Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 3  |  Page : 109-112

Acupuncture as a treatment choice for persistent chronic bacterial prostatitis-related symptoms: A pilot study


1 Tzaneio General Prefecture Hospital of Piraeus, Piraeus, Greece
2 Department of Urology, Agia Olga General Prefecture Hospital of Athens, Athens, Greece

Date of Submission23-Dec-2020
Date of Decision24-Dec-2020
Date of Acceptance24-Dec-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Konstantinos Stamatiou
Salepoula 2, 18536 Piraeus
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_18_20

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  Abstract 


Background and Aim: In several chronic bacterial prostatitis (CBP) cases, symptoms persist despite bacterial eradication. Since acupuncture has been shown to ameliorate the symptoms of chronic prostatitis/chronic pelvic pain syndrome, it may be an effective treatment option for clinically untreated CBP cases. In order to investigate the above hypothesis, we performed a pilot study. Methods: Patients with persistent CBP-related symptoms and confirmed bacterial eradication were randomly allocated to acupuncture or conventional medical treatment. Symptom burden was assessed at baseline, weeks 4 and 12. Eight patients received 30-min sessions of acupuncture twice weekly for 1 month (Group 1), ten patients received lornoxicam 8 mg orally once daily for 1 month (Group 2), eight patients received Serenoa repens (SR) 320 mg twice daily for 1 month (Group 3), and nine patients received pregabalin 25 mg twice daily for 1 month (Group 4). The primary outcome is the proportion of responders at week 4 with significant change from baseline in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score and International Prostate Symptom Score (IPSS) at week 4. Secondary outcomes included ratings of clinical pain (visual analog scale) and quality of life at week 12. Results: At week 4, no statistically significant differences in the mean decrease of NIH-CPSI and IPSS total scores from baseline among groups were noted. After 12 weeks, none of the participants experienced complete resolution of pain. Differences in the mean pain and quality of life levels were statistically insignificant. Conclusion: Acupuncture is an effective treatment option for persistent CBP-related pain however is inferior to conventional medical treatment in reducing CBP-related lower urinary tract symptoms. For this reason, it may be offered in combination with medical therapy in patients with combined symptoms.

Keywords: Acupuncture, chronic prostatitis, trial


How to cite this article:
Stamatiou K, Samara E, Pierris N, Karanasiou V, Christopoulos G, Kefalas K, Zioutos K. Acupuncture as a treatment choice for persistent chronic bacterial prostatitis-related symptoms: A pilot study. Hellenic Urology 2020;32:109-12

How to cite this URL:
Stamatiou K, Samara E, Pierris N, Karanasiou V, Christopoulos G, Kefalas K, Zioutos K. Acupuncture as a treatment choice for persistent chronic bacterial prostatitis-related symptoms: A pilot study. Hellenic Urology [serial online] 2020 [cited 2021 May 8];32:109-12. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/3/109/310047




  Introduction Top


Chronic bacterial prostatitis (CBP) is a relatively common condition mainly caused by common bacteria, characterized by pain or discomfort in the pelvic region, often accompanied by urologic symptoms or sexual dysfunction.[1] In several cases, symptoms persist despite bacterial eradication.[2] Cumulative evidence suggests that acupuncture may ameliorate the symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). For this reason, acupuncture may be an effective treatment option for clinically untreated CBP cases. The aim of this study was to investigate the above hypothesis.


  Methods Top


In this pilot study, patients with persistent CBP-related symptoms despite bacterial eradication were randomly allocated to acupuncture or conventional medical treatment. Inclusion criteria included confirmed bacterial eradication (absence of bacterial growth in EPS/VB3 on follow-up), the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score ≥3 on baseline visit, and absence of diseases expressing similar symptoms. Patients suffering from conditions affecting either bacterial virulence or host response (e.g., immunodeficiencies and immunosuppressive treatments and anatomical and functional abnormalities of the urogenital system) were excluded from the study.

The whole study consists of 2-week baseline, 4-week treatment, and 24-week follow-up. Symptom burden was assessed at baseline, weeks 4 and 12. Eight patients received 30-min sessions of acupuncture twice weekly for 1 month (Group 1), ten patients received lornoxicam 8 mg orally once daily for 1 month (Group 2), eight patients received Serenoa repens (SR) 320 mg twice daily for 1 month (Group 3), and nine patients received pregabalin 25 mg twice daily for 1 month (Group 4). The primary outcome is the proportion of responders at week 4 with a significant change from baseline in the NIH-CPSI total score and International Prostate Symptom Score (IPSS) at week 4. Secondary outcomes included ratings of clinical pain (visual analog scale) and quality of life at week 12.

Statistical analysis

Statistical analysis was performed using the Fisher exact test. The level of significance accepted in this study was 0.05 (P < 0.05 is significant).

