Meta-analysis of Acupuncture Intervening Benign Prostatic Hyperplasia

Abstract

Objective

This study aimed to evaluate the effectiveness of acupuncture for benign prostatic hyperplasia (BPH).

Methods

We searched PubMed, EMBASE, Cochrane Library, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Wanfang Data, and China Science and Technology Journal Database from their inceptions to February 1, 2022. The language was restricted to English and Chinese. Two researchers independently screened the literature, extracted data, and evaluated the risk bias of the included study according to the Cochrane Handbook 5.1.0. A meta-analysis was performed using Review Manager version 5.3.

Results

Twenty-two studies with 1,765 participants were selected to be incorporated in the meta-analysis. The experimental groups (EGs) showed greater benefit on therapeutic effects (relative risk [RR]: 1.23, 95% CI: 1.16, 1.3; P < 0.00001), International Prostate Score Scale (mean difference [MD]: −2.06, 95% CI: −3.17, −0.96; P = 0.0002), maximum urinary flow rate (MD: 1.7, 95% CI: 0.89, 2.52; P < 0.0001), postvoid residual urine volume (MD: −8.25, 95% CI: −12.14, −4.36; P < 0.0001), quality of life (MD: −0.55, 95% CI: −0.8, −0.29; p < 0.0001) compared with the control groups, whereas for prostate volume (MD: −0.87, 95% CI: −2.66, 0.92; P = 0.34) was not significantly improved in the EGs. Nevertheless, no statistical variation in the reduction of adverse reactions was observed.

Conclusion

Acupuncture therapy, a wildly applied complementary–alternative treatment, may help in the management of BPH.

Keywords

benign prostatic hyperplasia - acupuncture - meta-analysis - systematic review

Introduction

Benign prostatic hyperplasia (BPH) is one of the common urological diseases in middle-aged and elderly males.[1] Studies have shown that the pathogenesis of BPH is closely related to abnormal hormone levels, inflammatory reactions, and prostatic interstitial cell proliferation.[2] In recent decades, increased modifiable risk factors, such as metabolic diseases and obesity, have led to an increased incidence of BPH.[3] [4] [5] In 2010, there were more than 210 million BPH patients worldwide, accounting for 6.05% of the total male population.[6] In the United States, the incidence of BPH increases with age, increasing by 10% for every 10 years of age, and by approximately 80% for those older than 80 years.[7] [8] Clinically, BPH often presents with lower urinary tract symptoms of varying degrees, including frequent urination, urgent urination, increased nocturia, incomplete urination, and dysuria. If timely and effective treatment is not available, it may cause complications such as urinary retention, bladder stones, erectile dysfunction, and even renal insufficiency, seriously affecting the quality of life (QOL) of patients.[9] [10] [11] Current therapies can first be divided into medical or surgical intervention. Medical therapy for BPH includes 5-α-reductase inhibitors and α-blockers, or a combination of both. Surgical interventions include a conventional transurethral resection of the prostate (TURP), as well as newer modalities such as bipolar TURP, holmium laser enucleation of the prostate (HoLEP), Greenlight and thulium laser, and prostatic urethral lift (PUL).[12] [13] These treatments are prone to cause dizziness, headache, fatigue, drowsiness, orthostatic hypotension, abnormal ejaculation, bladder sphincter injury, and other adverse reactions (ARs).[14] Therefore, more and more urologists are noticing that complementary and alternative therapy may be an effective and personalized treatment option for some patients with drug and surgical intolerance.[15]

Complementary and alternative medicine is an option for reducing symptoms and enhancing efficiency, including acupuncture, music therapy, acupoint massage, homeopathy, traditional Chinese medicine (TCM), and exercise therapy.[16] [17] As an external method of TCM, acupuncture therapy has been used in treatment of a variety of diseases.[18] Acupuncture therapy includes manual acupuncture (MA), electroacupuncture (EA) and others, of which, both MA and EA have been proposed to treat BPH, but to date, evidence for immediate effects on BPH is limited. Therefore, a systematic study of randomized controlled trials (RCTs) at home and abroad was conducted in this study to further evaluate the efficacy of acupuncture treatment for BPH, and to provide certain reference significance for the application of acupuncture for BPH in subsequent clinical work.

