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Efficacy of focused shock-wave therapy in the treatment of chronic prostatitis / chronic pelvic pain syndrome in men


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Introduction. Chronic prostatitis / Chronic pelvic pain syndrome (CP / CPPS) is an extremely common condition for which no effective treatment has been found yet. Focused shockwave therapy (fSWT) is a safe method of physical intervention that could potentially be effective in CP / CPPS treating.

Objective. To evaluate the efficacy and quality of life of patients after treatment of CP / CPPS with fSWT.

Materials and methods. A prospective cohort study included 48 patients diagnosed with CP / CPPS. The patients attended the clinic three times a week for 4 weeks (12 sessions). Each time, patients received fSWT therapy sessions by “Chronic pelvic pain” protocol. One month after the last therapy session, the men completed the validated NIH-CPSI, IPSS, and QoL questionnaires.

Results. The mean age of the patients was 40 ± 9 years. After the course of therapy, the score of Domain I “Pain” from 10.0 ± 4.7 to 6.3 ± 1.9 (p < 0.001). At the same time, no statistically significant decrease was obtained in Domain II 'Urination' scores ((5,88 ± 2,40 vs 5,42 ± 1,64; p = 0,11). By the end of therapy for Domains III and IV, the scores had changed from 4.42 ± 0.90 and 4.04 ± 1.27 to 4.48 ± 1.01 and 3.08 ± 1.22, respectively (p < 0,001). It is noted that the mean IPSS questionnaire score showed no statistically significant change over the treatment period (17,2 ± 4,8 vs 17,8 ± 4,8; p = 0,074)). QoL changed from 4.48 ± 0.99 to 2.46 ± 1.03 (p < 0.001).

Conclusion. The study demonstrated the efficacy of fSWT as a standalone method in the treatment of CP / CPPS.

For citations:

Labetov I.A., Kovalev G.V., Volkova O.V., Shulgin A.S., Shkarupa D.D. Efficacy of focused shock-wave therapy in the treatment of chronic prostatitis / chronic pelvic pain syndrome in men. Urology Herald. 2022;10(3):28-35. (In Russ.)


Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a widespread condition, which is observed in around 10.0% of men worldwide [1]. At the end of the 1990s, the National Institute of Health – National Institute of Diabetes and Digestive and Kidney Diseases (USA NIH-NIDDK) proposed a consensus definition for this condition and a uniform system of classification [2]. This classification was approved in clinical practice and in the scientific environment. It includes bacterial forms of prostatitis (acute and chronic), an abacterial form (chronic pelvic pain syndrome), and asymptomatic prostatitis.

CP/CPPS (category III NIH-NIDDK, 1999) is defined as pain or discomfort in the pelvic area associated with micturition disorders and/or sexual dysfunction, which lasted for over three out of the previous six months [2]. Adequate diagnostics include differential diagnostics with such diseases as urinary tract infections, cancer, abnormal development, or neurological diseases. Depending on the presence or absence of leukocytes in the prostate fluid, the condition is classified into inflammatory (category IIIa, NIH-NIDDK, 1999) and non-inflammatory types (category IIIb, NIH-NIDDK, 1999) [2].

Infectious agents can be detected in less than 10.0% of patients with prostatitis symptoms. An episode of acute bacterial prostatitis leads to the chronic form only in 10.0% of patients and to CP/CPPS in another 10.0% of patients [1]. CP/CPPS can manifest most symptoms of prostatitis in over 90.0% of men. Due to the heterogeneity and unclear pathophysiology of CP/CPPS, the development of effective treatment methods remains a complicated task. Despite numerous clinical studies, the universal approach to therapy is not proposed [3]. Thus, currently, there is a need for novel, efficient, and available methods of treating this condition.

