A Phenotypic Approach to the Evaluation and Treatment of Men with Chronic Pelvic Pain Syndrome

  • Kiranpreet Khurana
  • Daniel A. ShoskesEmail author
Part of the Current Clinical Urology book series (CCU)


Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) or NIH category III prostatitis is a common and painful condition with a significant impact on quality of life. CP/CPPS is a syndrome rather than a specific disease and patients likely have multiple potential etiologies and groupings of symptoms (phenotypes). At least partly due to the heterogeneity of the syndrome, clinical trials of monotherapy have been marginally effective. In response to this, we developed a simple clinical phenotyping system with the acronym UPOINT that phenotypes patients in six domains (urinary, psychosocial, organ specific, infection, neurologic/systemic, tenderness of skeletal muscles) and helps to drive multimodal individualized therapy. We have shown a correlation between number of positive domains and symptom severity as well as a high response rate to multimodal therapy guided by the UPOINT phenotype. This chapter summarizes our approach to this challenging patient population.


Pelvic Floor Lower Urinary Tract Symptom Interstitial Cystitis Pollen Extract Pelvic Pain Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Schaeffer AJ. Epidemiology and demographics of prostatitis. Andrologia. 2003;35(5):252–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Schappert SM. National Ambulatory Medical Care Survey: 1991 summary. Vital Health Stat 13 1994;(116): 1–110.Google Scholar
  3. 3.
    Collins MM, Stafford RS, O’Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol. 1998;159(4):1224–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Krieger JN, Nyberg Jr L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Schaeffer AJ, Wendel EF, Dunn JK, Grayhack JT. Prevalence and significance of prostatic inflammation. J Urol. 1981;125(2):215–9.PubMedGoogle Scholar
  6. 6.
    Kirby RS, Lowe D, Bultitude MI, Shuttleworth KE. Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis. Br J Urol. 1982;54(6):729–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Shahed AR, Shoskes DA. Correlation of beta-endorphin and prostaglandin E2 levels in prostatic fluid of patients with chronic prostatitis with diagnosis and treatment response. J Urol. 2001;166(5):1738–41.PubMedCrossRefGoogle Scholar
  8. 8.
    Westesson KE, Shoskes DA. Chronic prostatitis/chronic pelvic pain syndrome and pelvic floor spasm: can we diagnose and treat? Curr Urol Rep. 11(4): 261–4.PubMedCrossRefGoogle Scholar
  9. 9.
    Schaeffer AJ. Etiology and management of chronic pelvic pain syndrome in men. Urology. 2004;63(3 Suppl 1):75–84.PubMedCrossRefGoogle Scholar
  10. 10.
    Anothaisintawee T, Attia J, Nickel JC, Thammakraisorn S, Numthavaj P, McEvoy M, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAMA. 305(1):78–86.PubMedCrossRefGoogle Scholar
  11. 11.
    Snow DC, Shoskes DA. Pharmacotherapy of prostatitis. Expert Opin Pharmacother. 11(14): 2319–30.PubMedCrossRefGoogle Scholar
  12. 12.
    Mehik A, Alas P, Nickel JC, Sarpola A, Helstrom PJ. Alfuzosin treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, double-blind, placebo-controlled, pilot study. Urology. 2003;62(3):425–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Nickel JC, Krieger JN, McNaughton-Collins M, Anderson RU, Pontari M, Shoskes DA, et al. Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome. N Engl J Med. 2008;359(25):2663–73.PubMedCrossRefGoogle Scholar
  14. 14.
    Evliyaoglu Y, Burgut R. Lower urinary tract symptoms, pain and quality of life assessment in chronic non-bacterial prostatitis patients treated with alpha-blocking agent doxazosin; versus placebo. Int Urol Nephrol. 2002;34(3):351–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Tugcu V, Tasci AI, Fazlioglu A, Gurbuz G, Ozbek E, Sahin S, et al. A placebo-controlled comparison of the efficiency of triple- and monotherapy in category III B chronic pelvic pain syndrome (CPPS). Eur Urol. 2007;51(4):1113–7; discussion 8.PubMedCrossRefGoogle Scholar
  16. 16.
    Alexander RB, Propert KJ, Schaeffer AJ, Landis JR, Nickel JC, O’Leary MP, et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann Intern Med. 2004;141(8):581–9.PubMedGoogle Scholar
  17. 17.
    Nickel JC, Narayan P, McKay J, Doyle C. Treatment of chronic prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial. J Urol. 2004;171(4):1594–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Chen Y, Wu X, Liu J, Tang W, Zhao T, Zhang J. Effects of a 6-month course of tamsulosin for chronic prostatitis/chronic pelvic pain syndrome: a multicenter, randomized trial. World J Urol. 29(3):381–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Gul O, Eroglu M, Ozok U. Use of terazosine in patients with chronic pelvic pain syndrome and evaluation by prostatitis symptom score index. Int Urol Nephrol. 2001;32(3):433–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Cheah PY, Liong ML, Yuen KH, Teh CL, Khor T, Yang JR, et al. Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized, placebo controlled trial. J Urol. 2003;169(2):592–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Nickel JC, Downey J, Clark J, Casey RW, Pommerville PJ, Barkin J, et al. Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial. Urology. 2003;62(4):614–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Zhou Z, Hong L, Shen X, Rao X, Jin X, Lu G, et al. Detection of nanobacteria infection in type III prostatitis. Urology. 2008;71(6):1091–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Leskinen M, Lukkarinen O, Marttila T. Effects of finasteride in patients with inflammatory chronic pelvic pain syndrome: a double-blind, placebo-controlled, pilot study. Urology. 1999;53(3):502–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Nickel JC, Downey J, Pontari MA, Shoskes DA, Zeitlin SI. A randomized placebo-controlled multicentre study to evaluate the safety and efficacy of finasteride for male chronic pelvic pain syndrome (category IIIA chronic nonbacterial prostatitis). Br J Urol Int. 2004;93(7):991–5.PubMedCrossRefGoogle Scholar
