Treatments

Embolization Treatment for Chronic Prostatitis

Posted on by Prof. Dr. Özgür KILIÇKESMEZ

Chronic prostatitis, especially common in middle-aged and older men, is a health issue that can severely impact quality of life, causing pain and various urinary problems.

What Is Chronic Prostatitis/CPPS and What Are Its Symptoms?

Chronic prostatitis, or “Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)” in the literature, is defined as inflammation/irritation of the prostate gland lasting longer than three months without clear evidence of infection. The prostate is an important part of the male reproductive system, located just below the bladder outlet. Therefore, any problem in the prostate manifests not only with pain complaints but also with functional symptoms such as frequent urination or difficulty urinating.

  • How Do Symptoms Arise?

People with chronic prostatitis/CPPS often complain of pain located in the groin area, testes, lower abdomen, or between the lower back and tailbone. This pain may sometimes be accompanied by a burning sensation. Functional complaints such as increased frequency of urination, difficulty during urination, and waking frequently at night may also be added to the picture.

  • Impact on Quality of Life

When pain becomes chronic, it can lead to involuntary contractions of the muscles in that area, creating a chronic cycle. The person cannot sleep comfortably and may have difficulty concentrating on work or social life. Psychologically, additional issues such as restlessness and depressive feelings may arise over time.

  • What Can Cause It?

The exact cause has not yet been fully elucidated. Sometimes past infections, sometimes autoimmune or neuropsychological factors are blamed. That is, it may be related to the body’s own immune system or microvascular changes in that area. Additionally, pelvic muscle spasms, stress, and anxiety disorders can exacerbate the condition.

Why Traditional Treatments May Not Always Be Sufficient

Traditional first-line treatments for chronic prostatitis/CPPS include antibiotics, alpha-blockers, anti-inflammatory drugs, and some supportive therapies. However, research shows that these treatments often are not as effective as expected or do not succeed in every patient. For example:

  • Antibiotics: Tried even when no bacteria are found in the prostate because some patients may experience short-term benefit. However, if there is no bacteria, antibiotics may remain an “ill-fitting” treatment in the long term.
  • Alpha-blockers: Help relax the muscles around the urinary tract. While they offer some relief, they may not always produce sufficient pain improvement.
  • Anti-inflammatory Drugs: Aim to reduce pain and inflammation. However, because the cause of inflammation in chronic prostatitis is complex, this treatment alone may be inadequate.

A brief analogy: chronic prostatitis can be thought of as a small splinter stuck in your hand. Unless you remove the splinter, superficial interventions may provide temporary relief, but the underlying issue persists. So what is the “splinter”? In some patients, it is the cycle created by abnormal blood vessels (neovascularization) and chronic inflammatory tissue within the prostate. This is where the method called “embolization” comes into play.

What Exactly Is Embolization and How Does It Work?

Embolization means deliberately delivering a substance into blood vessels to temporarily or permanently reduce/block blood flow feeding the target tissue. Here, the goal is to limit the blood supply to the problematic tissue (e.g., inflamed or hypervascular area) and thus “dry up” the source of pain or inflammation. It can be likened to stopping watering a plant that is already rotting, rather than continuing to water it in the garden.

  • What Happens in Chronic Prostatitis?

Chronic inflammation induces the formation of new blood vessels (neovascularization) in the affected area. These vessels increase sensitivity in surrounding tissues and contribute to the stimulation of pain-transmitting nerve fibers. Once established, this cycle can become self-sustaining.

  • How Does Embolization Help?

When we temporarily block these new vessels feeding the inflammation, excessive blood flow and migration of inflammatory cells to the area decrease. The level of inflammation can drop, pressure on nerves may be relieved, and as a result, pain can be brought under control.

How Is “Transcatheter Arterial Embolization” (TAE) Performed?

Breaking down the term:

  • Transcatheter: Using a thin catheter, usually inserted via the groin (femoral artery), to reach the desired area of the body.
  • Arterial: Performed through arteries.
  • Embolization: Blocking vessels with a “plug” or sealing substance.

Preparation Process

  • The patient’s overall health, medications, and prostate tissue structure are evaluated before the procedure.
  • In some patients, multiparametric MRI is performed to rule out cancer-like risks in prostate tissue and determine prostate size.

