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UDC 616.65-002:616-006.55:615.849.11 doi.org:10.31684/2541-8475.2019.1(13).52-56
OPTIMIZATION OF PHYSIOTHERAPY METHODS IN PATIENTS WITH CHRONIC PROSTATITIS WITH CONCOMITANT BENIGN PROSTATIC HYPERPLASIA
Federal Siberian Research Clinical Centre under the Federal Medical Biological Agency, Tomsk I.A. Kolmatsui, E.F. Levitsky
A method of complex treatment of patients with chronic prostatitis with concomitant benign prostatic hyperplasia (BPH) has been developed depending on the degree of prostate hyperplasia, severity of inappropriate urination, predominance of obstructive or irritative symptoms. Treatment complexes included the differentiated use of combined physiotherapeutic factors: low-energy light-magnetotherapy, magneto-pelotherapy (or micro-enemas of mineral water in combination with magnetotherapy), electrostimulation (or ultrasonic therapy), iodine-bromine baths. The use of optimized methods of physiotherapeutic impact combined with medicinal treatment in chronic prostatitis in combination with BPH allowed to expand the indications for its prescription, increased efficiency, provided a good profile of therapy tolerance, increased the period of remission, and did not cause the progression of prostate hyperplasia, symptoms of the lower urinary tract and risk of acute urination delay. Key words: chronic prostatitis, BPH, differentiated physiotherapy, optimization.
Chronic prostatitis (CP) is observed in most (67-97%) patients with benign prostatic hyperplasia (BPH), which burdens the course of the disease and reduces the quality of life [1, 2]. Physiotherapy occupies a significant place in the complex treatment of patients with CP, but with concomitant BPH, the factors of influence causing endogenous thermal reactions are not applied [3]. In patients with BPH in combination with CP, it is possible to use the magnetic laser therapy in the period before and after surgical treatment, which effectively reduces the irritative symptoms, the number of inflammatory complications and shortens the rehabilitation period [4, 5]. The use of low-level laser radiation, permanent magnetic field (PMF), electrical stimulation, and colour rhythm therapy leads to the improvement of indicators of prostate secretion, uroflowmetry, PSA level, prostate gland volume (PG), IPSS symptom index, QoL and significantly increases the effectiveness of treatment in the complex treatment of patients with BPH with concomitant CP [6]. According to A.A. Ushakov et al. (1999), the use of ultrasound therapy (UST), impulse magnetic therapy, electrical stimulation provides a pronounced anti-inflammatory effect, improves urination and a sexual function, with that, it does not stimulate the growth of prostatic hyperplasia in these patients [7]. In general, however, research on this issue is not sufficient and results are often contradictory.
The research objective was to increase the effectiveness of complex treatment in patients with CP with concomitant BPH by optimizing the methods of physiotherapeutic influence.
Materials and methods
141 patients with CP/chronic pelvic pain syndrome (CPPS) with concomitant I, II stage BPH 48
were observed. Depending on the severity of lower urinary tract symptoms (LUTS), patients were divided into two groups: a group with mild LUTS (S) IPSS <12 points (76 persons) and a group with moderate LUTS (s) IPSS 12-19 points (65 persons). These groups were distributed into the main groups (1A, 2A) and experimental groups (1B, 2B) by random sampling. The groups under study were comparable in the main baselines.
Study inclusion criteria are as follows: informed consent, verified diagnosis of CP/CPPS (IIIA, IIIB category; NIH, 1999) and I, II stage BPH, mild and moderate LUTS (S) IPSS <19 points, age of patients not more than 65 years old. Exclusion criteria are the following: high risk of BPH progression: Vpg>40 cm3, PSA total>1.6 ng/ml; presence of signs of infravesicular obstruction (IVO): Qmax<10 ml/ sec, Vru>50 ml; presence of acute urinary retention (AUR) in the anamnesis; presence of intravesical component of the PG average fraction (according to pelvic organs transrectal US) of more than 5 ml.