Methods

Inclusion and Exclusion Criteria

The inclusion criteria were as follows: (a) RCTs with regard to the effectiveness of acupuncture therapy for BPH; (b) the age of the research subjects and the source of the cases were not limited; (c) in the experimental groups (EGs), EA or acupuncture was adopted, with or without Western medication (WM) treatment. In the control groups (CGs), WM was used independently; (d) EGs and CGs provided complete data of treated patients; (e) the primary outcome indicators that we considered were therapeutic effects (TEs), International Prostate Score Scale (IPSS), maximum urinary flow rate (Qmax), post-void residual (PVR), and QOL; and (f) the secondary outcome indicators were prostate volume (PV) and ARs.

The following situations were excluded: (a) Reviews, conferences, case reports, animal studies, letters, editorials and qualitative studies; (b) articles with incomplete data and without full-text access; (c) duplicate publication; (d) EGs contained other TCM therapies; and (e) CGs referring to the other therapies involved except for WM.

Search Strategy and Data Extraction

Articles search was reported through February 1, 2022, including the following online databases, that is, PubMed, EMBASE, Cochrane Library, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Wanfang Data, and China Science and Technology Journal Database. Thirteen search components were applied: “benign prostatic hyperplasia,” “prostatic hyperplasia,” “acupuncture,” “electroacupuncture,” “acupuncture therapy,” “scalp acupuncture,” “ear acupuncture,” “abdominal acupuncture,” “filiform needle,” “acupoints,” “manual acupuncture,” “randomized controlled trial,” and “clinical trial.”

The reference lists of selected articles were also manually filtered for possible relevant new studies. The language was restricted to English and Chinese. Two researchers independently screened all the retrieved titles and abstracts and then obtained the full text of all potentially eligible articles. Two researchers independently examined these full-text articles in accordance with the inclusion criteria and selected eligible studies for inclusion in the review. The third party was consulted to determine if there was a divergence. The self-made data extraction table was used for data extraction. The extracted contents mainly included the author, publication year, sample size, age, intervention, course of treatment, dropout, acupuncture points, randomization methods, follow-up periods, quality of methods, and ARs.

Methodological Quality Evaluation

Two researchers independently evaluated each article using the RCT bias risk assessment tool recommended by Cochrane Handbook 5.1.0.[19] [20] Once there were differences, we discussed with each other or negotiated with a third party to resolve them. The evaluation contents included random allocation method, hidden allocation scheme, blind method, the integrity of result data, selective reporting, and other biases. According to the research results, the above six items were judged as “low risk” “high risk” and “unclear risk”.

Statistical Analysis

A meta-analysis was performed using Review Manager version 5.3. Subgroup analysis was performed according to possible heterogeneity factors among studies. χ ² tests (P < 0.05) and I ² statistics of heterogeneity were used for analysis. If the P > 0.1 and the I ² < 50%, the test of homogeneity was statistically significant, and then a fixed-effects model was adopted. Otherwise, a random-effects model was adopted, and sensitivity and subgroup analysis were performed to explore heterogeneity. Dichotomous variables were expressed as relative risk (RR) and continuous variables as mean difference (MD). Both were expressed by effect value and 95% confidence interval (CI). If the study was not suitable for meta-analysis, descriptive analysis was performed. If ≥10 articles were included in an outcome index, the publication bias was evaluated by funnel plots.

Results

Study Selection

The flow diagram of article retrieval process and results are depicted in [Fig. 1]. A total of 716 related articles were acquired from initial retrieval. The remaining 339 articles were individually screened when duplicate articles were removed. After further reading article titles and abstracts, 75 full-text articles were assessed for eligibility. Then, this assessment further excluded 53 studies because there were no CG (n = 9), no data for extraction (n = 4), no accordance with the inclusion criteria (n = 12), and was case report or duplication (n = 6). Eventually, 22 studies[21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] were selected to be incorporated into the meta-analysis.

Fig. 1 PRISMA 2020 flow diagram.

