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Efficacy of Different Acupuncture Therapies for Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Network Meta-Analysis
Authors Qin P , Cao X, Ni H, Yang L, Tong Y, Dang M, Xu J
Received 2 April 2025
Accepted for publication 8 July 2025
Published 17 July 2025 Volume 2025:18 Pages 3653—3673
DOI https://doi.org/10.2147/JPR.S530646
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Houman Danesh
Acupuncture for Chronic Prostatitis/Chronic Pelvic Pain Syndrome – Video abstract [530646]
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Peipei Qin, Xun Cao, Hua Ni, Liu Yang, Yiman Tong, Mengbo Dang, Juan Xu
Rehabilitation Department, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, People’s Republic of China
Correspondence: Juan Xu, Rehabilitation Department, The Second Affiliated Hospital of Xuzhou Medical University, 32 Meijian Road, Quanshan District, Xuzhou City, Jiangsu Province, People’s Republic of China, Email [email protected]
Background: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) presents substantial therapeutic challenges, as existing drug therapies demonstrate limited efficacy and often cause adverse effects. These limitations highlight the need to explore non-pharmacological alternatives.
Purpose: This network meta-analysis aimed to evaluate the comparative efficacy of eight acupuncture therapies versus usual treatment (UT) for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
Results: From 67 RCTs (5961 patients), all acupuncture modalities outperformed conventional drugs in clinical efficacy (P< 0.05), with long-needle acupuncture ranking highest (SUCRA 88.7%). Specific outcomes revealed: 1) symptom scores: thumb-tack needle (SUCRA 90.9%) and long-needle acupuncture (72.2%) showed the greatest NIH-CPSI reduction; 2) Pain: long-needle acupuncture (76.3%) and acupoint catgut embedding (69.3%) ranked top; 3) Urination: long-needle acupuncture (82.9%) and conventional acupuncture (47.9%) surpassed UT; 4) Quality of life: thumb-tack needle (72.3%), electroacupuncture (65.6%) and long-needle acupuncture (64.1%) were optimal. Long-needle acupuncture consistently demonstrated superior efficacy across both subjective symptoms and objective measures.
Conclusion: Acupuncture therapies, especially long-needle acupuncture, are more effective than UT for CP/CPPS, providing comprehensive symptom relief, pain reduction, and functional improvement, with long-needle acupuncture emerging as the most robust intervention.
Keywords: acupuncture, chronic prostatitis/chronic pelvic pain, network meta-analysis
Background
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is mainly manifested as long-term, recurrent pain or discomfort in the pelvic floor area and varying degrees of lower urinary tract symptoms, such as frequent urination, dysuria, incomplete emptying of the bladder, or painful ejaculation, etc. It is a common genitourinary disorder1 that seriously affects patients’ physical and mental health, causing psychological symptoms such as dizziness, fatigue, memory loss, and even depression and anxiety.2,3 CP/CPPS affects 2–10% of adult men globally, with an incidence reaching 8.2% among specific populations. This significant disease burden contributes to substantial healthcare costs and reduced quality of life (QOL) among affected individuals.4–6 Critically, research demonstrates that a significant proportion of patients (11.5%) are susceptible to anxiety disorders, with studies indicating that these patients exhibit a nearly two-fold elevated risk compared to the general population.7,8 This phenomenon is attributed to several molecular mechanisms. Neuroinflammatory pathways involve elevated tumor necrosis factor-α (TNF-α) derived from prostate tissue mast cells, which activates TRPV1+ nociceptors, subsequently inducing central sensitization.9,10 Oxidative stress responses are characterized by elevated levels of 8-hydroxydeoxyguanosine (8-OHdG) in seminal fluid, which can lead to mitochondrial dysfunction within pelvic nerves.11–13 Additionally, hypothalamic-pituitary-adrenal (HPA) axis and amygdala dysregulation is characterized by increased corticotropin-releasing factor (CRF) levels in the hypothalamic paraventricular nucleus (PVN). This, in turn, leads to reduced GABAergic inhibition in the basolateral amygdala, resulting in anxiety-like behaviors.14–16
