Primary Care And Urology Patients With The Male Pelvic Pain Syndrome: Symptoms And Quality Of Life

Low quality of life in men with chronic prostatitis-like symptoms

BACKGROUND

Chronic prostatitis (CP) can impair health-related quality of life (QOL), but the full impact of CP, including the impact of CP-like symptoms in men who have no CP diagnosis (CPS), is unknown. We estimated the impact of diagnosed CP (DCP) and CPS on Health-related QOL.

METHODS

From a representative nationwide survey of men aged 20-84 in Japan, we determined the prevalence of DCP and also of CPS. For CPS, we used Nickel's criteria, which were used previously to estimate the prevalence of CP and are based on the NIH Chronic Prostatitis Symptom Index. To test the robustness of Nickel's criteria, we used two other definitions of CPS (two sensitivity analyses). We measured QOL with the Short-Form 12-Item Health Survey. We compared the participants' QOL scores with the national-norm scores, and with the scores of men who had benign prostatic hyperplasia (BPH).

RESULTS

Among the 5 010 participants, 1.4% had DCP and 3.7% had CPS. The sensitivity analyses resulted in CPS prevalence estimates of 3.1% and 4.5%. CPS was particularly common in younger participants (5.7% of those in their 30 s had CPS). QOL was very low among men with CP: In most areas (domains) of QOL, their scores were more than 0.5 standard deviation below the national-norm mean. Their mental-health scores were lower than those of men with BPH. The lowest scores among all 8 QOL domains were in role-functioning.

CONCLUSIONS

CP is common, but it is underdiagnosed, particularly in younger men. Whether diagnosed or only suspected, CP's impact on QOL is large. Because CP is common, and because it substantially impairs individuals' QOL and can also reduce societal productivity, it requires more attention. Specifically, needed now is a simple tool for urologists and for primary care providers, to identify men, particularly young men, whose QOL is impaired by CP.

Efficacy of low-intensity extracorporeal shock wave therapy for the treatment of chronic prostatitis/chronic pelvic pain syndrome: A systematic review and meta-analysis

AIMS

Low-intensity extracorporeal shock wave therapy (Li-ESWT) has been applied in urolithiasis and some chronic diseases. We performed a systematic review and meta-analysis to assess the efficacy of Li-ESWT for the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS

A comprehensive search of MEDLINE, Web of Science, EMBASE, and the Cochrane Library to January 6, 2019 was performed for randomized controlled trials (RCTs) reporting on patients with CP/CPPS treated with Li-ESWT compared with the sham group. Outcomes were evaluated based on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). The quality assessment of included studies was performed by the Cochrane System.

RESULTS

Six publications involving five RCTs with 280 patients were assessed in this review. NIH-CPSI total score, pain domain and quality of life (QOL) were significantly better in the Li-ESWT group than those in the control group at the endpoint (P < 0.00001, P = 0.003, and P < 0.00001), 4 weeks (P < 0.00001, P = 0.0002 and P < 0.00001) and 12 weeks (P < 0.00001, P < 0.00001, and P = 0.0002) after the treatment. For urinary score, significant difference existed at 12 weeks after the treatment (P = 0.006). At 24 weeks after treatment, there was no significant difference between the two groups in NIH-CPSI total score (P = 0.26), pain domain (P = 0.32), urinary score (P = 0.07), and QOL (P = 0.29).

CONCLUSIONS

Li-ESWT showed great efficacy for the treatment of CP/CPPS at the endpoint and during the follow-up of 4 and 12 weeks, though the efficacy of 24-week follow-up was not significantly different due to insufficient data. Generally, Li-ESWT is a promising minimal invasive method for the treatment of CP/CPPS.

Prostatitis Syndromes and Sporting Activities

Introduction

Prostatitis-like syndromes are high prevalent health problems and frequently considered by patients and physicians as strictly correlated to sports causing perineal compression. These syndromes and their relationships with sporting activities have been discussed in this report.

Methods

We reviewed peer-reviewed scientific articles published by May 2009 and searched according to the following term selection: prostatitis, pudendal nerve, sport, cycling.

Results

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a major healthcare burden heavily affecting patients’ Quality of Life. No clear evidence of any direct etiologic relationship has been found in literature between prostatitis, either bacterial or non-bacterial, and sports activities. On the other hand, some types of sport causing perineal compression, such as cycling, can exacerbate symptoms of acute and chronic prostatitis; a temporary sport discontinuation is justified in these patients. CP/CPPS may be often caused by pudendal nerve entrapment (PNE). Prostatitis-like urogenital neuropathic pain together with voiding and sexual dysfunctions are the hallmark of PNE. A common feature is that flexion activities of the hip, such as climbing, squatting, cycling provoke or worsen urogenital pain or pelvic pain. Many of the patients with PNE are cyclists, played American football, lifted weights, or wrestled as teenagers and young adults. PNE represents the most common bicycling associated urogenital problems.

Conclusions

Overall, studies show that no causal relationship has been demonstrated between prostatitis and sporting activities. Conversely, urologists should be aware that sports involving vigorous hip flexion activities or prolonged perineal compression are a potential and not an infrequent cause of uroand rological symptoms caused by pudendal nerve entrapment.

The Vascular Factor Plays the Main Role in the Cause of Pain in Men with Chronic Prostatitis and Chronic Pelvic Pain Syndrome: The Results of Clinical Trial on Thermobalancing Therapy

Chronic pain in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), NIH category III is difficult to treat without understanding its cause. The main symptom of chronic prostatitis is pain. In this study, we would like to explain the origin of pain in men with CP/CPPS and its therapy. Forty-five patients with CP/CPPS have received thermobalancing therapy (TT) enabled by Dr Allen's therapeutic device (DATD) for six months as mono-therapy. The control group comprised 45 men with CP/CPPS did not receive TT. Before and after six months the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scores, prostatic volume (PV) by ultrasound measurement and uroflowmetry (Q_max) were compared between the groups. Baseline characteristics have shown no difference. After TT, significant improvements in pain score (p < 0.001), quality of life index (QoL) (p < 0.001), decrease of PV (p < 0.001), and increase Q_max (p < 0.001) were determined. There were not noteworthy changes in the control group. Chronic pain due to CP/CPPS happens as a consequence and challenges at the capillary level, namely pathological capillary activity. In response to initial triggers-such as inflammation, cold, psychological and other factors-constriction and spontaneous expansion of capillaries follows, creating a continuous secondary trigger-i.e., the micro-focus of hypothermia-which in turn provokes expansion of capillaries. The additional tissue due to vascular changes into the prostate increases pressure on nociceptors causing pain. TT relieves chronic pelvic pain by eliminating the lasting focus of hypothermia in the affected prostate tissue.

