Acupuncture-Related Interventions for Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Introduction

Prostatitis is a common urological condition affecting adult men. Studies show about 35%–50% of men experience prostatitis-related symptoms during their lifetime.^1–3 In urology clinics, prostatitis accounts for about 8%–25% of patient visits.^1–3 In China, the reported incidence of chronic prostatitis (CP) ranges from 6.0% to 32.9%,⁴ while globally, between 1% and 14.2% of people are affected.^3,5,6 Even though CP is common, primary-care doctors often miss it. Evidence also suggests a possible link between CP and an increased risk of benign prostatic hyperplasia (BPH) and prostate cancer.^3,7 CP is primarily characterized by chronic pelvic pain, urinary symptoms, and varying degrees of sexual and psychological dysfunction, all of which can substantially impair quality of life.^4,8–12

The causes of CP are not fully understood and likely involve many factors, including infection, immune dysfunction, nerve and hormone imbalances, and pelvic muscle problems.^13,14 Current management of CP commonly includes alpha-blockers, antibiotics, and anti-inflammatory medications, with antibiotics commonly used in selected patients, often for treatment courses lasting at least four weeks.^15–19 However, treatment responses remain variable, and long-term outcomes are often unsatisfactory, partly because of antibiotic resistance and individual differences in treatment response.^19,20 In addition, pharmacological treatments may cause side effects such as dizziness, low blood pressure, and gastrointestinal discomfort, which can reduce patient adherence.^17,18

Given these limitations, acupuncture has drawn interest as a potential non-drug treatment. Several clinical trials show acupuncture can relieve pelvic pain and urinary symptoms and improve NIH Chronic Prostatitis Symptom Index (NIH-CPSI) scores.^21,22 The therapeutic benefits may persist over time, with better symptom control and quality of life compared to sham acupuncture.^21,22 Acupuncture may work through several pathways: reducing inflammation, balancing immune function, improving antioxidant activity, influencing nerve signals, relaxing pelvic muscles, and modifying pain-related brain activities.^23,24

It should be noted that acupuncture-related therapies include several distinct technical forms, including Manual Acupuncture (MA), Electroacupuncture (EA), Warm Needle Acupuncture (WMA), Heat-Sensitive Moxibustion (SMS), Acupoint Application Therapy (AAT), and Moxibustion (MOX). These modalities differ in stimulation characteristics and potential mechanisms of action, which may contribute to differences in clinical outcomes. However, direct head-to-head comparisons among different acupuncture-related therapies remain limited. Previous conventional meta-analyses could not adequately evaluate the relative efficacy of different acupuncture modalities.²⁵ Network meta-analysis (NMA) is better suited to compare and rank different acupuncture-related therapies by using both direct and indirect evidence. Clearer classification of acupuncture stimulation types may also improve the interpretability and clinical applicability of comparative findings. This study aims to provide a clearer comparison of the effectiveness and safety of different acupuncture-related therapies for the treatment of CP and to help inform clinical practice.

Methods

This systematic review and network meta-analysis was conducted in accordance with the PRISMA 2020 statement and its extension for NMA.^26,27 The study protocol was prospectively registered with PROSPERO (CRD420251180258). The registered protocol is publicly accessible through the PROSPERO database under registration number CRD420251180258. No amendments were made to the protocol after registration.

Research Question (PICOS)

The review question was defined according to the PICOS framework:

Population

Adult patients diagnosed with chronic prostatitis according to established clinical criteria.

Interventions

Acupuncture-related therapies (including manual acupuncture, electroacupuncture, warm needle acupuncture, heat-sensitive moxibustion, moxibustion, and auricular acupoint therapy), administered either as monotherapy or in combination with conventional Western medicine or Chinese herbal medicine.

Comparators

Western medicine alone, Chinese herbal medicine alone, or other eligible acupuncture modalities.

Outcomes

Primary outcomes were the NIH-CPSI total score and subscores (pain, urinary symptoms, quality of life); secondary outcome was the response rate.

Study Design

Randomized controlled trials published in Chinese or English.

Eligibility Criteria

Study Type

Eligible randomized controlled trials (RCTs) published in Chinese or English evaluated the effectiveness and safety of acupuncture-related therapies for prostatitis. Trials were eligible regardless of whether blinding or allocation concealment was used, as these procedures are often difficult to apply in acupuncture studies. Non-randomized studies, quasi-experimental studies, case reports, and reviews were excluded.