One of the potentially interesting and promising methods in this area is focused shockwave therapy (fSWT). Shockwave therapy was implemented in clinical practice since 1970. It has been shown to be a well-tolerable and efficient treatment method in sportsmen with some orthopedic pathology (pseudarthrosis and various tendinopathies) [4][5]. Later, the method was used in urology to treat vasogenic erectile dysfunction and Peyronie’s disease [6][7]. In 2018, a major systemic Cochrane review was published on the efficiency of SWT in the treatment of CP/CPPS [8]. At the same time, the authors noted that it was impossible to evaluate the quality of life of patients.

The study aimed to evaluate the efficacy of the method and the quality of life of patients after treatment of CP/CPPS with fSWT.


Study design. A prospective cohort study included patients with diagnosed CP/CPPS. Before the study, all patients signed an informed consent form for participation in the study. The study included a detailed study of medical history, prostate transrectal ultrasound (TRUS), PSA in the blood (for men older than 40 years old), a cultural study of prostate fluid (to exclude the inflammatory component), uroflowmetry (to exclude infravesical obstruction), and a digital rectal examination in a chair to find trigger points in the pelvic floor muscles and in the projection of the prostate bed (Fig. 1). The diagnosis was verified based on the patient's questioning and the presence or absence of pain in the prostate area during palpation (the pain as disturbing). The study exclusion criteria included contraindications to the fSWT method, signs of active inflammation in prostate fluid, and prostate volume >40 cm3 with signs of infravesical obstruction (peak rate <12 ml/s by the results of uroflowmetry). In addition, patients with elevated levels of PSA (>4 ng/ml) underwent pelvic area MRI. Patients with a prostate nodule > Pi-RADS 2 were excluded from the study.

Figure 1. Palpation technique of pelvic floor trigger points, from left to right: palpation of the levator muscle group, palpation of the prostate, palpation of the internal obturator muscle

Endpoints. The primary study endpoint was the evaluation of a decrease in the score for each domain of the validated NIH-CPSI questionnaire (National Institute of Health – Chronic Prostatitis Symptom Index) validated in Russia. The secondary study endpoint was a decrease in the manifestation of accumulation symptoms according to the IPSS (International Prostate Symptom Score) and a change in the quality of life (QoL).

Treatment protocol. Men visited the clinics three times per week for 4 weeks (12 sessions). Each patient underwent a session of fSWT using BTL-6000 fSWT («BTL Medical Technologies», Reading, Berkshire, UK) by the protocol “Chronic pelvic pain”. The patients received 3500 impulses at 8 Hz frequency via an applicator applied to the area in the prostate projection. The position of the applicator was changed every 300–500 impulses. A month after the last session, the patients filled in validated questionnaires.

Statistical analysis. The data showed normal distribution by Shapiro-Wilk’s test. All quantitative data were described as mean ± standard deviation. The dynamic of the treatment results was evaluated using the Wilcoxon paired test. Treatment results at various dates were compared with the Friedman test. Multiple comparisons were evaluated using the Benjamini-Hochberg adjustment. Qualitative data were described with absolute values (n) and percent (%). They were analyzed with the Pearson chi-square test. Fisher’s test was used when the number of expected values in a cross-table cell was < 5. The differences were significant at p < 0.05. All calculations were made in R ver.4.1.3 («The R Foundation for Statistical Computing», Vienna, Austria).


The study included 48 men. The mean age of patients was 40 ± 9.0 years old. The size of the prostate was 27.6 ± 5.6 cm3 according to the TRUS results. The authors studied various domains of the questionnaire and obtained the following results in the pretreatment stage: 10.0 ± 4.7 score in domain I “Pain”, 5.88 ± 2.40 score in domain II “Micturition”, 4.42 ± 0.90 score in domain III “Influence of symptoms” and 4.04 ± 1.27 sore in domain IV “Quality of life”. The mean IPSS score before treatment was 17.2 ± 4.8 score; the quality of life was 4.48 ± 0.99 score.

