Using the UPOINT system to manage men with chronic pelvic pain syndrome.

OBJECTIVE: : To outline our approach for the evaluation and management of patients with chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS) based on our interpretation and application of currently available evidence. METHODS: : CP/CPPS in men is a medical condition that plagues both the patient and the practitioner, as it is widely believed to be poorly understood and difficult to treat. While pelvic pain is typically the predominant symptom, many men may exhibit voiding symptoms, sexual dysfunction and psychiatric complaints. Still, most studies of CP/CPPS management have evaluated singular treatments, without focussing on individual patients' clinical phenotypes. This is a clinically practical mini-review based on the authors' interpretation and application of currently available evidence related to management of CP/CPPS. RESULTS: : Patient evaluation should consist of history and physical examination (with focus on the genitourinary and digital rectal examination), laboratory tests (including urine analysis and urine culture with consideration of pre- and post-prostate massage urine cultures), post-void residual, and questionnaires including the National Institutes of Health Chronic Prostatitis Symptoms Index, which helps assess symptom severity and treatment response. Once CP/CPPS is diagnosed, the UPOINT phenotype system, which classifies patients into six domains: Urinary, Psychosocial, Organ Specific, Infectious, Neurological/systemic and Tenderness of skeletal muscles, is used to guide treatment. Each domain is characterised by specific complaints and thus is responsive to distinct treatments. As patients may be grouped into multiple domains, each patient's overall multimodal treatment can vary. CONCLUSION: : Using the UPOINT phenotype system is a holistic approach that can yield significant benefits for patients with CP/CPPS.

Comparative Effectiveness of Transurethral Prostate Procedures at Enabling Urologic Medication Discontinuation: A Retrospective Analysis.

OBJECTIVE: To test the hypothesis that transurethral prostate procedures (TUPPs) eliminating tissue result in greater medication discontinuation and lower de novo initiation rates than procedures inducing tissue necrosis. METHODS: Retrospective review of all men undergoing first time TUPPs at a large tertiary center from 2001 to 2016 was completed. Procedure type and urologic medication use before, 3-12 months after, and greater than 12 months after TUPP were analyzed with simple open prostatectomy as a comparator. Tissue-eliminating TUPPs included transurethral resection of the prostate and laser prostatectomy. Tissue-necrosing procedures included microwave therapy (transurethral microwave therapy) and radiofrequency ablation (transurethral needle ablation), which were grouped in analyses. Medication types were 5-alpha reductase inhibitors (5ARI), alpha blockers, anticholinergics, and beta-3 agonists (B3A). RESULTS: A total 5150 TUPPs were analyzed. Preoperative medication use significantly varied across TUPPs for 5ARI (P <.01), alpha-blockers (P .01), and anticholinergics (P .047), but not B3A (P .476). Transurethral resection of the prostate and laser prostatectomy were associated with significantly higher medication discontinuation rates and lower resumption and initiation rates compared to tissue-necrosing procedures. Relative to TUPPs, simple prostatectomy had significantly higher medication discontinuation, as well as the lowest resumption and initiation rates. CONCLUSION: Tissue-eliminating benign prostatic hyperplasia procedures were associated with better medication discontinuation, resumption, and de novo initiation rates compared to tissue-necrosing benign prostatic hyperplasia procedures.

Systemic Comorbidity Burden Using the ACTIONS Phenotype Predicts Urologic Medication Discontinuation Following Transurethral Resection of the Prostate.

OBJECTIVE: To assess the impact of systemic comorbidities on a validated health phenotype score (ACTIONS: Anxiety, Cardiovascular, Testosterone, Insulin/diabetes, Obesity, Neurologic, Sleep apnea) on outcomes of transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH) for symptoms and medication discontinuation. MATERIALS AND METHODS: Comorbidities of men undergoing TURP for BPH from 2004 to 2015 were assessed with the validated ACTIONS phenotype totaling a score from 0 to 2 for each domain (Anxiety, Cardiovascular, Testosterone, Insulin/diabetes, Obesity, Neurologic, Sleep apnea). BPH medication discontinuation, change in International Prostate Symptom Score, postvoid residual, and patient satisfaction were assessed. Descriptive and comparative statistics were calculated with significance set at P <.05. RESULTS: The 319 men had a median age of 74.0 (interquartile range 67-78). Mean ACTIONS score was significantly lower in men who discontinued alpha-blockers or 5-alpha reductase inhibitors compared to those who did not (3.37 ± 2.14vs 4.79 ± 2.75, P <.0001). ACTIONS score <4 was significantly associated with medication discontinuation (P = .0014). Lower scores in Testosterone (P = .04), Neurologic (P = .003), and Sleep apnea (P = .04) domains were significantly associated with medication discontinuation. Total ACTIONS score was not independently associated with changes in International Prostate Symptom Score or postvoid residual. CONCLUSION: Lower ACTIONS score was associated with BPH medication discontinuation after TURP, suggesting men with lower comorbidity burdens do better after the procedure. The ACTIONS phenotype score is easily calculated and may aid the preoperative counseling of men undergoing TURP for BPH.