Extracorporeal shock wave therapy (ESWT) in urology: a systematic review of outcome in Peyronie's disease, erectile dysfunction and chronic pelvic pain

PURPOSE

The objective was to evaluate high-level evidence studies of extracorporeal shock wave therapy (ESWT) for urological disorders.

METHODS

We included randomized controlled trials reporting outcomes of ESWT in urology. Literature search on trials published in English using EMBASE, Medline and PubMed was carried out. The systematic review was performed according to PRISMA guidelines.

RESULTS

We identified 10 trials on 3 urological indications. Two of 3 trials on Peyronie's disease (PD) involving 238 patients reported improvement in pain; however, no clinical significant changes in penile deviation and plaque size were observed. Four studies on erectile dysfunction (ED) including 337 participants were included. Using International Index of Erectile Function (IIEF-EF) and erectile hardness scale (EHS) data suggested a significant positive effect of ESWT in phosphodiesterase-5 inhibitor (PDE-5i) responders in 2 of 4 trials and 3 of 4 trials, respectively. Three studies on chronic pelvic pain (CPP) engaging 200 men reported positive changes in National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). There was considerable heterogeneity between trials both with regard to treatment techniques and outcome measures, making it difficult to compare results.

CONCLUSIONS

ESWT may resolve pain in PD patients, while evidence for reducing curvature and plaques size is poor. Effects of ESWT on IIEF in ED patients are inconsistent; however, data on EHS does imply that the treatment potentially may recover natural erection in PDE-5i responders. ESWT seems to be able to resolve pain in CPP patients in the short term. In all three disease entities, long-term outcome data are still warranted.

Comparison of National Institutes of Health-Chronic Prostatitis Symptom Index with International Index of Erectile Function 5 in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Large Cross-Sectional Study in China

The purpose of the study is to evaluate the relationship between NIH-CPSI and IIEF-5 in Chinese men with CP/CPPS. A large cross-sectional and multicenter survey was conducted from July 2012 to January 2014. Men were recruited from urology clinics which were located at the five cities in China. All men participated in the survey by completing a verbal questionnaire (consisted of sociodemographics, past medical history, sexual history, and self-estimated scales). The results showed that 1,280 men completed the survey. Based on the CP/CPPS definition, a total of 801 men were diagnosed as having CP/CPPS. Men with CP/CPPS reported higher scores of NIH-CPSI and lower scores of IIEF-5 than men without CP/CPPS. NIH-CPSI scores were significantly negatively correlated with IIEF-5 scores. The total scores of NIH-CPSI were significantly more strongly correlated with question 5 than other questions of IIEF-5. The total scores of IIEF-5 were significantly more strongly correlated with pain symptoms scores of NIH-CPSI. Strongest correlation was found between QoL impact and question 5 of IIEF-5. The findings suggested that NIH-CPSI scores were significantly negatively correlated with IIEF-5 scores. Strongest correlation was found between QoL impact and question 5 of IIEF-5.

Assessing psychological factors, social aspects and psychiatric co-morbidity associated with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) in men -- a systematic review

OBJECTIVE

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a chronic pain disease with high prevalence rates and substantial health care costs. An interdisciplinary classification system is commonly used (UPOINT) which includes psychosocial factors. Nevertheless, psychosocial influences on CP/CPPS only recently became a research focus. Therefore, we aimed to synthesize the existing data and to identify further research topics. Then, based on our results, diagnosis and treatment can be improved.

METHODS

In a systematic review conducted according to the PRISMA reporting guidelines we searched different databases (MEDLINE, EMBASE, PsychINFO) using the broad search terms "chronic pelvic pain syndrome AND men". Two raters independently screened the literature and assessed the risk of bias.

RESULTS

We included 69 original research articles which considered psychosocial variables. We found studies investigating different psychosocial factors (pain catastrophizing, stress, personality factors, social aspects), co-morbid psychiatric disorders (depression, anxiety and trauma-related disorders, somatization disorder, substance abuse) and Quality of Life (QoL). In addition, there is a high risk of bias in most studies e.g. concerning the study design or the measures.

CONCLUSIONS

There is evidence suggesting that psychological factors are important in understanding CP/CPPS. However, research concentrated on a few aspects while the others were not covered adequately. We found evidence of a higher number of psychosocial factors and psychiatric co-morbidities than is currently included in the UPOINT system. More high quality research is needed to understand the interplay of psychosocial factors in CP/CPPS. Furthermore, these factors should be incorporated into treatment approaches.

Pain, catastrophizing, and depression in chronic prostatitis/chronic pelvic pain syndrome

Persistent and disabling pain is the hallmark of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). However, disease severity (as measured by objective indexes such as those that use radiography or serology) is only marginally related to patients' reports of pain severity, and pain-related presentation can differ widely among individuals with CP/CPPS. Increasing evidence in support of the biopsychosocial model of pain suggests that cognitive and emotional processes are crucial contributors to inter-individual differences in the perception and impact of pain. This review describes the growing body of literature relating depression and catastrophizing to the experience of pain and pain-related sequelae in CP/CPPS. Depression and catastrophizing are consistently associated with the reported severity of pain, sensitivity to pain, physical disability, poor treatment outcomes, and inflammatory disease activity and potentially with early mortality. A variety of pathways, from cognitive to behavioral to neurophysiological, seem to mediate these deleterious effects. Collectively, depression and catastrophizing are critically important variables in understanding the experience of pain in patients with CP/CPPS. Pain, depression, and catastrophizing might all be uniquely important therapeutic targets in the multimodal management of a range of such conditions.

