Acupuncture & TCM in the News

UROLOGY UPDATE

The American Urological Association's recent annual meeting in Orlando, Fla., had its share of large, well-funded clinical trials, but often the most innovative of findings come in the smallest of packages, as individual physicians search for ways to help their most difficult-to-treat patients. That sort of research is highlighted here, as the Medical Post's Andrew Skelly reports on the use of botulinum toxin in refractory voiding dysfunction and acupuncture in chronic prostatitis. Also featured are new studies on sildenafil nonresponders, female sexual arousal disorder, and the foreskin's role in HIV transmission.

New trend is to think of condition as neuropathic pain syndrome

ORLANDO, FLA. – Acupuncture may offer hope to chronic prostatitis patients.
The study, conducted by two Canadian urologists, is part of a new trend toward regarding the condition as a neuropathic pain syndrome rather than a consequence of prostate infection.

Chronic nonbacterial prostatitis—also known as chronic pelvic pain syndrome (CPPS)—is a common but stubborn condition that frustrates physicians and patients alike, said study co-author Dr. Curtis Nickel, professor of urology and director of the Prostatitis Clinical Research Centre at Queen's University in Kingston, Ont.

"For most other things, especially in urology, we are reasonably successful in the majority of patients. Not in prostatitis," he said in an interview at the AUA meeting. "We do well if we get a 40% to 50% reduction in symptoms."

The researchers aren't even sure what causes CPPS, or how to evaluate it. In another study, for example, Dr. Nickel and colleagues showed there were no clinically useful differences in leukocyte counts or bacterial cultures in urine, expressed prostatic secretion or semen in men with prostatitis compared with controls.

"We are questioning now whether the standard evaluation—very uncomfortable and expensive and cumbersome—of looking at prostate-specific specimens after prostate massage is really indicated in clinical practice," Dr. Nickel said.

Instead, the latest thinking on CPPS is that although the problem may originate in the prostate, over the long-term it is a neurogenically mediated condition.

"Patients have neuropathic pain which is reflected in voiding and sexual disturbances and musculoskeletal pain. And that's why instead of using prostate-centric treatment, we should probably be using something a little more broad (such as acupuncture)."

He first observed the use of acupuncture in prostatitis patients on a lecture tour of China and was later approached by Dr. Richard Chen, a urologist and certified acupuncturist in Mississauga, Ont., who said he'd had some success with the technique.
Dr. Nickel tested that claim by sending him some of his most difficult patients, men who had failed antibiotics, alpha-blockers, anti-inflammatories and phytotherapy.

"I was more than pleasantly surprised. I was amazed at the results we got," he said. "My experience with acupuncture turned me from a skeptic to almost a believer."

But to confirm the results, researchers must conduct a randomized, multicentre trial using a standardized acupuncture technique and a sham acupuncture procedure.

The pilot study involved just 12 men (age 31 to 57 years). Treatment involved three sets of acupuncture points (a total of 30, eight of them electrically stimulated) and was given twice weekly for six weeks.

At six and 12 weeks following treatment, 11 patients had a greater than 50% decrease in the U.S. National Institutes of Health chronic prostatitis symptom index, and 10 patients perceived at least a 75% improvement in subjective symptoms from baseline.

Those initial improvements have held up over 24 to 52 weeks of followup.

Researchers are also looking at other ways of treating CPPS as a neuropathic pain syndrome. They are, for example, testing thermal therapy and electro stimulation, and are continuing to search for effective drug therapies.

A large trial is underway comparing tamsulosin (Flomax) plus ciprofloxacin (Cipro) to placebo, Dr. Nickel said, "because those are the two standard treatments almost everybody gets treated with in North America . . . and there's never been a clinical trial comparing them to placebo."

At the meeting, he also presented a small randomized, placebo-controlled trial of finasteride (Proscar) that showed a trend toward improved symptoms versus placebo. Subgroups of patients, including older men or those with larger prostates, might benefit more, he said.

Another multicentre trial showed pentosan polysulfate (Elmiron) produced modest but statistically significant improvements in quality of life and symptoms. The glycosaminoglycan substitute is approved for interstitial cystitis, which Dr. Nickel said is similar to CPPS.
Dr. Nickel, whose clinic is supported by the U.S. National Institutes of Health, said treatment of CPPS—a time-consuming condition not amenable to surgery—is not adequately remunerated by medicare.

"Physicians don't encourage prostatitis patients to come back," he said.

On top of that, there is a stigma associated with the condition, perhaps due in part to a misperception it's a sexually transmitted disease.

While prostate cancer and erectile dysfunction have prominent spokesmen, Dr. Nickel said no one has volunteered to champion the cause of prostatitis patients, despite the fact many politicians (and in one survey, 14% of health-care professionals) suffer from the condition.

"We always ask, would you mind being like the Guy Lafleur of Viagra for us in prostatitis?
"But none of the politicians we treat are willing to even let out a whisper—not a whisper—that they've been down to our treatment clinic."