Chronic Pelvic Pain Syndrome (CP/CPPS) Is a Common Condition
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Review Recent trend of chronic prostatitis/ chronic pelvic pain syndrome Hanyang Med Rev 2017;37:40-46 https://doi.org/10.7599/hmr.2017.37.1.40 (CP/CPPS) management pISSN 1738-429X eISSN 2234-4446 Seung Wook Lee Department of Urology, Hanyang University Guri Hospital, Guri, Korea Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common condition. Corresponding Author: Seung Wook Lee However, many of the traditional therapies like monotherapy used in clinical practice Department of Urology, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri fail to show efficacy. There is no one particular treatment to be recommended 11923, Korea as monotherapy for CP/CPPS. The new concept of treatment which is 'UPOINT' is Tel: +82-31-560-2374 introduced. The major barrier in treating men with CP/CPPS is the heterogenous Fax: +82-31-560-2372 E-mail: [email protected] nature of this syndrome. In order to treat appropriately, the patient should be evaluated individually to assess Received 25 Jan 2017 the nature of symptoms. To evaluate patients with chronic urologic pelvic pain, a Revised 27 Feb 2017 six-point clinical phenotyping system has been developed. The clinical domains Accepted 30 Mar 2017 are urinary symptoms, psychosocial dysfunction, organ specific findings, infection, This is an Open Access article distributed under the terms of neurologic/systemic, and tenderness of muscles, which produces the acronym the Creative Commons Attribution Non-Commercial License 'UPOINT'. This clinical phenotyping system may provide a useful and clinically relevant (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and framework for multimodal therapy for the treatment of CP/CPPS. However, the reproduction in any medium, provided the original work is concept of UPOINT needs randomization, placebo or sham control studies to show properly cited. verified treatment. Key words: Prostatitis; Pelvic Pain INTRODUCTION of the International Association for the Study of Pain, chronic pelvic pain syndrome and prostate pain syndrome have a Lower urinary tract symptoms (LUTS) and pelvic pain similar definition and they are widely used recently [2]. A caused by diseases of the prostate have decreased the quality of valid tool which can be used to assess CP/CPPS was developed life in men. Epidemiologic studies report that the prevalence of as represented by the National Institutes of Health chronic prostatitis-like symptoms is approximately similar to diabetes prostatitis symptom index (NIH-CPSI) [3]. A previous study mellitus and ischemic heart disease. The rate of prostatitis-like revealed that the prevalence of NIH-CPSI for the assessment of symptoms was reported to range from 2.2% to 9.7%, and mean CP/CPPS is about 8%–10% [4]. prevalence was 8.2% [1]. Only 20 years ago, collecting prostatic secretion was Prostatitis is a relatively common disease seen in the field performed to obtain bacterial culture, to confirm and treat of urology that reduces the quality of life of men in many bacterial causes of chronic prostatitis. Also, antibiotic treatment ways. The National Institutes of Health (NIH) published was prescribed for such symptoms [5]. that there are four categories in prostatitis, among which In 1995, the Korea National Institute of Health announced chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) clarification for prostatitis at the Diabetes and Digestive and corresponds to category III. According to the recommendation Kidney Diseases (NIDDK) consensus meeting. However, 40 ©2017 Hanyang University College of Medicine · Institute of Medical Science http://www.e-hmr.org Seung Wook Lee•Recent trend of chronic prostatitis/chronic pelvic pain syndrome(CP/CPPS) management in some studies, prescription of specific antibiotics failed to 3. Management affect symptom improvement. As a 3rd classification category, 3.1 Monotherapy chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) Several types of monotherapy have been introduced presents voiding symptoms without urinary tract infection and and researched for CP/CPPS. These treatment methods chronic pelvic pain. In 1999, the chronic prostatitis symptom include alpha blockers, antibiotics, hormone therapy, anti- index(CPSI) announced the definition and classification inflammatory treatment, plant therapy, anticonvulsant and supplemented CP/CPPS treatment manual based on previous non-pharmacological treatment. It was reported that these treatment [6].From the beginning of the latter half of the treatment methods are effective for treatment of CP/CPPS but 1900s and the early 2000s, some researchers reported that there are other reports that such methods are not effective. In various treatment