Chronic prostatitis and depressive disorder: a three year population-based study

BACKGROUND

There is limited research on the relationship between chronic prostatitis (CP) and the subsequent risk of depressive disorders (DD). This population-based study aims to prospectively examine the relationship between a history of CP and the risk of developing DD in Taiwan.

METHODS

A total of 3051 adult patients, newly diagnosed with CP during 2001 to 2005, were recruited, together with 15,255 matched enrollees without a history of CP as a comparison cohort. All patients were tracked for a three year period from their index healthcare encounters to identify those who had subsequent DD. The Cox proportional hazards models were carried out to compute the risk of DD in the study and comparison cohorts, after adjustment for socio-demographic characteristics.

RESULTS

Of a total of 18,306 patients, 163 (5.34%) from the CP group and 494 (3.24%) from the comparison group had a subsequent diagnosis of DD during the follow-up period. Stratified Cox proportional analysis shows that, after adjusting for monthly income, geographic region, and urbanization level of the community in which the patient resided, hypertrophy (benign) of prostate, and urinary incontinence, the hazard ratio of DD during the three year follow-up period is 1.63 for patients with chronic prostatitis (95% CI = 1.36-1.96) than those without chronic prostatitis. The differences are most significant in the younger group, aged less than 30 years (hazard ratio, 2.50; 95% CI = 1.18-4.51).

CONCLUSIONS

These results suggest that CP patients experience an increased risk of DD compared to non-CP patients during a three year follow-up period.

[Symptomatic approach to chronic prostatitis/chronic pelvic pain syndrome]

OBJECTIVE

To review the diagnosis and pathogenesis of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

MATERIAL AND METHODS

A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either medical subject heading (MeSH) keywords (microbiology, pelvic pain, prostatitis) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time.

RESULTS

Chronic bacterial prostatitis is a chronic, recurrent bacterial infection of the prostate, accounting for about 5 to 10% of all cases of chronic prostatitis (CP). CPPS is nonbacterial genitourinary pelvic pain present for at least 3 months, sometimes associated with sexual and voiding disorders. Although the prostate does not appear to be involved in all cases of chronic pelvic pain in men, the term CP usually remains associated with CPPS (CP/CPPS). CP/CPPS has a negative impact on quality of life. The precise pathogenesis of CP/CPPS has not been elucidated, but prostatic infection and inflammation could be involved, not as direct causes, but as initiating factors of a neurological hypersensitization phenomenon. Evaluation of CP/CPPS comprises clinical interview completed by the National Institutes of Health-Chronic Prostatitis Symptom Index questionnaire (NIH-CPSI), physical examination, urine culture and uroflowmetry combined with determination of the post-voiding residual volume. The other investigations are optional and are designed to exclude other urological diagnoses. The Meares-Stamey four-glass test should be abandoned in favour of a simplified test comprising urine analysis before and after prostatic massage. However, the indications for this test are limited to patients in whom chronic bacterial prostatitis is suspected or with bacteriuria on urine culture.

CONCLUSION

Chronic bacterial prostatitis represents only about 5 to 10% of all cases of CP. The usual terminology of chronic non-bacterial prostatitis has been replaced by the term CPPS or CP/CPPS in men, in order to situate this disease in a broader context not exclusively related to the prostate. Despite its prevalence and its impact on quality of life and sexuality, CP/CPPS remains poorly known and continues to raise diagnostic problems.

Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVE

To examine interactions between demographic, pain, urinary, psychological and environmental predictors of quality of life (QOL) in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

PATIENTS AND METHODS

In all, 253 men previously enrolled in the National Institutes of Health Chronic Prostatitis Cohort study in North American tertiary-care clinical centres (six in the USA and one in Canada) self-reported with validated instruments, including the QOL subscales of the Short Form-12 (physical, SF12-PCS; and mental, SF12-MCS), demographics, urinary symptoms, depression, current pain, pain coping, 'catastrophizing' (catastrophic thinking about pain), pain control, social support and solicitous responses from a partner. Data were collected through a one-time survey. Covariates determined to be significant were entered into a multivariable regression model predicting SF12-PCS and SF12-MCS.

RESULTS

Adjusting for covariates, regression models showed that poorer SF12-PCS scores were predicted by worse urinary function (P < 0.001) and increased use of pain-contingent resting as a coping strategy (P = 0.026). Further, poorer SF12-MCS scores were predicted by greater pain catastrophizing (P = 0.002) and lower perceptions of social support (P< 0.001). In separate follow-up analyses, helplessness was the significant catastrophizing subscale (P < 0.001), while support from family and friends were the significant social support subscales (P = 0.002 and <0.001).

CONCLUSIONS

These data suggest that specific coping and environmental factors (i.e. catastrophizing, pain-contingent resting, social support) are significant in understanding how patients with CP/CPPS adjust. These data can be used to develop specific cognitive-behavioural programmes for men with CP/CPPS who are refractory to standard medical therapy.

Symptoms Suggestive of Chronic Pelvic Pain Syndrome in an Urban Population: Prevalence and Associations With Lower Urinary Tract Symptoms and Erectile Function

PURPOSE

We determined the prevalence of symptoms suggestive of chronic pelvic pain syndrome in an urban population and assessed associations with lower urinary tract symptoms and erectile dysfunction.

MATERIALS AND METHODS

Men participating in a voluntary health examination free of charge that was organized by the Department of Preventive Health of the City of Vienna were analyzed. All participants completed 3 validated questionnaires on chronic pelvic pain syndrome (National Institutes of Health-Chronic Prostatitis Symptom Index), lower urinary tract symptoms (International Prostate Symptom Score) and erectile dysfunction (International Index of Erectile Function-5).