Because the etiology and pathogenesis of CP/CPPS are still unclear, the course of disease is long, and the symptoms are recurrent, effective treatment of CP/CPPS is still challenging, and there is no ideal treatment method.17,18 At present, the main treatment method is to alleviate patients’ clinical symptoms and improve their QOL.19,20 Clinically, relevant drug treatments such as antibiotics, a-receptor blockers, non-steroidal anti-inflammatory drugs, antidepressants and anti-anxiety drugs, 5-α-reductase inhibitors, M-receptor blockers, β3-receptor agonists, and analgesics, etc. are usually administered empirically.17,21 However, studies demonstrated that due to the natural defense system of the blood-prostate barrier, the passage rate of drugs is low, and the drug concentration at the lesion is far from sufficient, resulting in unsatisfactory efficacy.22 In addition, these drugs usually have side effects, such as orthostatic hypotension, gastrointestinal reactions, etc., which make patients unable to tolerate drug treatment and affect the efficacy.18
According to its main clinical symptoms, CP/CPPS belongs to the categories of “stranguria”, “turbid semen disease”, and “low back pain” in traditional Chinese medicine (TCM). Most of the cases are caused by factors such as downward flow of damp-heat, poor emotion, Qi stagnation and blood stasis, kidney deficiency and liver Qi stagnation, causing damp invasion of the bladder and resulting in water and fluid metabolism disorders.23 The regulation of Qi and blood and the balance of intestines are the theoretical basis of TCM for acupuncture treatment of CP/CPPS. Experimental data confirm that acupuncture therapy exhibits multi-target regulatory mechanisms. It significantly downregulates TNF-α expression and interleukin-1β (IL-1β) mRNA levels in prostatic tissue.24,25 Furthermore, acupuncture markedly enhances antioxidant capacity, as evidenced by increased superoxide dismutase (SOD) activity and decreased malondialdehyde (MDA) levels.26 It also effectively modulates hypothalamic-pituitary-adrenal axis function, reducing cortisol levels while increasing serum γ-aminobutyric acid (GABA) levels.27,28 Acupuncture can improve the symptoms of patients with CP/CPPS by regulating the immune system,29 improve clinical efficacy, and have fewer adverse events (AEs).30 These findings suggest that acupuncture could be a potential complementary therapy for CP/CPPS. Despite the evidence supporting its efficacy, acupuncture remains underutilized relative to conventional therapies for CP/CPPS in clinical practice. Key barriers to its implementation include inconsistent clinical protocols, as well as standardization gaps in treatment scheduling (frequency and duration), needle techniques (depth and stimulation), and acupoint selection. These factors limit reproducibility across practitioners.31–33 Methodological limitations in research also pose challenges, with many studies relying on non-standardized outcome measures and unvalidated diagnostic criteria. This undermines the reliability of evidence and hinders comparative analysis. For example, the lack of head-to-head trials is a concern.34 Additionally, mechanistic ambiguities remain, as the biological basis of acupuncture’s effects is still incompletely characterized within contemporary biomedical frameworks, impeding mechanistic justification for its clinical use.34,35 These limitations directly manifest as critical deficiencies in clinical acupuncture research: the absence of standards for diagnosis and treatment, syndrome differentiation and treatment, and efficacy evaluation.36 Thus, the current study aimed to resolve the above disputes via a network meta-analysis (NMA) and provide more precise treatment options for CP/CPPS.
Methods and Materials
This NMA strictly followed the PRISMA reporting guidelines to ensure transparency and reproducibility of its process and had been successfully registered on the PROSPERO platform with a registration number of CRD42024565661.
Literature Retrieval
The Cochrane, PubMed, Embase, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Network databases were retrieved for randomized controlled trials (RCTs) on the efficacy of different acupuncture therapies in treating CP/CPPS up to April 24, 2024. A combination of subject terms plus free terms (CP/CPPS and acupuncture) was employed for the retrieval. The detailed strategy is described in the Supplementary Methods and Material.
