Primary care physician practices in the diagnosis, treatment and management of men with chronic prostatitis/chronic pelvic pain syndrome

Development and internal validation of a screening tool for chronic prostatitis (S-CP)

PURPOSE

We developed a simple self-checkable screening tool for chronic prostatitis (S-CP) and internally validated it to encourage men (in the general population) with possible chronic prostatitis to consult urologists.

METHODS

The expert panel proposed the S-CP, which comprises three domains: Area of pain or discomfort (6 components), accompanying Symptom (6 components), and Trigger for symptom flares (4 components). We employed logistic regression to predict chronic prostatitis prevalence with the S-CP. We evaluated the predictive performance using data from a representative national survey of Japanese men aged 20 to 84. We calculated the optimism-adjusted area under the curve using bootstrapping. We assessed sensitivity/specificity, likelihood ratio, and predictive value for each cutoff of the S-CP.

RESULTS

Data were collected for 5,010 men-71 (1.4%) had a chronic prostatitis diagnosis. The apparent and adjusted area under the curve for the S-CP was 0.765 [95% confidence interval (CI) 0.702, 0.829] and 0.761 (0.696, 0.819), respectively. When the cutoff was two of the three domains being positive, sensitivity and specificity were 62.0% (95% CI 49.7, 73.2) and 85.4% (95% CI 84.4, 86.4), respectively. The positive/negative likelihood ratios were 4.2 (95% CI 3.5, 5.2) and 0.45 (95% CI 0.33, 0.60), respectively. The positive/negative predictive values were 5.7 (95% CI 4.2, 7.6) and 99.4 (95% CI 99.1, 99.6), respectively.

CONCLUSION

The reasonable predictive performance of the S-CP indicated that patients (in the general population) with chronic prostatitis were screened as a first step. Further research would develop another tool for diagnostic support in actual clinical settings.

Clinical Review of Neuromusculoskeletal Complementary and Alternative Approaches for the Treatment of Chronic Pelvic Pain Syndrome

Chronic pelvic pain syndrome (CPPS) is a functional pain disorder characterized by ongoing pain in the apparent absence of clinically identifiable causes. The prevalence of functional pain disorders demonstrates the importance of adequate management of ongoing symptomatology, but due to the uncertain etiology and myriad patient presentation phenotypes, reliable treatment options are difficult to implement. New interventions involving non-pharmacological approaches to pain management have been investigated across a spectrum of clinical and pre-clinical studies. Given that conservative care such as exercise, counseling, and musculoskeletal therapy is widely recommended as first-line treatment for CPPS, an updated review of these and related methodologies are needed. Familiarizing physicians and the public with the newest evidence for complementary and alternative medicine (CAM) and other conservative care treatments will assist with the promotion of evidence-based practices in a safe and reliable manner. This review aimed to summarize the current evidence and proposed mechanisms for non-pharmacological treatment specific to CAM and management of chronic pelvic pain centered on neuromusculoskeletal focused intervention such as acupuncture, auriculotherapy, manipulation, manual therapy, myofascial release, and phototherapy. The discussion suggests that reported improvements in pelvic pain or related symptomatology may be attributed to changes in the peripheral inflammasome and somatic origins of peripheral sensitization. Robustness of the included clinical studies is discussed throughout the review, and attention is paid to delineating inclusion criteria of formally diagnosed CPPS compared to general pelvic or abdominal pain. Overall, this review consolidates the current state of evidence regarding the utilization of non-traditional interventions using CAM techniques for the management of chronic pelvic pain and recommends a future direction for the field.

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.

Chronic prostatitis/chronic pelvic pain syndrome: a review of evaluation and therapy

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), also known as NIH Category III Prostatitis is a highly prevalent syndrome with significant impact on quality of life. As a heterogeneous syndrome, there exists no 'one size fits all' therapy with level 1 evidence to guide therapy. This often leads to a nihilistic approach to patients and clinical outcomes are poor. In this review, we examine the evidence for CP/CPPS therapies and discuss our technique of clinical phenotyping combined with multimodal therapy.

METHODS

Review of Medline articles with terms 'non-bacterial prostatitis', 'abacterial prostatitis' and 'chronic pelvic pain syndrome'.

RESULTS

Many individual therapies have been evaluated in the treatment of CP/CPPS; antibiotics, anti-inflammatory medications (including bioflavonoids), neuromodulators, alpha blockers, pelvic floor physical therapy and cognitive behavior therapy. Each of these has been found to have varying success in alleviating symptoms. UPOINT is a system of clinical phenotyping for CP/CPPS patients that has 6 defined domains, which guide multimodal therapy. It has been validated to correlate with symptom burden and therapy guided by UPOINT leads to significant symptom improvement in 75-84% of patients based on three independent studies.

CONCLUSIONS

CP/CPPS is a heterogeneous condition and, much like with prostate cancer, optimal therapy can only be achieved by classifying patients into clinically meaningful phenotypic groups (much like TNM) and letting the phenotype drive therapy.