RESULTS

A total of 1,765 men with a mean +/- SD age of 46.3 +/- 0.3 years (range 20 to 79) entered this study. The mean National Institutes of Health-Chronic Prostatitis Symptom Index score increased from 4.0 +/- 0.3 in the youngest age group of 20 to 29-year-old men to 6.3 +/- 0.6 in those 70 to 79 years old. The overall prevalence of symptoms suggestive of chronic pelvic pain syndrome, defined by a pain score of 4 or greater and perineal/ejaculatory pain, was 2.7% and it revealed no age dependence, such as the pain score. In contrast, urinary symptom and quality of life scores increased with age. International Index of Erectile Function-5 score was 20.6 +/- 0.3 for men without chronic pelvic pain symptoms vs 18.3 +/- 0.7 for men with mild symptoms and 16.5 +/- 1.1 for men with moderate/severe symptoms. A National Institutes of Health-Chronic Prostatitis Symptom Index score in the upper quartile was associated with 8.3-fold increased odds of erectile dysfunction.

CONCLUSIONS

The prevalence of symptoms suggestive of chronic pelvic pain syndrome in this large cohort of men participating in a health screening project was 2.7% and it revealed no age dependence. Our study suggests that chronic pelvic pain syndrome has a negative impact on erectile function.

Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments--could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study

PURPOSE

Chronic prostatitis/chronic pelvic pain syndrome is a major healthcare burden. Affected patient quality of life is poor and currently no investigated treatments have significant long-term benefit. We performed a preliminary investigation of the role of physical activity and its effects on select patients with chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS

Between 2002 and 2004 we recruited a volunteer sample of 231 eligible males 20 to 50 years old with chronic prostatitis/chronic pelvic pain syndrome who were unresponsive to conventional treatments and free of any contraindication for moderate intensity physical exercise. This group was screened and, if in accordance with study inclusion/exclusion criteria, patients were randomized into 2 groups. Participants were randomly assigned to the aerobic exercise group (52) and the placebo/stretching and motion exercises group (51). Main outcome measures were the Italian version of the National Institutes of Health Chronic Prostatitis Symptom Index, Beck Depression Inventory, State Anxiety Inventory-Y and a pain intensity visual analog scale administered at baseline, and 6 and 18 weeks.

RESULTS

At 18 weeks 36 subjects (75%) in the aerobic exercise group vs 40 (81.63%) in the placebo/stretching and motion exercises group completed the 18-week program and evaluation. Differences between the 2 groups were found in total National Institutes of Health Chronic Prostatitis Symptom Index, pain and quality life impact subscales, and pain visual analog score (ANCOVA p = 0.006, 0.0009, 0.02 and 0.003, respectively).

CONCLUSIONS

Improvements in the aerobic exercise group were significantly superior compared to those in the placebo/stretching and motion exercises group. Aerobic exercise represents a valid treatment option and it should be further investigated in a larger study with longer followup.

Chronic cough from the patient's perspective

OBJECTIVE

To identify the factors that patients consider most concerning about their cough.

PATIENTS AND METHODS

All consecutive patients who presented with a complaint of chronic cough between November 1, 2000, and February 28, 2001, were prospectively surveyed for cough-related complaints using an 18-item symptom-complaint questionnaire. We analyzed frequencies of responses and response patterns to specific items on the questionnaire. We also examined whether the responses to individual items related to the patient's age, sex, and duration of cough.

RESULTS

Of the 146 consecutive patients referred for evaluation of chronic cough, 136 were eligible for inclusion in the study. These patients cited feelings of frustration, irritability, or anger (43%), frequent physician visits and testing (41%), and sleep disturbances (38%) as the most prevalent major problems. The responses to individual items on the questionnaire were not related to patients' age, sex, and cough duration. Anxiety about underlying serious illness continued to be a concern for most patients.

CONCLUSIONS

Frustration, anger, or anxiety was the most frequent major problem cited by patients. Frequent physician visits and testing was the unexpected second most frequent major problem. These findings are important because most chronic cough guidelines are based on clinical efficacy and cost-effectiveness considerations rather than on patient satisfaction. Future studies regarding chronic cough evaluation should take into account patient satisfaction and perceived burden of disease as outcome variables.

Sexual dysfunction and prostatitis

Despite a large number of reports exploring the links between diseases of the prostate and effects on sexuality, the relationship between prostatitis and sexual dysfunction has not been as thoroughly investigated. A number of reports have focused on the adverse effects of prostatitis on quality of life, with resultant indirect effects on sexuality. More detailed studies are available on the links between ejaculation and the chronic prostatitis/chronic pelvic pain syndrome subgroup of prostatitis. Improvement of sexual dysfunction following treatment of prostatitis has been reported in a few studies, most notably in association with alpha-blocker therapy. This review addresses some of the more relevant reported links between prostatitis and sexual function.

Catastrophizing and Pain-Contingent Rest Predict Patient Adjustment in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Cognitive/behavioral and environmental variables are significant predictors of patient adjustment in chronic pain. Using a biopsychosocial template and selecting several pain-relevant constructs from physical, cognitive/behavioral, and environmental predictors, outcomes of pain and disability in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were explored. Men (n = 253) from a North American multi-institutional NIH-funded Chronic Prostatitis Cohort Study in 6 US and 1 Canadian centers participated in a survey examining pain and disability. Measures included demographics, urinary symptoms, depression, pain, disability, catastrophizing, control over pain, pain-contingent rest, social support, and solicitous responses from a significant other. Regressions showed that urinary symptoms (beta = .20), depression (beta = .24), and helplessness catastrophizing (beta = .29) predicted overall pain. Further, affective pain was predicted by depression (beta = .39) and helplessness catastrophizing (beta = .44), whereas sensory pain was predicted by urinary symptoms (beta = .25) and helplessness catastrophizing (beta = .37). With regard to disability, urinary symptoms (beta = .17), pain (beta = .21), and pain-contingent rest (beta = .33) were the predictors. These results suggest cognitive/behavioral variables (ie, catastrophizing, pain-contingent rest) may have significant impact on patient adjustment in CP/CPPS. Findings support the need for greater research of such pain-related variables in CP/CPPS.

PERSPECTIVE

This article explores predictors of patient adjustment in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Cognitive/behavioral variables of catastrophizing and pain-contingent rest respectively predicted greater pain and disability. Catastrophic helplessness was a prominent pain predictor. These findings inform clinicians and researchers on several new variables in CP/CPPS outcomes and suggest future research.

