorded. The plasma before LiST treatment was also collected, while liquid chromatography-tandem mass spectrometry was used to detect the metabolites. Least absolute shrinkage and selection operator (LASSO) regression analysis was employed to identify the prediction metabolites and generate the metabolism score. Receiver operating characteristic curves and calibration curves were drawn to assess the prediction accuracy of the nomogram.

Results

Twelve metabolites were identified at incomparable levels before and after LiST treatment. The metabolism score generated by LASSO analysis presented a perfect prediction value (AUC: 0.848, 95% CI: 0.719-0.940) in the training cohort and further increased to 0.892 (95% CI: 0.802-0.983) on the nomogram, which accompanied with the NIH-CPSI scores and age. Similar results of the metabolism score (AUC: 0.732, 95% CI: 0.516-0.889) and total nomogram (AUC: 0.968, 95% CI: 0.909-1.000) were obtained in the testing cohort. Further enrichment of the 12 metabolites indicated that the glycine and serine metabolism pathway was involved in the LiST treatment.

Conclusion

We used our system to accurately and quantitatively measure plasma metabolites and establish a predictive model to identify suitable patients for LiST treatment.

New Frontiers of Extracorporeal Shock Wave Medicine in Urology from Bench to Clinical Studies

A shock wave (SW), which carries energy and propagates through a medium, is a type of continuous transmitted sonic wave that can achieve rapid energy transformations. SWs have been applied for many fields of medical science in various treatment settings. In urology, high-energy extracorporeal SWs have been used to disintegrate urolithiasis for 30 years. However, at lower energy levels, SWs enhance the expression of vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), proliferating cell nuclear antigen (PCNA), chemoattractant factors, and the recruitment of progenitor cells, and inhibit inflammatory molecules. Low energy extracorporeal shock wave (LESW) therapy has been used in urology for treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, stress urinary incontinence, and erectile dysfunction through the mechanisms of anti-inflammation, neovascularization, and tissue regeneration. Additionally, LESW have been proven to temporarily increase tissue permeability and facilitate intravesical botulinum toxin delivery for treating overactive bladders in animal studies and in a human clinical trial. LESW assisted drug delivery was also suggested to have a synergistic effect in combination with cisplatin to improve the anti-cancer effect for treating urothelial cancer in an in vitro and in vivo study. LESW assisted drug delivery in uro-oncology is an interesting suggestion, but no comprehensive clinical trials have been conducted as of yet. Taken together, LESW is a promising method for the treatment of various diseases in urology. However, further investigation with a large scale of clinical studies is necessary to confirm the real role of LESW in clinical use. This article provides information on the basics of SW physics, mechanisms of action on biological systems, and new frontiers of SW medicine in urology.