Physiotherapy for chronic prostatitis/chronic pelvic pain syndrome in men: a systematic review

Introduction

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is defined as chronic pelvic region pain which has no apparent cause and which has persisted for at least three of the past 6 months. The prevalence of chronic pelvic pain syndrome in the adult male population is between 2% and 10%, although these figures appear to be underestimated. The highest incidence occurs after the age of 40 [1]. Chronic pain is among the most common symptoms, while patients may also report symptoms of dysuria and painful ejaculation [1, 2].
The treatment of CP/CPPS in men is a long and complicated process. This is because there is no single standard of management, and because the therapy itself needs to be selected on a case-by-case basis, taking into account the individual patient’s clinical condition, dominant and concomitant symptoms. Therefore, management may often require a combination of pharmacotherapy, physiotherapy and psychotherapy, especially since it has been confirmed that polytherapy is more effective than monotherapy [3]. Surgical intervention may be used in certain cases but this is reserved for patients with specific indications such as urethral stricture or bladder neck obstruction [4]. As there are still no clarified guidelines and recommendations for CPPS therapy (including physiotherapy), trying to synthesize the available knowledge seems crucial for offering comprehensive care to patients affected by CPPS.

Aim of the research

The aim of the present systematic review is therefore to systematically search and synthesize the results of available studies of physiotherapeutic interventions for the alleviation of symptoms of CP/CPPS and improvement of patients’ overall quality of life. The main research question adopted by the paper’s authors was: is the use of physiotherapeutic interventions effective in reducing the severity of CPPS symptoms in the affected male population?

Material and methods

In order to maintain high methodological standards when conducting the systematic literature review for this publication, the PRISMA protocol was used [5]. Thus independent literature searches were performed by each of the 2 authors of this paper, and any disagreements regarding the inclusion of individual articles in the analysis were resolved through discussions between the authors, with the final author having the final say. The literature search for this review was carried out from June to July 2022.

Search strategy

For the purpose of conducting a systematic literature review, it was decided to search the following medical literature databases: PubMed/Medline, Cochrane Library, and Polish Medical Library. Papers in English, French and Polish were sought using established keywords with language variations. A sample search query is shown in Table 1.

Eligibility criteria

Retrieved articles were screened manually according to criteria previously adopted and accepted by all authors of this study. These criteria are shown in Table 2.

Data extraction

Two independent reviewers extracted data from articles which met the eligibility criteria using an MS Excel spreadsheet. The following data were extracted:
– concerning the study: first author, year of publication, country of study origin, study design;
–concerning study participants: sample size, age;
– concerning the physiotherapeutic intervention: type, frequency, time of exposure, length of follow-up, outcome measures, main results.

Methodological quality assessment

Studies included in the final qualitative analysis were subjected to methodological quality assessment using Joanna Briggs Institute (JBS) questionnaires. We decided to use the JBS tools due to the wide range of study types for which the institute has developed its questionnaires [6]. Studies were assessed according to the JBS checklists and were classified as having high methodological quality when 100% of criteria were met, and as having a risk of low quality when no more than 25% of criteria were met.

Results

Selection of studies

Initially, more than 2000 studies were found in medical databases, and a further three relevant studies were identified through other sources (so-called grey literature). Subsequently, after removal of duplicate findings and full-text assessment using the eligibility criteria, 13 studies were selected for qualitative synthesis. Some of the most common reasons why the authors of this review excluded individual articles were: 1) lack of data separately for women and men for articles describing the physiotherapy process for both sexes, 2) lack of detailed description of the physiotherapy interventions undertaken when a comprehensive physiotherapy process was used, and 3) lack of re-evaluation of physiotherapy outcomes. Figure 1 presents a flow diagram of the study search process.

Description of studies included

We included 13 studies in the final analysis, with a total of 600 patients between the average ages of 34 and 64 suffering from chronic prostatitis/chronic pelvic pain syndrome. Of these studies, most were from Asia (five different countries) and Europe (four different countries), and one was from the USA. The majority of the studies used a randomized controlled trial design, while case studies were the least common type. The papers included in the final analysis came from the years 2009–2021. The most frequent physiotherapeutic interventions were acupuncture, shockwave therapy and magnetic stimulation. Participants in the studies were typically given one or two therapeutic sessions per week for a period of no more than 3 months. Follow-up periods varied widely, ranging from 6 weeks to 12 months. The NIH-CPSI (National Institute of Health-Chronic Prostatitis Symptom Index), IPSS (International Prostate Symptom Score), VAS (Visual Analogue Scale), and IIEF-5 (International Index of Erectile Function 5 Items) were most often used to assess outcomes. The characteristics of the studies included in the final analysis are presented in Table 3 [7–19].