More effects of extracorporeal magnetic innervation and terazosin therapy than terazosin therapy alone for non-inflammatory chronic pelvic pain syndrome: a pilot study

The objective of this study was to evaluate whether extracorporeal magnetic innervation (ExMI) combined with alpha-blocker therapy is more effective than alpha-blocker monotherapy for patients with non-inflammatory chronic prostatitis (CP)/chronic pelvic pain syndrome (CPPS), category IIIB. Patients were randomized to either terazosin monotherapy (group 1, n=21) or terazosin combined with ExMI therapy (group 2, n=19). Patients in group 2 had 12 treatment sessions of ExMI twice a week during 6 weeks. None of the patients experienced any side effects from treatment. The changes in each domain of the National Institutes of Health (NIH)-Chronic Prostatitis Symptom Index (CPSI) measured on week 6 were not significantly different between the groups. However, the difference (median, 25-75th percentiles) between the two groups in total NIH-CPSI scores was -4 (-11.5, -2) for group 1 and -12 (-17.3, -2.3) for group 2, respectively (P=0.047). At 6 weeks, 47.6% (10 of 21) of group 1 had a >25% decrease in total NIH-CPSI compared with 78.9% (15 of 19) of group 2 (P=0.041). Also, more patients in group 2 (78.9%) were rated as responders with a 6-point decrease in NIH-CPSI compared with group 1 (47.6%) (P=0.041). The early results suggest that ExMI combined with alpha-blocker therapy has better effect than alpha-blocker monotherapy for the treatment of CP/CPPS.

Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain

BACKGROUND

Nonbacterial prostatitis is a syndrome characterized by persistent pelvic area pain in men with or without voiding symptoms. Its causes are poorly understood, and evidence-based treatments are lacking. Although psychological stress has been proposed as an etiological factor, the literature lacks prospective studies using standardized measures to examine associations between stress and male pelvic pain problems over time.

PURPOSE

This study examined whether perceived stress was associated longitudinally with pain intensity and pain-related disability in a sample of men with nonbacterial prostatitis/pelvic pain.

METHODS

Men (N = 224) completed measures of perceived stress, pain intensity, and pain-related disability 1 month after a health care visit with a new nonbacterial prostatitis/pelvic pain diagnosis and 3, 6, and 12 months later.

RESULTS

Greater perceived stress during the 6 months after the health care visit was associated with greater pain intensity (p = .03) and disability (p = .003) at 12 months, even after controlling for age, symptom duration, and pain and disability during the first 6 months.

CONCLUSIONS

These findings support further research into the associations between stress and male pelvic pain syndromes, as well as the assessment of stress in the evaluation of patients with pelvic pain.

Men With Pelvic Pain: Perceived Helpfulness of Medical and Self-Management Strategies

OBJECTIVE

To assess the frequency of use of different treatments and pain management strategies and their perceived helpfulness in male patients with pelvic pain.

METHODS

Approximately 1 month after a health maintenance organization visit for pelvic pain, 286 men (mean age 46.7 years) completed telephone interviews about their symptoms and treatments and pain management strategies used in the past year. Participants rated the helpfulness of each treatment and strategy used on 0 to 10 scales.

RESULTS

Even though men with identified bacterial etiology were excluded from the study, antibiotic medication was the most commonly reported treatment (67% of patients) and rated as the second most helpful treatment [mean (SD)=6.3 (3.6)]. Opiates were rated as the most helpful treatment on average [mean (SD)=7.9 (2.1)], but were used by only 12% of patients. Substantial minorities of patients reported several behaviors as helpful, including urinating (reported as helpful by 26%), taking warm baths (23%), and drinking water (23%), although patterns of effects differed for men with versus without urinary symptoms. Activities most commonly reported as worsening symptoms were sitting (42%), walking/jogging (27%), and sexual activity (25%).

DISCUSSION

Patients with male pelvic pain syndrome are commonly prescribed antibiotics, which they perceive as moderately helpful, despite the lack of scientific evidence of efficacy. Clinicians may find it useful to support patient use of safe, inexpensive, self-management approaches, especially warm baths, increased water intake, and avoidance of prolonged sitting.

Prevalence, diagnosis, characterization, and treatment of prostatitis, interstitial cystitis, and epididymitis in outpatient urological practice: the Canadian PIE Study

OBJECTIVES

To determine the prevalence, diagnostic patterns, and management of prostatitis, interstitial cystitis, and epididymitis (PIE) in Canadian urology outpatient practice.

METHODS

Representative urologists were randomly selected from the Canadian and Quebec Urological Associations. Each patient identified with a PIE diagnosis during a typical 2-consecutive-week period during April 2004 to July 2004 was requested to complete a corresponding Chronic Prostatitis Symptom Index (CPSI), O'Leary-Sant Symptom Index (OSSI), or a Chronic Epididymitis Symptom Index (CESI). Each day the participant urologist completed an outpatient log and a detailed programmed chart review to transcribe demographics, investigations, and treatments associated with each PIE patient.

RESULTS

Sixty-five urologists were invited to participate. Fifty-seven (88%) agreed, and 48 (74%) completed the audit. Of the 8712 patients seen in outpatient practice (average 182 per urologist), 2675 were female and 6037 male. Prostatitis was identified in 2.7% of the men (n = 166; mean age 50 years; mean duration 3.1 years; mean CPSI score 19.7), interstitial cystitis in 2.8% of patients (n = 242; 211 women [7.9%], 26 men [0.4%]; mean age 50.2 years, mean duration 4.5 years, mean OSSI score 11.8), and epididymitis in 0.9% of men (n = 57; mean age 41.1 years, mean duration 2.5 years, mean CESI score 15.5). There was wide variance in investigations and treatments.

CONCLUSIONS

This prospective audit indicates that prostatitis might not be as common as frequently believed and that interstitial cystitis is more common, and it represents the first estimate of the prevalence of epididymitis in urologic practice. The wide variance in investigations and treatments confirms the need for practice management guidelines.

