Self-Reported Spousal Support Modifies the Negative Impact of Pain on Disability in Men with Chronic Prostatitis / Chronic Pelvic Pain Syndrome

Abstract

OBJECTIVES

To examine changes in the association between pain and patient quality of life (QoL), depressive symptoms, and disability in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) at varying levels of spouse responses to pain.

METHODS

One-hundred and eighty-eight men with CP/CPPS completed a questionnaire including demographic information. The outcome variables were mental QoL (SF-12 MCS), physical QoL (SF-12 PCS), depressive symptoms (Center for Epidemiological Studies Depression Scale), and disability (Pain Disability Index). Patients also reported on the types of responses they experienced from their spouses (Multidimensional Pain Inventory), and pain (Short-Form McGill Pain Questionnaire).

RESULTS

The association between pain and disability was stronger at higher levels of solicitous responses (e.g., “does some of my chores) (β = 0.66, p<.05) than it was at moderate (β = 0.44, p<.05) and lower (β = 0.23, ns) levels. In contrast, the association between pain and disability was stronger at lower levels (β = 0.64, p<.05) of distracting responses (e.g., “tries to get me involved in some activity”) than it was at moderate (β = 0.44, p<.05) and higher (β = 0.25, p<.05) levels.

CONCLUSIONS

Solicitous responses to pain increased the negative impact of pain on disability, while distracting responses to pain decreased the negative impact of pain on disability in men with CP/CPPS. Solicitous responses may be a reaction to patient pain and associated disability, or may help create or maintain the patient’s pain and disability. In either case, distracting rather than solicitous responses to patient pain are to be encouraged in symptom management.

INTRODUCTION

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a prevalent urogenital condition affecting between 2 and 16%.¹ It is primarily characterized by pain in the perineum, penis, suprapubic region, or scrotum, with voiding and is often exacerbated upon ejaculation.¹ Available treatments are limited in effectiveness and symptoms are associated with chronicity estimated at an average of 87 months before diagnosis.² Sufferers of CP/CPPS also frequently report comorbid medical conditions (e.g., allergies, sinusitis, irritable bowel syndrome), depressive symptoms, high rates of disability, diminished quality of life (QoL), and spousal discord. ^3–7 Given the pervasive refractory nature of CP/CPPS symptom impact and the limited biomedical treatment efficacy, it is important for Urologists to understand and be able to provide suggestions for adjunctive self-management strategies for patient QoL improvement.

Interestingly, research into the outcomes associated with persistent pain shows that psychosocial factors can account for patient disability more so than do indices of disease severity.^8,9 The transactional model of health suggests that, when under stress, the manner in which couples “react”, or provide support within the couple can exacerbate or improve outcomes associated with that stressor.¹⁰ As such, the chronic pain literature suggests that perceptions of low social support are associated with diminished quality of life (QoL), depression, disability, pain severity and pain behaviour. ¹¹ In the pain literature, social support has been examined as spouse responses to pain behaviour.¹¹ There are three major categories of spousal responses to patient pain behaviour: solicitous (e.g., “tries to get me to rest”, “does some of my chores”), distracting (e.g., “tries to get me involved in some activity”) and negative or punishing (e.g., “gets angry with me”). These spousal responses to pain behaviour are associated with increased depression and anxiety, physical and psychosocial disability, pain catastrophizing and greater pain severity in the identified patient.^12–15 In general, this research suggests that spousal responses to pain behaviour are associated with patient outcomes.

Current research suggests that distracting spousal responses decreases the negative impact of pain on mental QoL for women suffering from Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS).¹⁶ Given that CP/CPPS and IC/PBS are urogenital chronic pelvic pain syndromes (UCPPS) with similar presentations, psychosocial correlates and proposed etiology, and that gender differences have been demonstrated with respect to the ways in which men and women use and provide social support, investigation of spousal responses to patient pain behaviour in CP/CPPS is theoretically and clinically warranted.^17,18 The aim of the present study was to examine whether spousal responses to male pain behavior influenced the association between pain and patient adjustment (i.e., physical QoL, mental QoL, depressive symptoms, and disability) in CP/CPPS. It was hypothesized that, similar to women with IC/PBS, distracting spouse responses would diminish the negative impact of pain on mental QoL.