Participants

Eligible participants were adults diagnosed with CP according to established clinical criteria. There were no limits on age, CP subtype, disease duration, or severity, as long as the starting characteristics were similar between the treatment and control groups.

Interventions and Comparators

The intervention group received acupuncture-related therapies, given either as standalone treatments or in combination with conventional Western medicine (WM) or Chinese herbal medicine (CHM). Eligible approaches included AAT, EA, MA, MOX, SMS, and WMA, along with their combinations with oral medications (eg, EA + WM, EA + CHM). To maintain clinical consistency, included interventions were limited to: (i) acupuncture monotherapy or (ii) acupuncture combined with WM or CHM. We excluded trials that combined different acupuncture modalities or used sham acupuncture.

Control groups received WM alone, CHM alone, or one eligible acupuncture type. This design allowed for direct and indirect comparisons within a NMA.

Outcomes

The primary outcomes were the NIH-CPSI total score and its subscores for pain, urination, and quality of life. The secondary outcome was the response rate.

Search Strategy

English and Chinese databases were systematically searched for RCTs evaluating acupuncture-related therapies for CP. English databases included PubMed, Embase, Web of Science, and Cochrane Library; Chinese databases covered CNKI, Wanfang Data, VIP, and CBM. The search strategy followed the PICOS framework and combined Medical Subject Headings (MeSH) with free-text terms. We used Boolean operators (AND/OR) to connect synonyms and related concepts. Population terms included “chronic prostatitis,” “chronic pelvic pain syndrome,” and “CP/CPPS.” Intervention termscovered “acupuncture,” “electroacupuncture,” “moxibustion,” “heat-sensitivemoxibustion,” “warm acupuncture,” and “acupoint application therapy.” We focused on RCTs using keywords like “randomized controlled trial.” The search covered records from each database’s inception to October 1, 2025, without language restrictions. Two researchers independently checked the studies for eligibility and settled any disagreements through discussion or by consulting a third reviewer. Detailed search strategies are provided in Appendix 1.

Study Selection and Data Extraction

Two reviewers went through all the records on their own, using a two-stage method with pre-established criteria: initial title/abstract screening followed by full-text assessment. Duplicate records were removed using EndNote and checked manually. Clearly irrelevant studies were removed in the first screening, while those needing more assessment went on to a full-text review. Full-text articles were carefully checked to make sure they met the inclusion criteria for population, interventions, and outcomes. Studies with missing or unclear data were excluded if we could not get the necessary information from the authors. When there were duplicate publications, we kept the version with the most complete data and best methods. Any disagreements between reviewers were settled by discussion or with help from a third reviewer.

Data were extracted independently using standard forms. Extracted information included: study characteristics (authors, publication year, sample size, randomization methods, blinding procedures, participant demographics), intervention details (acupuncture modality, combination therapies, treatment duration and frequency), and comparator information. The main outcomes were the NIH-CPSI total score and its subscales (pain, urinary symptoms, and quality of life), while the response rate was a secondary outcome. All the collected data were double-checked before analysis to make sure they were accurate and complete. In addition to outcome data, we extracted prespecified study-level variables including publication year, country, diagnostic criteria, sample size, participant age, intervention type, comparator type, treatment duration, treatment frequency, and methodological characteristics relevant to risk-of-bias assessment. For studies with unclear or incomplete information, attempts were made to determine the necessary information from the published report; when outcome data remained unavailable or could not be derived in a usable form, the study was excluded from the corresponding quantitative synthesis. No imputation of missing outcome data across trials was performed.

Risk of Bias and Certainty of Evidence Assessment

A rigorous approach was used to assess the quality of the evidence. Two reviewers independently evaluated the risk of bias in each included study using the RoB 2.0 tool,²⁸ which examines five domains: the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selective reporting. Any disagreements were resolved through discussion or consultation with a third reviewer. Studies meeting the predefined criteria were considered low risk. The certainty of evidence for the main outcomes was further assessed using the CINeMA framework, which is based on GRADE, through its online platform. The assessment covered six domains: within-study bias, reporting bias, indirectness, imprecision, heterogeneity, and inconsistency. Final confidence ratings were then generated for the evidence.