After the first three sessions of the therapy, the control questionnaire survey revealed a significant decrease in NIH-CPSI score in the domain I “Pain”, which was observed to the third week (Fig. 2). At the same time, there was no significant decrease in the score in domain II “Micturition”. By the end of the study, in domains III and IV, the score was distributed as 4.67 ± 0.93 and 2.33 ± 1.06, respectively. It should be noted that the total mean IPSS score during the period of observation did not decrease significantly. By the end of the follow-up, it was 17.8 ± 4.8 score (p = 0.074). The QoL index changed from 4.48 ± 0.99 to 2.62 ± 0.91 (p < 0.001).

The dynamic of the changes in the NIH-CPSI parameters in each domain is presented in the table. The authors received statistically significant differences in domains I, II, and IV. IPSS score and domain II did not show significant changes.

Figure 2. Dynamics of NIH-CPSI scores during treatment. Explanation: pain — Domain I; urin — Domain II; sympt — Domain III; qol — Domain IV

Table. NIH-CPSI and IPSS points dynamics during the treatment period


Before treatment

Day 7

Day 14

Day 21

Day 28

2 month



Domain I

10.0 ± 4.7

9.0 ± 3.1

7.8 ± 2.9

6.4 ± 2.4

6.7 ± 2.2

6.3 ± 1.9

< 0.001

Domain II

5.88 ± 2.40

4.92 ± 1.74

5.23 ± 1.70

4.67 ± 1.97

5.02 ± 1.73

5.42 ± 1.64


Domain III

4.42 ± 0.90

4.04 ± 0.71

4.04 ± 0.71

3.21 ± 1.13

4.48 ± 1.01

4.67 ± 0.93

< 0.001

Domain IV

4.04 ± 1.27

3.75 ± 1.28

3.46 ± 0.99

2.58 ± 0.99

3.08 ± 1.22

2.33 ± 1.06

< 0.001

Total points

24.3 ± 5.7

21.7 ± 3.9

20.5 ± 3.4

16.9 ± 3.0

19.3 ± 3.5

18.7 ± 3.2

< 0.001


17.2 ± 4.8

15.9 ± 3.4

16.1 ± 3.0

15.7 ± 2.7

17.9 ± 4.6

17.8 ± 4.8



4.48 ± 0.99

4.73 ± 1.01

3.77 ± 0.75

2.50 ± 0.99

2.46 ± 1.03

2.62 ± 0.91

< 0.001

Note. NIH-CPSI — National Institute of Health Chronic Prostatitis Symptom Index; IPSS — International Prostatitis Symptom Index; QoL — Quality of Life


Symptoms of CP/CPPS can result from physical dysfunction, for example, pelvic muscles spasm and muscular hypersensitivity [9][10]. The methods of treatment that target the relaxation and improvement of pelvic muscles coordination (biological feedback, retraining of pelvic floor muscle control, myofascial release of the painful trigger points) can play a certain role in the weakening of symptoms in patients with CP/CPPS [11][12]. In the context of the treatment of myofascial pain syndrome, fSWT is grounded pathophysiologically. The results of a decrease in the pain domain can indirectly confirm this hypothesis.

Although the authors did not obtain a significant improvement in micturition symptoms, according to previous studies, the correlation tests between the NIH-CPSI symptoms domains showed that pain had a more significant effect on QoL than micturition symptoms [13]. Therefore, the treatment of pain syndrome is a priority aspect of therapy to improve QoL. Additionally, to improve the efficiency of treatment, a combination of SWT and other effective methods (peripheral magnetic neuromodulation) cannot be excluded [14].

The waves for fSWT can be generated by electrohydraulic, electromagnetic, and piezoelectric mechanisms depending on the apparatus used [15]. In all three methods of generation, the wave is formed in the fluid inside an applicator. Further, this wave is focused by a lens and transmitted to the tissue. In turn, waves for radial SWT are generated by the acceleration of compressed air via a tube, which is directed to the applicator and contacts the skin. Because of these differences in the generation, there are physical differences between the waves produced by each method. First, radial shock waves have a more superficial effect because maximal energy is achieved on the skin in comparison with focused shock waves that achieve maximal energy in the point of focus located deeper in the body tissues [16]. Second, it has been shown that pressure waves generated by the radial SWT cannot be called shock waves from the fundamental point of view because they do not possess typical physical properties of shock waves, such as short rising time, high peak pressure, and non-linearity [17].