MATERIALS AND METHODS

One hundred eighty-eight men diagnosed with CP/CPPS were recruited from an existing cohort enrolled in the NIH Chronic Prostatitis Cohort (CPC) Study from 7 North American tertiary care clinical centers (6 U.S., 1 Canada). All participants were recruited by letter invitation after approval from the respective ethics boards. Adult men with a clinical diagnosis of CP/CPPS were identified as eligible for participation during their routine clinical care. The Multidimensional Pain Inventory (MPI), used to assess psychosocial variables associated with pain, consists of 52-items distributed in three sections.¹⁹ For the current study, only the section assessing spouse responses to communications of pain as identified by the CP/CPPS patient was used. This section consists of 14 observable behaviors that may be exhibited by spouses in response to pain behaviors. Respondents are asked to rate each item from 0 (never) to 6 (very often) how often their significant other responds in that manner to expressions of pain. Kerns et al. report internal consistency of .78 for the solicitous responses scale, with a two-week test-retest reliability coefficient of .89.¹⁹ The Center for Epidemiological Studies Depression Scale (CES-D) was used to assess depressive symptoms, and contains 20 items assessing depressive symptoms within the last week.²⁰ Scores above 16 suggest clinical depression. Radloff reported internal consistency for the general population and patient samples of .84–.90 and test-retest reliability of .48–.67.²⁰ The CES-D correlates highly with clinician rating measures of depression, such as the Hamilton Depression Rating Scale and global ratings and has better sensitivity in chronic pain patients than the Beck Depression Inventory (BDI)(81.8% vs. 68.2%). ^20,21 The Short-Form McGill Pain Questionnaire (SF-MPQ) consists of 15 word descriptors of pain that assess sensory and affective qualities of pain and overall pain intensity.²² Eleven descriptors represent the sensory dimension of pain experience (e.g., throbbing, stabbing, gnawing) and four descriptors represent the affective dimension (e.g., tiring-exhausting, fearful). Each descriptor is rated on a 4-point intensity scale ranging from 0 (none) to 3 (severe) and are summed to provide the Pain Rating Index Total (PRIT). Higher scores on the PRIT indicate greater overall pain. The SF-MPQ is a reliable and valid measure, commonly used in clinical pain applications.²² Wright and colleagues report internal consistencies of .70 for both subscales. ²³ The Pain Disability Index (PDI) assesses the extent to which chronic pain interferes with a person’s ability to engage in various life activities.²⁴ For each of seven categories of life activity (Family/Home Responsibility, Recreation, Social Activity, Occupation, Sexual Behaviour, Self-Care, and Life Support Activity), patients are asked to rate their level of disability on a numeric rating scale ranging from 0 (no disability) to 10 (total disability).²⁵ Higher scores on the PDI indicate higher pain-related disability and patients with high PDI scores report more psychological distress, more pain, and more restriction of activities than patients with low PDI scores. Internal consistency of the PDI is reported at .86 demonstrating that the PDI has high internal consistency.²⁵ Health related Quality of life was assessed using the Medical Outcomes Study Short Form 12 (SF-12).²⁶ Using twelve items, two SF-12 subscales can be computed; the Physical Component Summary (SF12-PCS) and the Mental Component Summary (SF12-MCS). The SF-12 is a generic measure and does not target a specific age or disease group. The mean is set at 50 (range 0–100; higher scores indicate better QOL) for both the SF12-MCS and SF12-PCS scores in the general population.

Statistical Analyses

Data were analyzed using the repeated measures GLM procedure in SPSS 17 (Chicago, IL). The within subjects factor (or repeated measure) was outcome and consisted of physical QoL, mental QoL, disability, and depressive symptoms. Pain (SF-MPQ), solicitous, distracting and negative spouse responses were included in the model as covariates. Additionally, to determine whether or not any of the spousal responses moderated the relationship between patient pain and the outcome variables, the model included two-way interaction terms involving patient pain and for each of the spousal response variables (solicitous, distracting and negative). All covariates were centered to reduce collinearity with product terms.²⁷ Following repeated measures analysis, simple slopes analyses were conducted for each outcome variable significantly predicted by the pain interaction term(s). These separate analyses can be illustrated in a figure that superimposes the individual findings to provide a visual inspection of slope differences.

RESULTS

Men in this study had an average age of 48.4 (SD=10.8) with 76% reporting current employment, and 9.6 % reported education of less than high school, while 90.4% reported education of high school or more. Additionally, 93% of the sample (n=174) indicated that they were currently living with a spouse, while the remaining 7% (n=14) indicated that they were living with a partner/companion. Bivariate correlations between solicitous, negative and distracting spouse responses and patient adjustment variables were significant (Table 1), with few exceptions, and consistent with the literature. ^12–15 That is, spouse responses and pain were significantly associated with poorer physical and mental QoL, higher levels of disability, and higher levels of depressive symptoms. Of note, neither solicitous nor distracting spouse responses were significantly associated with mental QoL or depressive symptoms.

Table 1.

