Analgesics, muscle relaxants and neuromodulators

become frustrated by the lack of efficacy seen in

Analgesics can alleviate some of the pain, but

well designed randomized placebo controlled

trials in CP/CPPS despite solid theoretical con­

narcotics should be avoided except for short

siderations, strong anecdotal evidence from

term control of

serious

pain

exacerbations.

clinical practice, and evidence from numerous

Skeletal muscle

relaxants

such

as diazepam,

small usually single center clinical trials. We

baclofen and cyclobenzaprine are utilized in

have come to the realization that it is the very

men with spastic or dysfunctional pelvic floors

restrictive nature of these randomized trials, in

with some anecdotal success. Amitriptyline is

which we routinely exclude over 90% of the

an important adjunct

to neuropathic pain

patients we see in our clinics on a daily basis, in

management, has proven efficacious in inter­

order to enroll very homogenous and compara­

stitial cystitis, and should be considered for

tive populations. The patients in our clinical tri­

the neuropathic

type

pain experienced by

als may not truly represent patients we see in

many men with CP/CPPS. Similarly, the gabap­

our clinical practice. In fact, each patient diag­

entinoids are indicated for neuropathic pain

nosed with CP/CPPS has a unique clinical phe­

control and the results from a recently com­

notype based on etiology, age, duration since

pleted NIH sponsored

randomized

placebo

diagnosis, concurrent disease, associated condi­

controlled trial is available soon. Based on the

tions, symptom trajectory, and coping behav­

results from other similar pain syndromes, we

iors. Based on this new understanding, a clinical

would expect this drug to prove efficacious in

phenotyping classification system was devel­

some patients.

oped to describe the characteristics of individ­

ual patients. The UPOINT system56 describes

Surgery

the following phenotypes; Urinary, Psycho­

social, Organ specific, Neurogenic/systemic and

A number of minimally invasive surgical app­

Tenderness (of muscles). UPOINT is outlined in

roaches

(transurethral

microwave

thermo­

more detail in Table 22.4. The number of

therapy, transurethral radiofrequency needle

UPOINT domains a patient is classified in is

ablation etc.) have been advocated for CP/CPPS,

associated with severity of both general CP/

however no real concrete evidence is available

CPPS symptoms and CP/CPPS related pain.57

to support any suggestion of efficacy.23 Radical

The domains are not correlated with age, but

transurethral and open prostatectomy has sim­

with duration since diagnosis. Each domain is

ilarly been suggested as a last resort and it is

associated with a slightly different impact on

evident from anecdotal experience that this

symptoms and pain. By employing this clinical

may create more harm than benefit for patients

phenotyping system, UPOINT, the physician

with CP/CPPS. Surgery should be restricted to

can categorize patients into one or more

discrete indications, usually those causing

domains using standardized workup (perhaps

lower urinary tract obstruction (urethral

asking a few questions about depression and/or

meatal stenosis, urethral stricture, bladder neck

coping) and then use this information to direct

stenosis).40

specific and usually multi­modal therapies.

Table 22.4 describes how therapies can be tai­

A Practical Management Plan

lored for individual UPOINT domains experi­

enced by the patient. As we learn more about

Table 22.3 describes the various medical thera­

the etiology and pathogenesis of CP/CPPS

(which has so far eluded us), discoveries, includ­

pies that we employ to treat the prostatitis

ing important biomarkers, can be incorporated

syndromes and the evidence (or lack of it) to

into the UPOINT system, allowing for stratifica­

support therapeutic recommendations and sug­

tion of the six domains. The future for patients

gestions. One can quickly determine, that except

diagnosed with a prostatitis syndrome is look­

for the bacterial prostatitis syndromes (Cat I

ing brighter as we can now rationalize our

and II), therapy for the much more prevalent

clinical approach for this difficult medical

CP/CPPS

condition.

References

17.

eters impact quality of life in men diagnosed with

Nickel JC, Tripp DA, Chuai S, et al. Psychosocial param­

chronic prostatitis/chronic pelvic pain syndrome (CP/

1.

Nickel JC. The three A’s of chronic prostatitis therapy;

CPPS). BJU Int. 2007;101:59­64

antibiotics, alpha­blockers, and anti­inflammatories:

18.

Calhoun EA, McNaughton Collins M, Pontari MA, et al.

what is the evidence? BJU Int. 2004;94:1230­1233

Chronic Prostatitis Collaborative Research Network.

2.

Schaeffer AJ. Chronic prostatitis and the chronic pelvic

The economic impact of chronic prostatitis. Arch Intern

pain syndrome. N Engl J Med. 2006;355: 1690­1698

Med. 2004;164:1231­1236

3.

Nickel JC. Chronic prostatitis/chronic pelvic pain syn­

19.

Neal DE Jr. Treatment of acute prostatitis. In: Nickel JC,

drome: a decade of change. AUA. 2006;25: 309­316

ed. Textbook of Prostatitis. Oxford: ISIS Medical Media

4.

Krieger JN, Nyberg LJ, Nickel JC. NIH consensus

Ltd.; 1999:279­284

definition and classification of prostatitis. JAMA.

20.

Nickel JC, Moon T. Chronic bacterial prostatitis: an

1999;282:236­237

evolving clinical enigma. Urology. 2005;66:2­8

5.

Roberts RO, Lieber MM, Rhodes T, et al. Prevalence of a

21.