Procedure Steps

  • Local anesthesia (regional numbing) is usually sufficient.
  • A thin catheter is inserted into the femoral artery in the groin. Since the entry site is as small as a needle prick, there is no large surgical incision.
  • The catheter is advanced to the prostatic artery feeding the prostate gland and, if needed, to related vessels such as the internal pudendal artery supplying pelvic muscles.
  • During the procedure, contrast agent or “evoked pain” tests are used to identify which vessels are truly associated with the painful area.
  • An embolic agent such as an imipenem/cilastatin (IPM/CS) mixture or similar temporary occlusive material is delivered to the target vessel. Blood flow through that vessel is largely reduced or stopped.
  • Once embolization is complete, the catheter is withdrawn, pressure is applied at the entry site, and the patient is often discharged the same day.

Why Is Temporary Embolization Important?

Instead of permanent-occlusion microspheres (e.g., those used for prostate enlargement), temporary occlusive materials are sometimes preferred. Because in chronic prostatitis, the goal is not to destroy the tissue completely but to calm chronic inflammation by stopping abnormal blood flow. Oxygen and inflammatory cell over-delivery to the tissue is blocked, but this effect is temporary. Thus, healthy tissue is preserved, and serious complications are less likely.

What Does Research Show?

Data before and after treatment in these patients were examined using various scales. The main metrics:

  1. NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index):
    • Score range 0–43; higher scores indicate more severe symptoms.
    • The average baseline score of participants was 27 (indicating moderate to severe symptoms).
  2. Pain Score (Numeric Rating Scale, NRS):
    • A 0–10 scale is typically used (0: no pain, 10: worst imaginable pain).
    • The average baseline pain level was 7.0 (quite severe).

Findings

  • NIH-CPSI Changes:
    1. 1 month: 21
    2. 3 months: 20
    3. 6 months: 17

    At follow-up beyond 12 months (around 16–17 months): 18

    These numbers show a statistically significant decrease. The total score reflecting pain, urinary complaints, and quality-of-life impairment dropped from 27 to around 17–18, indicating notable relief in many patients.

  • Pain Score (NRS) Changes:
    1. 1 month: 4.8
    2. 3 months: 4.1
    3. 6 months: 3.7

    At over 12 months: 3.4

    This shows pain levels fell to a tolerable range. A drop from 7 to 3.4 can mean a major improvement in daily activities.

  • Clinical Success Rate:

    Defining “clinical success” as at least a 6‑point improvement in NIH-CPSI score, 70% of patients showed significant, lasting improvement at 6 months, and 64% at final follow-up. These rates are encouraging for patients suffering from chronic prostatitis for a long time.

  • Repeat Sessions and Follow‑Up:

    While a single TAE session was sufficient for some, others needed 2 or 3 sessions. Nonetheless, the fact that most procedures are day‑case demonstrates the relative safety and repeatability of the method.

What Are the Risks and Reliability of the Procedure?

As with any invasive procedure, TAE carries some risks. However, these are much lower compared to major surgery. In this study:

  • No major complications were reported.
  • Common but mild issues included small groin bruising (hematoma) or mild pain, and rarely allergic rash (hives).
  • All these side effects resolved within a week, mostly without additional intervention.

Concerns about vessel occlusion are mitigated by using temporary agents, avoiding long‑term tissue death or functional loss. However, accidental embolization of non-target pelvic arteries can risk erectile function or regional blood flow. Therefore, experienced interventional radiologists must use fine catheters to precisely identify and target vessels.

Who Can Benefit from This Treatment?

  • Diagnosis: Those with pelvic pain lasting over three months, diagnosed with non‑bacterial prostatitis, and having at least moderate symptoms (e.g., NIH-CPSI ≥ 15).
  • Treatment Resistance: Patients who have not benefited from or cannot tolerate classical medications (antibiotics, alpha‑blockers, painkillers).
  • Prostate Cancer Suspicion: After excluding serious conditions like prostate cancer via MRI or biopsy, TAE may be a logical option.

What to Watch for After the Procedure?