  25. 25.
    De Rose AF, Gallo F, Giglio M, Carmignani G. Role of mepartricin in category III chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized prospective placebo-controlled trial. Urology. 2004;63(1):13–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Nickel JC, Pontari M, Moon T, Gittelman M, Malek G, Farrington J, et al. A randomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis. J Urol. 2003;169(4):1401–5.PubMedCrossRefGoogle Scholar
  27. 27.
    Nickel JC, Forrest JB, Tomera K, Hernandez-Graulau J, Moon TD, Schaeffer AJ, et al. Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicenter, randomized, placebo controlled study. J Urol. 2005;173(4):1252–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Goldmeier D, Madden P, McKenna M, Tamm N. Treatment of category III A prostatitis with zafirlukast: a randomized controlled feasibility study. Int J STD AIDS. 2005;16(3):196–200.PubMedCrossRefGoogle Scholar
  29. 29.
    Bates SM, Hill VA, Anderson JB, Chapple CR, Spence R, Ryan C, et al. A prospective, randomized, double-blind trial to evaluate the role of a short reducing course of oral corticosteroid therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome. Br J Urol Int. 2007;99(2):355–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Zhao WP, Zhang ZG, Li XD, Yu D, Rui XF, Li GH, et al. Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA). Braz J Med Biol Res. 2009;42(10):963–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology. 1999;54(6):960–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Elist J. Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized, double-blind, placebo-controlled study. Urology. 2006;67(1):60–3.PubMedCrossRefGoogle Scholar
  33. 33.
    Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brahler E, Weidner W. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol. 2009;56(3):544–51.PubMedCrossRefGoogle Scholar
  34. 34.
    Pontari MA, Krieger JN, Litwin MS, White PC, Anderson RU, McNaughton-Collins M, et al. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: a randomized controlled trial. Arch Intern Med. 170(17):1586–93.PubMedCrossRefGoogle Scholar
  35. 35.
    FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2009;182(2):570–80.PubMedCrossRefGoogle Scholar
  36. 36.
    Jeong CW, Lim DJ, Son H, Lee SE, Jeong H. Treatment for chronic prostatitis/chronic pelvic pain syndrome: levofloxacin, doxazosin and their combination. Urol Int. 2008;80(2):157–61.PubMedCrossRefGoogle Scholar
  37. 37.
    Ye ZQ, Lan RZ, Yang WM, Yao LF, Yu X. Tamsulosin treatment of chronic non-bacterial prostatitis. J Int Med Res. 2008;36(2):244–52.PubMedGoogle Scholar
  38. 38.
    Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. Urology 75(6):1249–53.PubMedCrossRefGoogle Scholar
  39. 39.
    Roehrborn CG. Alfuzosin: overview of pharmacokinetics, safety, and efficacy of a clinically uroselective alpha-blocker. Urology 2001;58(6 Suppl 1):55–63; discussion 63–4.PubMedCrossRefGoogle Scholar
  40. 40.
    Yokoyama O, Yusup A, Oyama N, Aoki Y, Tanase K, Matsuta Y, et al. Improvement of bladder storage function by alpha1-blocker depends on the suppression of C-fiber afferent activity in rats. Neurourol Urodyn. 2006;25(5):461–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Sugaya K, Nishijima S, Miyazato M, Ashitomi K, Hatano T, Ogawa Y. Effects of intrathecal injection of tamsulosin and naftopidil, alpha-1A and -1D adrenergic receptor antagonists, on bladder activity in rats. Neurosci Lett. 2002;328(1):74–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Geppetti P, Nassini R, Materazzi S, Benemei S. The concept of neurogenic inflammation. Br J Urol Int. 2008;101(Suppl 3):2–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155–60.PubMedCrossRefGoogle Scholar
  44. 44.
    Anderson RU, Wise D, Sawyer T, Chan CA. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol. 2006;176(4 Pt 1):1534–8; discussion 8–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Shoskes DA, Nickel JC, Rackley RR, Pontari MA. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis. 2009;12(2):177–83.PubMedCrossRefGoogle Scholar
  46. 46.
    Nickel JC, Shoskes D, Irvine-Bird K. Clinical phenotyping of women with interstitial cystitis/painful bladder syndrome: a key to classification and potentially improved management. J Urol. 2009;182(1):155–60.PubMedCrossRefGoogle Scholar
  47. 47.
    Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology 2009;73(3):538–42; discussion 42–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Hedelin HH. Evaluation of a modification of the UPOINT clinical phenotype system for the chronic pelvic pain syndrome. Scand J Urol Nephrol. 2009;43(5):373–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Magri V, Wagenlehner F, Perletti G, Schneider S, Marras E, Naber KG, et al. Use of the UPOINT chronic prostatitis/chronic pelvic pain syndrome classification in European patient cohorts: sexual function domain improves correlations. J Urol. 2010;184(6):2339–45.PubMedCrossRefGoogle Scholar
  50. 50.
    Samplaski MK, Li J, Shoskes DA. Inclusion of erectile domain to UPOINT phenotype does not improve correlation with symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome. Urology. 2011;78(3):653–8.Google Scholar
  51. 51.
    McNaughton Collins M, Pontari MA, O’Leary MP, Calhoun EA, Santanna J, Landis JR, et al. Quality of life is impaired in men with chronic prostatitis: the Chronic Prostatitis Collaborative Research Network. J Gen Intern Med. 2001;16(10):656–62.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Department of UrologyThe Glickman Urologic and Kidney Institute, Cleveland ClinicClevelandUSA

Personalised recommendations