Study Characteristics

[Table 1] summarizes the main characteristics of the included studies. A total of 1,765 patients with BPH [889 (50.4%) in EGs and 876 (49.6%) in CGs] were included in this study. All participants were Chinese and studies were published between 2005 and 2021. All studies reported comparable or no significant differences between intervention groups with respect to general information such as age and course of disease. EGs in the included studies utilized MA[21] [22] [24] [25] [26] [28] [29] [32] [33] [34] [40] [41] [42] or EA[23] [27] [30] [31] [35] [36] [37] [38] [39] as intervening measurse; seven studies mixed MA with WM,[24] [26] [29] [34] [40] [41] [42] three studies mixed EA with CWM.[27] [30] [31] CGs were WM as intervening measures, including the following drugs: tamsulosin hydrochloride sustained release capsules (THSRC),[21] [22] [23] [27] [29] [30] [31] [32] [33] [34] [35] [36] [39] [40] [41] terazosin hydrochloride capsules (THC),[25] [37] finasteride tablets (FT),[24] [26] [28] [38] [42] doxazosin mesylate extended-release tablets (DMERT).[38] [42] The duration of treatment ranged from 10 days to 12 weeks. The intervention in 2 studies lasted <4 weeks[30] [42] and those in the remaining 20 studies lasted ≥4 weeks. Only one study had follow-up records.[34] Seventeen studies evaluated TEs,[22] [24] [25] [26] [27] [28] [29] [30] [32] [33] [34] [35] [36] [38] [39] [41] [42] 19 studies reported IPSS,[21] [23] [24] [25] [26] [27] [28] [29] [31] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] 15 studies reported Qmax,[21] [23] [25] [27] [28] [31] [32] [34] [35] [36] [37] [38] [39] [40] [41] 12 studies presented PVR,[21] [23] [24] [25] [27] [29] [31] [32] [38] [39] [40] [41] 14 studies tested QOL,[23] [25] [26] [27] [29] [31] [33] [34] [35] [36] [37] [38] [40] [41] 12 studies assessed PV,[24] [25] [28] [29] [31] [34] [35] [37] [38] [39] [40] [41] and 5 studies mentioned AR.[22] [23] [33] [37] [39]

