Emerging treatments

Botulinum toxin injection

Botulinum toxin type A injection is a minimally invasive technique that has been used to treat various pain disorders. Injection into the pelvic floor or prostate may have a modest effect on pain reduction in people with chronic pelvic pain syndromes, although it is not currently licensed for this indication.[4][78] A Cochrane review of pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome found that based on low-quality evidence, intra-prostatic injection (1 study, 60 participants) may reduce symptoms of prostatitis compared with placebo, whereas injection into the pelvic floor muscle (1 study, 29 participants) may not reduce symptoms of prostatitis compared with placebo.[78] A subsequent systematic review identified two randomised control trials and one non-randomised comparative study assessing intra-prostatic injections to treat pain in patients with chronic pelvic pain, including primary pelvic pain syndrome (PPPS).[97] Incomplete data and methodological differences between the studies precluded calculation of a summary effect estimate for treatment-related improvement in pain. Consequently, no definite conclusions can currently be drawn or recommendations made about the use of botulinum toxin injection for treating PPPS.

Phytotherapy

Phytotherapeutic treatments, such as rye grass pollen extract and rye flower pollen extract, in conjunction with vitamins or the polyphenolic bioflavonoid quercetin may be an option to improve symptoms and quality of life in patients with PPPS.[4][12][50] A systematic review and meta-analysis of studies with phytotherapy found significant improvement in pain and a favourable overall response rate.[12] A further meta-analysis of 7 studies with 551 participants concluded that phytotherapy may reduce prostatitis symptoms compared with placebo (NIH‐CPSI scores mean difference -5.02, 95% CI -6.81 to -3.23) without an associated increase in adverse effects.[78]

Tadalafil

Tadalafil, an oral phosphodiesterase type 5 (PDE5) inhibitor, may be effective in improving lower urinary tract symptoms and sexual dysfunction symptoms associated with PPPS.[78][98] In one placebo-controlled clinical trial, treatment with tadalafil for 6 weeks showed improvement of all NIH Chronic Prostatitis Symptom Index (CPSI) domains (pain, micturition, quality of life, and total scores) compared with baseline and placebo.[99] A retrospective study investigating tadalafil, both with and without rectal diazepam, found that patients with PPPS achieved improved symptom scores across all domains of the NIH-CPSI questionnaire.[100] Treatment with PDE5 inhibitors in patients with PPPS requires further investigation to clarify effectiveness.[6][99]

Nerve stimulation

There is limited evidence in studies that nerve stimulation (posterior tibial nerve stimulation or transcutaneous electrical nerve stimulation) can improve symptoms in patients with PPPS, but further research is needed.[101]

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