Is Pelvic Floor Muscle Tenderness a Distinct Urologic Chronic Pelvic Pain Syndrome Phenotype? Findings from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Symptom Pattern Study.

PURPOSE: Of women with interstitial cystitis/bladder pain syndrome and men with chronic prostatitis/chronic pelvic pain syndrome 85% have concomitant pelvic floor muscle tenderness (PFT). The significance of this finding is incompletely understood. This study examines PFT among participants in the MAPP (Multidisciplinary Approach to the Study of Chronic Pelvic Pain) Research Network and its relationship with urologic chronic pelvic pain syndrome (UCPPS) symptom severity in order to determine whether this is a phenotypic predictor in UCPPS. MATERIALS AND METHODS: Participants in the MAPP Network Symptom Patterns Study underwent a standardized pelvic examination (PEX). Trained examiners palpated 6 locations evaluating the pelvic musculature for PFT. Participants were assigned a 0 to 6 PEX score based on the number of areas with tenderness on PEX. Using regression tree models, PEX scores were divided into low (0, 1), mid (2, 3, 4, 5) and high (6). The relationship between PFT and UCPPS symptoms was examined using several validated questionnaires. RESULTS: The study cohort consisted of 562 UCCPS participants (375 females and 187 males) and 69 controls. Diagnoses included interstitial cystitis/bladder pain syndrome (397), chronic prostatitis/chronic pelvic pain syndrome (122), both (34) or no diagnosis (9). Of UCPPS participants 81% had PFT on PEX compared to 9% of controls: 107 (19%) low, 312 (56%) mid and 143 (25%) high. Participants with higher PFT scores had more severe disease burden (worse pelvic pain and urinary symptoms), worse quality of life and more widespread distribution of nonpelvic pain. CONCLUSIONS: UCPPS patients with more widespread PFT have severe pain and urinary symptoms, worse quality of life and a more centralized pain phenotype.

Effects of inflammatory prostatitis on the development and progression of benign prostatic hyperplasia: A literature review.

Benign prostatic hyperplasia is a major disease that affects the quality of life of middle-aged and older men. Although >70% of men aged >70 years have pathological benign prostatic hyperplasia, its pathogenesis and progression remain unclear. In this article, we reviewed the scientific literature on this condition and examined the development of lower urinary tract symptoms. Clinically, the weight of the prostate is not always proportional to the severity of the symptoms, and many factors can influence the progression of benign prostatic hyperplasia. Other than androgens, chronic inflammation can play an essential role in its development and the induction of symptoms, especially in symptomatic hyperplasia, because inflammatory cell infiltration is frequently observed in the prostate. Inflammation-induced changes in the prostate environment lead to changes in gene expression and subsequent chronicity of inflammation. It has been suggested that chronic asymptomatic prostatitis might be associated with changes in prostate structure and subsequent symptoms. In animal studies, the administration of anti-inflammatory drugs in rats with chronic prostatitis prevented the infiltration of inflammatory cells and increased the gland-to-stroma ratio. It is hoped that future research on the molecular biology of asymptomatic prostatitis might help to develop new therapeutic strategies for lower urinary tract symptoms associated with symptomatic prostatitis. Our conclusions provide a comprehensive insight into the prevalence and development of benign prostate hyperplasia and the treatment methods that can be used to treat it.

Nonablative transurethral Erbium:YAG laser treatment for chronic prostatitis/chronic pelvic pain syndrome: A prospective comparative study.

