Acupuncture Used as a Method of Peripheral Nerve Stimulation in Chronic Prostatitis: A Case Study

Introduction

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is defined as chronic pelvic pain lasting for at least 3 months, often associated with lower urinary tract symptoms and/or sexual dysfunction [1]. Prostatitis is a common condition, with 35–50% of men affected by symptoms suggesting prostatitis during their lifetime. It is associated with negative psychological effects and substantial health care costs [2]. There are currently many approaches for its management, using both pharmacological and non‐pharmacological interventions, though there is a lack of evidence for the efficacy of these treatments.

A systematic review [3] examined the evidence for 16 different pharmacological treatments of CP/CPPS. Ninety-nine studies included 9119 men. Treatment approaches included alpha-blockers, 5-alpha reductase inhibitors, antibiotics, anti-inflammatories, allopurinol and botulinum toxin injections. The authors found low‐ to very low‐quality evidence that these interventions cause a reduction in prostatitis symptoms, without an increased incidence of adverse events in the short term. They reported lack of evidence regarding the effects of these drugs on sexual dysfunction, quality of life, or anxiety and depression.

The efficacy of acupuncture on CP/CPPS was examined in a systematic review and meta-analysis [4] of 10 published trials (n=770). Analysis revealed that acupuncture significantly reduced the National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) score and provided pain relief, compared to standard medication, and reduced symptoms when compared to sham. Four acupuncture sessions were the minimum “dose” to reach clinical efficacy, and prolonged acupuncture sessions continuously improved urinary symptoms and quality of life.

Peripheral Nerve Stimulation (PNS) is an effective tool for the treatment of chronic pain. Miniaturized devices that are less invasive than previous generations has brought this treatment modality into mainstream use. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period [5].

Acupuncture is a minimally invasive method of PNS. Acupuncture points have been shown to overlie major neuronal bundles, which correlate with cutaneous branches of major nerves [6]. These nerves converge and interact with visceral nociceptive inputs at the spinal cord level. This anatomical correlation provides the basis on which acupuncture applied to a specific region could treat a variety of conditions such as prostatitis, remote to the site of treatment.

Case Presentation

The patient was a 64-year-old previously healthy, non-smoking, male psychologist. He was not taking any medication. During September 2020, an irritating, itchy rash developed on the head of his penis, after 2 weeks it spread to the shaft. He was advised to use anti-fungal cream (Canesten 10mg/g) twice a day by his General Practitioner (GP). The rash was not reduced after 4 weeks of use. A referral to a dermatologist resulted in a prescription for hydrocortisone cream (10mg/g), which reduced itching for 30-60 minutes after application but was otherwise ineffective.

The patients’ symptoms increased in November. As well as the rash, he was troubled by an ache in his testicles and perineum. He also experienced sexual dysfunction, lack of erection during sexual activity, and the cessation of nightly spontaneous erection. He experienced an increased frequency of urination at night and the flow was interrupted.

In January 2021 the patient was referred to a consultant urologist, who found normal prostate-specific antigen levels. After a clinical examination, he was diagnosed with bacterial prostatitis. He was prescribed trimethoprim 160mg-sulfamethoxazole 800mg (1 tablet twice a day), voltaren (75 mg twice a day) and tamsulosin (0.4 mg once a day) for 4 weeks. During the first 3 weeks the penile rash and the peroneal/testicular ache were reduced, but his symptoms increased again during the fourth week of medication use. After a second and later a third consultation, different antibiotics, doxycycline (100mg twice a day) and ciprofloxacin (500mg twice a day), were successively prescribed, each of them for 4 weeks, with continued use of voltaren and tamsulosin. The patient again experienced initial symptom relief, but a return of symptom severity during the fourth week. Adverse effects during the second and third periods included extreme tiredness, lack of energy, weight loss (4kg) and diarrhea when medicated with ciprofloxacin. Between the three separate monthly periods when antibiotics were prescribed, the patient had a 7 day wash out period without antibiotics, but he continued to take voltaren and tamulosin. Symptoms increased during these weeks to the same level recorded before the start of each antibiotic treatment.

