Clinical Question

Are nonpharmacologic therapies safe and effective for men with long-standing pelvic pain and lower urinary tract symptoms, also known as chronic prostatitis/chronic pelvic pain syndrome?

Evidence-Based Answer

In men with chronic pelvic pain and urinary dysfunction who have not responded to standard medical management, extracorporeal shock wave therapy reduces symptoms and increases quality of life. Acupuncture may also provide benefit to some patients.¹ (Strength of Recommendation: B, based on limited-quality patient-oriented evidence.)

Circumcision, transrectal thermotherapy, and physical activity demonstrated a statistically but not clinically significant reduction in symptoms. It is unclear whether lifestyle modifications or prostatic massage provides any benefit. Most nonpharmacologic interventions are not associated with an increased risk of adverse events.¹ (Strength of Recommendation: B, based on limited-quality patient-oriented evidence.)

Practice Pointers

Prostatitis is a common disorder affecting 10% to 14% of men in the United States, and it accounts for 1% of primary care visits each year.^2,3 Chronic prostatitis/chronic pelvic pain syndrome, defined as pelvic pain and lower urinary tract symptoms lasting more than three months, is a diagnosis of exclusion and comprises most cases. Men typically present with pain in the lower abdomen, perineum, testicles, or penis, as well as urinary symptoms and sexual dysfunction, including ejaculatory pain. The variety of presentations likely reflects the unclear etiology of this disease. As such, there is no standard first-line pharmacologic intervention. Antibiotics, nonsteroidal anti-inflammatory drugs, pregabalin (Lyrica), alpha blockers, and 5-alpha reductase inhibitors are most commonly used, and response to medical management is often limited.

This Cochrane review of 38 randomized controlled trials involving 3,290 men evaluated the effectiveness of several nonpharmacologic interventions for chronic prostatitis/chronic pelvic pain syndrome.¹ Participants were younger than 50 years. In 11 of 12 studies included in this meta-analysis, previous pharmacologic therapy had been unsuccessful. The primary outcome was the previously validated 13-question, 43-point National Institutes of Health–Chronic Prostatitis Symptom Index (NIH-CPSI) scale, which assessed pain, urinary symptoms, and quality of life. On this scale, the minimal clinically important difference is considered a six-point reduction from baseline.

Extracorporeal shock wave therapy applied at the perineum demonstrated significant improvement in NIH-CPSI score vs. sham procedure at six weeks in three studies (mean difference [MD] = −6.18; 95% CI, −7.46 to −4.89), but this effect was no longer present at 12 and 24 weeks. Moderate evidence in one study supported improvement in sexual dysfunction with extracorporeal shock wave therapy vs. control.

Three high-quality studies (N = 204) found that acupuncture vs. a sham procedure likely improved symptoms at six to eight weeks (NIH-CPSI score MD = −5.79; 95% CI, −7.32 to −4.26). One study demonstrated persistent benefit at 24 weeks. However, there was no improvement in sexual dysfunction. In two lower-quality studies with inadequate blinding (N = 78), acupuncture provided statistical benefit (MD = −4.09; 95% CI, −6.87 to −1.30) compared with pharmacotherapy (i.e., levofloxacin [Levaquin], ibuprofen, or pollen extract).

Of the other interventions evaluated, few provided meaningful benefit. In one study of 700 men, circumcision provided statistical benefit on the NIH-CPSI score (MD = −3.00; 95% CI, −3.82 to −2.18) without a significant increase in adverse events at 12 weeks of follow-up. In one study of transrectal thermotherapy alone vs. medical therapy and another study of transrectal thermotherapy plus medical therapy vs. medical therapy alone, transrectal thermotherapy provided statistical, but not clinical, improvement (MD = −2.5; 95% CI, −3.8 to −1.2 and MD = −4.34; 95% CI, −5.65 to −3.04, respectively). Interestingly, in one low-quality study, physical activity reduced pain and increased quality of life, but worsened urinary symptoms. Prostatic massage, ultrasound, myofascial trigger point release, transurethral thermotherapy, transurethral needle ablation, and sono-electromagnetic therapy did not improve prostatitis symptoms. Evidence for the effectiveness of biofeedback, lifestyle modifications, laser therapy, tibial nerve stimulation, and transcutaneous electrical nerve stimulation was very low-quality because of the potentially high risk of bias.

Consensus guidelines suggest using individualized, symptom-based treatment for chronic prostatitis/chronic pelvic pain syndrome. Multimodal therapy is recommended because of the complex nature of this syndrome similar to other chronic pain disorders.⁴ Evidence for nonpharmacologic interventions is generally limited, and many of the interventions are expensive and not widely available. Yet, given the desperate situation of many patients in whom standard medical management has failed, even small improvements in symptoms may be beneficial. Therefore, family physicians should consider extracorporeal shock wave therapy and acupuncture for the management of chronic prostatitis/chronic pelvic pain syndrome.

The practice recommendations in this activity are available at http://www.cochrane.org/CD012551.