Verification of the diagnosis of CP/CPPS and BPH and evaluation of treatment effectiveness were carried out on the basis of questionnaires (NICH-CPSI, QoL, IPSS), urination diary, prostate digital investigation, microscopy, microbiological and PCR studies of prostatic secretion (PS), transrectal US (echography) of pelvic organs, urofluometry. The degree of tension of nonspecific adaptation mechanisms was determined by the type of adaptation reaction and the level of reactivity according to L.H. Harkavy et al. (1998). Treatment effectiveness evaluation was determined by the integral indication (V.F. Kazakov et al., 2004) constituting "improvement" (20.1-30%) and "significant improvement" (over 30.1%) [8]. The results of the treatment were evaluated immediately
after the end of the treatment course and 4 weeks after its end (prostatic secretion microscopy), the long-term results of the treatment were evaluated after 1 year.
Patients of the main groups (1A, 2A) received LED therapy (infrared and blue bands) intrarectally to the prostate projection in combination with PMF magnetic therapy, sapropelic tampon (t 37-38°C) in combination with PMF exposure, SMC electrostimulation (1A group) or micro-enemas of mineral water (t 37-38°C) in combination with PMF exposure, and ultrasound (US) therapy (2A group). Patients of the experimental groups (1B, 2B) were treated with LED therapy (infrared and red bands), sapropelic tampons (t 37-38°C) (1B group), or micro-enemas of mineral water (t 37-38°C) (2B group).
Photomagnetotherapy was carried out by a cavitary emitter intrarectally to the prostate projection by means of a device generating LED radiation of red (660 nm) and infrared (840-950 nm) bands or blue (420-450 nm) and infrared bands with a total power density of 5 mW/cm2 and a value of magnetic induction of 30-40 mT. PMT therapy was conducted by the 3 and 4 operation modes (5 min each), modulation frequency 100 (150) Hz, modulation depth 25 (50) %, half-period duration 1:1.5 s per the course of 10 procedures. The ultrasound therapy (UST) was carried out on the lumbar area (L1-L3), paravertebrally, urinary bladder and perineum, radiation power 0.2 (0.4) W/cm2, libale, 3-4 min per zone, the course of 10 procedures.
In the treatment complex, all patients received iodine-bromine baths for the course of 10 procedures and basic drug therapy including a-adrenergic blockers.
SPSS 15.0 statistical package was used for statistical processing (Nasledov A.D., 2008). The normality of distribution of features was checked using Kolmogorov-Smirnov and Shapiro-Wilk tests. The data are presented as "mean ± standard deviation" (M ± ct). If the data were presented in scores, Wilcoxon T test was applied. If the sample distribution was different from normal or the data was presented in scores, the non-parametric MannWhitney U-test was applied. The significance critical level was assumed to be 0.05 (Glantz S.A., 1999).
Results and discussion
As a result of the treatment, pain and dysuric symptoms were relieved in most patients. However, in patients of the main groups (1A, 2A), the positive dynamics was more pronounced, which was manifested by a more significant decrease in the total score on the NIH-CPSI scale (Table 1). In patients of these groups, a more
significant decrease in the total score on the IPSS scale, QoL quality of life index was observed during treatment. Imperative symptoms decreased more dramatically in the main groups, with patients in the main group 2A showing a statistically significant decrease compared to the experimental group 2B (Table 1). The improvement of the copulative function was manifested by the increase in the total score of the MIEF-5 questionnaire from 16.2±2.2 to 19.8±1.1 (p<0.05) only in patients of the main group 1A, which was due to the lower severity of the disorders and more directed physiotherapeutic effects. Prostate digital investigation of patients of the main groups (1A, 2A) as a result of treatment revealed a decrease in painfulness and improved consistency, more pronounced in patients of the main group 1A (Table 1). The examination of PS more objectively reflected the dynamics of effectiveness 4 weeks after the treatment. Thus, the number of leukocytes in the prostatic secret was increased in 38.5% and 31.1% of cases respectively immediately after the course of treatment in the main groups (1A, 2A), which was due to the improvement of the drainage function of acini and was accompanied by normalization of PG palpatory parameters (painfulness and consistency). Normalization of the content of leukocytes occurred a month after treatment in 90.4% and 88.9% of patients of the main groups (1A, 2A) respectively. During treatment, normalization of adaptive reactivity occurred relatively more often in patients of the main groups (1A, 2A), which testified to good tolerability of treatment and was manifested by an increase in the number of patients with a calm activation reaction and a decrease in the number of patients with a high activation reaction at a high level of reactivity. In the patients of the main groups, one month after the treatment, the PSA level did not exceed the initial values of indicators and indicators in the experimental groups. According to urofluometry, there was an increase in Qmax and the effective capacity of the urinary bladder only in patients of the main groups, and Qmax was significantly different from that in the experimental groups (Table 1). In PG ultrasound examination, there was a slight decrease in its size due to decreased edema, improved echostructure, and statistically significant decrease in residual urine volume more pronounced in the main groups of patients (p<0.01) (Table 1). In the course of physiotherapy, pathological reaction in the form of increased pain, dysuria, painfulness in DRI was not observed. The integral indicator of evaluation of treatment effectiveness ("improvement" and "significant improvement") in patients of the main groups (1A, 2A) and the experimental groups (1B, 2B) was 90.4%, 86.7% and 61.5%, 57.7% respectively (p<0.01).
