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Daneshwar D. et al., 2023: Treatment of prostatitis with low-intensity extracorporeal shockwave therapy (LI-ESWT)

Urology Clinic, Prince Court Medical Centre, 39, Jalan Kia Peng, 50450, Kuala Lumpur, Malaysia.
MedCentral Consulting, International Youth Centre, Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000, Kuala Lumpur, Malaysia.

Abstract

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.

Int Urol Nephrol. 2023 Dec;55(12):3133-3145. doi: 10.1007/s11255-023-03616-y. Epub 2023 May 5. PMID: 37145375.

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Comments 1

Jens Rassweiler on Tuesday, 12 December 2023 08:45

Summary

Prostatitis, characterized by prostate inflammation, is commonly treated using pharmacological or non-pharmacological approaches. Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) is defined as unspecific poorly localized pelvic inconvenience or tenderness without definite infection or pathology, which lasts for at least three of the prior six months Common symptoms include prostatodynia, lower urinary tract symptoms (LUTS), genital pain, and low back pain.

The exact cause of CP is not fully understood, but chronic inflammation is considered a significant factor. Autoimmune activity against prostate cells induced by inflammation, coupled with leukocyte recruitment, is believed to contribute to CP development. Pathogenetic features, including anatomical factors leading to ischemia, further exacerbate the condition.
Current treatment options for CP include medications such as analgesics, anti-inflammatory agents, and antibiotics, as well as surgical procedures when first-line treatments fail. However, these approaches are not universally effective and can be associated with side effects. In the search for more effective and less invasive treatments, low-intensity extracorporeal shockwave therapy (LI-ESWT) has gained attention. LI-ESWT, known for its non-invasiveness, has shown efficacy in reducing pain in CP patients through various mechanisms, including interrupting nerve impulse flow and promoting tissue healing.
Despite its effectiveness, there is no standardized treatment protocol for LI-ESWT in CP. Variability in the number of sessions and shock parameters (pulses, energy flux density, and frequency) complicates the determination of the most effective protocol. This review tries to fill this gap by systematically reviewing and comparing the efficacy of different LI-ESWT protocols in treating CP. The study analyzed various protocols from different studies, considering factors such as intensity, duration, frequency, and combination with pharmacotherapy. Three intensity categories emerged: 3000 pulses, 3000 pulses. Most studies reported the effectiveness and safety of each protocol in improving symptoms related to chronic prostatitis (CP), urinary issues, erectile function, and overall quality of life (QoL).

Common LI-ESWT Protocols included 3000 pulses at EFD of 0.25 mJ/mm2 and a frequency of 3 Hz usually administered at 6 different anatomical sites over four sessions (once a week for 4 weeks). Shockwave transducer location changed after every 500 pulses to cover the entire prostate and pelvic floor area.

Comparison between LI-ESWT and sham procedure groups showed significant improvements in various parameters. The effects maintained over weeks and even up to 12 months. There were no reported adverse effects with the described treatment protocol. Different studies modified parameters like frequency, duration, and additional medications with positive outcomes. Combined treatments with medications showed better results than medication alone. Longer treatment periods, increased frequency, and adjusted energy levels demonstrated lasting effects. Nevertheless, there is no standardization concerning the treatment parameter when applying 3000 impulses.

LI-ESWT protocols with varying parameters (2000–2500 pulses, EFD 0.06–0.25 mJ/mm2, frequency 2–3 Hz, sessions 4–10) proved to be safe without reported adverse effects.
These protocols showed effectiveness in maintaining clinical improvements in urinary symptoms, pain, erectile function, and QoL over short-term and long-term follow-up periods.

Higher frequencies of 5000 SW are usually applied with radial shock wave sources and presented only from one Greek center showing a similar efficacy.

Future perspectives:
o Research on the long-term efficacy of 3000 pulses LI-ESWT protocol is lacking, and further investigations are needed.
o Combining LI-ESWT with other treatments, such as medication, should be explored for improved efficiency.
o Clinical trials are required to understand the short-term and long-term effects of LI-ESWT better.
o Comparative studies between focused and radial LI-ESWT are needed to determine their differential efficacy in treating CP.