Statistical Analysis

NMA was performed using Stata 17.0 with the mvmeta command under a frequentist framework. For continuous outcome measures, including the NIH-CPSI total score and its subdomain scores for pain, urinary symptoms, and quality of life, pooled mean differences along with 95% confidence intervals were calculated. The response rate was analyzed using risk ratios and 95% confidence intervals. All analyses used random-effects models, with heterogeneity estimated by restricted maximum likelihood and reported as τ² values.^29–31To evaluate consistency between direct and indirect evidence, we applied the node-splitting method. Network diagrams were used to show evidence structures, and treatment efficacy was ranked using the surface under the cumulative ranking curve (SUCRA).³² Finally, we assessed potential publication bias and small-study effects through adjusted funnel plots. Study selection was summarized using a PRISMA flow diagram. Characteristics of included studies are summarized in Table 1. Network geometry was presented using network plots, and synthesis results were presented using forest plots, league tables, SUCRA-based treatment rankings, and Supplementary Appendices where appropriate. Prior to synthesis, interventions were grouped into clinically meaningful treatment nodes according to acupuncture modality and whether they were administered alone or in combination with Western medicine or Chinese herbal medicine. We assessed statistical heterogeneity using the between-study variance (τ²) estimated under the random-effects model and interpreted heterogeneity in conjunction with the distribution of study characteristics across comparisons. We also examined inconsistency between direct and indirect evidence using node-splitting analyses. Because the included studies were limited for several direct comparisons and the network structure was relatively sparse for some outcomes, no additional subgroup analyses or formal meta-regression analyses were undertaken. No sensitivity analyses were conducted.

Table 1 Characteristics of Included Studies

Results

Literature Search Results

The initial search identified 1,924 records from nine databases: PubMed (n=113), Embase (n=159), Cochrane Library (n=52), Web of Science (n=122), CNKI (n=426), VIP (n=210), Wanfang Data (n=361), and CBM (n=481). After removal of 959 duplicates, 965 unique records remained for title and abstract screening, of which 700 were excluded as clearly irrelevant. The remaining 265 reports underwent full-text assessment for eligibility. Of these, 220 reports were excluded because of non-randomized design, ineligible population, ineligible intervention or comparator, insufficient outcome data, duplicate publication, or failure to meet other predefined eligibility criteria. Finally, 45 RCTs^33–77 were included in the quantitative synthesis and network meta-analysis (Figure 1).

Figure 1 Flow chart of the search for eligible RCTs.

Included Study Characteristics

This analysis examined 45 RCTsprimarily conducted in China between 2007 and 2025. The sample sizes generally ranged from 10 to 60 participants per study arm, with most trials enrolling 30 to 45 patients. There was a wide age range among participants, with the majority aged 30 to 50. Several studies included older adults, such as Wang et al (2021), where the mean age was around 60 years. The investigated interventions encompassed various acupuncture modalities, including EA, WMA, SMS, MOX, AAT, and MA, applied either as monotherapy or in combination with WM or CHM. The control groups received WM, CHM, or different acupuncture methods. Treatment duration was typically 4 weeks, though some trials implemented courses lasting 2, 3, 6, 8, or 12 weeks. All these studies formed a connected network of comparisons between treatments and controls, with participants having comparable starting characteristics (Table 1). The main characteristics and outcome domains reported by individual studies are summarized in Table 1.

Risk of Bias, Consistency and Certainty of Evidence

We assessed the methodological quality of the included studies using the Cochrane Risk of Bias 2.0 tool (RoB 2.0). Of the 45 randomized controlled trials, 38 (84.4%) were judged as low risk in the randomization process, whereas 7 (15.6%) raised some concerns because the methods used for sequence generation or allocation concealment were insufficiently described. For deviations from intended interventions, 44 studies (97.8%) were judged as having some concerns, mainly because blinding of participants and personnel is difficult to implement in acupuncture trials, while 1 study (2.2%) was rated as low risk. All studies were judged as low risk for missing outcome data, outcome measurement, and selective reporting. Overall, 1 study (2.2%) was rated as low risk of bias, 35 (77.8%) as having some concerns, and 9 (20.0%) as high risk. Detailed domain-level assessments are presented in Figure 2 and Appendix 2, Table S1.

Figure 2 Risk-of-bias assessment of included studies using the RoB 2.0 tool. Green indicates low risk, yellow indicates some concerns, and red indicates high risk of bias.