An evaluation of the pharmacotherapy for interstitial cystitis.

INTRODUCTION: Interstitial cystitis (IC) and bladder pain syndrome (BPS) are chronic conditions that can be debilitating for patients. There is no consensus as to their etiology, and there are many proposed treatment algorithms. Oftentimes multimodal therapy, such as combining behavioral modification and physical therapy alongside pharmacotherapies, will be utilized. With the various treatment options available to patients and providers, there is an ever-growing need to implement evidence-based therapies. AREAS COVERED: The authors explore the different pharmacotherapies as commonly recommended in the American Urological Association (AUA) and European Association of Urology (EAU) multitiered guidelines for IC/BPS treatment as well as other investigational therapies. Pharmacotherapies targeting bladder, pelvic, and/or systemic factors in the overall treatment of IC/BPS are discussed with a particular focus on evidence-based guideline therapies. This article also looks at emerging therapies of interest. EXPERT OPINION: IC/BPS is a syndrome that requires a multimodal approach, including clinical phenotyping and directed therapy based on the patient's symptoms. The AUA and EAU provide guidelines for practitioners to follow, but adequate treatment requires the therapy to be targeted toward the patient's phenotypic domain.

Utility of trigger point injection as an adjunct to physical therapy in men with chronic prostatitis/chronic pelvic pain syndrome.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT. METHODS: Using an IRB approved Men's Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the "T" domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5-1 cc was injected into each TP of a local anesthetic mixture (30:70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each. RESULTS: We identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21-70 years) and median UPOINT domains was 3 (range 1-5). Initial CPSI was pain 13.7±3.4, urinary 5.3±2.2, quality of life 9.8±2.1 and total 28.8±6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8±6.0 to 21.8±7.2 (P<0.0001). 18 men had a drop of 6 or more points in CPSI (53%). Of note, none of 3 men who were noncompliant with PT had benefit. 3 men had temporary numbness in the lateral thigh after the injection (4.4%) and 1 had difficulty weight bearing on 1 leg for about 30 minutes. CONCLUSIONS: TP injection in CP/CPPS patients as an adjunct to PT is well tolerated and leads to symptom improvement in about half. Durability and long term results are yet to be determined.

Pharmacotherapy of prostatitis.

IMPORTANCE OF THE FIELD: Prostatitis is a prevalent and morbid condition with a significant impact on a patient's quality of life. The four distinct prostatitis syndromes have different pathophysiologies, therapy and prognosis. Acute and chronic bacterial prostatitis is best treated with appropriate antibiotics that penetrate the prostate and kill the causative organisms. The most challenging category to treat is category III or chronic prostatitis/chronic pelvic pain syndrome. AREAS COVERED IN THE REVIEW: This review covers the categories of prostatitis and currently recommended therapies, as well as novel approaches on the horizon. WHAT THE READER WILL GAIN: Knowledge of the current framework for the diagnosis and management of the diverse prostatitis spectrum. TAKE HOME MESSAGE: Prostatitis is a diverse group of syndromes. Chronic prostatitis/chronic pelvic pain syndrome is a multifactorial syndrome that requires a multimodal approach to effectively treat the patient. The UPOINT technique is used to clinically phenotype these patients and drive the selection of multimodal therapy.

Chronic prostatitis/chronic pelvic pain syndrome and pelvic floor spasm: can we diagnose and treat?

National Institutes of Health category III prostatitis, also known as chronic prostatitis/chronic pelvic pain syndrome, is a common condition with significant impact on quality of life. This clinically defined syndrome has a multifactorial etiology and seems to respond best to multimodal therapy. At least half of these patients have pelvic floor spasm. There are several approaches to therapy including biofeedback, acupuncture, and myofascial release physical therapy. However, the only multicenter study of pelvic floor physical therapy for pelvic floor spasm in men failed to show an advantage over conventional Western massage. We have proposed a clinical phenotyping system called UPOINT to classify patients with urologic chronic pelvic pain and subsequently direct appropriate therapy. Here, we review the current approach to category III prostatitis and describe how clinical phenotyping with UPOINT may improve therapy outcomes.

New therapies in chronic prostatitis.

The optimal management of category III prostatitis (chronic pelvic pain syndrome) is not known. Conventional therapy usually consists of prolonged courses of antibiotics; however, clinical trials have never shown their efficacy. Newer therapies with some evidence for efficacy include alpha-blockers, anti-inflammatory phytotherapy (quercetin, bee pollen), physiotherapy, neuroleptics, and others with unique actions such as antinanobacterial treatment. A stepwise approach involving multiple treatment modalities is often successful for patients with this common and frustrating condition.

