madman
Super Moderator
Abstract
Introduction: In this study, the efficacy of low-intensity shock wave therapy (LSWT) in improving symptoms of chronic pelvic pain syndrome (CPPS) and erectile dysfunction (ED) was investigated.
Methods: Men diagnosed with CPPS and ED (n=50) were prescribed LSWT. The LSWT was administered in 10 sessions over the course of 5 weeks at 3,000 pulses with .25mJ/mm2 energy flow and 5Hz frequency. Outcome parameters were measured before and after LSWT.
Results: Clinical symptoms related to CPPS and ED were measured using four validated questionnaires namely the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function (IIEF), the International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM). The effect of LSWT on each of the three domains of NIH-CPSI, namely Pain, Symptoms, and Quality of Life (QoL) was also analyzed. Uroflowmetry was measured to assess LSWT effect on urine voiding. The mean baseline CPPS symptoms on NIH-CPSI domains of pain, symptoms, and QoL were 9.92±5.72 (mean±SD), 5.14±14.5, and 8.02±3.17, respectively. LSWT resulted in a significant reduction of CPPS symptoms on all NIH-CPSI domains (Pain=.9±1.37; Symptoms=.74±1.03; QoL=1.16±1.78). The baseline means of CPPS symptoms on IIEF, IPSS, and SHIM were 45.42±16.24, 24.68±9.28, and 14.28±6.02, respectively. LSWT significantly improved CPPS symptoms on IIEF (49.48 ±28.30) and IPSS (9.04±7.01) but not on SHIM (16.02±9.85). No statistically significant differences were observed with all uroflowmetry parameters.
Conclusion: The current study demonstrated for the first time the safety and efficacy of LSWT administered in 10 sessions over 5 weeks in improving symptoms of CPPS and ED without causing any significant adverse effect to the patient.
1. Introduction
Chronic pelvic pain syndrome (CPPS) is a common occurrence among adult men, with an estimated prevalence of 2.7% to 16%.[1] Erectile dysfunction (ED) affects most men who are suffering from CPPS. Although the exact underlying mechanisms are unclear, CPPS is thought to be associated with increased risk factors of ED—arterial stiffness and endothelial dysfunction. Besides, psychological factors also contribute to ED in CPPS patients. This is because CPPS patients suffer from considerable stress, depression, and anxiety, which together with the pain symptoms and voiding dysfunction of CPPS lead to decreased sexual activity and erectile function.[2] A recent study by Crocetto et al[3] even suggested the association of CPPS with burning mouth syndrome (BMS), a medical condition characterized by the burning and painful sensation in the oral cavity without any visible wounds or lesions. Like CPPS, the exact etiopathogenesis of BMS is unknown and seems to be complicated with suspected interactions between local, systemic, and psychogenic factors. A theory suggested that BMS may be due to either peripheral nerve damage or dopaminergic system disorders, which suggested a neuropathic characteristic in BMS and thus, probably gives rise to CPPS.[4] Nonetheless, more studies need to be conducted to confirm the co-occurrence of CPPS with BMS since the study by Crocetto et al[3] was the first study to demonstrate a connection between CPPS and BMS.
Despite the ubiquitous nature of CPPS, consensus on a specific treatment for its management is still lacking. Among treatment managements for CPPS include various anti-inflammatory agents, analgesics, antibiotics, a-receptor blockers, and 5areductase inhibitors, either to be used separately or in combination.[5] To date, the efficacy of each treatment type is still not established with mixed outcomes in numerous studies.
A shock wave is a continuous transmission of a sound wave, carrying energy that propagates through a medium, and terminates in a burst of energy, similar to a mini-explosion.[6] In medical science, shock wave has been utilized to break aggregated deposits within the tissue such as kidney stones.[7] At low intensity, shock wave was found to induce cell proliferation,[8] angiogenesis,[9], and nerve regeneration.[10] These benefits of the low-intensity shock wave were found to be due to the modulation of various mechanisms, depending on tissue type and condition.[11] Consequently, low-intensity shock wave therapy (LSWT) has been used to treat musculoskeletal disorders,[12] nonhealing wounds,[13] and myocardial infarction.[14]
In urology, LSWT is a well-known treatment for ED, with its popularity continuing to grow over time.[15] Additionally, the body of literature on LSWT application for other indications within urology, keep on expanding over the years. Other indications include prostatic hyperplasia,[16] Peyronie’s disease,[17] stress-induced urinary incontinence,[18] and overactive bladder.[19] More recently, interest in the utility of LSWT in CPPS is growing. Numerous studies, either randomized or non-randomized, reported a significant improvement of CPPS clinical symptoms following LSWT.[20–29]
The treatment modalities of LSWT in CPPS have not yet been established. The majority of the studies delivered their LSWT in 4 sessions over the course of 4weeks.[20–27] Zhang et al[28] expanded their sessions into 8 over the week. In terms of the parameters of the shock, the majority setting was at 3000 pulses with .25mJ/mm2 energy flow density (EFD) and 3Hz frequency. Some other settings include 5000 pulses with .096mJ/mm2 EFD and 5 Hz frequency,[25] 2000 pulses with .14mJ/mm2 EFD and 3Hz frequency,[29] and 2500 pulses with .25mJ/mm2 EFD and 3Hz frequency.[21,22] In the current study, the efficacy of LSWT was investigated among CPPS patients with ED, administered in 10 sessions over the course of 5weeks at 3000 pulses with .25mJ/ mm2 energy flow and 5Hz frequency, on improving the clinical symptoms of CPPS and ED was evaluated.