Bivariate Correlations Between Predictors and Outcome Variables

	Physical QoL	Mental QoL	PDI	CES-D
SR	−.24**	−.11	.25**	.08
DR	−.17*	−.11	.16*	.10
NR	−.26**	−.26**	.28**	.28**
SF-MPQ	−.41**	−.38**	.56**	.34**

Note. SR = Solicitous spouse responses to pain behaviour; DR = Distracting spouse responses to pain behaviour; NR = Negative spouse responses to pain behaviour; SF-MPQ = Short-Form McGill Pain Questionnaire; PDI = Pain Disability Index; CES-D = Centre for Epidemiological Studies Depression Scale.

^*p<.05.

^**p<.01.

Results of the repeated measures GLM indicated that there was a significant interaction among outcome, pain, and solicitous spousal responses (e.g., “tries to get me to rest”, “does some of my chores”) (p<.05), and among outcome, pain, and distracting spouse responses (e.g., “tries to get me involved in some activity”) (p<.05). The interaction among outcome, pain and negative spousal responses (e.g., “gets angry with me”), however, was not significant. Therefore, negative spousal responses did not influence the association between pain and outcome for men suffering from CP/CPPS. Parameter estimates indicated that the interaction between pain and solicitous spousal responses was only significant for the pain disability outcome (t(180) = 2.69, p<.05), and not physical or mental QoL (t(180) = −1.83, ns; t(180) = −0.43, ns), nor depressive symptoms (t(180) = −0.45, ns). Follow up simple slopes analyses then indicated that the relationship between pain and disability was stronger at high levels of solicitous spousal responses (β = 0.66, p<.05), than at moderate (β = 0.44, p<.05) levels of solicitous responses. The relationship between pain and disability at low levels of solicitous spouse responses, however, was not significant (β = 0.23, ns) (Figure 1). Similarly, parameter estimates indicated that the interaction between pain and distracting spouse responses was only significant in predicting disability (t(180) = −2.30, p<.05), and not physical or mental QoL (t(180) = 0.88, ns; t(180) = 1.40, ns), or depressive symptoms (t(180) = 0.09, ns). This interaction was such that the association between pain and disability was strongest at lower levels (β = 0.64, p<.05) of distracting responses than it was at moderate (β = 0.44, p<.05) and higher (β = 0.25, p<.05) levels of distracting responses (Figure 2). That is, solicitous spouse responses increased the negative impact of pain on disability, whereas distracting spouse responses decreased the negative impact of pain on disability.

Figure 1.

Relationship between pain and disability at different levels of solicitous spouse responses to pain behaviour.

Figure 2.

Relationship between pain and disability at different levels of distracting spouse responses to pain behaviour.

COMMENT

The main objective of this study was test if spousal responses to pain behaviour could positively affect the relationships between pain and outcomes of mental QoL, physical QoL, depressive symptoms, and disability. This was the first study to examine these associations in men with CP/CPPS. Interestingly, at higher levels of female spouse solicitousness (e.g., “tries to get me to rest”, “does some of my chores”), pain had a more negative impact on level of disability than at lower levels of spouse solicitousness for men with CP/CPPS. In fact, at lower levels of spousal solicitousness, pain was not significantly associated with disability. Such findings suggest that spouse solicitousness may exacerbate the negative impact of pain on disability for men with CP/CPPS. Spouses may respond solicitously as a reaction to the patient’s pain and level of disability (i.e., patients are physically incapable of completing certain tasks, and thus, require the help of their spouse). Alternatively, consistent with operant theories of pain, solicitous responding may help create or maintain the patient’s pain and disability by reinforcing pain behaviors.²⁸ Given the cross-sectional nature of this study, a conclusion of the direction of these relationships cannot be made and thus it is possible that both explanations may be equally valid.

Consistent with research on women with IC/PBS, it was hypothesized that distracting spouse responses would diminish the association between pain and mental QoL.¹⁶ The results were similar to this prediction, such that distracting spouse responses diminished the association between pain and disability. Perhaps men with CP/CPPS who are distracted from their pain, are able to continue with their voluntary and obligatory activities, and thus, the impact of pain on disability is diminished. It is possible that pain has a differential impact on mental QoL and disability across men and women with UCPPS, and thus, distracting spouse responses did not affect the relationship between pain and mental QoL in men with CP/CPPS. However, pain was equally associated with mental QoL and disability in both of our male and female samples with UCPPS. Research is clearly warranted to determine the exact mechanism by which spousal responses to pain can be beneficial for men and women with UCPSS.

Urologists can directly apply the results of this study into CP/CPPS management. Patients reporting high disability can be counseled to participate in as many activities of daily living as possible. It is also recommended that Urologists advocate that spouses encourage patients’ engagement in several group activities including exercise programs, including those they could attend together, which may act to increase feelings of support in the patient. Such physical engagement will also aid in patient distraction from pain. Urologists can also suggest simple pain distraction techniques, such as watching or listening to a media program, calling friends and discussing things other than pain, word puzzles, or participation in some form of hobby. Lastly, Urologists can suggest that the benefits of increased activity and social distraction from pain are best applied when used in combination, such as a group-walking program.