Table 1 Characteristics of included studies

Study	Number of participants	Finished number	Mean age (years)		Course of disease		Intervening measure		Stimulus parameters
	E/C	E/C	E	C	E	C	E	C	Stimulus	Time (minutes)	Frequency (n/day)	Relevant outcomes
Wang (2021)[22]	30/30	30/30	65.6 ± 11.2	59.3 ± 11.2	18.3 ± 6.1(m)	21.7 ± 5.3 (m)	MA, 4 w, 6 times a week	THSRC, 0.2 mg, qn	Acupuncture manipulation	30	1	①⑦
Hu et al. (2020)[34]	33/34	30/30	61.3 ± 5.1	61.7 ± 4.9	6.1 ± 2.1 (y)	6.3 ± 2.1 (y)	MA + THSRC, 4 w, qod	THSRC, 0.2 mg, qn	Acupuncture manipulation	30	1	①②③⑤⑥
Jiang (2020)[24]	31/31	30/30	60.4 ± 6.4	59.3 ± 6.6	14.9 ± 7.0 (m)	16.5 ± 5.2 (m)	MA + FT, 12 w, qod	FT, 5 mg, qd	Acupuncture manipulation	30	1	①②④⑥
Yuan et al. (2009)[25]	35/30	35/30	64.5		1–13 (y)		MA, 4 w, qod	THC, 2 mg, qn	Acupuncture manipulation	30	1	①②③④⑤⑥
Wang et al. (2020)[26]	31/31	30/30	66.3	67	1–22 (y)	10 (m)–2 0 (y)	MA + FT, 6 w, 5 times a week	FT, 5 mg, qd	Acupuncture manipulation	20	1	①②⑤
Huang et al. (2016)[40]	30/30	30/30	60 ± 14		–		MA + THSRC, 4 w, take 3 days off every 10 days	THSRC, 0.2 mg, qn	Acupuncture manipulation	30	1	②③④⑤⑥
Zhao et al. (2020)[28]	30/30	28/28	66 ± 6	64 ± 6	3.9 ± 1.7 (y)	3.9 ± 1.9 (y)	MA, 12 w, qod	FT, 5 mg, qd	Acupuncture manipulation	30	1	①②③⑥
Liu et al. (2021)[29]	34/34	30/30	63.7 ± 6.7	62.8 ± 5.9	6.3 ± 2.8 (y)	6.7 ± 2.6 (y)	MA + THSRC, 4 w, qod	THSRC, 0.2 mg, qn	Acupuncture manipulation	30	1	①②④⑤⑥
Gou (2017)[41]	40/40	40/40	66.8 ± 7.8	67.9 ± 8.0	5.2 ± 1.9 (y)	5.5 ± 1.8 (y)	MA + THSRC, 4 w, 5 times a week	THSRC, 0.2 mg, qn	Acupuncture manipulation	20	1	①②③④⑤⑥
Zhou et al. (2018)[42]	50/50	50/50	68.5 ± 5.7	68.6 ± 5.5	5.4 ± 4.7 (y)	5.3 ± 4.7(y)	MA+ FT, DMERT, 10 days, bid	FT, 5 mg, qd, DMERT, 4 mg, qn	Acupuncture manipulation	30	2	①②
Xu et al. (2020)[32]	35/35	35/35	61.6 ± 5.8	62.1 ± 5.4	3.0 ± 1.2 (y)	3.0 ± 1.1 (y)	MA, 4 w, 5 times a week	THSRC, 0.2 mg, qn	Acupuncture manipulation	30	1	①③④
Chen et al. (2018)[33]	32/32	32/32	63.3 ± 9.8	65.5 ± 7.6	54.6 ± 38.6 (m)	43.1 ± 31.4 (m)	MA, 4 w, biw	THSRC, 0.2 mg, qn	Acupuncture manipulation	20	1	①②⑤⑦
Kong et al. (2017)[21]	80/80	80/80	50–75		1–12 (y)		MA, 4 w, bid	THSRC, 0.2 mg, qn	Acupuncture manipulation	15	2	②③④
Du (2020)[35]	30/30	30/30	63.1 ± 4.2	64.3 ± 4.1	20.3 ± 8.0 (m)	20.3 ± 8.6 (m)	EA, 4 w, 6 times a week	THSRC, 0.2 mg, qn	2 Hz	30	1	①②③⑤⑥
Wang et al. (2018)[36]	22/22	22/22	61.6 ± 6.4	62.3 ± 6.2	3.2 ± 1.9 (y)	3.0 ± 1.9 (y)	EA, 4 w, 6 times a week	THSRC, 0.2 mg, qn	2–10 Hz	30	1	①②③⑤
Yang et al. (2008)[37]	47/46	46/45	67.4 ± 8.4	69.7 ± 8.7	4.4 ± 4.0 (y)	3.8 ± 3.3 (y)	EA, 4 w, qod	THC, 2 mg, qn	20 Hz	30	1	②③⑥⑦
Wang (2010)[38]	33/32	33/32	61.5 ± 5.1	62.1 ± 5.5	5.6 ± 3.8 (y)	5.3 ± 3.4 (y)	EA, 4 w, qod	FT, 5 mg, qd, DMERT, 4 mg, qn	20 Hz	30	1	①②③④⑤⑥
Yu (2005)[39]	50/44	48/44	—		—		EA, 4 w, 6 times a week	THSRC, 0.2 mg, qn	Patient tolerance	20–30	1	①②③④⑥⑦
Zheng et al. (2017)[23]	30/30	26/24	65.4 ± 10.0	68.0 ± 8.4	110.3 ± 102.8 (m)	85.6 ± 61.6 (m)	EA, 6 w, 5 times a week	THSRC, 0.2 mg, qn	5 Hz	20	1	②③④⑤⑥⑦
Zhang et al. (2011)[27]	42/42	42/42	61 ± 9		5.6 ± 2.4 (y)	5.5 ± 2.3 (y)	EA + THSRC, 4 w, 6 times a week	THSRC, 0.2 mg, qn	Patient tolerance	30	1	①②③④⑤
Liu (2013)[30]	96/96	96/96	56.5		5.4 (y)		EA + THSRC, 14 days, qd	THSRC, 0.2 mg, qn	100 Hz	30	1	①
Wu (2020)[31]	48/47	48/47	67.6 ± 13.2	66.8 ± 12.0	9.6 ± 6.5 (y)	9.1 ± 6.4 (y)	EA + THSRC, 4 w, 5 times a week	THSRC, 0.2 mg, qn	Patient tolerance	20	1	②③④⑤⑥