2.4. Treatment protocol
Prior to the LSWT treatments, the patients have prescribed either 500mg of levofloxacin once daily or 500mg of ciprofloxacin twice a day for 1/12 along with alpha-blockers, Harnal, or Tamsolusin. Their CPPS symptoms recurred and they were then treated with 5mg of Cialis once daily for a month in combination with the LSWT treatments. The LSWT treatments were given twice a week for 10 sessions over the duration of 5weeks in an outpatient setting without local or systemic anesthesia. At each therapy session, 3000 impulses were applied on the perineum, with a total energy flow density of .25mJ/mm2, 5Hz (Duolith SD1 Ultra, Storz Medical AG). Follow-up was done 1/12 post LSWT treatment and the patients were not on any medication then.
*The exact pathophysiology of CPPS is relatively unknown. One of the manifestations of CPPS is the abnormal tone of periprostatic muscle, which may indicate abnormalities of the neuromuscular connection.[31] Accordingly, the pain sensation in CPPS can be a result of endogenous generation of pain via nociceptive nerve endings and receptors. LSWT is known to modulate various cellular and molecular mechanisms by utilizing mechanotransduction systems available in a certain type of tissue.[32] Hence, it is possible that the LSWT could hyperstimulate nociceptors within the periprostatic muscle and interrupt the process of pain generation. Further study with a cellular model of the periprostatic muscle is required to confirm this hypothesis.
5. Conclusion
The LSWT administered in 10 sessions over 5weeks presented significant improvement in terms of the patient’s pain, urinary symptoms, erectile function, and quality of life-related to CPPS as demonstrated by the improvement in NIH-CPSI, IIEF, and IPSS outcome.
Introduction: In this study, the efficacy of low-intensity shock wave therapy (LSWT) in improving symptoms of chronic pelvic pain syndrome (CPPS) and erectile dysfunction (ED) was investigated.
Methods: Men diagnosed with CPPS and ED (n=50) were prescribed LSWT. The LSWT was administered in 10 sessions over the course of 5 weeks at 3,000 pulses with .25mJ/mm2 energy flow and 5Hz frequency. Outcome parameters were measured before and after LSWT.
Results: Clinical symptoms related to CPPS and ED were measured using four validated questionnaires namely the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function (IIEF), the International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM). The effect of LSWT on each of the three domains of NIH-CPSI, namely Pain, Symptoms, and Quality of Life (QoL) was also analyzed. Uroflowmetry was measured to assess LSWT effect on urine voiding. The mean baseline CPPS symptoms on NIH-CPSI domains of pain, symptoms, and QoL were 9.92±5.72 (mean±SD), 5.14±14.5, and 8.02±3.17, respectively. LSWT resulted in a significant reduction of CPPS symptoms on all NIH-CPSI domains (Pain=.9±1.37; Symptoms=.74±1.03; QoL=1.16±1.78). The baseline means of CPPS symptoms on IIEF, IPSS, and SHIM were 45.42±16.24, 24.68±9.28, and 14.28±6.02, respectively. LSWT significantly improved CPPS symptoms on IIEF (49.48 ±28.30) and IPSS (9.04±7.01) but not on SHIM (16.02±9.85). No statistically significant differences were observed with all uroflowmetry parameters.
Conclusion: The current study demonstrated for the first time the safety and efficacy of LSWT administered in 10 sessions over 5 weeks in improving symptoms of CPPS and ED without causing any significant adverse effect to the patient.