AIMS: This prospective study aimed to compare the clinical outcomes between the use of Erbium:YAG (Er:YAG) laser in a nonablative mode, to the use of the pharmacological treatment of oral tadalafil for the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS: The laser group received two sessions of Erbium:YAG laser, administered intraurethrally in a long, nonablative train of long pulses (SMOOTH™ mode), applied at the level of the male prostatic urethra. Tadalafil group received oral tadalafil at a dose of 5 mg/day, consecutively for 2 months. Effectiveness was assessed using the International Prostate Symptom Score (IPSS) questionnaire, VAS (visual analogue scale) pain score, and maximum urethral flow at follow-up visits up to 12 months after initiating treatment. Adverse effects were recorded after each treatment and follow-up sessions. RESULTS: The results show a significant decrease in the IPSS score in both groups up to the 12-month follow-up. The increase in Q-max was evident up to 3-months follow-up in the tadalafil group and up to 6 months in the laser group. The decrease in the VAS pain score was also significant in both treatment groups, lasting up to 3 months in the tadalafil group and up to 6 months in the laser group. CONCLUSIONS: The nonablative Er:YAG SMOOTH™ laser seems to be a promising treatment for this widely occurring condition. More studies are needed to confirm its safety and efficacy.

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline.

OBJECTIVES: To improve awareness and recognition of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) among non-specialists and patients. To provide guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non-specialist and specialist settings. To promote efficient referral of care between non-specialists and specialists and the involvement of the multidisciplinary team (MDT). PATIENTS AND METHODS: The guideline population were men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months). Consensus recommendations for the guidelines were based on a search to identify literature on the diagnosis and management of CBP and CP/CPPS (published between 1999 and February 2014). A Delphi panel process was used where high-quality, published evidence was lacking. RESULTS: CBP and CP/CPPS can present with a wide range of clinical manifestations. The four main symptom domains are urogenital pain, lower urinary tract symptoms (LUTS - voiding or storage symptoms), psychological issues and sexual dysfunction. Patients should be managed according to their individual symptom pattern. Options for first-line treatment include antibiotics, α-adrenergic antagonists (if voiding LUTS are present) and simple analgesics. Repeated use of antibiotics, such as quinolones, should be avoided if there is no obvious symptomatic benefit from infection control or cultures do not support an infectious cause. Early use of treatments targeting neuropathic pain and/or referral to specialist services should be considered for patients who do not respond to initial measures. An MDT approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, general practitioners, cognitive behavioural therapists/psychologists, and sexual health specialists) is recommended. Patients should be fully informed about the possible underlying causes and treatment options, including an explanation of the chronic pain cycle. CONCLUSION: Chronic prostatitis can present with a wide variety of signs and symptoms. Identification of individual symptom patterns and a symptom-based treatment approach are recommended. Further research is required to evaluate management options for CBP and CP/CPPS.

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.

A meta-ethnography of patients' experiences of chronic pelvic pain: struggling to construct chronic pelvic pain as 'real'.

AIM: To review systematically and integrate the findings of qualitative research to increase our understanding of patients' experiences of chronic pelvic pain. BACKGROUND: Chronic pelvic pain is a prevalent pain condition with a high disease burden for men and women. Its multifactorial nature makes it challenging for clinicians and patients. DESIGN: Synthesis of qualitative research using meta-ethnography. DATA SOURCES: Five electronic bibliographic databases from inception until March 2014 supplemented by citation tracking. Of 488 papers retrieved, 32 met the review aim. REVIEW METHODS: Central to meta-ethnography is identifying 'concepts' and developing a conceptual model through constant comparison. Concepts are the primary data of meta-ethnography. Two team members read each paper to identify and collaboratively describe the concepts. We next compared concepts across studies and organized them into categories with shared meaning. Finally, we developed a conceptual model, or line of argument, to explain the conceptual categories. RESULTS: Our findings incorporate the following categories into a conceptual model: relentless and overwhelming pain; threat to self; unpredictability, struggle to construct pain as normal or pathological; a culture of secrecy; validation by diagnosis; ambiguous experience of health care; elevation of experiential knowledge and embodiment of knowledge through a community. CONCLUSION: The innovation of our model is to demonstrate, for the first time, the central struggle to construct 'pathological' vs. 'normal' chronic pelvic pain, a struggle that is exacerbated by a culture of secrecy. More research is needed to explore men's experience and to compare this with women's experience.

The efficacy of mirodenafil for chronic prostatitis/chronic pelvic pain syndrome in middle-aged males.