Since the procedure is usually day‑case, patients can be discharged the same or next day. However, a few days of rest are recommended. Your doctor may advise:

  • Light Activity Restriction: Avoid heavy exercise for the first week, especially movements that strain the groin or heavy lifting.
  • Medications: Short‑term painkillers or mild anti-inflammatories as needed.
  • Hydration: Adequate water intake helps regulate circulation and reduce side‑effect risks.
  • Follow‑Up: Assess pain and other symptoms after a few weeks. Monitoring NIH-CPSI scores in the first months helps decide on second or third sessions if needed.

What Are the Long‑Term Effects?

The study showed that improvements starting as early as one month continued at 6 and 12 months. Although individual results vary, symptom control remained significant over an average follow‑up of 16–17 months. For example, 90% of those who achieved “clinical success” maintained their gains for over a year.

Like chronic back pain, chronic prostatitis can have flare‑ups and remission periods. TAE can greatly reduce or control these recurrences. Additionally, post‑procedure reliance on medications appears to decrease by about half, offering long‑term advantages in terms of side effects and costs.

What If Pelvic Pain Originates from Muscles/Bones?

In chronic prostatitis/CPPS, pelvic floor muscle spasms or other soft‑tissue issues may also contribute to pain. Therefore, the study reports that embolization was applied not only to prostatic arteries but also to vessels like the internal pudendal artery (IPA) that supply pelvic floor muscles when “evoked pain” testing indicated typical groin pain. Results show this approach significantly aids pain management, though it may not apply to every patient. Accurate identification of the target vessel by the physician is crucial.

How to View the Question “What If It Needs Repeating?”

Embolization is less invasive than cardiovascular surgery or major operations. Nevertheless, symptoms may return or first‑session improvement may be insufficient in some patients. In such cases, a second or even third session can be performed. In the referenced study, 76 TAE sessions were performed: 22 patients underwent two sessions, and 5 patients underwent three sessions. Still, most patients were satisfied with results after the first or second session.

Who Is Not a Candidate for This Treatment?

  • Patients with Prostate Cancer: Cancer treatment takes priority in those diagnosed with prostate cancer.
  • Severe Cardiovascular Issues: Extra precautions are needed if the patient has significant heart or vascular problems.
  • Active Infection: An ongoing fever or detected bacterial growth must be treated before embolization.
  • Anatomic Barriers: Severe vascular abnormalities or inaccessible vessels may make the procedure technically difficult.

Future Research and Final Thoughts

While these initial findings are promising, larger, multi‑center studies in different countries with more patients are needed before transcatheter arterial embolization becomes a “standard” treatment for chronic prostatitis/CPPS. Nonetheless, current results suggest the method is effective and safe, particularly:

  • Six‑month success rates up to 70%
  • ~64% durability at an average 16–17‑month follow‑up
  • Half of patients significantly reducing or eliminating medication needs

These are encouraging developments that can improve quality of life for many men suffering from chronic pain for years.

Remember that the human body is a complex system, and pelvic pain may not always originate from the prostate. Therefore, detailed examination, imaging, and tests are essential during diagnosis. Embolization can yield successful results in appropriately selected patients, but it is not suitable for everyone. A multidisciplinary evaluation by a qualified urologist, interventional radiologist, and, if necessary, a pain specialist is the healthiest approach.

In Summary

Chronic prostatitis/CPPS is a condition causing years of groin and pelvic pain in men, significantly reducing quality of life.

  • Traditional drug treatments are not always effective, as the underlying mechanism is multifactorial and not fully understood.
  • Transcatheter Arterial Embolization temporarily restricts abnormal blood supply and inflammatory vessel growth in the problematic area.
  • Research data show that about 70% of patients achieve “clinical success” at six months (≥6‑point NIH‑CPSI reduction), and about 64% maintain it over ~1.5 years.
  • The procedure can be done as a day case or with short hospitalization, is less traumatic than major surgery, and has a very low serious complication rate.
  • Long‑term results are encouraging, though larger clinical trials are needed to support the data.

Chronic prostatitis/CPPS is not a “fate.” While each patient’s story differs, modern medical approaches offer many more solutions than before. If you or someone you know suffers from long‑term pelvic pain, consulting specialists to learn which treatment options are suitable is the first step. Innovative methods like TAE, when applied to the right patient, can bring visible improvement in pain and quality of life. In other words, that persistent “background pain” of years can finally fall asleep, opening the door to a more comfortable life.

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