Abbreviations: bid, bis in die; biw, bid times a week; C, control group; DMERT, doxazosin mesylate extended-release tablet; E, experimental group; EA, electroacupuncture; FT, finasteride tablet; MA, manual acupuncture; min, minutes; qd, quaque die; qn, quaque nocte; qod, quaque omni die; THC, terazosin hydrochloride capsule; THSRC, tamsulosin hydrochloride sustained release capsule; w, week.

Notes: ① Therapeutic effects. ② International Prostate Score Scale. ③ Maximum urinary flow rate. ④ Postvoid residual urine volume. ⑤ Quality of life. ⑥ Prostate volume. ⑦ Adverse reactions; tamsulosin hydrochloride sustained release capsule.

Bias Risk Assessment

All studies were randomized controlled studies, 10 studies[21] [25] [28] [30] [32] [34] [38] [39] [40] [41] did not introduce specific randomization methods, and 12 studies were grouped by low-risk random number table. None of the studies mentioned the allocation of hidden information, nor did they describe the blind method of patients and evaluators. Of all the studies, 14[21] [22] [25] [27] [30] [31] [32] [33] [35] [36] [38] [40] [41] [42] had complete data, and 8 reported missing data and were judged to be at high risk. Because there was no prior registration of the studies, it was not clear whether there was reporting bias and other risks. Overall, the methodological quality of the included studies was generally low, as shown in [Figs. 2] and [3].

Fig. 2 Risk for bias graph.

Fig. 3 Risk for bias summary.

Effects of the Interventions

Therapeutic Effects

Seventeen studies[22] [24] [25] [26] [27] [28] [29] [30] [32] [33] [34] [35] [36] [38] [39] [41] [42] reported TEs, including 1,212 participants. The meta-analysis revealed that the comparison of TEs between EGs and CGs had statistical significance (RR: 1.23, 95% CI: 1.16, 1.3; P < 0.00001, I ² = 10%). As there was no heterogeneity among studies, subgroup analysis was not conducted, as shown in [Fig. 4].

Fig. 4 Forest plot of TEs. TE, therapeutic effect.

International Prostate Score Scale

Nineteen studies[21] [23] [24] [25] [26] [27] [28] [29] [31] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] assessed IPSS as an outcome measure, including 1,406 participants. In the meta-analysis, MA or EA combined with or without WM was superior to WM in terms of reducing IPSS (MD: −2.06, 95% CI: −3.17, −0.96; P = 0.0002, I ² = 95%). We provided the subgroup analysis based on interventions to explore the sources of heterogeneity. Heterogeneity was not reduced when the interventions were divided into four groups. For MA versus WM, the results of four studies[21] [25] [28] [33] revealed no statistical significance (MD: 0.2, 95% CI: −2.82, 3.22; P = 0.9, I ² = 96%). Seven studies[24] [26] [29] [34] [40] [41] [42] that compared MA plus WM versus WM (MD: −2.72, 95% CI: −3.66, −1.79; P < 0.00001, I ² = 85%) demonstrated a lower IPSS in the EGs. In addition, six studies[23] [35] [36] [37] [38] [39] involving EA versus WM showed a significant difference (MD: −2.76, 95% CI: −4.19, −1.33; P = 0.0002, I ² = 75%). Two studies[27] [31] discovered that EA combined with WM showed a better effect than WM alone (MD: −2.26, 95% CI: −2.83, −1.68; P < 0.00001, I ² = 0%). Sensitivity analysis of IPSS outcome indicators showed that changing the effect model had no significant effect on the results. Nevertheless, when we deleted the study of Kong et al.,[21] the heterogeneity reduced to 84%. We considered that the small sample size of included studies may have contributed to the significant heterogeneity. The result was relatively stable, as shown in [Fig. 5].