However, often, the term “shock wave therapy” is used not correctly. Besides, not all available devices really generate focused shock waves. Such terms as “radial waves”, “acoustic waves”, “sound waves”, or “radial impulse therapy” are synonyms for many people; sometimes, they are used as synonyms for shock waves, although based on physical nature, these are different technologies [18]. This can provide quite controversial results from previous studies.

In addition, the search for the optimal treatment protocol is the priority task currently. Zhang et al. (2018) reported on the effectiveness of treatment by the protocol 10 Hz 1 time/week for 8 weeks [19]. At the same time, Zeng et al. (2012) proposed the following protocol: 2000 impulses at 2 Hz 5 times/week for 2 weeks [20]. In the present study, the authors chose the main protocol based on clinical experience.

Limitations. However, the study has some limitations. It is the absence of blinding and the control group, which cannot exclude a placebo effect.


The study showed the effectiveness of focused shock wave therapy as an independent method of treatment for CP/CPPS. Further well-planned multicenter studies are needed to establish the optimal protocol and duration of therapy.


1. Krieger JN, Lee SW, Jeon J, Cheah PY, Liong ML, Riley DE. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008;31 Suppl 1(Suppl 1):S85-90.

2. Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999 Jul 21;282(3):236-7.

3. Magistro G, Wagenlehner FM, Grabe M, Weidner W, Stief CG, Nickel JC. Contemporary Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Eur Urol. 2016;69(2):286-97.

4. Thiel M. Application of shock waves in medicine. Clin Orthop Relat Res. 2001;(387):18-21.

5. Haupt G. Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendinopathy and other orthopedic diseases. J Urol. 1997;158(1):4-11.

6. Gruenwald I, Appel B, Kitrey ND, Vardi Y. Shockwave treatment of erectile dysfunction. Ther Adv Urol. 2013;5(2):95-9.

7. Husain J, Lynn NN, Jones DK, Collins GN, O'Reilly PH. Extracorporeal shock wave therapy in the management of Peyronie's disease: initial experience. BJU Int. 2000;86(4):466-8.

8. Franco JV, Turk T, Jung JH, Xiao YT, Iakhno S, Garrote V, Vietto V. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev. 2018;1(1):CD012551.

9. Hetrick DC, Ciol MA, Rothman I, Turner JA, Frest M, Berger RE. Musculoskeletal dysfunction in men with chronic pelvic pain syndrome type III: a case-control study. J Urol. 2003;170(3):828-31.

10. Nickel JC, Alexander RB, Anderson R, Berger R, Comiter CV, Datta NS, Fowler JE, Krieger JN, Landis JR, Litwin MS, McNaughton-Collins M, O'Leary MP, Pontari MA, Schaeffer AJ, Shoskes DA, White P, Kusek J, Nyberg L; Chronic Prostatitis Collaborative Research Network Study Groups. Category III chronic prostatitis/chronic pelvic pain syndrome: insights from the National Institutes of Health Chronic Prostatitis Collaborative Research Network studies. Curr Urol Rep. 2008;9(4):320-7.

11. Rees J, Abrahams M, Doble A, Cooper A; Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015 Oct;116(4):509-25.

12. Kruglov V.A., Asfandiyarov F.R., Vybornov S.N., Seyidov K.S. Treatment of patients with chronic pelvic pain syndrome: result of single-center follow up study. Urology Herald. 2018;6(4):27-35. (In Russ.)