Conclusions:
Most LI-ESWT protocols are deemed safe and effective for treating CP, with minimal adverse effects and maintenance of clinical effects over short-term and long-term periods. Stable EFD during LI-ESWT sessions appears crucial for maintaining desired clinical effects, regardless of changes in other parameters.The protocol involving 3000 pulses at EFD 0.25 mJ/mm2 and frequency 3 Hz is recommended as an alternative treatment option for CP based on favorable outcomes reported in multiple studies.

Summary Prostatitis, characterized by prostate inflammation, is commonly treated using pharmacological or non-pharmacological approaches. Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) is defined as unspecific poorly localized pelvic inconvenience or tenderness without definite infection or pathology, which lasts for at least three of the prior six months Common symptoms include prostatodynia, lower urinary tract symptoms (LUTS), genital pain, and low back pain. The exact cause of CP is not fully understood, but chronic inflammation is considered a significant factor. Autoimmune activity against prostate cells induced by inflammation, coupled with leukocyte recruitment, is believed to contribute to CP development. Pathogenetic features, including anatomical factors leading to ischemia, further exacerbate the condition. Current treatment options for CP include medications such as analgesics, anti-inflammatory agents, and antibiotics, as well as surgical procedures when first-line treatments fail. However, these approaches are not universally effective and can be associated with side effects. In the search for more effective and less invasive treatments, low-intensity extracorporeal shockwave therapy (LI-ESWT) has gained attention. LI-ESWT, known for its non-invasiveness, has shown efficacy in reducing pain in CP patients through various mechanisms, including interrupting nerve impulse flow and promoting tissue healing. Despite its effectiveness, there is no standardized treatment protocol for LI-ESWT in CP. Variability in the number of sessions and shock parameters (pulses, energy flux density, and frequency) complicates the determination of the most effective protocol. This review tries to fill this gap by systematically reviewing and comparing the efficacy of different LI-ESWT protocols in treating CP. The study analyzed various protocols from different studies, considering factors such as intensity, duration, frequency, and combination with pharmacotherapy. Three intensity categories emerged: 3000 pulses, 3000 pulses. Most studies reported the effectiveness and safety of each protocol in improving symptoms related to chronic prostatitis (CP), urinary issues, erectile function, and overall quality of life (QoL). Common LI-ESWT Protocols included 3000 pulses at EFD of 0.25 mJ/mm2 and a frequency of 3 Hz usually administered at 6 different anatomical sites over four sessions (once a week for 4 weeks). Shockwave transducer location changed after every 500 pulses to cover the entire prostate and pelvic floor area. Comparison between LI-ESWT and sham procedure groups showed significant improvements in various parameters. The effects maintained over weeks and even up to 12 months. There were no reported adverse effects with the described treatment protocol. Different studies modified parameters like frequency, duration, and additional medications with positive outcomes. Combined treatments with medications showed better results than medication alone. Longer treatment periods, increased frequency, and adjusted energy levels demonstrated lasting effects. Nevertheless, there is no standardization concerning the treatment parameter when applying 3000 impulses. LI-ESWT protocols with varying parameters (2000–2500 pulses, EFD 0.06–0.25 mJ/mm2, frequency 2–3 Hz, sessions 4–10) proved to be safe without reported adverse effects. These protocols showed effectiveness in maintaining clinical improvements in urinary symptoms, pain, erectile function, and QoL over short-term and long-term follow-up periods. Higher frequencies of 5000 SW are usually applied with radial shock wave sources and presented only from one Greek center showing a similar efficacy. Future perspectives: o Research on the long-term efficacy of 3000 pulses LI-ESWT protocol is lacking, and further investigations are needed. o Combining LI-ESWT with other treatments, such as medication, should be explored for improved efficiency. o Clinical trials are required to understand the short-term and long-term effects of LI-ESWT better. o Comparative studies between focused and radial LI-ESWT are needed to determine their differential efficacy in treating CP. Conclusions: Most LI-ESWT protocols are deemed safe and effective for treating CP, with minimal adverse effects and maintenance of clinical effects over short-term and long-term periods. Stable EFD during LI-ESWT sessions appears crucial for maintaining desired clinical effects, regardless of changes in other parameters.The protocol involving 3000 pulses at EFD 0.25 mJ/mm2 and frequency 3 Hz is recommended as an alternative treatment option for CP based on favorable outcomes reported in multiple studies.
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