Eligibility Criteria
Inclusion criteria: Adults who met the diagnostic criteria for CP/CPPS37 were included. The intervention group received various acupuncture therapies, including long-needle acupuncture, warm needle acupuncture, thumb-tack needle acupuncture, elongated-needle acupuncture, fire-needle therapy, conventional acupuncture, acupoint catgut embedding, and electroacupuncture. The control groups received conventional drug treatment, sham acupuncture, other physical therapies (such as neuromuscular electrical stimulation, Chang Qiang acupoint application, lower abdominal nerve block, radiofrequency therapy, and ultrashort wave therapy), or no treatment at all. In this NMA, these different types of control interventions were used as usual treatment (UT) for analysis and comparison. The primary outcome was clinical efficacy, secondary outcomes were chronic prostatitis symptom index scores (NIH-CPSI symptom score), pain, urination symptoms, and QOL, and the study type was an RCT.
Exclusion criteria: Duplicate literature, animal studies, case reports, conference abstracts, reviews, articles with unavailable full texts, studies combining other organic diseases.
Data Extraction
The two authors conducted a rigorous review of articles according to the predefined eligibility criteria. Any disagreements were resolved via discussion or third-party consultation. Information extracted consisted of the following: first author, publication year, country, sample size, gender, age, intervention, and outcome indicators.
Quality Evaluation
The risk of bias (ROB) was evaluated via the latest recommendations of the Cochrane Bias Assessment Manual ROB Assessment Tool 2.0 (ROB 2.0),38 which encompassed five main parts: randomization bias, bias due to deviation from intervention, bias due to missing outcome data, bias due to outcome measurement, and bias due to selective reporting of outcomes. The quality of literature was categorized as “low ROB”, “some concerns” and “high ROB”. The study results were reviewed by two investigators, and any disagreements were resolved via discussion or third-party consultation.
Data Analysis
By utilizing R4.4.1 software (R Foundation for Statistical Computing), a Bayesian NMA was conducted on multiple groups of trials via a priori fuzzy random effect model. The Markov chain Monte Carlo (MCMC) method39 was adopted to obtain the best pooled estimates and probabilities for each treatment regimen. Trajectory charts and Brooks-Gelman-Rubin plots were applied to evaluate the model convergence, and continuity results were expressed as posterior mean difference (MD) and its 95% confidence interval (CI). The surface under the cumulative ranking curve (SUCRA) was computed to estimate the probability of the best intervention. A pass-through macro command was loaded in STATA 15.0 to draw network diagrams and funnel plots. In a network diagram, each circle represented a drug and the edges represented existing comparisons. The size of a circle was proportional to the number of patients included. Cumulative probability plots were plotted via the ggplot2 package.
Results
Data Screening Process and results
A preliminary retrieval yielded 1011 articles, 260 duplicates were removed first, 678 articles were excluded by reading titles and abstracts, and 6 articles were removed by reading full texts. Finally, 6740–106articles were incorporated in this NMA (Figure 1).
 |
Figure 1 Literature retrieval process. |
Basic Characteristics of Literature and ROB Assessment
The 67 articles included 5938 patients with CP/CPPS. Acupuncture therapies encompassed long-needle acupuncture, warm needle, thumb-tack needle, elongated-needle acupuncture, fire-needle therapy, conventional acupuncture, acupoint catgut embedding, and electroacupuncture. The specific characteristics are illustrated in Table 1.40–106 The blinding method employed was clearly accounted for in these studies, and the high risk was mainly due to the deviation from the intended interventions. The ROB assessment for the included studies is presented in Figures 2 40–106 and 3.