INCIDENCE AND CLINICAL CHARACTERISTICS OF NATIONAL INSTITUTES OF HEALTH TYPE III PROSTATITIS IN THE COMMUNITY

PURPOSE

Few population-based epidemiological studies of prostatitis have been performed. We used coded physician diagnoses and subsequent chart reviews to estimate the incidence and clinical characteristics of physician diagnosed National Institutes of Health (NIH) type III prostatitis.

MATERIALS AND METHODS

Computer searches of the Kaiser Permanente Northwest (Portland, Oregon) database were performed on the 2-year interval May 2002 to May 2004 to identify new diagnoses of chronic prostatitis (International Classification of Diseases, 9th Revision code 601.1) and prostatitis not otherwise specified (International Classification of Diseases, 9th Revision code 601.9). Of the 1,223 men identified with these coded diagnoses, chart reviews were performed on a random subset of 413 (33.8%). Patients were categorized based on NIH prostatitis definitions of type I/II-evidence of pyuria and/or bacteriuria on urinalysis or culture, type III-presence of at least 1 of the pain or urinary symptoms in the NIH Chronic Prostatitis Symptom Index (pain in the perineum, testicles, tip of penis, pubic or bladder area, dysuria, ejaculatory pain, incomplete emptying, urinary frequency), type IV-inflammation on prostate biopsy and Other-symptoms other than those listed.

RESULTS

Of the 413 patients 57 were previously diagnosed with prostatitis (prevalent cases), 46 had no evidence of a prostatitis diagnosis in the medical record and 7 were treated by physicians outside of the Kaiser Permanente Northwest plan. Of the remaining 303 the distribution was 58 type I/II, 189 type III, 33 type IV and 23 Other. The incidence of physician diagnosed type III prostatitis was 3.3 per 1,000 person-years. If those with isolated urinary symptoms were excluded from analysis, the incidence decreased to 2.8 per 1,000 person-years. The mean age of those with type III prostatitis was 52.9 years (range 29 to 82). The most common presenting symptoms were dysuria, urinary frequency and perineal pain. Symptom duration at presentation was less than 3 months in 44%, 3 months or greater in 31% and unspecified in 25%. The majority (78%) of new prostatitis diagnoses was made by primary care physicians.

CONCLUSIONS

These data indicate that prostatitis is commonly diagnosed in the community setting, and that type III prostatitis accounts for the majority of these diagnoses. The duration and complexity of symptoms are less than those reported in established prostatitis research cohorts. Most prostatitis diagnoses in the community are made by nonurologists.

Self-report of prostatitis and its risk factors in a random sample of middle-aged men

OBJECTIVES

To determine the risk factors for the self-reported history of prostatitis and to determine whether a self-reported history of prostatitis is related to the diagnosis of prostate cancer.

METHODS

Random digit dialing was used to select a group of controls aged 40 to 64 years without prostate cancer matched by age with a group of patients with prostate cancer in a study on the epidemiology of prostate cancer. Controls were divided into those who reported a diagnosis of prostatitis (cases) and those who denied ever having had prostatitis (controls). We adjusted for the time from a prostatitis diagnosis to the in-person interview. We also compared the number of men with a prostatitis diagnosis to the number of men diagnosed and not diagnosed with prostate cancer.

RESULTS

Of the 645 control men without a history of prostate cancer, 58 (9.0%) reported a diagnosis of prostatitis. The men with prostatitis had a mean age of 39.5 years at diagnosis. The urinary symptoms among prostatitis cases and controls was similar. Prostatitis cases more frequently reported urinary (P < or =0.05) or urethral infections (P < or =0.01) before diagnosis. Men with prostatitis were more likely to have procedures aimed at diagnosing both prostatic and other diseases. Men with prostate cancer reported a diagnosis of prostatitis more often than the noncancer controls (13.6% versus 9.0%). After controlling for the number of prostate-specific antigen tests this difference disappeared.

CONCLUSIONS

Nine percent of a randomly selected group of middle-aged men reported they had been diagnosed with prostatitis. The prevalence of a prostatitis diagnosis is similar in men with and without prostate cancer.

Toe spreading ability in men with chronic pelvic pain syndrome

Background

We examined toe-spreading ability in subjects with chronic pelvic pain syndrome (CPPS) to test the hypothesis that subjects with CPPS could have deficiencies in lower extremity functions innervated by sacral spinal roots.

Methods

Seventy two subjects with CPPS and 98 volunteer controls were examined as part of a larger study on CPPS. All the subjects underwent a detailed urologic and neurological examination including a toe-spreading examination with a quantitative scoring system. We compared the groups in terms of ability of toe-spreading as either "complete" (all toes spreading) or "incomplete" (at least one interdigital space not spreading) and also by comparing the number of interdigital spaces. For CPPS subjects only, we also analyzed the variation of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scales by toe-spreading categories.

Results

CPPS subjects were less often able to spread all toes than subjects without CPPS (p = 0.005). None of the NIH-CPSI sub-scales (pain, urinary symptoms, and quality of life), nor the total score showed an association with toe spreading ability.

Conclusion

We found toe spreading to be diminished in subjects with CPPS. We hypothesize that incomplete toe spreading in subjects with CPPS may be related to subtle deficits involving the most caudal part of the spinal segments.

Predictors of quality of life and pain in chronic prostatitis/chronic pelvic pain syndrome: findings from the National Institutes of Health Chronic Prostatitis Cohort Study

OBJECTIVES

To examine the cross-sectional relationship of age, urinary and depressive symptoms and partner status on pain intensity and quality of life (QoL) in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

PATIENTS AND METHODS

In all, 463 men enrolled in the National Institutes of Health (NIH) Chronic Prostatitis Cohort Study from seven clinical centres (six in the USA and one in Canada) reported baseline screening symptoms using the NIH Chronic Prostatitis Symptom Index (CPSI). The CPSI provides scores for pain, urinary symptoms and QoL. In addition, a demographic profile, including age and partner (living with another) status, and a depressive symptom score were obtained. Regression modelling of QoL, adjusting for between-centre variability, examined the unique effects of age, partner status, urological symptoms, depressive symptoms and pain.