13. Wagenlehner FM, van Till JW, Magri V, Perletti G, Houbiers JG, Weidner W, Nickel JC. National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) symptom evaluation in multinational cohorts of patients with chronic prostatitis/chronic pelvic pain syndrome. Eur Urol. 2013;63(5):953-9.

14. Labetov I.A., Kovalev G.V., Shulgin A.S., Kubin N.D., Shkarupa D.D. Possibilities of peripheral magnetic neuromodulation in the treatment of lower urinary tract symptoms in men. Urology Herald. 2021;9(4):51-59. (In Russ.)

15. Ogden JA, Tóth-Kischkat A, Schultheiss R. Principles of shock wave therapy. Clin Orthop Relat Res. 2001;(387):8-17.

16. McClure S, Dorfmüller C. Extracorporeal shock wave therapy: Theory and equipment. Clinical Techniques in Equine Practice 2003;2:348-57.

17. Cleveland RO, Chitnis PV, McClure SR. Acoustic field of a ballistic shock wave therapy device. Ultrasound Med Biol. 2007;33(8):1327-35.

18. Canguven O, Khalafalla K, Al Ansari A. Low-intensity extracorporeal shockwave therapy for erectile dysfunction. Arab J Urol. 2021;19(3):340-345.

19. Zhang ZX, Zhang D, Yu XT, Ma YW. Efficacy of Radial Extracorporeal Shock Wave Therapy for Chronic Pelvic Pain Syndrome: A Nonrandomized Controlled Trial. Am J Mens Health. 2019;13(1):1557988318814663.

20. Zeng XY, Liang C, Ye ZQ. Extracorporeal shock wave treatment for non-inflammatory chronic pelvic pain syndrome: a prospective, randomized and sham-controlled study. Chin Med J (Engl). 2012;125(1):114-8. PMID: 22340476

About the Authors

I. A. Labetov
St. Petersburg State University – Pirogov Clinic of Advanced Medical Technologies
Russian Federation

Ivan A. Labetov — Urologist

7 – 9 Universitetskaya Qy, St. Petersburg, 199034, Russian Federation

G. V. Kovalev
St. Petersburg State University – Pirogov Clinic of Advanced Medical Technologies; JSC «North-West Center for Evidence-Based Medicine»
Russian Federation

Gleb V. Kovalev — M.D., Cand.Sc.( Med); Urologist; Urologist

7 – 9 Universitetskaya Qy, St. Petersburg, 199034, Russian Federation

5 Stachek Sq, St. Petersburg, 198095, Russian Federation

O. V. Volkova
St. Petersburg State University – Pirogov Clinic of Advanced Medical Technologies
Russian Federation

Olga V. Volkova — Urologist;

7 – 9 Universitetskaya Qy, St. Petersburg, 199034, Russian Federation

A. S. Shulgin
St. Petersburg State University – Pirogov Clinic of Advanced Medical Technologies; JSC «North-West Center for Evidence-Based Medicine»
Russian Federation

Andrey S. Shulgin — M.D., Cand.Sc.(Med); Urologist; Urologist

7 – 9 Universitetskaya Qy, St. Petersburg, 199034, Russian Federation

5 Stachek Sq, St. Petersburg, 198095, Russian Federation

D. D. Shkarupa
St. Petersburg State University – Pirogov Clinic of Advanced Medical Technologies; JSC «North-West Center for Evidence-Based Medicine»
Russian Federation

Dmitry D. Shkarupa — M.D., Dr.Sc. (Med); Deputy CEO for Medical Care Organization; Urologist

7 – 9 Universitetskaya Qy, St. Petersburg, 199034, Russian Federation

5 Stachek Sq, St. Petersburg, 198095, Russian Federation


For citations:

Labetov I.A., Kovalev G.V., Volkova O.V., Shulgin A.S., Shkarupa D.D. Efficacy of focused shock-wave therapy in the treatment of chronic prostatitis / chronic pelvic pain syndrome in men. Urology Herald. 2022;10(3):28-35. (In Russ.)

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