 |
Table 1 Characteristics of Literature |
 |
Figure 2 Risk of bias summary (green circle with a plus mark: indicates a low risk of bias, red circle with a minus mark: indicates a high risk of bias, yellow circle with a question mark: indicates an unclear risk of bias.). |
 |
Figure 3 Risk of bias graph. |
Results of NMA
Clinical Efficacy
Fifty-six articles40–50,53–57,59,60,63–100 mentioned the clinical efficacy, as illustrated in Figure 4A. Compared to UT, long-needle acupuncture [MD=5.9, 95% CI (2.8, 13.0)], thumb-tack needle [MD=3.8, 95% CI (1.8, 8.6)], elongated-needle acupuncture [MD=3.1, 95% CI (1.6, 5.9)], conventional acupuncture [MD=2.8, 95% CI (2.3, 3.5)], electroacupuncture [MD=2.6, 95% CI (1.5, 4.6)], acupoint catgut embedding [MD=2.6, 95% CI (1.4, 4.9)], and warm needle [MD=4.5, 95% CI (2.4, 8.8)] improved the clinical efficacy for CP/CPPS patients, and no significant difference was found between the efficacy of fire-needle therapy and conventional drug treatment for CP/CPPS patients [MD=2.7, 95% CI (0.78, 11.0)] (Figure 4B). However, there was no significant difference in the efficacy for CP/CPPS patients among long-needle acupuncture, warm needle, thumb-tack needle, elongated-needle acupuncture, conventional acupuncture, acupoint catgut embedding, electroacupuncture (Table S1). The long-needle acupuncture exhibited the largest SUCRA (88.7%), followed by warm needle (77%), thumb-tack needle (65.8%), elongated-needle acupuncture (51.1%), fire-needle therapy (44.5%), conventional acupuncture (44%), acupoint catgut embedding (39.5%), electroacupuncture (38.7%), and UT (0.8%) (Figure 4C and Table 2).
 |
Table 2 SUCRA Comprehensive Ranking |
 |
Figure 4 Meta-analysis of clinical efficacy ((A) Network diagram, (B) Forest plot, (C) Area under the cumulative probability curve). |
NIH-CPSI Symptom Score
Thirty-two articles41,42,44,45,48,51,52,54–56,60,61,63–65,68,69,71,75,76,80,82,85,88,97–104 referred to NIH-CPSI symptom scores, as illustrated in Figure 5A. Compared to UT, conventional acupuncture [MD=−3.6, 95% CI (−5, −2.2)], electroacupuncture [MD=−3.5, 95% CI (−6.8, −0.26)], long-needle acupuncture [MD=−6.1, 95% CI (−10, −1.6)], and thumb-tack needle [MD=−8.9, 95% CI (−15, −2.7)] improved patients’ NIH-CPSI symptom scores more effectively (Figure 5B). However, there was no significant difference among long-needle acupuncture, thumb-tack needle, conventional acupuncture, and electroacupuncture in improving the NIH-CPSI symptom score in CP/CPPS patients (Table S2). The thumb-tack needle exhibited the largest SUCRA (90.9%), followed by long-needle acupuncture (72.2%), electroacupuncture (41.6%), conventional acupuncture (41.5%), and UT (1%) (Figure 5C and Table 2).
 |
Figure 5 Meta-analysis of NIH-CPSI symptom scores ((A) Network diagram, (B) Forest plot, (C) Area under the cumulative probability curve). |
Pain
Twenty-six articles45,48,51,54,55,58,61,63–65,68,69,80,81,85,88,91,92,98–102,104–106 referred to pain, as illustrated in Figure 6A. Compared to UT, conventional acupuncture [MD=−1.3, 95% CI (−2, −0.58)], electroacupuncture [MD=−1.7, 95% CI (−3.1, −0.25)], long-needle acupuncture [MD=−2.4, 95% CI (−4.4, −0.49)], thumb-tack needle [MD=−2.0, 95% CI (−3.9, −0.085)], and acupoint catgut embedding [MD=−2.2, 95% CI (−4.4, −0.49)] improved patients’ pain scores more effectively (Figure 6B). However, there was no significant difference among long-needle acupuncture, thumb-tack needle, conventional acupuncture, electroacupuncture, and acupoint catgut embedding in improving the pain score in CP/CPPS patients (Table S3). The long-needle acupuncture exhibited the largest SUCRA (76.3%), followed by acupoint catgut embedding (69.3%), thumb-tack needle (63.4%), electroacupuncture (52.9%), conventional acupuncture (37%), and UT (1.1%) (Figure 6C and Table 2).