Summary of main results

A statistically significant reduction in CP/CPPS symptoms as measured on the NIH-CPSI scale can be observed based on the results of the studies on the effect of acupuncture treatments. In the case of the studies by Qin et al. [7] and Sahin et al. [11], these therapeutic effects persisted for many weeks after the treatment cycle had been completed.
Analysis of studies evaluating the effectiveness of using different types of shockwaves in the conservative treatment of CP/CPPS also reveals promising results. Treatments using EWST, rEWST and LIST resulted in statistically significant improvements in parameters assessed by the NIH-CPSI [8, 10, 15], VAS [8, 10] and IIEF [10, 15] scales. However, it should be noted that observations of the subjects of these studies were limited to a maximum of several weeks.
The third most common intervention among the studies included in the analysis was magnetic field stimulation, whose effectiveness is not as promising as that of the previously described acupuncture or shockwave therapies.
In one of the two studies evaluating the effects of magnetic field stimulation, improvements in scores as measured by the NIH-CPSI scale were observed, although the results are not statistically significant [14]. In the second study, by Kim et al. [18], statistically significant improvements in NIH-CPSI and IPSS scores were observed after both six and 24 weeks of follow-up. In addition, more than 75% of the study participants expressed the view that the intervention used had been helpful. It should be noted, however, that the study design did not involve recruiting and comparing results with a control group.
The last of the studies included in the final analysis was that of Schneider et al. [13], which measured the effectiveness of TENS electrotherapy. The results show a statistically significant reduction in pain on the VAS scale (a decrease of about three points), although again the data were not compared to a control group.
The effectiveness of manual therapy and myofascial techniques was evaluated in studies by Burzynski et al. [9] and Van Alstyne et al. [19]. Both articles (which are case reports) described improvements in patients’ functioning and reductions in the severity of disease symptoms. It should be noted that in the case of the Burzynski et al. study [9], the only standardized tool to assess the effectiveness of therapy was a pain rating scale, which makes it significantly more difficult to assess the impact of the therapy used on the patient’s quality of life.
From a clinician’s point of view, based on the data in Table 3, the most optimal form of therapy in CPPS seems to be interventions based on treatments from the field of physical therapy (such as shockwave therapy and its variations, and electrotherapy treatments like TENS – Transcutaneous Electrical Nerve Stimulation) and acupuncture treatments. Based on the studies cited, even a few physiotherapy sessions can significantly reduce pain and improve the quality of life of patients.

Discussion

The treatment of CP/CPPS is challenging and requires the attention of a multispecialty team of health care professionals as with most chronic pain conditions, such as chronic low back pain [20]. The process of treating the symptoms of the disease is often lengthy and requires patience and commitment from both patients and medical professionals [1]. Analysis of the studies included in this literature review confirms the growing popularity of physiotherapy as an integral part of conservative treatment for pelvic floor dysfunction in men [21, 22]. Physiotherapeutic management of chronic pelvic pain is becoming an integral part of therapy [1, 23]. This literature review focuses on an attempt to synthesize the knowledge of physiotherapy (expanded to include interventions incorporating acupuncture and patient education) that is integral to chronic pain therapy. It delves only into those interventions used by practicing physiotherapists, which distinguishes this review from studies that capture CPPS therapy in general and point to physiotherapy as one possible component of therapy [1, 3, 4].
However, in the modern approach to chronic pain management, one of the most essential elements of therapy is patient education. Such education, consisting in proper information about what pain is and what factors may influence its onset and severity, can be of significant help in the treatment of chronic pain [24]. Unfortunately, when searching for articles in medical databases, we did not come across any studies evaluating the impact of patient education on the effectiveness of the treatment undertaken and the results of therapy (quality of life, pain level).

Limitations and strengths

This systematic review of the literature provides a wealth of information regarding both the type of physiotherapeutic interventions used in the treatment of CP/CPPS and the methodology and therapeutic effects achieved. One of the main advantages of this article is the use of the PRISMA protocol ensuring that the literature survey is conducted accurately and the use of JBS tools to assess the methodological quality of each type of study. However, it is worth noting the limitations of this review.
The first is the fact that, as a consequence of limited translation capabilities, studies had to be written in English, Polish or French in order to qualify. This resulted in the arbitrary exclusion of Spanish- and Asian-language articles from the qualitative analysis.
A further major shortcoming is the generally low methodological quality of the studies included in the analysis. This fact, coupled with the inclusion of studies without control groups or descriptions of individual cases, makes it impossible to conduct a meta-analysis of the results of the studies, and thus makes it impossible to draw general conclusions.

Implications for further research

One of the main advantages of this article is the use of the PRISMA protocol ensuring that the literature survey is conducted accurately and the use of JBS tools to assess the methodological quality of each type of study. Based on our search of medical article databases and qualitative analysis of the individual studies included in our systematic review, it is possible to point out some aspects worth considering when planning similar studies in the future.
Most of the studies included in this analysis evaluated the effectiveness of physiotherapeutic interventions based on physical therapy and acupuncture treatments, while only one study related to patient education and physical activity programming in the context of self-management of symptoms. However, the fact that CP/CPPS is a chronic disease with a significant psychosocial component means that physiotherapy programming that engages the patient in building a solid foundation in self-management of the effects of symptoms should be a key element of treatment. In addition, few researchers have assessed patient satisfaction with the treatment provided, thereby overlooking the importance of viewing the disease and treatment from the patient’s point of view.
An assessment of the methodological quality of the studies included in this literature review indicates that for randomized clinical trials, the most common factors that reduce quality are a deficiency or absence of information on the method of randomization and incomplete or absent description regarding situations in which subjects did not complete planned treatments or dropped out of studies.

Conclusions

Physiotherapy is an increasingly popular non-pharmacological mode of intervention for treating pelvic floor dysfunction, including among men. This is due to the increasing effectiveness and safety of the physiotherapeutic treatments used.
Studies in the field of the use of physiotherapy measures (especially those related to physical therapy) provide information on the effectiveness of their use in reducing symptoms of CPPS severity. The multiplicity and availability of many physiotherapy techniques (physical therapy, acupuncture, manual therapy and others) enables the creation of individualized treatment processes for CP/CPPS symptoms, improving quality of life for patients.
This review of the literature does not fully exhaust the question contained in the objectives of the paper, but it does point in the direction of the search for optimal physiotherapeutic management among men with CPPS. Conducting research of high methodological quality is crucial for building reliable recommendations and guidelines for physiotherapeutic management of chronic prostatitis/chronic pelvic pain syndrome.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References