For network assumptions, both global and local consistency assessments supported the use of the consistency model (Appendix 3, Table S2). Node-splitting analyses showed no statistically significant disagreement between direct and indirect evidence across evaluated comparisons (all P > 0.05; Appendix 3, Table S3, Table S4). Between-study heterogeneity, expressed as τ², was low to moderate across outcomes and remained within an acceptable range for interpretation. Adjusted funnel plots did not show major asymmetry, suggesting no strong evidence of small-study effects or major reporting bias (Appendix 4, Figure S1–S5). Confidence in the evidence, assessed using the CINeMA framework, was generally low to moderate for many comparisons, although some comparisons were rated very low and some key comparisons were supported by higher-certainty evidence. Overall, these findings suggest that the network estimates are reasonably robust in parts of the network, but several comparisons still warrant cautious interpretation because of study limitations, imprecision, heterogeneity, and incoherence (Appendix 5, Figures S6–S13 and Tables S5–S8). No additional subgroup analyses, meta-regression analyses, or sensitivity analyses were performed. Accordingly, the robustness of the findings was judged primarily on the basis of network consistency, heterogeneity estimates, and certainty-of-evidence assessment.

Network Diagrams of NIH-CPSI Scores

The NIH-CPSI total score and subscales formed well-connected networks with WM and CHM as central nodes, connected to various acupuncture therapies including MA, EA, WMA, and their combinations. This design allowed for complete comparisons of the treatments, with edge thickness representing study numbers and node size indicating sample size (Figure 3).

Figure 3 Network plots for the primary outcomes. Node size represents the sample size of each intervention, and line thickness represents the number of direct comparisons.

NIH-CPSI Total Score

Analysis of the forest plot (Figure 4) showed that acupuncture therapies, whether used alone or combined with conventional oral medications, consistently reduced NIH CPSI total scores compared to oral drug controls. The treatments led to notable improvements, especially over CHM. WMA, EA, and EA with WM were the most effective. Specific results showed WMA versus CHM (MD −6.81, 95% CI −9.14 to −4.48; SUCRA 94.1%; high certainty evidence) and WMA versus WM (MD −5.55, 95% CI −7.27 to −3.83; SUCRA 94.1%; high certainty evidence). EA was effective compared with CHM (MD −6.05, 95% CI −8.15 to −3.95; SUCRA 86.2%; low certainty evidence) and with WM (MD −4.78, 95% CI −6.30 to −3.72; SUCRA 86.2%; low certainty evidence). EA plus WM showed effectiveness versus CHM (MD −6.00, 95% CI −8.80 to −3.21; SUCRA 84.1%; low certainty evidence) and versus WM (MD −4.74, 95% CI −6.94 to −2.54; SUCRA 84.1%; low certainty evidence) (Appendix 6, Figure S14, Table S9; Appendix 5, Table S5).

Figure 4 Forest plots for NIH-CPSI total score. (A) Compared with CHM; (B) compared with WM.

The league table (Appendix 7, Table S14) suggestedthat EA and EA+WM were more effective compared to other interventions. EA showed better results than several other treatments: EA+CHM (−2.58, −5.09 to −0.07, 86.2%), MOX (−3.43, −5.74 to −1.13, 86.2%), SMS (−3.16, −5.64 to −0.69, 86.2%), and WMA+CHM (−2.83, −5.11 to −0.55, 86.2%). Additionally, EA+WM showed significant improvements compared with MOX (−3.39, −6.24 to −0.55, 84.1%) and SMS (−3.12, −6.16 to −0.08, 84.1%). None of the remaining comparisons were statistically significant.

NIH-CPSI Pain Subscore

Forest plot analysis (Figure 5) showed that acupuncture therapies, either as monotherapy or combined with oral medications, consistently produced greater reductions in NIH-CPSI pain subscores than oral drug controls. Specifically, when compared with CHM, three interventions showed statistically significant improvements: AAT (MD −2.24, 95% CI −4.26 to −0.58; SUCRA 76.6%), EA (MD −2.07, 95% CI −3.90 to −0.25; SUCRA 71.5%), and MA+CHM (MD −2.06, 95% CI −3.41 to −0.72; SUCRA 69.3%) (Appendix 6, Figure S15, Table S10; Appendix 5, Table S6).