 |
Figure 6 Meta-analysis of pain ((A) Network diagram, (B) Forest plot, (C) Area under the cumulative probability curve). |
Urination Symptoms
Sixteen articles45,48,51,54,61,65,68,69,80,85,88,98,100,102,104,105 mentioned urination symptoms, as depicted in Figure 7A. Compared to UT, conventional acupuncture [MD=−1.0, 95% CI (−1.8, −0.19)] and long-needle acupuncture [MD=−2.1, 95% CI (−3.8, −0.29) improved patients’ urination discomfort more effectively (Figure 7B). However, there was no significant difference between long-needle acupuncture and conventional acupuncture in improving the urination discomfort in CP/CPPS patients (Table S4). The long-needle acupuncture exhibited the largest SUCRA (82.9%), followed by conventional acupuncture (47.9%), and UT (4%) (Figure 7C and Table 2).
 |
Figure 7 Meta-analysis of urination symptoms (A: Network diagram, (B) Forest plot, (C) Area under the cumulative probability curve). |
QOL
Eighteen articles41,45,48,51,54,61,65,68,69,80,85,88,98–100,102,104,105 mentioned QOL, as illustrated in Figure 8A. The network diagram demonstrated a closed loop, so a local inconsistency test was adopted. The results (Figure S1) indicated that there were no differences in direct comparisons, indirect comparisons, and network comparisons between long-needle acupuncture and conventional acupuncture, conventional drug treatment and conventional acupuncture, UT and long-needle acupuncture. Compared to UT, conventional acupuncture [MD=−0.89, 95% CI (−1.9, 0.14)], electroacupuncture [MD=−1.6, 95% CI (−3.3, 0.092)], long-needle acupuncture [MD=−1.6, 95% CI (−4.0, 0.76), and thumb-tack needle [MD=−2.1, 95% CI (−5.5, 1.2)] exhibited no significant differences in improving QOL (Figure 8B). In addition, there was no significant difference among long-needle acupuncture, conventional acupuncture, electroacupuncture, and thumb-tack needle in improving QOL in CP/CPPS patients (Table S5). The thumb-tack needle demonstrated the largest SUCRA (72.3%), followed by electroacupuncture (65.6%), long-needle acupuncture (64.1%), conventional acupuncture (41.7%), and UT (6.29%) (Figure 8C and Table 2).
 |
Figure 8 Meta-analysis of quality of life (A: Network diagram, (B) Forest plot, (C) Area under the cumulative probability curve). |
PB Evaluation
Funnel plots were employed to evaluate PB of clinical efficacy, NIH-CPSI symptom score, pain, urination symptoms, and QOL. The results suggested that there was a high possibility of PB in clinical efficacy, NIH-CPSI symptom score, pain, urination symptoms, and QOL (Figures S2–6).
Discussion
The current NMA was the first of its kind to evaluate the effect of different acupuncture therapies on the clinical efficacy, NIH-CPSI symptom score, pain, urination symptoms, and QOL in CP/CPPS patients. This is the novelty of the study.
This NMA compared 8 different acupuncture therapies based on 67 RCTs. The results revealed that in terms of overall efficacy, long-needle acupuncture, warm needle, and thumb-tack needle were the best three treatments compared to UT. With regard to the improvement of NIH-CPSI symptom scores, thumb-tack needle, long-needle acupuncture, and acupoint catgut embedding were the best three treatments compared to UT. With regard to pain improvement, thumb-tack needle, long-needle acupuncture, and acupoint catgut embedding were the best three treatments compared to UT. With regard to the improvement of urinary symptoms, long-needle acupuncture and conventional acupuncture were better than UT. With regard to the improvement of QOL, thumb-tack needle, electroacupuncture, and long-needle acupuncture exhibited better efficacy.
