The evolving clinical picture of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): A look at 1310 patients over 16 years

摘要

IntroductionTwo decades of increasing understanding of etiopathogenesis and clinical phenotyping produces an impression the clinical face of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is changing. We sought to retrospectively analyze trends in CP/CPPS patients presenting to our clinic for evaluation over a 16-year period.Methods: Patients with CP/CPPS presenting to a tertiary clinic were evaluated prospectively from 1998–2014 with Chronic Prostatitis Symptom Index (CPSI) and UPOINT (urinary, psychosocial, organ-specific, infection, neurogenic, and tenderness) categorization. Patients were stratified in four cohorts, based on year of presentation, and we retrospectively analyzed variations in symptom scores and patterns, UPOINT categorization, and treatment modalities amongst cohorts.Results: Mean age of the 1310 CP/CPPS patients was 44.7 years, while mean CPSI pain, urination, and total scores were 10.6, 4.8, and 23.3, respectively. The most prevalent UPOINT domain, urinary (U) (71.8%) was associated with a higher CPSI urination score (6.3), more frequent penile tip pain (37%), dysuria (48%), and more treatment with alpha-blockers (70%). Increase in UPOINT domains was associated with higher CPSI pain, quality of life (QoL), and total scores. Trends over time included increased prevalence of psychosocial (P), organ (O), and tenderness (T) domains, as well as increased use of alpha-blockers, neuromodulation, and phytotherapy as treatment modalities. There was little variation in age, CPSI scores, and pain locations over time.Conclusions: The changing clinical face of CP/CPPS reflects the increased recognition of psychosocial (P domain) and pelvic floor pain (T domain), along with the concomitant use of associated therapies. There was little variation of pain/urinary symptom patterns and QoL.IntroductionProstatitis syndromes, including prostate pain complaints among men, have long been recognized as a common clinical scenario encountered by physicians.1,2 It took several years of concerted effort from the National Institutes of Health (NIH) via their Chronic Prostatitis Collaborative Research Network (CPCRN) to help define the disease of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). International consensus following a 1995 chronic prostatitis workshop classified CP/CPPS into four categories3,4 — this helped define the disease for clinicians, provided a framework from which to approach a disease with a challenging, heterogeneous presentation, and furthermore, allowed for a more standardized approach to research in the field.The continued enthusiasm of the NIH collaboration led to the development of a validated symptom index tool5 — the NIH Chronic Prostatitis Symptom Index (CPSI) — which has allowed for objective evaluation of patients and their response to treatment.This tool has proved invaluable in evaluating various treatments for CP/CPPS in clinical trials,6–8 has proved helpful in evaluating CP/CPPS prevalence,9 and has been used to validate tiers of disease severity.10Despite these advancements, CP/CPPS remained a difficult entity to manage. Randomized controlled trials of various treatment modalities failed to show significant improvements in measured outcomes.11 Furthermore, the etiology and pathogenesis of CP/CPPS remained an enigma and likely represented a constellation of disease contributors and pathways. There were, however, some subgroups that appeared to benefit from various treatment modalities.11,12 It was becoming accepted that the heterogeneous nature of patients presenting with CP/CPPS would be best evaluated by subgrouping patients according to either mechanisms, biomarkers, or symptoms. Using available clinical assessment, a phenotypic approach to classifying patients in clinical practice was proposed. UPOINT phenotyping13 built on the improvements made by the NIH classification by further recognizing that even within these four broad categories, patients were still heterogeneous. Assessing individual patients according to the proposed six domains allowed for improved patient-centred care, leading to development of individualized clinical treatment strategies.14It has now been close to two decades since our updated classification system came into general use and a decade since UPOINT was first introduced, and this has led to a plethora of current research in the field. But have any of these developments made an impact on patient evaluation and subsequent treatment?This study is a retrospective look at CP/CPPS patients evaluated in a single outpatient clinic over the course of a 16-year period, beginning with introduction of our current classification system and spanning the introduction of UPOINT phenotyping. We were interested in observing the initial presentatio