Abstract and Introduction
Abstract
The urologic chronic pain conditions such as chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis are syndromes whose evaluation and management are controversial. Part of the difficulty in diagnosis and therapy is the heterogeneity of etiologies and symptoms. We propose a six-domain phenotype, which can classify these patients clinically and can direct the selection of therapy in the most evidence based multimodal manner. The domains are urinary, psychosocial, organ specific, infection, neurologic and tenderness of skeletal muscles. This system is flexible and responsive to new biomarkers and therapies as their utility and efficacy are proven.
Introduction
Chronic prostatitis (CP) and interstitial cystitis (IC) are perplexing disorders for both patients and physicians. Definitions and classifications for these conditions remain clinical syndrome based. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) classification of prostatitis has replaced the older terms 'nonbacterial prostatitis' and 'prostatodynia' with category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS or now commonly call CPPS). These patients have pelvic and genital pain, often associated with urinary and sexual symptoms, but no history of documented urinary tract infection (UTI). Despite conclusive evidence that empiric antibiotic therapy is not effective for CPPS, most physicians do not culture anything but urine and use antibiotics as primary therapy regardless of the culture results. Several therapies have been shown to help the symptoms of CPPS in small clinical trials, and while multimodal therapy may be the most effective approach, it is the most difficult to test in a systematic, stratified and controlled way. One of the largest barriers to successful therapy is the lack of biomarkers that can stratify patients into etiologic or therapeutic categories. Clinical trials on CPPS are, by the nature of the syndrome, treating patients with multiple etiologies and therefore may fail on the basis of a heterogeneous population.
IC similarly has several proposed etiologies and therapeutic options. Given the nature of symptoms, the condition is being referred to as painful bladder syndrome (PBS) and more recently, bladder pain syndrome. Beyond symptoms, the value of biomarkers (for example, antiproliferative factor) and definitive objective diagnostic tests (hydrodistension, potassium sensitivity) is controversial, and do not appear to predict therapy outcome. Again, multimodal therapy has been proposed as the best approach to manage this condition, but has not been studied in a systematic way. Given the overlap of symptoms, the NIDDK has proposed an umbrella term for CPPS and IC as Urologic chronic pelvic pain syndromes (UCPPS). This 'lumping' rather than 'dividing' as a strategy to lead to a better understanding and management of these conditions remains untested. We propose that instead of including all patients under a homogenous envelope, it is best to classify the various subtypes of UCPPS patients and manage individual patients according to the subtype classification. As the etiology and pathogenesis of these syndromes remain unknown, few objective parameters are available to differentiate patients and the various potential biomarkers have not yet been feasible to use or validated as useful, we propose a purely clinical phenotyping of patients with UCPPS and then therapy directed at the individual phenotype(s) based on best available evidence.