methods other than antibiotics are effective addition, research cases were limited and therapeutic methods for treatment of CP/CPPS. Also, research was performed on that were available were not backed up by adequate research. randomized placebo- or sham-controlled treatment trials. Alpha blockers have been researched as monotherapy and Benign prostatic hyperplasia and prostate cancer are typical its therapeutic effect on CP/CPPS symptoms were reported prostate disease conditions and their diagnoses and treatment in several theses. Nickel et al. reported in their research that methods have significantly developed. Prostatitis are entities Silodosin was effective for improvement of symptom and that need to be explored and have not been actively researched. quality of life of in patients with CP/CPPS[14]. And it was Recently, some researchers proposed a new treatment method further reported that terazosin[15] and alfuzosin[16] that for prostatitis, particularly, CP/CPPS, and what type of method are alpha blockers are also effective. However, according to that was suggested will be observed. a multicenter research performed at two places, their results The criteria for CP/CPPS could comprise several different presented the opposite. According to research done by types of symptoms. Shoskes et al. well outlined the UPOINT Alexander et al., the NIH-CPSI score for 6-weeks of tamsulosin classification [7]. The categories are composed of urinary, treatment did not show any improvement and in another psychosocial, organ specific, large scaled research done on alfuzosin, it was reported that infection, neurologic, and skeletal muscle tenderness. Lately, the advantage of alpha blocker was not represented and the the UPOINT system has been used to look at gathering of symptom was not improved[17]. symptoms, to try to distinguish a common cause for some Antibiotics have been used for bacterial prostatitis almost groups of patients. Two clusters have demonstrated the essentially even in the case when culture tests were negative [18]. analysis of men with CP/CPPS using the UPOINT system, a And there is also research reporting symptom improvement. In ‘systemic group’ of infection, neurologic, and psychosocial and tetracycline research, symptom improvement was represented a ‘pelvic’ group with the domains of organ specific, urinary, and when comparing with the control group by using such an tenderness [8]. agent for 12 weeks. However, a survey on quality of life was not sufficient[19]. In a randomized controlled research, 2. Cause of CP/CPPS levofloxacin was used for 6 weeks and it was compared with CP/CPPS affects quality of life adversely on the one hand and placebo[20]. In total score of the NIH-CPSI, improved score entails financial burden on the other. Various complex causes between two groups was represented but its difference was not (urinary tract infection, prostatic urinary tract counterflow shown. In NIDDK-sponsored research, it was announced that [9], Cytokines [10], pelvic floor spasm[11], systemic nervous ciprofloxacin was not superior to placebo[21]. In Meta-analysis or endocrine cause[12] and neuropsychiatric cause [13]) for use of antibiotics[22], there was a research study that affects CP/CPPS in terms of pathological physiology (Fig. 1). presented results that it may be clearly, individually effective, Generally, these causes appear in a complex form, not a single but not statistically and clinically. It is considered that CP/ one. Therefore, recently, breaking away from existing practice CPPS was caused by bacteria and that it may not be cultured in of monotherapy, the UPOINT phenotyping system that treats some patients or uncultured due to anti-inflammatory cytokine symptoms by discovering several causes of the condition in the blocked antibiotics[23]. This result suggests that antibiotics patient has been introduced. treatment should not be recommended as first line therapy and this case is applicable particularly to a patient who fails Hanyang Med Rev 2017;37:40-46 http://www.e-hmr.org 41 Seung Wook Lee•Recent trend of chronic prostatitis/chronic pelvic pain syndrome(CP/CPPS) management antibiotic treatment previously. was more effective than monotherapy. Nickel et al. reported Anti-inflammatory medicine has also been widely used for that when treating with alpha blocker, antibiotics or pain killing several symptoms of CP/CPPS and various drugs particularly anti-inflammatory drug at the same time, the clinical score including rofecoxib [24], pentosanpolysulfate [25], zafirlukast was more improved than control group and in other studies, it (a leukotriene antagonist) [26],prednisone [27], and reported that when treating with alpha blocker, antibiotics and tanezumab[28] have been researched. In case of administering pain killing