It must be noted that given the cross-sectional design of the present study, we cannot conclude causality. Further, as data were not stratified according to education, social and ethnic status, the current sample of men with CP/CPPS may not be representative of the larger CP/CPPS population. Additionally, this is the first study to examine these associations in men with CP/CPPS. Thus, replication with clinical samples from other cohorts or ethnicities would be useful. However, the current study remains an important contribution to the UCPPS literature, as it is a novel examination of biopsychosocial variables among men with CP/CPPS. The current research also supports the notion that spouse responses to pain behaviour may be differentially associated with patient adjustment in men and women with UCPPS. Results from the present study suggest that men with CP/CPPS may benefit from psychosocial interventions targeting spouses of men with CP/CPPS regarding responding to expressions of pain and its impact on level of disability.

Future studies should examine other sources of social support, and how support from other sources (e.g., healthcare system) may influence the relationship between pain and patient adjustment. Controlling for marital satisfaction is a consideration, with some evidence suggesting a relationship between marital satisfaction and disability, psychological distress, pain severity, and pain behaviors.¹¹ Perceptions of spousal responses to patients’ exhibiting positive behaviors (e.g., exercising, walking, or participating in an activity that is incompatible with the sick role) are suggested to have important associations with patient functioning, and remain another area of investigation.²⁹ Additionally, qualitative research suggests that spouse responses to pain behaviour could be described into other categories than those assessed by the MPI, including observe only (i.e., absence of overt behavioural responding), hostile solicitous (i.e., solicitousness with aggressive manner), and offer help (i.e., offer act of solicitousness, instead of just doing it).³⁰ Future investigations of these other types of spouse responses to pain behaviour would provide us a deeper understanding of the role of spouses in shaping patient adjustment to CP/CPPS. These investigations will be important for informing psychosocial interventions for men and women suffering from UCPPS.

CONCLUSIONS

It was found that greater solicitous responding by spouses exacerbated the negative impact of pain on disability, whereas higher levels of distracting responses had the opposite effect. This was the first study to examine such relations suggesting that men with CP/CPPS have differential associations compared to women suffering from IC/PBS. Further investigations are necessary to better understand how gender differences in social support impacts associations between pain and patient adjustment variables in UCPPS.

Appendix A

Chronic Prostatitis Collaborative Research Network (CPCRN) Study Group Northwestern University

Anthony J. Schaeffer, MD Principal Investigator (PI); Charles L. Bennett, MD, PhD; Wade Bushman, MD, PhD; Elizabeth A. Calhoun, PhD; Alisa Erika Koch, MD; Robert B. Nadler, MD; Mary Healy, RN; Marylin Dopona

Brigham and Women’s Hospital

Michael P. O’Leary, MD, MPH (PI); Debra Rhodes, MD: Judith Spolarich-Kroll, BA; Alex Adler

Massachusetts General Hospital

Mary McNaughton Collins, MD, MPH; Michael J. Barry, MD

Queen’s University

J. Curtis Nickel, MD (PI); Dean A. Tripp, PhD; Dale Ardern, RN; Janet Clark, ACP; Joseph Downey, MSc

Temple University

Michel A. Pontari, MD (PI); Michael R. Ruggieri, PhD; Linda Kish, BA; Sharon Filer-Maerten, BS

University of California, Los Angeles

Mark S. Litwin, MD, MPH Principal Investigator (PI); Scott I. Zeitlin, MD; Yining Xie, MD

University of Maryland

Richard B. Alexander, MD Principal Investigator (PI); Sathibalan Ponniah, PhD; Cindy S. Lowder, MS, RN; Kim Burton

University of Mississippi

Jackson E. Fowler, Jr, MD (PI); Rachael Tapley, RHIA; Anne Dautenhahn

Cleveland Clinic, Fort Lauderdale

Daniel Shoskes, MD (PI); Kim Thomas

Martin Luther King Hospital

Nand S. Datta, MD (PI); Mary Ellen Raimo; Kawajalen Mervin

University of Arizona

Craig V. Comiter, MD (PI); Pat Conrad

University of Pennsylvania School of Medicine

J. Richard Landis, PhD Principal Investigator (PI); Kathleen J. Propert, ScD; John T. Farrar, MD; Harold I. Feldman, MD, MS; Denise Cifelli, BS; Stephen Durborow, BS; Lori Fanelli, BA; Xueyou Hu, MS; Lee Randall, BA; Jill S. Knauss, MS; Randy Hildebrand, MS; Gina Norwood, BS; Marie Durborow; Christopher Helker, RN, MPH

The National Institute of Diabetes and Digestive and Kidney Disease (NIDDK)

John W. Kusek, PhD (Project Officer); Leroy M. Nyberg, PhD, MD