Although thumb-tack needle was effective in improving NIH-CPSI symptom scores, relieving pain, and enhancing QOL, it showed poor overall clinical efficacy. This limitation is attributable to the shallow stimulation depth (≤5 mm), which fails to engage the core pathophysiological mechanisms, resulting in suboptimal therapeutic outcomes.43,101,107 As Wang et al demonstrated, the use of sham acupuncture with shallow needling (2–3 mm) resulted in only a modest improvement in symptoms and QOL when compared to deep needling (50–60 mm).101 In contrast, long-needle acupuncture (75–90 mm depth) directly targets the prostatic plexus ganglia,100 delivering dual therapeutic benefits: it not only significantly improves patients’ subjective symptom scores but also yields objective clinical improvements. Zhou et al demonstrated that long-needle acupuncture significantly improved urination, pain, and discomfort, as well as QOL.100
This NMA establishes long-needle acupuncture as the most efficacious modality for multidimensional CP/CPPS management. Its effectiveness aligns with current international guidelines, including the World Health Organization’s recommendation for acupuncture in chronic pelvic pain syndromes (ICD-11 ME94.2) with Evidence Level II, which specifically endorses deep needling (≥75 mm depth) at sacral/pudendal plexus points. The European Association of Urology’s 2025 Guidelines also provide a Grade B recommendation for “deep pelvic needling” (depth ≥70 mm) in treatment-refractory cases, particularly targeting prostatic autonomic ganglia.108,109 The consistency between our findings and these authoritative recommendations underscores the clinical applicability of long-needle acupuncture in CP/CPPS treatment protocols. Accumulating evidence demonstrates that the pathogenesis of CP/CPPS is intricately linked to immune dysregulation, primarily characterized by imbalances in pro-inflammatory cytokine profiles, particularly TNF-α and IL-8. TNF-α, a potent pro-inflammatory mediator secreted by activated mononuclear macrophages, exerts multiple biological effects including inflammation induction, pyrogenicity, and nociceptor sensitization. Elevated TNF-α levels in prostatic tissue activate TRPV1+ nociceptors, subsequently inducing central sensitization and contributing to chronic pelvic pain.9 IL-8, which can be upregulated by TNF-α, functions as a chemotactic factor that orchestrates the directional migration of neutrophils and T lymphocytes to the prostate, thereby perpetuating local inflammatory responses and tissue damage.110–112 Mechanistic studies have revealed that long-needle acupuncture therapy significantly downregulates the expression of TNF-α and IL-8 in prostatic fluid, effectively attenuating the neuroinflammatory cascade.113 This therapeutic effect is consistent with the multi-target regulatory mechanisms of acupuncture previously described. Studies have also indicated that deep long-needle acupuncture can cause local parasympathetic nerves to excite and dilate blood vessels, thereby improving blood circulation in the prostate and promoting inflammatory absorption.114
Although this study confirmed that long-needle acupuncture had a more significant effect in treating CP/CPPS, the following limitations were of note. Firstly, the included studies did not analyze the clinical efficacy, NIH-CPSI symptom score, pain, urination symptoms, and QOL as their primary outcome indicators; secondly, the statistical outcome indicators of many studies were inconsistent in time, resulting in great heterogeneity. Thirdly, there was a large heterogeneity in treatment methods among the populations of included studies.
Conclusions
Most acupuncture therapies achieved better clinical efficacy in the treatment of CP/CPPS compared to UT. Among them, long-needle acupuncture not only relieved subjective symptoms, but also exhibited better efficacy when evaluated under objective conditions. Limited by the quality and contents of studies, this NMA still had some limitations. Although the differences between different categories were examined, it was found that the difference among those high-ranking interventions in the league table was not significant. Thus, more studies are required to support the findings.
Abbreviations
CP, Chronic prostatitis; CI, Confidence interval; CNKI, China National Knowledge Infrastructure; CPPS, Chronic pelvic pain syndrome; MCMC, Markov chain Monte Carlo; MD, Mean difference; NIH-CPSI, National Institutes of Health Chronic Prostatitis Symptom Index; NMA, Network meta-analysis; QOL, Quality of life; RCTs, Randomized controlled trials; ROB, Risk of bias; SUCRA, Surface under the cumulative ranking curve; TCM, Traditional Chinese medicine; UT, Usual treatment.
Data Sharing Statement
The data that supports the findings of this study are available in the supplementary material of this article.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Funding
No funding was received for this paper.
Disclosure
The authors have no conflict of interest to declare.
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