Compared to WM, several interventions presented enhanced effects: EA+WM (MD −3.28, −5.02 to −1.55; 80.4%), AAT (MD −3.13, −5.78 to −0.48; 76.6%), EA (MD −2.78, −3.82 to −1.75; 71.5%), MA+CHM (MD −2.78, −5.11 to −0.44; 69.3%), WMA (MD −2.37, −4.51 to −0.23; 58.2%), and MA (MD −1.84, −2.87 to −0.81; 42.9%). The league table (Appendix 7, Table S15) showed no other statistically significant differences between intervention pairs.

Figure 5 Forest plots for NIH-CPSI pain score. (A) Compared with CHM; (B) compared with WM.

NIH-CPSI Urinary Subscore

Forest plot analysis (Figure 6) showed that acupuncture treatments, whether used alone or with oral medications, reliably improved NIH-CPSI urinary subscores compared with oral medication alone. When compared with CHM, three interventions showed statistically significant benefits: AAT (MD −1.60, 95% CI −3.11 to −0.09; SUCRA 83.4%), MA+CHM (MD −1.20, 95% CI −2.18 to −0.22; SUCRA 73.7%), and EA+CHM (MD −1.16, 95% CI −2.13 to −0.19; SUCRA 72.8%) (Appendix 6, Figure S16, Table S11; Appendix 5, Table S7).

Figure 6 Forest plots for NIH-CPSI urinary score. (A) Compared with CHM; (B) compared with WM.

Compared to WM, multiple interventions showed advantages: AAT (MD −2.71, −4.99 to −0.42; 83.4%), MA+CHM (MD −2.32, −4.29 to −0.33; 73.7%), EA+CHM (MD −2.27, −4.25 to −0.29; 72.8%), MOX (MD −2.15, −4.22 to −0.08; 67.5%), EA (MD −1.68, −2.54 to −0.81; 56.5%), and EA+WM (MD −1.27, −2.43 to −0.10; 43.2%). The league table (Appendix 7, Table S16) presented no other statistically significant differences between intervention pairs.

NIH-CPSI Quality of Life Subscore

Forest plot analysis (Figure 7) indicated that most acupuncture interventions, whether used alone or in combination with conventional oral medications, showed improving trends in NIH-CPSI quality of life subscores compared to CHM, though these were not statistically significant. The exception was MA+CHM (MD −1.79, 95% CI −2.93 to −0.66; SUCRA 83.6%), which showed both clinically meaningful improvement and statistical significance.

Figure 7 Forest plots for NIH-CPSI quality-of-life score. (A) Compared with CHM; (B) compared with WM.

Compared to WM, showed statistically significant benefits: MA+CHM (MD −2.41, −4.37 to −0.44; 83.6%), EA (MD −1.95, −2.88 to −1.02; 74.6%), and EA+WM (MD −1.72, −3.14 to −0.30; 66.1%) (Appendix 6, Figure S17, Table S12; Appendix 5, Table S8). The league table (Appendix 7, Table S17) showed no other significant differences in direct comparisons between treatment pairs.

Whether used alone or in combination with conventional medications (either CHM or WM), most treatments showed clear advantages over oral medication alone in reducing the total NIH-CPSI score and its subscale scores, with advantages particularly evident for WMA, EA (either as monotherapy or combined with conventional oral medications), and AAT compared to control groups receiving oral drugs.

Response Rate

The network structure (Figure 8) showed high connectivity, with WM and CHM acting as central nodes that connected multiple acupuncture interventions including MA, EA, WMA, SMS, AAT, MOX, and their combination therapies. This configuration allowed for thorough direct and indirect comparisons of treatments. Forest plot analysis (Figure 9) indicated that most acupuncture-related therapies showed improved response rates compared to CHM and WM. Significant improvements were seen with WMA (RR 1.34, 95% CI 1.12 to 1.60; SUCRA 91.4%), EA+CHM (1.05, 0.86 to 1.27; 77.6%), MA +CHM (1.20, 1.03 to 1.39; 65.3%), and SMS (1.18, 1.01 to 1.38; 61.7%). Compared to WM, all acupuncture therapies, particularly WMA (1.35, 1.20 to 1.51; SUCRA 91.4%), EA+CHM (1.25, 1.06 to 1.48; 77.6%), SMS (1.19, 1.01 to 1.39; 61.7%) showed improved response rates, with statistically significant effects (Appendix 6, Figure S18, Table S13). The analysis in the league table (Appendix 7, Table S18) showed that WMA was better than EA, EA plus WM, MA, and MOX, with significant statistical differences.