The patient did not take any time off work. However, from late January 2021 until the end of May he suffered from a progressively increasing lack of energy during work hours and reported an increase in the need for sleep (2 hours after work and going to bed at night an hour earlier than usual).

From June 2021 he stopped all medication apart from Paracetamol 500 x1 before bed when needed, and was treated with electroacupuncture every second day for a total of 4 weeks (14 treatments).

Treatment results were monitored by information noted by the patient once a week in a symptom diary and by the use of the validated National Institute of Health‐Chronic Prostatitis Symptom Index. The total index score was recorded before and after each new type of treatment.

Time-Line for Case History

Acupuncture therapy

Treatment was not based on traditional Chinese medicine principles (Table 1). The area to be treated was chosen to correspond with the segmental innervation of the prostate (T12-S4). Needles were inserted into the fascia over the lower thoracic, lumbar and sacral vertebrae. Needles were angled distally and stimulated by hand, until pain radiated distally from the needle tip. Another needle was inserted where the radiating pain stopped, and so on. This so-called relay method is often used in peripheral neuralgia conditions, and was chosen as an appropriate method in this case in order to ensure that the strong needle stimulation covered all relevant segments.

  

    
Date
    
Symptoms before treatment start
    
Treatment
    
Result after 4 weeks of treatment
    
Adverse effects
  
  

    
Sep 2020
    
Rash-head of penis
      
CPSI score: 13
    
Canesten (10mg/g) applied 3 times a day for 1    month.
    
No effect
      
CPSI score: 15
    
None
  
  

    
Oct 2020
    
Rash – head and distal penis shaft
      
CPSI score: 15
    
Hydrocortisone cream (10mg/g) applied 3 times a    day for 1 month.
    
No effect
      
CPSI score: 18
    
Reduced penis skin elasticity
  
  

    
November/Dec 2020
    
Penile rash. Ache in perineum and testicles.    Interrupted urinary flow. Increased urination frequency at night.

      Sexual dysfunction.
      
CPSI score: 26
    
Paracetamol 500mg x2 Hydrocortisone cream (10g/g)    applied 3 times a day for 1 month
    
Short term pain relief (2 hours)
      
CPSI score: 26
    
Reduced penis skin elasticity
  
  

    
Jan 2021
    
Same symptoms
      
CPSI score: 26
    
Trimethoprim – 160mg sulfamethoxazole – 800mg x2

      Voltaren 75mg x2     Tamsulosin 0.4mg x1
      
Treatment duration 4 weeks
    
Reduction of all symptoms, during the first 3    weeks (CPSI: 11) increase in symptoms during the fourth week of treatment.
      
CPSI score: 21
    
Whole body rash
      
Some tiredness/lack of energy from week 4
  
  

    
Mar 2021
    
Same symptoms
      
CPSI score: 26
    
Ciproflaxacin 500mg x2    Tamsulosin 0.4 mgx1

      Voltaren 75mg x2
      
Treatment duration 4 weeks
    
Same result as previous period
      
CPSI score: 25
    
Increasing tiredness and lack of energy
      
Weight loss
  
  

    
May 2021
    
Same symptoms
      
CPSI score:28
    
Doxycycline 500mg x2 Tamsulosin    0.4 mg x1 Voltaren 75mg x2
      
Treatment duration 4 weeks
    
Same result as previous period
      
CPSI score: 26
    
Tiredness. Lack of energy
      
Diarrhea
  
  

    
Jun 2021
    
Same symptoms
      
CPSI score:26
    
Electro-acupuncture
      
Paracetamol 500mg x1 when needed
      
Treatment duration 4 weeks
    
Initial exacerbation of rash and peroneal ache    (1-4 treatments)
      
Reduction in perineal/testicular ache and strong    reduction in symptoms of tiredness after 4th treatment.
      
After 6th treatment normal sexual    function, return of spontaneous erection at night.

        Reduced frequency of urination at night. Urinary    flow still interrupted.

        Slight rash on the penis head

        Average frequency of paracetamol use was 1x 500mg    twice a week.
      
CPSI score: 11
    
None
  

Table 1: