Estimation of efficiency of shock wave therapy in patients with chronic nonbacterial prostatitis / chronic pelvic pain syndrome

Abstract

Chronic prostatitis is the most common urological disease among men of working age (up to 50 years), and its characteristic symptoms are a common (up to 8% of cases) reason for seeking urological care. The prevalence of chronic prostatitis in the male population according to various authors is from 3 to 35%. The incidence of prostatitis in Ukraine is about 19% among the male population aged 20 to 60 years. A single universal successful therapy of chronic prostatitis does not exist today. Particularly difficult is the management of patients with a non-inflammatory form of chronic pelvic pain. In this research, we assessed the effectiveness of extracorporeal shock wave therapy (ECT) in the complex treatment of patients with chronic prostatitis, with the syndrome of non-inflammatory chronic pelvic pain (SNCTB), (NIH III B). Materials and methods. We observed 43 patients with chronic nonbacterial prostatitis, with non-inflammatory chronic pelvic pain syndrome (NCPPS) / (CP / CPPS- (NIH III B)), with a long recurrent course of the disease, which was difficult to respond to traditional therapy. The average age of the patients was 37.4 ± 8.1 years; the duration of the disease is from 3 to 7 years (on average 5.4 ± 2.3 years). The state of hemodynamics in the prostate gland (PG) was evaluated using TRUS in the color Doppler mapping mode with the determination of peak systolic velocity (cm/s), diastolic velocity (cm/s) and average linear blood flow velocity (cm/s). Volumetric blood flow (l/min.), Pulsation index (c.u.), Resistance index (c.u), vascular diameter (cm) and vascular plexus density (blood vessels/cm) were also determined. Endothelial function was evaluated by the concentration in the blood serum of endothelin-1 (ET-1) by enzyme-linked immune assay. The obtained initial data on the state of blood flow in the prostate and the concentration of ET-1 in the blood serum of patients were compared with the corresponding average data in the group of 25 healthy men. Patients were also questioned on the international symptom assessment system using the Chronic Prostatitis Symptom Index Questionnaire (NIH-CPSI, 1999). Patients were randomized into two groups. The first group, 20 patients, received standard therapy for a month - non-steroidal anti-inflammatory drugs, alpha-blockers, antidepressants or antiepileptic drugs. The second group, 23 patients, on the background of standard therapy underwent a course of ESWT. ESWT sessions were carried out twice a week for a month (eight procedures), with the additional appointment of L-arginine in syrup per os 15 ml 2 times a day - 30 days. The dynamics of symptoms, blood flow in the prooostate, and the state of vascular endothelial function immediately after the course and 3 and 6 months after the treatment were evaluated in both groups of patients. Results. In patients with NCPPS, during Doppler color mapping, a vascular pattern was depleted with a decrease in the diameter of the vessels and, in turn, the density of the vascular plexus by more than two times, with a pronounced decrease in volumetric blood flow in the prostate gland. A significant decrease in peak systolic, diastolic and average linear velocity was also noted, with an increase in the pulsation index and resistance index. There was also an increase in the average concentration of endothelin-1 in the blood serum, more than three times, which indicates the manifestations of endothelial dysfunction in patients with NCPPS. In patients who underwent a course of ESWT with standard therapy, with the additional prescription of L-arginine, the hemodynamic parameters in the prostate changed significantly. A significant increase in the peak linear velocity of blood flow in the vessels was observed, with an increase in the diameter of the vessels and the density of the vascular plexus, with a significant decrease in the pulsation index and the resistance index. The total relative improvement in vascularization after treatment was 32.4%, after 3 and 6 months, respectively - 45.1% and 39.2%., With an increase in volumetric blood flow by more than four times. Whereas in the group of patients who received only basic therapy, the hemodynamic parameters in the prostate after treatment did not change significantly and remained at the same level 3 months after treatment, and 6 months after treatment, these values †returned almost to the initial data. The total relative improvement in prostate hemodynamics in this group of patients after treatment was 14.1%, and after 3 and 6 months, 14.4% and 5.9%, respectively. In patients receiving standard therapy, the concentration of endothelin-1 in serum decreased significantly after treatment by 21.2%, after 3 months by 26.4%, and after 6 months only by 9.4% without a significant difference with the indicator before treatment (p > 0.05). Whereas in the group of patients who additionally received L-arginine, the concentration in the blood serum of endothelin-1 decreased after treatment by 44.1%, after 3 months by 56.3%, while remaining after 6 months at a level of 53.2% lower than before treatment (p <0, 05). When questioning patients of group I who received basic therapy, the total score for NIH-CPSI after treatment decreased by 35.8%, after 3 months - by 44.6%, and after 6 months it was lower by 28.4% before treatment with a tendency to return symptoms. Whereas in patients of group II, the total score for NIH-CPSI decreased after treatment by 52.3%, after 3 months - by 64.8%, and after 6 months remained at a level of 62.2% below the pre-treatment level while maintaining a stable clinical effect. Conclusions 1. According to the Doppler mapping of the prostate gland in patients with NCPPS revealed significant hemodynamic disorders that correlate with clinical manifestations. 2. An increase in the concentration of endothelin-1 in the blood serum of patients indicates the manifestations of endothelial dysfunction in patients with NCPPS. 3. According to the data obtained, it is possible to put forward a hypothesis about chronic ischemic disease of the prostate gland, as the cause of the non-inflammatory form of chronic nonbacterial prostatitis. 4. The use of extracorporeal shock wave therapy with the additional prescription of L-arginine in the presence of standard therapy improves hemodynamics in the prostate gland and vascular endothelial function in patients with NCPPS, while maintaining a long-term and persistent clinical effect.