Figure 8 Network plots for response rate. Node size represents the sample size of each intervention, and line thickness represents the number of direct comparisons.

Figure 9 Forest plots for response rate. (A) Compared with CHM; (B) compared with WM.

Adverse Events

The included clinical studies on CP showed that MA, EA, MOX, and CHM were generally safe, with no serious side effects reported. Minor and short-lived reactions happened occasionally, including acupuncture-related vasovagal responses (eg, dizziness or sweating), localized bleeding or needle retention, gastrointestinal discomfort associated with herbal medicine, and local skin reactions following acupoint application. These reactions were generally mild, self-limiting, and did not require stopping therapy. Furthermore, there were no significant differences in side effect rates between the intervention and control groups, indicating that these therapies are well tolerated and generally safe for managing CP.

Discussion

Primary Findings

This NMA of 45 RCTs suggests most acupuncture-related therapies were associated with greater symptom improvement than medication alone in active-controlled trials.⁷⁸ WMA and EA showed relatively consistent benefits across several major symptom domains. WMA showed the most consistent improvements in overall symptom scores and response rates, while EA, either alone or combined with WM, was associated with improvements in pain relief and quality of life. Nevertheless, these findings should be interpreted with caution because many included studies had methodological limitations and relied predominantly on active-controlled rather than sham-controlled designs. Further high-quality sham-controlled studies are still needed to confirm these findings.

Comparison with Previous Evidence

The present findings are consistent with previous systematic reviews and meta-analyses.^79,80 Current evidence indicates that acupuncture significantly improves NIH-CPSI scores, pain, and urinary symptoms in CP/CPPS patients.⁸⁰ Specifically, verum acupuncture has been associated with greater reductions in NIH-CPSI total scores (MD = −6.41)²⁵ and higher response rates compared to sham acupuncture and WM,⁷⁸ which the present NMA further supports. Regarding safety, observed minor adverse events, including subcutaneous hematoma and temporary pain, are in line with previous reports²⁵ and are far less severe than potential systemic reactions associated with oral medications.²⁵ The present findings contrast with a 2024 NMA by Qin et al⁸¹ which found long-needle and thumb-tack needles to be the most effective, but had serious flaws in its methods. The “thumb-tack needle paradox” shows that while these needles appear effective, their mechanism seems unlikely,⁸¹ suggesting possible statistical errors.²⁵ Furthermore, the study confused needle length with stimulation method, because long needles are frequently used for EA or WMA,⁸² which likely led to wrongly assigning the effects of stimulation to needle length. In comparison, our NMA used clear definitions of interventions, separating thermal and electrical stimulation, and identified WMA and EA as the most favorable modalities based on solid methods and results that can be applied in practice.

Mechanisms of Acupuncture Therapies for CP

WMA achieves its effects by using both needling and moxibustion. The thermal component induces vasodilation that significantly improves prostatic microcirculation and enhances inflammatory mediator clearance,⁸³ while simultaneously downregulating local pro-inflammatory cytokines and relaxing hypertonic pelvic floor muscles.⁸¹ EA shows clear benefits in reducing central sensitization and improving neuromuscular function,⁸⁴ while both EA and WMA offer overall pain relief and anti-inflammatory effects.

Dual Synergistic Mechanisms of Warm Needle Acupuncture

WMA combines the mechanical effect of needling with the heat from moxibustion, creating a combined effect that improves treatment outcomes.¹⁴ The thermal component induces vasodilation that significantly improves local prostatic microcirculation,⁸³ enhances inflammatory mediator clearance, and consequently reduces tissue congestion and edema, advantages not achieved by MA alone. At the same time, the heat from moxibustion (around 47–52°C)¹⁷ works together with needling to reduce local pro-inflammatory cytokines (including TNF-α and IL-1β)⁸¹ while relaxing hypertonic pelvic floor musculature, thereby providing direct pain relief and anti-inflammatory effects.⁸¹

