Chronic prostatitis is one of the most common health problems in men among urological diseases. This disease is similar to the “pelvic pain syndrome” that is common in women. The clinically prominent complaint is long-term pain in the groin and perineum (around the breech). For this reason, it is also known as “chronic prostatitis/chronic pelvic pain syndrome”. Most patients do not benefit from current treatments. The disease negatively affects the quality of life of people by causing psychological problems.

In this article, I will make a general summary of the articles published in world-renowned Urology journals on the use of shock wave-ESWT therapy in the treatment of chronic prostatitis. At the same time, I will make an assessment about our own practices and treatment plan.

What is prostatitis, what are its symptoms?

Prostatitis is an inflammatory disease of the prostate. Common urological complaints in patients are as follows:

• Urinary complaints: Burning during urination, sudden need to urinate, difficulty urinating, frequent urinary tract infections.
• Pain: It is seen in the form of pain in the groin, testicles, around the anus.
• Sexual problems: Burning semen, premature ejaculation, erection problems
• Psychological problems: Due to the long-term persistence of chronic prostatitis complaints, patients may experience psychological problems, and their daily work life and quality of life may deteriorate.

Classification of prostatitis disease

The American National Institutes of Health (NIH) has divided prostatitis into 4 categories. To summarize this category;

• Category-I: Acute bacterial ptostatitis
• Category-II: Chronic bacterial prostatitis. Recurrent urinary tract infections are seen here during infection periods.
• Category III: Chronic prostatitis/chronic pelvic pain syndrome
• Category-IV: Asymptomatic prostatitis diagnosed on biopsy or semen analysis.

According to this classification, patients in Category I and II groups are treated with antibiotics, Category IV patients do not need treatment because they do not have any complaints. The main problem is Category III chronic prostatitis patients. This group constitutes approximately 90% of prostatitis patients. The exact cause of chronic prostatitis is not known and there is no one hundred percent effective treatment method.

What are the advantages of ESWT therapy in the treatment of chronic prostatitis?

If chronic prostatitis patients do not respond to current treatments, one of the most effective treatments today is ESWT-shock wave therapy. Since most of these patients are young patients, we do not prefer the surgical procedure because of its side effects. The widespread use of ESWT therapy in chronic prostatitis patients in the world has many advantages. These advantages are:

• No hospitalization required
• No anesthesia required
• It is a painless treatment method
• Does not have any side effects
• Its effectiveness is 70-80%
• Easy to apply
• It is an inexpensive treatment method
• Can be used with other treatment methods

What are the side effects of ESWT treatment?

One of the most important features sought in the methods to be used in the treatment of a disease is that it has very few or very few side effects. Considering this aspect, ESWT treatment is an ideal treatment option in the treatment of chronic prostatitis.

According to the results reported in reputable medical journals in the field of urology, the side effects of ESWT treatment are very few and insignificant. The most common side effects associated with ESWT: They are very mild complaints in the form of mild itching, redness and bruising in the application area.

We have been applying ESWT treatment to our eligible patients for a long time due to erectile dysfunction (ED, erectile dysfunction, erectile dysfunction), Peyronie’s disease and chronic prostatitis. To date, we have not encountered any serious complications related to ESWT in our patients.

Who should not undergo ESWT?

There are no serious restrictions for the application of ESWT therapy. Conditions that may prevent the application of this treatment or need attention;

• Open wound in the application area
• Infection in the application area
• Having a penile prosthesis

What are the objective criteria for improvement after ESWT treatment?

In order to evaluate the effectiveness of ESWT treatment in patients, complaints before and after treatment are compared. Complaints of patients before treatment (crypnic prostatitis symptom score, symptom index) are compared with after treatment. If the following results are obtained as a result of ESWT treatment in chronic prostatitis patients, it means that the treatment has been successful;

• Pain improves or decreases
• Urinary complaints are reduced
• Premature ejaculation due to chronic prostatitis improves
• Erection problem due to chronic prostatitis improves
• Psychological problems related to chronic prostatitis improve
• Quality of life improves

Does ESWT show the same effect in every patient with chronic prostatitis?

ESWT treatment does not show the same effect in every patient. The urologist applying the treatment should pay attention to some issues and make recommendations to his patients in order to achieve the best result.

• The success rate is lower in those with high chronic prostatitis symptom score
• Efficiency is less in obese (extremely obese) patients
• Less activity in those with psychological problems
• Efficiency is higher in those receiving combined treatment.

How is ESWT – shock wave therapy applied in chronic prostatitis?

There is no definitive treatment for chronic prostatitis. Different treatment methods are applied, one of the most up-to-date treatments is ESWT shock wave treatment.

ESWT treatment was first used in 2009 in chronic prostatitis. Since then, many scientific articles on this subject have been published.

ESWT is applied as follows: Shock waves are applied from outside the body with a special apparatus (probe) so that the patient is in the supine position, in the perineum (between anus and scrotum) and over the prostate. No anesthesia or hospitalization is required for this, it is a painless procedure.

How many sessions of ESWT – Shock wave therapy are applied in chronic prostatitis?

Since 2009, in all applications, it is applied as a total of 4 or 6 sessions, usually once or twice a week, and 3000 shock waves in each session. In our own practice, we usually apply it in the form of 4 or 6 sessions. Social security institutions do not cover the treatment fee.