RESULTS

Urinary scores, depressive symptoms and pain intensity scores significantly predicted QoL for patients with CP/CPPS (higher CPSI QoL scores indicated more impairment; median 8.0, range 0-12). On average, for every 1-point increase in urinary scores, there was a corresponding increase in QoL score of 0.118 points (P = 0.001); for every 1-point increase in pain intensity score, there was a corresponding increase in QoL score of 0.722 points (P < 0.001); and for every 1-point decrease in depressive symptoms (lower scores equal poorer mood), the QoL score increased (poorer quality of life) by 0.381 points (P < 0.001). Age and partner status did not significantly contribute to poorer QoL. Urinary scores and depressive symptoms were significant predictors (P < 0.001) of pain in patients with CP/CPPS.

CONCLUSIONS

These data show that depressive symptoms and pain intensity significantly predict a poorer QoL in patients with CP/CPPS, and that these effects are independent of partner status, age and urinary status. In particular, pain intensity was the most robust predictor of a poorer QoL. Further data relating pain and psychological factors to CP/CPPS are highly recommended, to aid in determining specific factors for pain and its impact on QoL. These data are essential if empirically guided efforts to manage pain are to progress.

The Italian version of the National Institutes of Health Chronic Prostatitis Symptom Index

OBJECTIVES

To perform the Italian version of the National Institutes of Health Chronic Prostatitis Symptom Index (NHI-CPSI), and to study its linguistic validity and its correlations with the Visual Analogue Scale for pain (VAS) and the Italian version of International Prostatic Symptom Score (I-PSS) in men with chronic pelvic pain syndrome (CPPS) and healthy controls.

METHODS

A rigorous double-back translation of the original English NHI-CPSI was performed by a staff composed of 3 professional bilingual experts and 3 urologists. The study population consisted of 160 male CPPS patients and 125 healthy controls, who were asked to self complete the Italian version of the NHI-CPSI together with the VAS and the Italian I-PSS. The discriminatory power, psychometric properties, internal correlations and convergent validity of the questionnaire were tested.

RESULTS

Of the 285 enrolled patients, 223 patients (142 with CPPS and 81 healthy patients) were definitively considered for the study. The overall Italian NIH-CPSI scores and each subscale differed significantly (p<0.001) between the two groups, and so that the index proved a good discriminant validity. High correlations were found between the VAS and the pain domain (0.88) and between I-PSS and void domain (0.94), suggesting a good convergent validity of the Italian version of the NIH-CPSI. The questionnaire proved to have a high internal consistency.

CONCLUSIONS

The Italian NIH-CPSI is a reliable symptom index that can be self-administrated in about 5 minutes in daily clinical practice for the follow-up of the Italian patients with chronic prostatitis.

Prognosis of patients with new prostatitis/pelvic pain syndrome episodes

PURPOSE

Little is known about the natural history of nonbacterial prostatitis/male pelvic pain syndrome, the transition from acute to chronic pelvic pain and risk factors for chronicity. In this study we determined the course of symptoms after physician visits for new nonbacterial prostatitis/pelvic pain syndrome episodes, and determined predictors of symptom persistence 1 year later.

MATERIALS AND METHODS

A total of 286 male health maintenance organization enrollees (87% white, mean age 46.7 years, 83% completed the 12-month followup) with recent physician visits for new prostatitis/pelvic pain episodes completed baseline, and 3, 6 and 12-month followup telephone interviews, including the National Institutes of Health Chronic Prostatitis Symptom Index in a prospective longitudinal inception cohort study.

RESULTS

On average symptoms improved substantially during months 1 to 3, modestly from months 3 to 6 and then remained unchanged. At each followup outcomes were better for men whose initial visit was for a first lifetime episode compared with a recurrent prostatitis/pelvic pain episode. Patients with more severe symptoms (Wald chi-square 11.27, p = 0.0008) and whose episode was recurrent (OR 2.2, 95% CI 1.16 to 4.06) at baseline were significantly more likely to report symptoms 1 year later.

CONCLUSIONS

Most men who make physician visits for new nonbacterial prostatitis/pelvic pain episodes experience symptom improvement during the next 6 months. However, chronic, mild, persistent or recurrent symptoms are common. Patients with previous episodes and more severe symptoms are at higher risk for chronic pelvic pain.

INTRAVESICAL POTASSIUM CHLORIDE SENSITIVITY TEST IN MEN WITH CHRONIC PELVIC PAIN SYNDROME

PURPOSE

Intravesical potassium chloride has been reported to cause pain in patients with interstitial cystitis and male chronic prostatitis (CP)/chronic pelvic pain syndrome (CPPS). We performed the potassium chloride sensitivity test (PST) in subjects with CP/CPPS and healthy men without pelvic pain.

MATERIALS AND METHODS

We recruited 40 men with CP/CPPS and 63 healthy men. The National Institutes of Health CPPS symptom index was used to measure the severity of symptoms. We instilled 100 ml physiological saline (NaCl 0.9%) intravesically. The bladder was emptied and 100 ml potassium chloride solution (KCl 40 mEq) were instilled. The subjects were asked to score urgency (0 to 10) and pain (0 to 10) sensations after each instillation. A positive PST was defined by 5 different cut-off points as the difference in score between KCl and NaCl instillations. Logistic regression analyses and area under the receiver operating characteristics curve were used to determine the predictive power of PST in CP/CPPS.

RESULTS

There was no difference in pain and urgency scores between the men with CP/CPPS and controls (p >0.05 for each). Men with CP/CPPS had higher pain and urgency scores with KCl than with NaCl (p = 0.011 and 0.033, respectively). The rates of positive PST were 50% and 36.5% in the CP/CPPS and control groups, respectively (p = 0.160). There was no significant correlation of potassium chloride sensitivity scores with National Institutes of Health symptom scores (p >0.05 for each). The sensitivity, specificity, and positive predictive and negative predictive values of PST were 50%, 63.5%, 46.5% and 66.7%, respectively.

CONCLUSIONS

Although there was a significant increase in pain and urgency scores following KCl instillation in patients with CP/CPPS, these scores and the rate of positive PST were not statistically different from those of healthy subjects. Thus, PST does not have a good predictive value in the diagnosis of CP/CPPS.