Multi-Level Neuroregulatory Mechanisms of EA

As a therapy that acts on the nervous system outside the central nervous system, EA affects CP/CPPS processes in different ways through specific electrical frequency stimulation.⁸⁵ Locally, EA suppresses inflammatory responses and oxidative stress in prostatic tissue, reducing levels of pro-inflammatory factors (eg, IL-1β, IL-6, TNF-α) and oxidative stress markers (COX-2, iNOS, MDA).⁸⁶ At the spinal level, EA directly inhibits hyperactivation of dorsal horn glial cells, downregulates activation markers (including GFAP and Iba1), and decreases release of chemokines such as CXCL1, thereby calming central sensitization and increasing pain tolerance.^86,87 Systemically, EA affects the neuro-endocrine-immune system,⁸⁸ helping to correct T-cell imbalances associated with CP/CPPS and other immune dysfunctions while promoting restoration of immune homeostasis.⁸³

In summary, WMA and EA act through two different pathways that complement each other in producing their effects—“thermodynamic-microcirculatory” and “electrophysiological-neuromodulatory”—that precisely target the core pathological mechanisms of CP/CPPS. These mechanisms may partly explain the favorable clinical effects observed for WMA and EA in the present NMA.

Clinical Implications

This NMA provides comparative evidence that may help inform clinical decision-making and future guideline development in CP. Current guidelines provide only broad recommendations for acupuncture because past evidence is varied and there are few direct comparisons between different acupuncture methods.^25,89 This study suggests that WMA and EA may represent useful acupuncture-related therapies for patients with insufficient response to conventional medications. Besides, combining acupuncture with standard medications may provide additional benefits. While medications primarily target local organ structures, previous studies suggest that WMA and EA may also influence neuroimmune regulation and central sensitization pathways.⁸⁵ However, because most included studies were based on active-controlled comparisons and the overall certainty of evidence was predominantly low to moderate, these findings should not yet be interpreted as definitive evidence of superiority over other therapeutic approaches. This multimodal approach may support the use of acupuncture as a complementary strategy in CP management.

Strengths and Limitations

To our knowledge, this is the first network meta-analysis based on a relatively large evidence base (45 RCTs) to distinguish WMA, EA, and MA as separate intervention nodes while also treating combination regimens as independent comparators within the network. By revisiting the methodological limitations in Qin et al,⁸¹ this study further clarified the so-called “thumb-tack needle paradox” and highlighted the importance of defining intervention nodes according to stimulation type rather than needle form alone. These design features improve the interpretability and clinical relevance of the present findings.

Several limitations should also be considered. Clinical heterogeneity remained substantial across studies, including differences in acupoint selection, treatment frequency, treatment duration, and co-interventions.⁹⁰ The methodological quality of many RCTs was also limited, particularly regarding blinding, allocation concealment, and incomplete reporting of intention-to-treat analyses.^91,92 In addition, most studies compared acupuncture-related therapies with active medications rather than sham controls, making it difficult to fully distinguish specific treatment effects from contextual or nonspecific effects. Most included studies were conducted in China, which may limit generalizability and increase the risk of location-related publication bias or selective reporting of positive findings.⁹³ Response rate outcomes should also be interpreted cautiously because definitions of clinical response varied across studies. Some network comparisons relied mainly on indirect evidence or a limited number of small studies, reducing the precision of certain treatment contrasts. Furthermore, because no additional subgroup analyses, meta-regression analyses, or sensitivity analyses were performed, the influence of specific clinical or methodological factors on treatment rankings could not be explored further. Therefore, although the overall findings support the potential value of acupuncture-related therapies, particularly WMA and EA, the rankings should still be interpreted with caution.

Future studies should prioritize rigorously designed head-to-head randomized trials comparing WMA and EA, with standardized diagnostic criteria, harmonized treatment protocols, and longer follow-up periods. Improved methodological transparency and broader geographic representation will also be important for strengthening the evidence base and improving the reliability of future treatment rankings.

Conclusions

This NMA suggests that WMA and EA may serve as useful complementary approaches for improving core CP symptoms in active-controlled trials. WMA showed the most favorable overall results, while EA demonstrated benefits in pain relief and quality of life. By re-evaluating the methodological limitations in Qin et al,⁸¹ the findings further suggest that the “thumb-tack needle paradox” may partly result from inappropriate node classification.^25,82 These findings highlight the importance of clearly defining stimulation types in future NMAs. Nevertheless, the current findings should be interpreted with caution because most included studies were active-controlled trials with predominantly low-to-moderate certainty evidence and limited long-term follow-up. Further high-quality head-to-head and sham-controlled studies are needed.