1. Introduction
Chronic pelvic pain syndrome (CPPS) is a common occurrence among adult men, with an estimated prevalence of 2.7% to 16%.[1] Erectile dysfunction (ED) affects most men who are suffering from CPPS. Although the exact underlying mechanisms are unclear, CPPS is thought to be associated with increased risk factors of ED—arterial stiffness and endothelial dysfunction. Besides, psychological factors also contribute to ED in CPPS patients. This is because CPPS patients suffer from considerable stress, depression, and anxiety, which together with the pain symptoms and voiding dysfunction of CPPS lead to decreased sexual activity and erectile function.[2] A recent study by Crocetto et al[3] even suggested the association of CPPS with burning mouth syndrome (BMS), a medical condition characterized by the burning and painful sensation in the oral cavity without any visible wounds or lesions. Like CPPS, the exact etiopathogenesis of BMS is unknown and seems to be complicated with suspected interactions between local, systemic, and psychogenic factors. A theory suggested that BMS may be due to either peripheral nerve damage or dopaminergic system disorders, which suggested a neuropathic characteristic in BMS and thus, probably gives rise to CPPS.[4] Nonetheless, more studies need to be conducted to confirm the co-occurrence of CPPS with BMS since the study by Crocetto et al[3] was the first study to demonstrate a connection between CPPS and BMS.
Despite the ubiquitous nature of CPPS, consensus on a specific treatment for its management is still lacking. Among treatment managements for CPPS include various anti-inflammatory agents, analgesics, antibiotics, a-receptor blockers, and 5areductase inhibitors, either to be used separately or in combination.[5] To date, the efficacy of each treatment type is still not established with mixed outcomes in numerous studies.
A shock wave is a continuous transmission of a sound wave, carrying energy that propagates through a medium, and terminates in a burst of energy, similar to a mini-explosion.[6] In medical science, shock wave has been utilized to break aggregated deposits within the tissue such as kidney stones.[7] At low intensity, shock wave was found to induce cell proliferation,[8] angiogenesis,[9], and nerve regeneration.[10] These benefits of the low-intensity shock wave were found to be due to the modulation of various mechanisms, depending on tissue type and condition.[11] Consequently, low-intensity shock wave therapy (LSWT) has been used to treat musculoskeletal disorders,[12] nonhealing wounds,[13] and myocardial infarction.[14]
In urology, LSWT is a well-known treatment for ED, with its popularity continuing to grow over time.[15] Additionally, the body of literature on LSWT application for other indications within urology, keep on expanding over the years. Other indications include prostatic hyperplasia,[16] Peyronie’s disease,[17] stress-induced urinary incontinence,[18] and overactive bladder.[19] More recently, interest in the utility of LSWT in CPPS is growing. Numerous studies, either randomized or non-randomized, reported a significant improvement of CPPS clinical symptoms following LSWT.[20–29]
The treatment modalities of LSWT in CPPS have not yet been established. The majority of the studies delivered their LSWT in 4 sessions over the course of 4weeks.[20–27] Zhang et al[28] expanded their sessions into 8 over the week. In terms of the parameters of the shock, the majority setting was at 3000 pulses with .25mJ/mm2 energy flow density (EFD) and 3Hz frequency. Some other settings include 5000 pulses with .096mJ/mm2 EFD and 5 Hz frequency,[25] 2000 pulses with .14mJ/mm2 EFD and 3Hz frequency,[29] and 2500 pulses with .25mJ/mm2 EFD and 3Hz frequency.[21,22] In the current study, the efficacy of LSWT was investigated among CPPS patients with ED, administered in 10 sessions over the course of 5weeks at 3000 pulses with .25mJ/ mm2 energy flow and 5Hz frequency, on improving the clinical symptoms of CPPS and ED was evaluated.
2.4. Treatment protocol
Prior to the LSWT treatments, the patients have prescribed either 500mg of levofloxacin once daily or 500mg of ciprofloxacin twice a day for 1/12 along with alpha-blockers, Harnal, or Tamsolusin. Their CPPS symptoms recurred and they were then treated with 5mg of Cialis once daily for a month in combination with the LSWT treatments. The LSWT treatments were given twice a week for 10 sessions over the duration of 5weeks in an outpatient setting without local or systemic anesthesia. At each therapy session, 3000 impulses were applied on the perineum, with a total energy flow density of .25mJ/mm2, 5Hz (Duolith SD1 Ultra, Storz Medical AG). Follow-up was done 1/12 post LSWT treatment and the patients were not on any medication then.
*The exact pathophysiology of CPPS is relatively unknown. One of the manifestations of CPPS is the abnormal tone of periprostatic muscle, which may indicate abnormalities of the neuromuscular connection.[31] Accordingly, the pain sensation in CPPS can be a result of endogenous generation of pain via nociceptive nerve endings and receptors. LSWT is known to modulate various cellular and molecular mechanisms by utilizing mechanotransduction systems available in a certain type of tissue.[32] Hence, it is possible that the LSWT could hyperstimulate nociceptors within the periprostatic muscle and interrupt the process of pain generation. Further study with a cellular model of the periprostatic muscle is required to confirm this hypothesis.
5. Conclusion
The LSWT administered in 10 sessions over 5weeks presented significant improvement in terms of the patient’s pain, urinary symptoms, erectile function, and quality of life-related to CPPS as demonstrated by the improvement in NIH-CPSI, IIEF, and IPSS outcome.