Combination treatment with curcumin and quercetin of adenomas in familial adenomatous polyposis.

BACKGROUND & AIMS: Familialadenomatous polyposis (FAP) is an autosomal-dominant disorder characterized by the development of hundreds of colorectal adenomas and eventual colorectal cancer. Regression of adenomas in this syndrome occurs with the administration of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, but these compounds can have considerable side effects. We evaluated the efficacy of the combination of diet-derived nonprescription supplements curcumin and quercetin to regress adenomas in patients with FAP. METHODS: Five FAP patients with prior colectomy (4 with retained rectum and 1 with an ileal anal pouch) received curcumin 480 mg and quercetin 20 mg orally 3 times a day. The number and size of polyps were assessed at baseline and after therapy. The Wilcoxon signed-rank test was used to determine differences in the number and size of polyps. Treatment side effects and medication compliance also were evaluated. RESULTS: All 5 patients had a decreased polyp number and size from baseline after a mean of 6 months of treatment with curcumin and quercetin. The mean percent decrease in the number and size of polyps from baseline was 60.4% (P < .05) and 50.9% (P < .05), respectively. Minimal adverse side effects and no laboratory abnormalities were noted. CONCLUSIONS: The combination of curcumin and quercetin appears to reduce the number and size of ileal and rectal adenomas in patients with FAP without appreciable toxicity. Randomized controlled trials are needed to validate these findings.

Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome.

Category III chronic prostatitis/chronic pelvic pain syndrome is a syndrome rather than a specific disease and the cause can be multifactorial. In clinical practice, monotherapy often has proven ineffective. Multimodal therapy, which sequentially or simultaneously can address infection, inflammation, and neuromuscular spasm appears to have the greatest potential for symptom improvement, especially in patients with longstanding symptoms.

Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is principally defined by pain in the pelvic region lasting more than 3 months. No cause of the disease has been established, and therapies are empirical and mostly untested. Antimicrobial agents and alpha-adrenergic receptor blockers are frequently used. OBJECTIVE: To determine whether 6-week therapy with ciprofloxacin or tamsulosin is more effective than placebo at improving symptoms in men with refractory, long-standing CP/CPPS. DESIGN: Randomized, double-blind trial with a 2 x 2 factorial design comparing 6 weeks of therapy with ciprofloxacin, tamsulosin, both drugs, or placebo. SETTING: Urology outpatient clinics at 10 tertiary care medical centers in North America. PATIENTS: Patients were identified from referral-based practices of urologists. One hundred ninety-six men with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score of at least 15 and a mean of 6.2 years of symptoms were enrolled. Patients had received substantial previous treatment. MEASUREMENTS: The authors evaluated NIH-CPSI total score and subscores, patient-reported global response assessment, a generic measure of quality of life, and adverse events. INTERVENTIONS: Ciprofloxacin, 500 mg twice daily; tamsulosin, 0.4 mg once daily; a combination of the 2 drugs; or placebo. RESULTS: The NIH-CPSI total score decreased modestly in all treatment groups. No statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin (P = 0.15) or tamsulosin versus no tamsulosin (P > 0.2). Treatments also did not differ significantly for any of the secondary outcomes. LIMITATIONS: Treatment lasting longer than 6 weeks was not tested. Patients who had received less pretreatment may have responded differently. CONCLUSION: Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms.

Herbal and complementary medicine in chronic prostatitis.

Chronic prostatitis is a very common and poorly understood condition with significant impact on quality of life. The etiology of prostatitis can be multifactorial and can present with a variety of symptoms. Given the lack of proven efficacy of conventional therapies such as antibiotics, many patients have turned to phytotherapy and other alternative treatments. This review will cover the alternative therapies commonly used in prostatitis with an emphasis on those with published data. These treatments include phytotherapy (quercetin, bee pollen) and physical therapy. Complementary therapies have shown the potential to help men with prostatitis, particularly when allopathic therapies have failed.

Long-term results of multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome.