Fig. 5 Forest plot of IPSS. CI, confidence interval; EA, electroacupuncture; IPSS, International Prostate Score Scale; MA, manual acupuncture; SD, standard deviation; WM, Western medicine.

Maximum Urinary Flow Rate

Fifteen studies[21] [23] [25] [27] [28] [31] [32] [34] [35] [36] [37] [38] [39] [40] [41] measured Qmax, including 1,132 participants. There was evidence of a better improvement in Qmax in EGs than in CGs. The difference was statistically significant (MD: 1.7, 95% CI: 0.89, 2.52; P < 0.0001, I ² = 92%). There was considerable study heterogeneity. Consequently, we conducted subgroup analyses to quantify the heterogeneity. Four studies[21] [25] [28] [32] discovered that MA showed a better effect compared with WM (MD: 2.03, 95% CI: 0.14, 3.93; P = 0.04, I ² = 93%). In addition, studies that compared EA with WM (MD: 1.83, 95% CI: 0.56, 3.09; P = 0.005, I ² = 90%),[23] [35] [36] [37] [38] [39] and EA plus WM with WM (MD: 2.83, 95% CI: 1.02, 4.63; P = 0.002, I ² = 62%),[27] [31] demonstrated a higher Qmax rate in the EGs. Merely three studies[34] [40] [41] presented MA plus WM versus WM, but no significant difference was found for Qmax between these two groups (MD: 0.3, 95% CI: −1.05, 1.64; P = 0.67, I ² = 83%). when we removed the studies of xu et al. and Hu et al.,[32] [34] the heterogeneity just reduced to 82%. The outcome was steady, as shown in [Fig. 6].

Fig. 6 Forest plot of Qmax. CI, confidence interval; EA, electroacupuncture; IPSS, International Prostate Score Scale; MA, manual acupuncture; Qmax, SD, standard deviation; WM, Western medication.

Post-void Residual

Twelve studies[21] [23] [24] [25] [27] [29] [31] [32] [38] [39] [40] [41] were included in the analysis of the reduction in PVR, including 1,032 participants. The meta-analysis results demonstrated marked divergence between the two groups in reducing PVR (MD: −8.25, 95% CI: −12.14, −4.36; P < 0.0001, I ² = 95%). With obvious heterogeneity being seen, subgroup analyses were run for analysis. For MA versus WM, three studies[21] [25] [32] presented no remarkable difference (MD: −8.89, 95% CI: −18.33, 0.54; P = 0.06, I ² = 99%). For MA plus WM versus WM, four studies[24] [29] [40] [41] indicated a better effect that favor MA plus WM (MD: −7.67, 95% CI: −13.62, −1.71; P = 0.01, I ² = 65%). For EA versus WM, three studies[36] [38] [39] exhibited no marked divergence between the two groups in reducing PVR (MD: −4.75, 95% CI: −9.63, 0.12; P = 0.06, I ² = 65%). The remaining two studies[27] [31] revealed that PVR in the EA plus WM group was less than WM group, and the variance between both groups was statistically significant (MD: −14.42, 95% CI: −21.29, −7.55; P < 0.0001, I ² = 80%). By excluding the studies one by one, we found that after removing Xu et al.,[32] the heterogeneity dropped from 95% to 81%. There was no significant change, as shown in [Fig. 7].

Fig. 7 Forest plot of PVR. CI, confidence interval; EA, electroacupuncture; IPSS, International Prostate Score Scale; MA, manual acupuncture; PVR, postvoid residual urine volume; SD, standard deviation; WM, Western medication.

Quality of Life

Fourteen studies[23] [25] [26] [27] [29] [31] [33] [34] [35] [36] [37] [38] [40] [41] tested QOL, including 847 participants. The evidence of a reduction in QOL score was statistically significant (MD: −0.55, 95% CI: −0.8, −0.29; P < 0.0001, I ² = 91%). There was remarkable heterogeneity, so subgroup analysis was used to perform further analysis. Two studies[25] [33] involving MA versus WM showed no significant difference (MD: −0.39, 95% CI: −1.4, 0.63; p = 0.46, I ² = 90%). Five studies[23] [35] [36] [37] [38] involving EA versus WM also showed no significant difference (MD: −0.66, 95% CI: −1.37, 0.05; p = 0.07, I ² = 82%). There were statistical differences in the MA combined with WM groups to WM using alone in five studies[26] [29] [34] [40] [41] (MD: −0.57, 95% CI: −1.01, −0.12; P = 0.01, I ² = 96%). Besides, two studies[27] [31] that compared EA plus WM with WM also presented marked divergence between the EGs and CGs. When we removed one study,[26] the heterogeneity was not significantly reduced (81%), suggesting a robust result, as shown in [Fig. 8].

