Objective: To assess the effects of non-pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Patients and Methods: We performed a comprehensive search using multiple databases, trial registries, grey literature and conference proceedings with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017. We included randomized controlled trials in men with a diagnosis of CP/CPPS. We included all available non-pharmacological interventions. Two review authors independently classified studies and abstracted data from the included studies, performed statistical analyses and rated quality of evidence (QoE) according to the Grading of Recommendations Assessment, Development and Evaluation methods. The primary outcomes were prostatitis symptoms and adverse events. The secondary outcomes were sexual dysfunction, urinary symptoms, quality of life, anxiety and depression. Results: We included 38 unique studies in 3290 men with CP/CPPS across 23 comparisons, reporting outcomes mostly at short-term follow-up. Our analysis showed that acupuncture probably leads to clinically meaningful reduction in prostatitis symptoms compared with a sham procedure (mean difference [MD] in total National Institutes of Health – Chronic Prostatitis Symptom Index [NIH-CPSI] score −5.79, 95% confidence interval [CI] −7.32 to −4.26, moderate QoE). Acupuncture may result in little or no difference in adverse events (low QoE). Acupuncture may also lead to a clinically meaningful reduction in prostatitis symptoms compared with standard medical therapy (MD −6.05, 95% CI −7.87 to −4.24, two studies, 78 participants, low QoE). Lifestyle modifications may be associated with a reduction in prostatitis symptoms compared with control (risk ratio for improvement in NIH-CPSI scores 3.90, 95% CI 2.20 to 6.92, very low QoE), but we found no information regarding adverse events. A physical activity programme may cause a small reduction in prostatitis symptoms compared with control (NIH-CPSI score MD −2.50, 95% CI −4.69 to −0.31, low QoE), but we found no information regarding adverse events. It was uncertain whether prostatic massage reduces or increases prostatitis symptoms compared with control (very low QoE) and we found no information regarding adverse events. Extracorporeal shockwave therapy reduces prostatitis symptoms compared with control (NIH-CPSI score MD −6.18, 95% CI −7.46 to −4.89, high QoE), but these results may not be sustained at medium-term follow-up (low QoE). This treatment may not be associated with a greater incidence of adverse events (low QoE). Transrectal thermotherapy, alone or in combination with medical therapy, may decrease prostatitis symptoms slightly when compared with medical therapy alone (NIH-CPSI score MD −2.50, 95% CI −3.82 to −1.18, low QoE). One included study reported that participants may experience transient adverse events. Conclusions: Based on the findings with moderate to high QoE, this review found that some non-pharmacological interventions, such as acupuncture and extracorporeal shockwave therapy, are likely to result in a decrease in prostatitis symptoms and may not be associated with a greater incidence of adverse events. The QoE for most other comparisons was predominantly low. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient-important outcomes including potential treatment-related adverse events and appropriate sample sizes.
Bibliographical noteFunding Information:
We thank the Cochrane Urology Group for their support in publishing this review, especially Phillip Dahm. We also thank the Instituto Universitario Hospital Italiano and the Family and Community Medicine Service and Urology Service, Hospital Italiano de Buenos Aires (Argentina). We also thank the following individuals for their input to this review: Iv?n Sol?, Jennifer Lyon, Jonathan Rees, Giuseppe Magistro, Florian Wagenlehner, Federico Tirapegui, Byung-Cheol Lee, Giuseppe Magistro and Jordan Dimitrakoff.
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