PURPOSE: The aim of this study was to investigate the efficacy of mirodenafil in middle-aged male patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). MATERIALS AND METHODS: Eighty-eight males with CP/CPPS were randomized to receive either levofloxacin (500 mg/d) (group L, 40 patients) or levofloxacin (500 mg/d) and mirodenafil (50 mg/d) (group ML, 48 patients) for six weeks. The International Prostate Symptom Score (IPSS), National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) questionnaire were used to grade symptoms at baseline and 6 weeks after treatment. RESULTS: The mean change in total IPSS from baseline was higher in group ML than that in group L (group L, -1.1 vs. group ML, -4.3; p<0.05). Significant improvements were also seen in the IPSS voiding subscore (group L, -0.7 vs. group ML, -3.0; p<0.05). Changes observed in the NIH-CPSI of group ML at six weeks were greater than those at baseline (group L, -3.2 vs. group ML, -7.2; p<0.05). Significant improvements were seen in the NIH-CPSI voiding (group L, -0.5 vs. group ML, -1.7; p<0.05) and quality of life domains (group L, -1.0 vs. group ML, -1.8; p<0.05). Group ML showed a significantly greater increase in the IIEF-EF score than did group ML (group L, +0.2 vs. group ML, +7.8; p<0.05). CONCLUSIONS: Mirodenafil (50 mg once daily) was well tolerated and resulted in significant symptomatic improvement in middle-aged males with CP/CPPS.

The Efficacy of Mirodenafil for Chronic Prostatitis/Chronic Pelvic Pain Syndrome in Middle-Aged Males

PURPOSE: The aim of this study was to investigate the efficacy of mirodenafil in middle-aged male patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). MATERIALS AND METHODS: Eighty-eight males with CP/CPPS were randomized to receive either levofloxacin (500 mg/d) (group L, 40 patients) or levofloxacin (500 mg/d) and mirodenafil (50 mg/d) (group ML, 48 patients) for six weeks. The International Prostate Symptom Score (IPSS), National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) questionnaire were used to grade symptoms at baseline and 6 weeks after treatment. RESULTS: The mean change in total IPSS from baseline was higher in group ML than that in group L (group L, -1.1 vs. group ML, -4.3; p<0.05). Significant improvements were also seen in the IPSS voiding subscore (group L, -0.7 vs. group ML, -3.0; p<0.05). Changes observed in the NIH-CPSI of group ML at six weeks were greater than those at baseline (group L, -3.2 vs. group ML, -7.2; p<0.05). Significant improvements were seen in the NIH-CPSI voiding (group L, -0.5 vs. group ML, -1.7; p<0.05) and quality of life domains (group L, -1.0 vs. group ML, -1.8; p<0.05). Group ML showed a significantly greater increase in the IIEF-EF score than did group ML (group L, +0.2 vs. group ML, +7.8; p<0.05). CONCLUSIONS: Mirodenafil (50 mg once daily) was well tolerated and resulted in significant symptomatic improvement in middle-aged males with CP/CPPS.

Acupuncture and Traditional Chinese Medicine for the management of a 35-year-old man with chronic prostatitis with chronic pelvic pain syndrome.

OBJECTIVE: The purpose of this case report is to describe the resolution of pain in a patient with chronic prostatitis and chronic pelvic pain syndrome after receiving a course of management using acupuncture and Chinese herbal medicine. CLINICAL FEATURES: A 35-year-old man presented with chronic prostatitis with chronic pelvic pain syndrome. He scored 38 out of a possible 43 on the National Institutes of Health/Chronic Prostatitis Symptom Index (NIH/CPSI) that rates pain, urinary symptoms, and quality of life impact, indicating severe symptoms. The patient had experienced recurrent episodes of nonbacterial prostatitis over a 3-year period, and this was the most severe. INTERVENTION AND OUTCOME: After 8 acupuncture treatments over an 8-week period and daily use of Ba Zheng San and Yi Guan Jian, the patient scored his symptoms 9 on the NIH/CPSI. The patient was then put on a supportive anti-inflammatory regimen of green tea. He rated his symptoms 4 on the NIH/CPSI 4 months later, 2 on the NIH/CPSI 8 months later, and 0 on the NIH/CPSI 1 year later. CONCLUSION: This case demonstrated that the patient experienced long-lasting relief from chronic prostatitis with chronic pelvic pain syndrome after a course of 8 treatments of acupuncture and Chinese herbs.