Fig. 8 Forest plot of QOL. CI, confidence interval; EA, electroacupuncture; IPSS, International Prostate Score Scale; MA, manual acupuncture; QOL, quality of life; SD, standard deviation; WM, Western medication.

Prostate Volume

A total of 814 participants were studied in the included 12 studies[24] [25] [28] [29] [31] [34] [35] [37] [38] [39] [40] [41] to measure PV. Pooled data showed no conspicuous difference in reducing PV between the EGs and the CGs (MD: −0.87, 95% CI: −2.66, 0.92; P = 0.34, I ² = 84%) with obvious heterogeneity. The heterogeneity among the subgroups of MA versus WM (MD: −0.61, 95% CI: −1.43, 0.22; p = 0.15, I ² = 0%),[25] [28] MA plus WM versus WM (MD: −0.13, 95% CI: −2.12, 1.86; p = 0.9, I ² = 24%),[24] [29] [34] [40] [41] and EA versus WM (MD: 0.42, 95% CI: −4.12, 4.96; p = 0.86, I ² = 87%) were not significant. EA plus WM versus WM (MD: −6.42, 95% CI: −8.75, −4.09; P < 0.00001) was included in only one study, so they could not be compared with other studies.[31] When we removed Du,[35] the heterogeneity was only reduced to 76%, and the results were stable, as shown in [Fig. 9].

Fig. 9 Forest plot of PV. CI, confidence interval; EA, electroacupuncture; IPSS, International Prostate Score Scale; MA, manual acupuncture; PV, prostate volume; SD, standard deviation; WM, Western medication.

Adverse Reactions

Five studies[22] [23] [33] [37] [39] reported mild ARs, the risks of which were no statistically significant difference between EGs and CGs (RR: 0.73, 95% CI: 0.26, 2.05; P = 0.55, I²  = 29%) with the following incidence details: a total of five cases[23] [33] with slight dizziness in the CGs; one case[22] with stuck needle, and one case[22] with fainting; two cases[37] with pain, all occurred in the EGs. Another study[39] reported ARs with no details of THSRC side effects.

Publication Bias

A funnel plot was drawn to evaluate publication bias based on the outcome index, the TEs. The results testified that the distribution of the studies was asymmetric, suggesting that there might be bias, as shown in [Fig. 10].

Fig. 10 Publication bias of the TEs. RR, relative risk; TE, therapeutic effect.

Discussions

The objective of this review was to summarize and evaluate the clinical efficacy and safety of acupuncture therapy for BPH through improving TEs, IPSS, Qmax, PVR, QOL, and PV. Twenty-two studies were included in this meta-analysis, with a total of 1,765 participants. Among the relevant articles included in this study, only MA and EA were included in the EGs. The data showed significant heterogeneity among MA or EA interventions and comparators used to evaluate acupuncture therapy for patients with BPH. Studies comparing MA with WM, MA plus WM with WM, EA with WM, EA plus WM with WM were included in our review.

Of the 22 original articles included in this review, 12[22] [23] [24] [26] [27] [29] [31] [33] [35] [36] [37] [42] were evaluated by the Cochrane Bias risk assessment tool as a low risk in the randomized method, and the remaining 10 articles did not give specific random allocation methods. In the eight studies[23] [24] [26] [28] [29] [34] [37] [39] with shedding cases, no intentional analysis was conducted, which may lead to incomplete outcome reports and loss of follow-up bias. All the articles did not mention allocation concealment and the implementation of blinding for researchers, and the particularity of acupuncture therapy increased the difficulty of blinding for patients, which also caused potential risks, so the overall quality of the literature was low.