PURPOSE: Chronic prostatitis/chronic pelvic pain syndrome is a prevalent and multifactorial condition. Many patients have the condition for years despite conventional therapies. We assess the outcomes of multimodal therapy in patients with long-standing chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: A total of 53 patients with chronic prostatitis treated at our clinic with a minimum followup of 6 months were assessed by the National Institutes of Health-Chronic Prostatitis Symptom Index and by a global assessment score. Treatments included antibiotics, prostatic massage, anti-inflammatory phytotherapy, alpha-blockers and neuromuscular agents. RESULTS: Mean age patient was 45 years and median symptom history was 3.5 years. Based on localizing cultures, and microscopy of urine and prostatic fluid 13% of the cases were category II, 41% were category IIIa and 46% were category IIIb. Mean followup from the last visit was 417 days (range 185 to 1,247). Mean changes +/- SE from the initial to the final score on the National Institutes of Health-Chronic Prostatitis Symptom Index were 10.4 +/- 3.3 to 5.9 +/- 4.4 for pain, 4.2 +/- 2.9 to 2.0 +/- 2.7 for urinary, 8.2 +/- 2.9 to 4.7 +/- 3.4 for quality of life and 22.7 +/- 6.6 to 13.2 +/- 9.5 for total score (p <0.0001). Based on a global subjective assessment 43 of the patients (80%) were better, 8 were the same and 3 were worse. At final assessment 39% of the patients were on no therapy, 22% were on an alpha-blocker, 37% were on quercetin, 13% were on neuromuscular agents and 9% were on antibiotics. CONCLUSIONS: An approach using stepwise therapy with antibiotics, anti-inflammatories and neuromuscular agents can be successful in the majority of patients with long-standing chronic prostatitis.

Phytotherapy and other alternative forms of care for the patient with prostatitis.

Chronic prostatitis is a very common and poorly understood condition with significant impact on quality of life. Given the lack of proven efficacy of conventional therapies such as antibiotics, it is not surprising that patients have turned with increasing frequency to phytotherapy and other alternative treatments. Although alternative therapies are plentiful, few have been subjected to scientific scrutiny and prospective controlled clinical trials. This review discusses therapies commonly used by patients with prostatitis and focuses in detail on those with published data. These treatments include zinc, cernitin pollen extract (bee pollen), quercetin, saw palmetto (Serenoa repens), and acupuncture. Complementary therapies may indeed have much to offer patients, particularly those with chronic degenerative conditions in which allopathic therapies have proven less successful. Alternative therapies, however, require the same scientific criteria for validation and acceptance as do conventional medical therapies.

Cytokine polymorphisms in men with chronic prostatitis/chronic pelvic pain syndrome: association with diagnosis and treatment response.

PURPOSE: The chronic pelvic pain syndrome is a common disorder of unknown etiology. Elevated cytokines in prostate fluid and semen are frequent findings. We studied genetic polymorphisms that can alter cytokine gene expression in men with the chronic pelvic pain syndrome. MATERIALS AND METHODS: Genomic DNA was extracted from blood from 36 men with the chronic pelvic pain syndrome. Reversed sequence specific oligonucleotide probing was used to genotype the polymorphisms for cytokine promoter sites, namely tumor necrosis factor (TNF)-alpha 308, transforming growth factor (TGF)-beta 25, TGF-beta 10, interleukin (IL)-10 1082 and IL-6 174. Genotype frequencies were compared with 252 controls as well as among groups of patients with the chronic pelvic pain syndrome according to diagnostic category and treatment response. RESULTS: There were no differences in men with the chronic pelvic pain syndrome and control patients in the frequency of TNF-alpha, TGF-beta or IL-6 alleles, although those with the chronic pelvic pain syndrome were more likely to express the genotype associated with low IL-10 production (30.6% versus 12.1%, p = 0.007). When comparing National Institutes of Health diagnoses, category IIIa patients were more likely to have the low TNF-alpha genotype (categories II, IIIa and IIIb 33%, 100% and 18%, respectively, p = 0.04). All 11 of the 28 patients treated with the anti-inflammatory quercetin in whom treatment failed had the low TNF-alpha genotype versus 29.4% of those in whom treatment succeeded (p = 0.0003). Similarly men with quercetin treatment failure were much less likely to have the low IL-10 genotype than those with treatment success (9.1% versus 47.1%, p = 0.04). CONCLUSIONS: Patients with the chronic pelvic pain syndrome are more likely to have a low IL-10 producing genotype, suggesting autoimmunity as a potential etiology. Anti-inflammatory phytotherapy failure was associated with low TNF-alpha and high IL-10 phenotypes, which may help define a subset of patients with the chronic pelvic pain syndrome without an inflammatory etiology.

Phytotherapy in chronic prostatitis.

Chronic prostatitis is a very common condition that is poorly understood and has a significant impact on quality of life. Given the lack of proven efficacy of conventional therapies, such as antibiotics, it is not surprising that patients have turned with increasing frequency to phytotherapy and other alternative treatments. Although alternative therapies are plentiful, few have been subjected to scientific scrutiny and prospective controlled clinical trials. This review will cover phytotherapies commonly used in prostatitis patients and focus in detail on those with published data. These treatments include zinc, cernilton (bee pollen), quercetin, and saw palmetto. Although many of these therapies appear promising in small preliminary studies, phytotherapy requires the same scientific criteria for validation and acceptance as do conventional medical therapies.