Nickel JC, Alexander RB, Schaeffer AJ, et al. Leukocytes

physician­assigned diagnosis of prostatitis: the Olmsted

and bacteria in men with chronic prostatitis/chronic

County Study of urinary symptoms and health status

pelvic pain syndrome compared to asymptomatic con­

among men. Urology. 1998;51:578­584

trols. J Urol. 2003;170:818­822

6.

McNaughton­Collins M, Meigs JB, Barry MJ, et al.

22.

Pontari MA, Ruggieri MR. Mechanisms in prostatitis/

Prevalence and correlates of prostatitis in the health

chronic pelvic pain syndrome. J Urol. 2004;172:839­845

professionals follow­up study cohort. J Urol. 2002; 167:

23.

Nickel JC. Inflammatory conditions of the male genito­

1363­1366

urinary tract: prostatitis and related conditions, orchitis,

7.

Nickel JC, Downey J, Hunter D, Clark J. Prevalence of

and epididymitis. In: Walsh P et al., eds. Campbell­Walsh

prostatitis­like symptoms in a population based study

Urology. 9th ed. Philadelphia, PA: W. B. Saunders

employing the NIH­chronic prostatitis symptom index

Company; 2006:330­370

(NIH­CPSI). J Urol. 2001;165:842–845

24.

Meares EM Jr, Stamey TA. Bacteriologic localization pat­

8.

McNaughton­Collins M, Stafford RS, O’Leary MP, Barry

terns in bacterial prostatitis and urethritis. Invest Urol.

MJ. How common is prostatitis? A national survey of

1968;5:492­518

physician visits. J Urol. 1998;159: 1224­1228

25.

McNaughton­Collins M, Fowler EH, Elliott DB, et al.

9.

Moon TD, Hagen L, Heisey DM. Urinary symptomatol­

Diagnosing and treating chronic prostatitis: do urolo­

ogy in younger men. Urology. 1997;50:700­703

gists use the 4­glass test? Urology. 2000;55:403­407

10.

Roberts RO, Jacobson DJ, Girman CJ, et al. Prevalence of

26.

Nickel JC. The Pre and Post Massage Test (PPMT): a sim­

prostatitis­like symptoms in a community based cohort

ple screen for prostatitis. Tech Urol. 1997;3:38­43

of older men. J Urol. 2002;168:2467­2471

27.

Nickel JC, Shoskes D, Wang Y, et al. How does the pre­

11.

Clemens JQ, Meenan RT, O’Keeffe Rosetti MC, et al.

and post­ massage test (PPMT) 2­glass test compare to

Incidence and clinical characteristics of National

the Meares­Stamey 4­glass test in men with chronic

Institutes of Health type III prostatitis in the commu­

prostatitis/chronic pelvic pain syndrome? J Urol.

nity. J Urol. 2005;174:2319

2006;176:119­124

12.

McNaughton­Collins M, Joyce GF, Wise M, et al. US

28.

Litwin MS, McNaughton­Collins M, Fowler FJ, et al. The

Department of Health and Human Services, Public

National Institutes of Health chronic prostatitis symp­

Health Service, National Institutes of Health, National

tom index: development and validation of a new out­

Institute of Diabetes and Digestive and Kidney Diseases.

come measure. J Urol. 1999;162:369­375

In: Litwin MS, Saigal CS, et al., eds. Urologic Diseases in

29.

Nickel JC, McNaughton­Collins M, Litwin SM.

America. Washington, DC: U.S. Government Publishing

Development and use of a validated outcome measure for

Office; 2007:9­41

prostatitis. J Clin Outcomes Manag. 2001;8:30­37

13.

Wenninger K, Heiman JR, Rothman I, et al. Sickness

30.

Propert KJ, Litwin MS, Wang Y, et al. Responsiveness of

impact of chronic nonbacterial prostatitis and its corre­

the National Institutes of Health Chronic Prostatitis

lates. J Urol. 1996;155:965­968

Symptom Index (NIH­CPSI). Qual Life Res. 2006; 15:

14.

McNaughton­Collins M, Pontari MA, et al. Quality of life

299­305

is impaired in men with chronic prostatitis: the Chronic

31.

Nickel JC. Clinical evaluation of the man with chronic

Prostatitis Collaborative Research Network. J Gen Int

prostatitis/chronic pelvic pain syndrome. Urology.

Med. 2001;16:656­662

2000;60:20­23. Suppl 6A

15.

Tripp DA, Nickel JC, Landis JR, et al. Predictors of qual­

32. Schaeffer AJ, Knauss JS, Landis JR, et al. Leukocyte and

ity of life and pain in chronic prostatitis/chronic pelvic

bacterial counts do not correlate with severity of symp­

pain syndrome: findings from the National Institutes of

toms in men with chronic prostatitis: the NIH Chronic

Health Chronic Prostatitis Cohort Study. BJU Int.

Prostatitis Cohort (CPC) study. J Urol. 2002;168:1048­1053

2004;94:1279­1282

33.

Shoskes DA. Use of antibiotics in chronic prostatitis syn­

16.

Tripp DA, Nickel JC, Wang Y, et al. Catastrophizing and

dromes. Can J Urol. 2001;8:24­28

Pain­Contingent Rest Predict Patient Adjustment in

34.

Naber KJ.Antibiotic treatment of chronic bacterial pros­

Men with Chronic Prostatitis/Chronic Pelvic Pain

tatitis. In: Nickel JC, ed. Textbook of Prostatitis. Oxford:

Syndrome. J Pain. 2006;7:697­708

ISIS Medical Media Ltd.; 1999:283­292