The local ethical committee approved the research protocol for the present retrospective study.


  Results Top


No statistically significant difference in the mean age was found between the groups, although the mean age of Group 3 patients was slightly higher. Thirteen out of the 35 patients reported long-standing chronic bacterial prostatitis.

Primary outcome

At week 4, six out of the seven (83.3%) participants who completed ibuprofen treatment responded, while 3 discontinued treatment. Six out of 8 (75%) participants who completed pregabalin treatment responded, while one discontinued treatment. Of 8 acupuncture participants, 6 (75%) responded compared to 8 (88.8%) of 9 participants who received Serenoa repens. No statistically significant differences in response rates among the four groups were found. Mean pretreatment CPSI and IPSS values of Group 1 patients were significantly higher than those of the remaining groups. All groups had NIH-CPSI and IPSS total scores decrease from baseline. No statistically significant differences in the mean decrease of NIH-CPSI and IPSS total scores from baseline among groups were noted. Mild adverse events occurred in eight participants in the lornoxicam and pregabalin groups (5 and 3, respectively). All adverse events resolved quickly.

Secondary outcome

After 12 weeks, none of the participants experienced complete resolution of pain. Differences in the mean pain and quality of life levels were statistically insignificant. Demographics and main outcome of the four groups are shown in [Table 1] and [Table 2].
Table 1: Patients' demographics

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Table 2: Patients' outcome

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  Discussion Top


A prostate bacterial infection may recur either because antibiotics were not able to get deep enough into the prostate tissue to destroy all of the bacteria or because the original antibiotic was not effective against the specific bacterium causing the infection.[3] Several persistent infections may be asymptomatic. In contrast to the above, in an important number of cases, symptoms persist despite proven bacterial eradication.[4] Reasons explaining this phenomenon are poorly investigated, however it may be relating to prostatic tissue damage associated with local inflammation. Whether this condition represents a shift to CP/CPPS remains unknown. As with CP/CPPS, treatment with different antibiotics or longer courses of antibiotics is usually ineffective.[5],[6] Physicians currently prescribe a wide variety of medications, including many that have not yet been sufficiently studied. As a matter of fact, there is little evidence regarding gabapentenoids efficiency in the treatment of prostatitis-related pain. The sole randomized controlled trial published up to date found an improvement in inflammatory symptoms in almost 50% of patients who received pregabalin. However, no statistically significant difference in improvement between the pregabalin and placebo arms was established, though there was less pain with a higher point improvement in the pregabalin group compared to the placebo group.[7] Certain authors suggest gabapentin to be more effective than pregabalin in relieving prostatitis related pain.[8]

The use of COX-2 selective nonsteroidal anti-inflammatory drugs (NSAID) demonstrated to improve inflammatory symptoms in more than 50% of patients. Both the reduction of symptoms burden and improvement of quality of life are significant, however long-term use of NSAID is limited by side effect profile.[9] The newest NSAIDs may be more effective than the oldest ones.

SR extract as monotherapy in the treatment of prostatitis-related symptoms demonstrated to improve inflammatory symptoms in almost 50% of patients. This significant efficacy (as measured in IPSS and NIH-CPSI questionnaires) becomes evident after the 1st month of treatment.[10] The effectiveness of saw palmetto was found inferior of that of finasteride and tamsulosin but clearly higher than that of placebo in the treatment of mild and moderate lower urinary tract symptoms (LUTS) and discomfort. There was no comparable efficacy for pain management.[11]

There are quite few randomized controlled trials examining the efficiency of acupuncture in the treatment of prostatitis-related pain. Overall, evidence supports acupuncture as an effective treatment for prostatitis symptoms, particularly in relieving pain. decreases in total NIH-CPSI score from baseline have been reported as high as 55%.[12],[13] Several authors compared acupuncture to NSAID treatment and they found that reduction of pain, urinary symptoms, quality of life, and total NIH-CPSI score was higher in the acupuncture group compared with the medical group.[14]

In this pilot study, despite wide variation in mean pretreatment NIH-CPSI and IPSS total scores among groups, no statistically significant differences in the mean decrease of both questionnaire total scores from baseline among the four groups were noted. These variations probably represent problems occurred in randomization and are related to the low sample.

This fact may explain why the mean posttreatment NIH-CPSI and IPSS values of Group 1 are significantly higher than that of the remaining groups. However, patients of Group 1 achieved a significant decrease of both mean NIH-CPSI and IPS scores, similar to that reported in the literature.[13] Moreover, in this study presented comparable decrease in mean NIH-CPSI with that of lornoxicam and pregabalin.