Tamsulosin Monotherapy versus Combination Therapy with Antibiotics or Anti-Inflammatory Agents in the Treatment of Chronic Pelvic Pain Syndrome.

PURPOSE: Chronic pelvic pain syndrome (CPPS) is treated by use of various protocols. We compared tamsulosin monotherapy with tamsulosin in combination with antibiotics or anti-inflammatory agents and evaluated the efficacy of these treatments in patients with CPPS. METHODS: Patients (n=107) who were younger than 55 years and diagnosed with CPPS were randomly assigned to treatment with tamsulosin at 0.2 mg (group A), tamsulosin at 0.2 mg plus anti-inflammatory drugs (group B) or tamsulosin at 0.2 mg plus antibiotics (group C) daily. We applied the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostate Symptom Score (IPSS) to evaluate 100 patients who were treated for 12 weeks (7 withdrew). Scores of the three groups were compared by analysis of variance and we also evaluated subscores, which included pain, voiding and quality of life (QoL). RESULTS: All three groups showed statistically significant decreases in NIH-CPSI score, IPSS and subscore scores (P<0.05). There were no statistically significant differences between the groups except for the QoL domain of the IPSS (group A vs. C; P<0.01). CONCLUSIONS: Tamsulosin monotherapy for 12 weeks was effective for treating patients with CPPS, compared with combination therapy with antibiotics or anti-inflammatory drugs.

Tamsulosin Monotherapy versus Combination Therapy with Antibiotics or Anti-Inflammatory Agents in the Treatment of Chronic Pelvic Pain Syndrome / 대한배뇨장애요실금학회지

PURPOSE: Chronic pelvic pain syndrome (CPPS) is treated by use of various protocols. We compared tamsulosin monotherapy with tamsulosin in combination with antibiotics or anti-inflammatory agents and evaluated the efficacy of these treatments in patients with CPPS. METHODS: Patients (n=107) who were younger than 55 years and diagnosed with CPPS were randomly assigned to treatment with tamsulosin at 0.2 mg (group A), tamsulosin at 0.2 mg plus anti-inflammatory drugs (group B) or tamsulosin at 0.2 mg plus antibiotics (group C) daily. We applied the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostate Symptom Score (IPSS) to evaluate 100 patients who were treated for 12 weeks (7 withdrew). Scores of the three groups were compared by analysis of variance and we also evaluated subscores, which included pain, voiding and quality of life (QoL). RESULTS: All three groups showed statistically significant decreases in NIH-CPSI score, IPSS and subscore scores (P<0.05). There were no statistically significant differences between the groups except for the QoL domain of the IPSS (group A vs. C; P<0.01). CONCLUSIONS: Tamsulosin monotherapy for 12 weeks was effective for treating patients with CPPS, compared with combination therapy with antibiotics or anti-inflammatory drugs.

Role of alpha blocker therapy in chronic prostatitis/chronic pelvic pain syndrome: limited options with promising results.

Chronic prostatitis / chronic pelvic pain syndrome (NIH-type II and type III prostatitis) are common cause of chronic pelvic pain. The exact etiology of these entities are unknown. They are associated with varying degree of voiding and sexual dysfunction. Consensus regarding treatment of these pain syndromes is lacking. Review of literature suggest a therapeutic role of alpha adrenergic receptor blockers in the management of NIH-type II and type III prostatitis. A trial of alpha-blocker is reasonably inexpensive and appropriate for most patients suffering from NIH-type III prostatitis and NIH-type II prostatitis. A general consensus is that if a patient agrees to a trial of alpha-blocker therapy which subsequently shows a good response then it should be continued for at least 6 months for a proper therapeutic effect. This review analyses the role of alpha-blockers in this disease/syndrome; discusses the possible mechanism of action through which these drugs provide relief and also highlights some of the important trials which have paved way for this particular treatment option in this intriguing disease /syndrome.