UroToday - At a glance one could assume that this study was solely empirical - on the contrary! Shock waves (SWs) seem to have a greater therapeutic potential than is assumed and understood today. Finally, the effect of SW cannot be explained by current models of thinking. The recently published SW model by Wess1 is a very promising and tremendous basic approach: SW could modify brain processes and pain storage patterns - both to be influenced therapeutically. We are going to follow these concepts by specific research investigating processes inside the brain during SW application. Possible reactions in the brain and changes under running Extracorporeal Shock Wave Treatment (ESWT) are presently the most promising approaches to understanding the working mechanisms of SW. We intend to apply SWs not only clinically, but also to enhance our knowledge by basic research about their therapeutic effects. The missing animal model for chronic pelvic pain syndrome (CPPS) does not contribute to simplifying the understanding of pathophysiological processes influenced by ESWT, in particular due to the fact that the knowledge about CPPS pathophysiology itself is very limited.

Alteration in local perfusion is one more explanation for SW effects: We know that perfusion increases immediately after SW application. As a long-term effect, the VEGF expression in treated tissue increases. There are very conclusive investigations on ischemic heart tissue in which processes of neovascularisation have been induced by ESWT and consecutive VEGF increase. Whether there is a link from increased perfusion to pain relief is, however, still unclear.

Based on most recent in vitro research we could imagine also extending this treatment to chronic bacterial prostatitis. The rationale could be several investigations proving the bactericide effects of SW. The in vitro findings could be linked with clinical effects and results in this group of patients who are still a therapeutic (and personal!) challenge to us urologists.

Finally, ESWT is a typical outpatient therapy that can be offered very easily in private offices. Unfortunately, there is no reimbursement by public health services either in Germany or in Austria at the moment. Therefore, the incentive for urologists to apply ESWT for CPPS in their private offices is low.

Additionally, many urologists are not aware of the fact that SW does not inevitably mean stone therapy, therefore equating to destruction. In fact, SWs have clearly shown tissue-regenerating effects. These effects are successfully used for the treatment of disorders of local perfusion, wound and fracture healing and even for cellulite. This fact must enter into urologists` awareness and the therapeutic potential of ESWT has to be understood. As a result of these changes, hopefully more urologists will consider this treatment as a viable option and recommend it to their CPPS patients.

1. Wess OJ, A neural model for chronic pain and pain relief by extracorporeal shock wave treatment. Urol Res. 2008 Dec;36(6):327-34.

Reinhold Zimmermann, MD as part of Beyond the Abstract on UroToday

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