Patients of Groups 2 and 4 achieved the higher mean decrease of NIH-CPSI score, while patients of Group 3 achieved the higher mean decrease in the IPSS score. According to the above findings, none of the treatments worked perfectly for every patient for both pain and urinary symptoms. Moreover, none of the treatments provided definite cure. In fact, after 12 weeks, none of the participants experienced complete resolution of pain. It seems that similar to chronic CP/CPPS, no specific treatment exists for persistent CBP-related symptoms after the eradication of pathogens. In addition, similar to chronic CP/CPPS patients, subjects of this study reported low quality of life over time.[15]


  Conclusion Top


Acupuncture is an effective treatment option for persistent CBP-related pain however is inferior to conventional medical treatment in reducing CBP-related LUTS. For this reason, it may be offered in combination with medical therapy in patients with combined symptoms. Paradoxically, chronic prostatitis could be also considered as a single “disease” since CP/CPPS may represent the evolution of such disease following an initial diagnosis of CBP, thus representing a condition characterized by the persistence of CP symptoms despite bacterial eradication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stamatiou K, Avakian R, Zioutos K, Fokas K, Kefalas K, Zavradinos D, et al. Chronic prostatic infection: Epidemiology and clinical characteristics. Hellenic Urology 2019;31:21-7.  Back to cited text no. 1
    
2.
Stamatiou KN, Moschouris H. A prospective interventional study in chronic prostatitis with emphasis to clinical features. Urol J 2014;11:1829-33.  Back to cited text no. 2
    
3.
Gill BC, Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis 2016;29:86-91.  Back to cited text no. 3
    
4.
Stamatiou K, Magri V, Perletti G, Papadouli V, Rekleiti N, Mamali V, et al. Chronic prostatic infection: Microbiological findings in two Mediterranean populationsArchivio Italiano di Urologia e Andrologia 2019;91:177-81.  Back to cited text no. 4
    
5.
Nickel JC, Downey J, Clark J, Casey RW, Pommerville PJ, Barkin J, et al. Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: A randomized placebo-controlled multicenter trial. Urology 2003;62:614-7.  Back to cited text no. 5
    
6.
Alexander RB, Propert KJ, Schaeffer AJ, Landis JR, Nickel JC, O'Leary MP, et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: A randomized, double-blind trial. Ann Intern Med 2004;141:581-9.  Back to cited text no. 6
    
7.
Pontari MA, Krieger JN, Litwin MS, White PC, Anderson RU, McNaughton-Collins M, et al. Chronic Prostatitis Collaborative Research Network-2. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: A randomized controlled trial. Arch Intern Med 2010;170:1586-93.  Back to cited text no. 7
    
8.
Agarwal MM, Elsi Sy M. Gabapentenoids in pain management in urological chronic pelvic pain syndrome: Gabapentin or pregabalin? Neurourol Urodyn 2017;36:2028-33.  Back to cited text no. 8
    
9.
Magri V, Boltri M, Cai T, Colombo R, Cuzzocrea S, De Visschere P, et al. Multidisciplinary approach to prostatitis. Arch Ital Urol Androl 2019;90:227-48.  Back to cited text no. 9
    
10.
Lopatkin NA, Apolikhin OI, Sivkov AV, Aliaev IuG, Komiakov BK, Zhuravlev VN, et al. Results of a multicenter trial of serenoa repens extract (permixon) in patients with chronic abacterial prostatitis. Urologiia 2007;5:3-7.  Back to cited text no. 10
    
11.
Tacklind J, Macdonald R, Rutks I, Stanke JU, Wilt TJ. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2012;12:CD001423.  Back to cited text no. 11
    
12.
Wazir J, Ullah R, Li S, Hossain MA, Diallo MT, Khan FU, et al. Efficacy of acupuncture in the treatment of chronic prostatitis-chronic pelvic pain syndrome: A review of the literature. Int Urol Nephrol 2019;51:2093-106.  Back to cited text no. 12
    
13.
Qin Z, Wu J, Xu C, Sang X, Li X, Huang G, et al. Long-term effects of acupuncture for chronic prostatitis/chronic pelvic pain syndrome: Systematic review and single-arm meta-analyses. Ann Transl Med 2019;7:113.  Back to cited text no. 13
    
14.
Küçük EV, Suçeken FY, Bindayı A, Boylu U, Onol FF, Gümüş E. Effectiveness of acupuncture on chronic prostatitis-chronic pelvic pain syndrome category IIIB patients: A prospective, randomized, nonblinded, clinical trial. Urology 2015;85:636-40.  Back to cited text no. 14
    
15.
Tripp DA, Nickel JC, Shoskes D, Koljuskov A. A 2-year follow-up of quality of life, pain, and psychosocial factors in patients with chronic prostatitis/chronic pelvic pain syndrome and their spouses. World J Urol 2013;31:733-9.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2]



 

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