Table 1
Comparative dynamics of indicators in the study groups (M±a)
Indicator Main group (1A) Experimental group (1B) Main group (2A) Experimental group (2B)
n= =52 n= =24 n= =45 n= =20
b/t a/t b/t a/t b/t a/t b/t a/t
NIH-CPSI (S) 14.7±2.2 8.1±1.5*# 14.4+2.1 11.2±1.4* 18.5±2.4A 10.3±2.2*# 18.3±2.3 14.8±2.0*
NIH-CPSI (QoL) 3.7±0.3 2.1±0.2*# 3.5±0.4 2.7±0.2* 4.5±0.3A 2.6±0.2*# 4.4±0.3 3.2±0.2*
IPSS (S) 10.3±1.4 6.4±1.3** 10.2±1.3 8.1±1.2* 16.2±2.3A 9.1±1.7** 15.9±2.2 11.4±1.6*
storage 5.1±0.6 3.5±0.5** 5.0±0.6 4.0±0.4* 8.7±0.6A 4.9±0.4**# 8.6±0.5 5.8±0.3*
symptoms (questions 2, 4, 7)
DRI, 2.8±0.2 1.7±0.3**# 2.7±0.3 2.3±0.2 2.7±0.3 1.9±0.3* 2.7±0.2 2.4±0.2
painfulness (score)
DRI, 2.9±0.2 1.9±0.2**# 2.8±0.2 2.6±0.1 2.9±0.3 2.3±0.2* 2.8±0.2 2.6±0.2
consistency (score)
PS leukocytes 25.2±9.5 7.9±3.4**# 24.6±8.4 17.4±5.3 24.8±9.7 8.2±3.8** 23.8±8.2 15.9±4.8
(number per HPF)
Qmax M/s) 17.3±2.0 22.7±1.2**# 17.5±1.8 18.8±1.1 13.1±1.4A 16.9±1.1**# 13.4±1.3 15.5±1.0
V (ml) 278.4±22.7 328.2±18.3* 285.3±21.5 296.3±17.6 236.3±20.3A 282.7±18.4* 242.3±20.1 263.8±16.4
RU volume 14.8±5.4 4.7±2.6** 14.3±5.7 9.6±2.9 28.2±4.6AA 15.4±3.7** 28.5±4.2 18.2±3.5*
(ml)
Note: * - criterion of significance of differences within groups at p<0.05; ** - at p<0.01; # - criterion of significance of differences with the experimental group at p<0.05; A - criterion of significance of differences between the main groups at p<0.05; A A - at p<0.01. PS - prostatic secret, RU - residual urine, V - urination volume, HPF - high power field, DRI - digital rectal investigation, PG -prostate gland, b/t - before treatment, a/t - after treatment, * - on the IPSS scale.
In the analysis of remote treatment results, it was found that the frequency of relapses of CP during the year was observed in 9 (17.3%) and 8 (17.8%) patients of the main groups and in 11 (45.8%) and 8 (40%) patients of the experimental groups (2.6 and 2.2 times more often respectively, p<0.01). Dynamic observation did not reveal the stimulating effect of the performed complex treatment on the growth of PG hyperplasia and the IVO progression (Table 2). In patients of the main groups (1A, 2A), the PG
volume amounted to 27.9±3.1 and 36.9±3.2 cm3 respectively and did not differ significantly from the experimental groups (p>0.05). The PSA level did not significantly increase in patients of the main groups and the experimental groups (Table 2). Patients of the main groups (1A, 2A) maintained positive dynamics of LUTS according to the IPSS questionnaire, Qmax, and Vru (Table 2). The studied patients did not have episodes of AUR and progression of disease symptoms during the year.