The meta-analysis evaluated the TEs of 16 studies, and the results showed that the TEs of two groups were statistically significant, without heterogeneity. In terms of other outcomes of IPSS, Qmax, QOL, and PVR, studies manifested statistically significant benefits of the EGs compared with CGs. However, pooled data showed no conspicuous difference in reducing PV between the two groups. Due to the high heterogeneity in this study, we divided the study into four subgroups according to the intervention used in the EGs. The results indicated that (a) Qmax was significantly higher with MA alone than WM, but there was no significant difference in IPSS, PVR, QOL, and PV; (b) IPSS, PVR, and QOL in the treatment of BPH with MA plus WM were significantly lower than WM, indicating the statistical significance, but without statistical significance differences in Qmax and PV; (c) for EA versus WM, the results of studies revealed statistically significant in IPSS and Qmax, nevertheless, in terms of improving PVR, QOL, and PV, studies presented no remarkable difference; (d) compared with WM, studies indicated a better effect in IPSS, Qmax, PVR, QOL, and PV that favor EA plus WM. When the EGs were classified by the type of acupuncture, the heterogeneity was not significantly reduced. Furthermore, sensitivity analysis also found no heterogeneous sources, which limited the reliability of the results. Besides, the safety analysis showed that there may be a certain adverse event in the treatment of BPH, whether acupuncture therapy or WM, but within an acceptable range. In summary, acupuncture therapy can be used as a supplement and alternative therapy for BPH.

In addition, after sorting out the acupuncture points commonly used in clinical acupuncture, this study found that Zhongji (CV3), Guanyuan (CV4), and Sanyinjiao (SP6) were the most common in the acupuncture treatment of BPH. The inferior nerve at Zhongji (CV3) and Guanyuan (CV4) points originates from T12-L1 and contains the pelvic nerve that innervates the bladder detrusor. The nerves at Sanyinjiao (SP6) point enter the spinal cord segment L4-S2, overlapping with the segment where the nerves innervating the bladder enter the spinal cord. The study has also found that acupuncture is applied to these points which can regulate nerve excitability and effectively improve bladder compensatory function.[43]

This meta-analysis had certain limitations. (a) All of the included studies were published in China, and most of the literature was single-center and small-sample trials. (b) In terms of the treatment course, 10 days to 12 weeks of treatment were included in the study, which had an impact on the difference in results. (c) The quality of the hidden allocation and blind implementation of most literature was not high, which may have some bias, so no definitive conclusions could be drawn. (d) acupoints selection, acupuncture manipulation, the evaluation criteria of curative effect, and different types of WM resulted in heterogeneity. (e) The follow-up data to evaluate the long-term efficacy were insufficient, and more long-term studies were needed.

Clinical studies should aim to perfect blinding methods. Acupuncture site selection and operation methods should be standardized when possible. Outcome measures should be observed from multiple perspectives and measured multiple times over a long period of time to facilitate comprehensive analysis and thus improve the reliability of clinical decision-making. From the included trials, many acupoints selected by the acupuncture group required good patient compliance. Using the least acupoints, the least stimulation and the optimized therapy to achieve the best curative effect will be the content of future research.

Conclusion

In summary, acupuncture therapy has a certain effect on improving TEs, IPSS, Qmax, PVR, and QOL in patients with BPH, but the effect on reducing PV is not significant compared with the CGs. However, considering that the ARs of acupuncture therapy are slight, and acupuncture therapy does not conflict with other standard treatments, acupuncture therapy can be considered in specific circumstances in clinical practice. Therefore, a more rigorous design and a large sample of multicenter randomized controlled trials are needed to verify the conclusions of this study.

Conflict of Interest

The authors declare no conflict of interest.

CRediT Authorship Contribution Statement

Xueyuan Yang: Conceptualization, investigation, formal analysis, and writing—original draft. Wanling Cai: Software, methodology, and data curation. Wenjuan Yu: Supervision, validation, resources, and project administration. Fang Zhou: Writing—review and editing, visualization, and funding acquisition.

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Publikationsverlauf

Eingereicht: 27. November 2024

Angenommen: 10. Februar 2025

Artikel online veröffentlicht:
08. April 2025