Healthcare use and costs of primary and secondary care patients with prostatitis

OBJECTIVES

To examine and identify predictors of healthcare use and prostatitis-related and total healthcare costs for primary and secondary care patients with new episodes of care for prostatitis.

METHODS

We compared the use and costs for 270 men with a new episode of care for prostatitis to those of randomly selected male health maintenance organization enrollees matched by age and primary care provider. We examined the episode of care (index visit and next 2 months) and the previous and subsequent years. Patients with prostatitis were interviewed 1 month after the index visit.

RESULTS

Compared with controls, patients with prostatitis had significantly greater total healthcare use (P <0.001) and costs (P <0.05) in each period. The prostatitis costs were only a small proportion of the total costs of the patients with prostatitis and of the difference in costs between patients with prostatitis and controls. The 10% of patients with prostatitis with the greatest total costs accounted for about one half of all costs. White race (P = 0.04), less education (P = 0.02), greater disability (P = 0.003), and greater number of non-pelvic pain sites (P = 0.004) at baseline predicted greater total healthcare costs after the index visit.

CONCLUSIONS

Health maintenance organization enrollees who seek care for prostatitis have greater total healthcare use and costs than do other enrollees of the same age and primary care provider. Most of the difference in costs reflects care for problems other than prostatitis. A small proportion of patients account for most of the costs.

Low Agreement Between Previous Physician Diagnosed Prostatitis and National Institutes of Health Chronic Prostatitis Symptom Index Pain Measures

PURPOSE

We evaluate the agreement between self-reported physician diagnosed prostatitis and pain questions from the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI).

MATERIALS AND METHODS

A randomly selected cohort of white men 47 to 90 years old from Olmsted County, Minnesota completed a study questionnaire on a history of physician diagnosed prostatitis in the preceding 2 years, including the CPSI questions. The medical records were also reviewed for physician diagnosis of chronic prostatitis during the preceding 10 years.

RESULTS

Of 1,543 men 27 (1.7%) reported a physician diagnosis of prostatitis in the preceding 2 years. There were strong associations between self-reported prostatitis and pain at the tip of the penis (OR 6.3, 95% CI 1.4, 28.5), ejaculatory (5.9, CI 1.3, 26.6) and testicular (3.6, 1.2, 10.8) pain. The chance corrected agreement between self-reported prostatitis and pain symptoms was low at 0.01 (pubic pain) to 0.07 (pain at the tip of the penis, ejaculatory pain and testicular pain). Agreement in positive responses was also low at 3.7% (perineal pain) to 8% (pain at the tip of the penis, ejaculatory pain and testicular pain). The predictive value of the modified total CPSI score for prostatitis was 0.67, which was better than chance (0.5). Associations based on medical record ascertainment of prostatitis during followup were weak, and the area under the curve was 0.57, which was no better than chance.

CONCLUSIONS

These findings demonstrate low agreement between CPSI-like pain measures and self-reported physician diagnosed prostatitis. The stronger associations between pain symptoms and self-reported diagnosed prostatitis, and the moderate predictive ability of the modified total CPSI score measures for self-reported prostatitis compared to medical record ascertainment demonstrate the sensitivity of the CPSI to prevalent symptoms. Thus, the tool may be best used to evaluate the severity of current symptoms rather than to assess the presence or absence of prostatitis.

Chronic pelvic pain following prostate brachytherapy: A case report

PURPOSE

To alert physicians and potential patients that chronic postimplant pelvic pain syndromes can occur, and that dosimetric parameters (i.e., implant technique) may predispose patients to it.

METHODS AND MATERIALS

The authors are currently following 3 prostate brachytherapy patients with what appear to be chronic radiation-related pelvic pain, variously exacerbated by urination or perineal pressure. The 3 patients were identified in the course of routine follow-up, and do not represent a concerted attempt to identify such patients from a larger group of patients being followed by the authors. Three control groups of 10 patients each treated with (125)I, (103)Pd, or (103)Pd + external beam radiation and with no reported dysuria at 6 months postimplant were taken from two ongoing prospective trials. The 3 patients reported here were each administered a brief questionnaire regarding the effect of their urinary pain on daily activities.

RESULTS

Patients with chronic pain tended to have high central prostatic doses, at least on some planes. Maximal, mean, and median urethral doses were higher for patients with chronic pain, but there was some overlap with control patients. The prostate V100s were similar between patients with chronic pain and controls, but there was a trend toward higher V200s and V300s in pain syndrome patients.

CONCLUSION

Recalcitrant brachytherapy-related pelvic pain is an uncommon occurrence that may be partly related to higher central prostatic doses.

Chronic prostatitis

PURPOSE OF REVIEW

This review covers recent developments in the classification, epidemiology, aetiology, diagnosis and treatment of patients diagnosed with chronic prostatitis (NIH classification types II, IIIa/IIIb and IV prostatitis) in the period of review (2001-2002).

RECENT FINDINGS

Recent studies highlight some of the problems with the 1995 NIH classification. Epidemiological studies have confirmed that "prostatitis" is common, with a prevalence of 10-15%. Associations of prostatitis include benign prostatic hyperplasia, sexually transmitted disease, lower urinary tract symptoms, stress, and reduced sunlight exposure. Elevated levels of cytokines in the seminal plasma and prostatic secretions have been detected in men with chronic prostatitis compared with normal individuals, suggesting an active inflammatory process in the male genital tract. This inflammatory reaction may be mediated by an adaptive immune response directed against a genital tract antigen(s) (autoimmunity). Increased levels of bacterial 16S ribosomal DNA in the prostates of men with chronic prostatitis compared with controls are compatible with the notion that a bacterial inflammatory event initiates an auto-immune process; however, the role of bacteria in the continuation of symptoms is unknown.

SUMMARY

The aetiology of chronic pelvic pain syndrome is still not certain, although an auto-immune process is favoured. Further research is required to determine the putative auto-antigen, the immune responses of patients, the role of bacteria in the inflammatory process, and the patients' pain response to genitourinary insults. As yet no diagnostic tests (other than to eliminate other pathology) and few treatments for chronic prostatitis can be recommended on the basis of scientific evidence.