Table 2
Remote treatment results in the study groups (M±a)
Indicator Main group (1A) n=52 Experimental group (1B) n=24 Main group (2A) n=45 Experimental group (2B) n=20
b/t n=52 rem. res. n=44 b/t n=24 rem. res. n=18 b/t n=45 rem. res. n=38 b/t n=20 rem. res. n=17
IPSS (S) 10.3±1.4 9.4±1.2 10.2±1.3 9.6±1.1 16.2±2.3A 15.3±1.9 15.9±2.2 15.5±2.0
Qmax (ml/s) 17.3±2.0 22.3±1.6 17.5±1.8 19.1±1.4 13.1±1.4A 16.3±1.3 13.4±1.3 15.1±1.4
PG volume (cm3) 27.1±3.2 27.9±3.1 26.5±3.1 27.4±3.4 35.9±2.5aa 36.9±3.2 35.5±2.3 36.6±3.1
RU volume (ml) 14.8±5.4 6.4±2.5* 14.3±5.7 12.3±3.3 28.2±4.6aa 18.7±3.0* 28.5±4.2 25.3±3.2
PSA (ng/ml) 0.9±0.2 1.0±0.2 0.8±0.2 0.9±0.2 1.2±0.3 1.4±0.2 1.2±0.3 1.4±0.3
Note: * - criterion of significance of differences within groups at p<0.05; a - criterion of significance of differences between the main groups at p<0.05; a a - at p<0.01.
RU - residual urine, PG - prostatic gland, b/t - before treatment, rem. res. - remote treatment results. 50
The therapeutic effect of low-energy LED therapy causes anti-inflammatory, trophic and microcirculation improving impact. Compared to the red spectrum, the blue spectrum of radiation more pronouncedly suppresses the alterative and exudative phases of inflammation, stimulates phagocytosis, improves blood circulation and rheological blood properties, has a bactericidal effect [9]. The magnetic field significantly reduces the absorption of electromagnetic oscillations, increasing the light penetration depth and reducing the reflection coefficient, thereby potentiating the effects [10]. In CP in elderly patients, including the combination with the I stage BPH, rectal sapropel tampons are carried out at a temperature of therapeutic mud 37-38°C, but at the same time, there is a decrease in the rectal mucosa permeability for biologically active substances, decrease in the action of chemical factors, which causes an insufficient anti-inflammatory effect. Therapeutic efficiency of sapropel and micro-enemas of mineral water in combination with PMF significantly increases, making it possible to use them at a temperature of 37-38°C, excluding the thermal influence factor [11]. Optimized parameters of PMT stimulate the contractile function of detrusor and PG, therefore they are recommended for detrusor hyporeflexia and contraindicated for detrusor hyperactivity against the background of IVO [3, 12]. US therapy has mainly an anti-inflammatory and antispasmatic effect and is used for detrusor hyperreflexia [12]. Artificial iodine-bromine baths have a regulatory effect on the hypothalamus-pituitary system, reduce the dynamic component of IVO (reduce sphincter hypertonia) and detrusor hyperactivity [12].
Conclusion
Optimization of physiotherapeutical influence in patients with CP in combination with BPH was carried out by using the blue spectrum of LED radiation and combined methods of PMF magnetic therapy: photomagnetotherapy and magnetopelotherapy.
The use of optimized methods of physiotherapy in patients with CP in combination with BPH allowed to conduct differentiated treatment depending on the severity of LUTS, the prevalence of obstructive or irritative symptoms, and the level of prostatic hyperplasia, which increased the treatment effectiveness, increased the remission period and provided a good safety profile.
Conflict of interest. The authors declare that there is no conflict of interest.
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Contacts
Corresponding author: Kolmatsui Igor Anatolievich, Candidate of Medical Sciences, Senior Researcher of the Advisory Group of the Department of Prevention and Rehabilitation Treatment of Professional Diseases, Federal Siberian Research Clinical Centre under the Federal Medical Biological Agency, Tomsk 634009, Tomsk, ul. Rosy Luxembourg, 1. Tel.: (3822) 906511; 8 (913) 8060158. E-mail: [email protected]
Author information
Levytsky Evgeny Fedorovich, Doctor of Medical
Sciences, Professor, Honoured Worker of Science
of the Russian Federation, Tomsk.
634009, Tomsk, ul. Rosy Luxembourg, 1.
Tel.: (3822) 512005.
E-mail: [email protected]