How much does ESWT-shock wave therapy cost in the treatment of chronic prostatitis?

Treatment costs are important for patients. Not every treatment method may be economically viable for patients. The treatment fee may vary according to the number of sessions applied and the number of shock waves in each session. In general, the effective success rate of ESWT-shock wave therapy is not very high. Social security institutions do not cover the treatment fee.

When does the effectiveness of ESWT treatment in chronic prostatitis start and how long does it last?

When the literature on the application of ESWT treatment to patients with chronic prostatitis was examined, it was seen that the effect started at the end of the first month. Studies differ on the duration of the effect. Generally, ESWT efficacy was evaluated at 3, 6 and 12 months. In most studies, when the patients were called for control in the 3rd and 6th months, it was observed that there was an 80% improvement in the complaints. In a small number of scientific articles, patients were evaluated at 12 months after ESWT, and it was seen that there was a decrease in complaints in them.

According to our observations, most of the patients begin to improve in their complaints from the first month and continue in the following periods. If patients relapse in the late stages, there is no risk in re-administering ESWT. We recommend ESWT treatment again to our patients whose complaints recur in later periods.

What should be considered in order to get positive results from ESWT treatment?

Things to consider in order to get effective results with this treatment;

• Correct indication
• Using ESWT devices with known activity
• Applying ESWT at the appropriate dose and time
• The procedure must be performed by an experienced urologist.

What are the combined treatment methods with ESWT?

There are some drug treatments available in the treatment of chronic prostatitis. The drugs that are frequently used for this purpose are usually used in combination.

• Alpha blockers, muscle relaxants, anti-inflammatory drugs
• Alpha blocker, muscle relaxant, antibiotic therapy drugs
• Alpha blockers, muscle relaxants, anti-inflammatory drugs
• Antidepressant (sedative) drugs

ESWT-shock wave therapy can be used with these treatment modalities. There is no negative effect of using them together, on the contrary, the success rate is higher (Prostate Cancer Prostatic Dis 2022)

How to achieve more success with EWST in the treatment of chronic prostatitis?

No treatment method shows the same effect in every patient. We can list the important points to be considered in order to obtain maximum results from ESWT-shock wave therapy in the treatment of chronic prostatitis;

• Applying treatment at the appropriate dose and time
• Using the appropriate device
• Use of combined therapies
• Lose weight
• Giving supportive treatment if psychological treatment is required
• Doing pelvic muscle exercises
• Application of hot sitz0 baths
• Avoiding spicy, spicy foods and drinks
• Prostate massage, having regular sexual intercourse
• Not drinking excessive alcohol
• Not to be exposed to extreme cold

ESWT – how does shock wave therapy work in chronic prostatitis?

One of the curious issues is how ESWT-shock wave therapy works in the treatment of chronic prostatitis, that is, its mechanism of action. In order to explain the effectiveness of ESWT treatment, I made a general evaluation by examining the respected Urology journals from 2009 when the treatment was first applied. When the literature is reviewed, it is possible to list the mechanisms of action of ESWT-shock wave therapy in the treatment of chronic prostatitis as follows;

• It reduces passive muscle contraction: It is claimed that there is a contraction in the pelvic muscles in chronic prostatitis patients. With ESWT treatment, these muscle contractions are reduced and pain relief is achieved (Eur Urol 2009).
• It acts on pain receptors: With ESWT treatment, pain receptors are affected, as a result of which the perception of pain is reduced (Eur Urol 2009).
• Affects nerve conduction: Shock wave therapy blocks the flow of nerve impulses or the neuroplasticity of pain memory is affected (Eur Urol 2009).
• Regulates nerve damage: Neurovascularization is stimulated and in this way, nerve damage is healed.
• It regresses inflammation: It does this by blocking the TLR4-NFκB pathway, reducing or inhibiting COX-2 release. As a result, inflammation in chronic prostatitis regresses (Prostate 2019).
• Regulates hypersensitization: It reduces pain by regulating peripheral and central nerve sensitivity: It has been shown that there is neurogenic inflammation and central hypersensitization in the case of chronic prostatitis in experimental animals. This situation is regulated by ESWT treatment (Int J Mol Sci. 2022).
• It affects the mast cells in the prostate tissue: In chronic prostatitis, increased mast cells and the intermediate products released as a result of their breakdown increase pain. A reduction in mast cell count and destruction has been demonstrated with ESWT treatment (Mol Cell Biochem . 2021).
• Reduces oxidative stress, pain and inflammation: In studies conducted on experimental animals, it has been reported that oxidative stress and inflammation increase in the prostate tissue in chronic prostatitis, resulting in pain development. It has been reported that with ESWT treatment, oxidative stress and inflammation are prevented through the PI3 K/AKT/FOXO1 pathway, resulting in improvement in patients. In other words, tissue damage caused by oxidative stress in chronic prostatitis at the cellular level is corrected by ESWT (Andrology 2021).

As a result; If patients with chronic prostatitis have not benefited from current drug treatments, ESWT-shock wave therapy is a highly effective and up-to-date treatment method. With ESWT, pain complaints, urinary problems, erection problems and quality of life are improved by an average of 80%. Complaints improved in 70-80% of our patients. After 6 months, complaints may reoccur, in which case re-treatment may be required. It has no side effects, no hospitalization and anesthesia are required.

Prof. Dr. Emin ÖZBEK

Urology Specialist