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.

The efficacy of extracorporeal magnetic stimulation for treatment of chronic prostatitis/chronic pelvic pain syndrome patients who do not respond to pharmacotherapy

OBJECTIVE

To investigate the effect of extracorporeal magnetic stimulation (EMS) on symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men who did not respond to pharmacotherapy.

METHODS

Patients with chronic pelvic pain and/or voiding symptoms in the absence of urinary tract infection for at least 3 months in spite of medication were included in this study. All patients underwent EMS for 6 weeks for a total of 12 sessions. The primary endpoint was the changes in total and pain scores of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) at 24 weeks after treatment. Patients were also evaluated by International Prostate Symptom Score (IPSS), voiding diary, Benefit Satisfaction and Willingness (BSW) questionnaire, and patient perception of symptom improvement (PPSI).

RESULTS

A total of 46 men were included, and data from 37 patients who completed this study were analyzed. The baseline vs 24 weeks mean NIH-CPSI score was total score 25.0 ± 6.9 vs 15.6 ± 7.7, pain score 11.8 ± 3.7 vs 6.9 ± 4.7 (all P <.05). Total and subdomain sums of IPSS improved significantly after treatment, and the improvements were maintained until 24 weeks. Patient voiding diaries demonstrated a tendency toward a decrease in all subdomains after treatment. In BSW, >70% of patients reported positive answers to each domain at 24 weeks after treatment. PPSI measured by the visual analog scale was maintained from immediately after treatment until 24 weeks.

CONCLUSION

EMS offers a new treatment option for patients with CP/CPPS who do not respond to pharmacotherapy.

[Chronic pelvic pain in urology: a nationwide questionnaire survey among French urologists]

OBJECTIVE

To know the opinion of French urologists concerning the importance of pelvic and perineal pain syndromes in their clinical activity, their management, self-admitted knowledge and training needs concerning this situation.

MATERIAL AND METHODS

Eight hundred and seventy-eight urologists exercising in France, all French Urology Association (AFU) members, have been asked to fill in an online questionnaire concerning their daily management of chronic pelvic and perineal pain syndromes.

RESULTS

Three hundred and fifty-two urologists answered (response rate 40%). For about 20%, chronic pelvic and perineal pain syndromes took up more than 5% of consult activity. More than half took care of between 20 and 100 new cases of chronic pelvic and perineal pain every year. More than two thirds deemed their knowledge concerning chronic pelvic and perineal pain fair to insufficient. Three quarters of urologists would like to benefit from an opinion from another specialist for more than one out of four patients. More than 56% deemed that the organization of their daily consult activity was inadequate for the management of this type of patient. Most of them deemed useful to develop additional specific training programs.

CONCLUSION

This survey shows that pelvic and perineal pain syndromes are frequent in daily urological consult activity, despite the fact that urologists feel they lack in training and organization to manage properly these diseases.

A survey of primary care physician practices in the diagnosis and management of women with interstitial cystitis/painful bladder syndrome

OBJECTIVES

To describe the practice patterns among primary care physicians' (PCPs) managing patients with symptoms suggestive of interstitial cystitis/painful bladder syndrome (IC/PBS).

METHODS

We developed a clinical vignette describing a woman with typical IC/PBS symptoms to elicit questions about etiology, management strategies, and familiarity with this syndrome. We mailed the questionnaire to 556 PCPs, including academicians and community physicians, in Boston, Los Angeles, and Chicago.

RESULTS

We received 290 completed questionnaires (response rate, 52%). Nineteen percent of respondents reported they had "never" seen a patient like the one described in the vignette. Two-thirds of respondents correctly identified the hallmark symptom of IC/PBS (bladder pain/pressure). Regarding etiology, 90% correctly indicated that IC/PBS was a noninfectious disease, 76% correctly reported that it was not caused by a sexually transmitted infection, and 61% correctly indicated that it was not caused by a psychiatric illness. Common treatments included antibiotics and nonsteroidal anti-inflammatory agents. Referrals were often made to a specialist.

CONCLUSIONS

Although most PCPs indicate familiarity with IC/PBS, they manage the condition infrequently. They also appear to have significant knowledge deficits about the clinical characteristics of IC/PBS, and they indicate variable practice patterns in the diagnosis and treatment of the condition. Educational efforts directed at PCPs will likely improve the care of patients with IC/PBS.

[Chronic pain in urology: inguinal pain, post vasectomy pain, and chronic pelvic pain]

Undertreatment of all forms of acute and chronic pain is also present in Germany. Chronic inguinal pain and post vasectomy pain are frequently observed in urological practice and appear as chronic postsurgical pain. Chronic pelvic pain has inflammatory causes in the majority of cases and appears as a challenge for the treating physician. Pain should be treated as early as possible, if necessary also interdisciplinary, with regard to the further chronification process with changes of biological, psychological and social factors. For the patient the pain chronification can be accompanied by the reduction of quality of life and social isolation.