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Canadian Urological Association Journal logoLink to Canadian Urological Association Journal
. 2018 Feb 23;12(6):196–202. doi: 10.5489/cuaj.4876

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

R Christopher Doiron 1,✉, Dean A Tripp 1,2, Victoria Tolls 1, J Curtis Nickel 1
PMCID: PMC5994985  PMID: 29485036

Abstract

Introduction

Two 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.

Introduction

Prostatitis 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.10

Despite 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.14

It 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 presentation of CP/CPPS patients in a tertiary prostatitis clinic to determine changes in symptom patterns, UPOINT phenotype, and treatment modality trends over time.

Methods

Participants and study design

This study is a retrospective examination of a cohort of CP/ CPPS patients examined at a single outpatient clinic. The cohort was examined as part of a large, prospective clinical quality assurance database and was examined by a single urologist (JCN). The evaluation of this patient population has been described in previous publications.6 Data presented was collected from initial presentation between the years 1998–2014. This study was done under ongoing IRB approval for continued quality assurance with all patient data de-identified before analysis.

Measures

Data regarding the patients’ demographics, symptom duration, CPSI scores (pain, urinary, impact/quality of life [QoL]), and UPOINT scoring were collected through initial evaluations at the CP/CPPS outpatient clinic (UPOINT scoring was retrospective prior to 2009 and prospective from 2009). Data regarding treatments received, therefore, represent interventions prior to initial evaluation at CP/CPPS clinic and would have been administered by referring physicians. Data was examined first as an overall cohort and then over time in four separate cohorts ranging from 1998–2001, 2003–2005, 2006–2009, and 2010–2014.

Data analysis

Statistical analysis was completed using Microsoft Excel 2010 Data Analysis package and the online Social Science Statistics software (http://www.socscistatistics.com). Continuous variables (age and CPSI scores) were analyzed using ANOVA (using R version 3.3.1), with p<0.05 regarded as significant. Categorical variables (UPOINT, pain locations, and treatments) were analyzed using Chi-squared test for trend in proportions (using R version 3.3.1), with p<0.05 regarded as significant.

Results

Between the years of 1998–2014, 1349 patients with CP were evaluated at a single tertiary referral outpatient clinic. Of these, 39 patients were diagnosed with bacterial prostatitis (Category II) and were excluded from the current analysis. The remaining 1310 patients were given a diagnosis of Category III CP/CPPS. The majority of patients (n=804, 61.4%) were referred by a general practitioner, while 474 (36.2%) patients were referred by another urologist. Mean age of the 1310 CP/CPPS patients was 44.7 years (Table 1). Their mean CPSI pain, urination, QoL and total scores were 10.6, 4.8, 7.9, and 23.3, respectively (Table 1).

Table 1.

Age, CPSI scores, UPOINT analysis, pain locations, and treatments provided by referring physicians for 1310 CP/CPPS patients evaluated in a single outpatient clinic from 1998–2014

1998–2014
n=1310
 Age 44.7 (±13.3)
 CPSI pain 10.6 (±4.9)
 CPSI urination 4.8 (±3.1)
 CPSI QoL 7.9 (±3.1)
 CPSI total 23.3 (±9.0)
UPOINT
 U 941 (71.8%)
 P 361 (27.6%)
 O 660 (50.4%)
 I 440 (33.6%)
 N 402 (30.7%)
 T 644 (49.2%)
Pain location
 Perineum 788 (60.2%)
 Testicular 658 (50.2%)
 Tip of penis 441 (33.7%)
 Pubic/bladder 798 (60.9%)
 Urination 553 (42.2%)
 Ejaculation 615 (46.9%)
Treatment by referring physician*
 Alpha-blockers 806 (61.5%)
 Antidepressants 198 (15.1%)
 Quercetin 449 (34.3%)
 QUrol 115 (8.8%)
 Gabapentinoids 79 (6.0%)
 Acupuncture/acupressure 10 (0.8%)
 Physiotherapy 33 (2.5%)
 Antibiotics 293 (22.4%)
 Prostate massage 43 (3.3%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CPSI: Chronic Prostatitis Symptom Index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Overall, the most prevalent UPOINT domain was the urinary (U) domain (n=941, 71.8%), followed by organ-specific (O) (n=660, 50.4%), tenderness (T) (n=644, 49.2%), infection (I) (n=440, 33.6%), neurologic (N) (n=402, 30.7%), and psychosocial (P) (n=361, 27.6%) domains (Table 1). Positive reporting of the urinary domain was associated with a higher CPSI total score (25.8), higher CPSI urination score (6.3), more frequent penile tip pain (n=348, 37%), more frequent dysuria (n=454, 48.2%), and treatment with alpha-blockers (n=659, 70%) (Supplementary Table 1). Those patients who reported in the P domain were associated with a higher UPOINT total score (3.3) and were more commonly treated with antidepressants (n=105, 29.1%) and gabapentinoids (n=37, 10.2%) compared with the other domains (Supplementary Table 1).

An increased reporting of total UPOINT domains was associated with higher CPSI pain score (14.3), worse QoL (10.9), and higher total CPSI scores (31.4) (Supplementary Table 2). Pain location was not associated with severity of disease, nor was it associated with UPOINT domain or treatment modality (Supplementary Table 3).

An analysis of trends over time through examination of the four separate time cohorts revealed an increased prevalence of P domain (p=0.0009), O (p≤0.0001), and T (p≤0.0001) (Table 2). A decrease in the I domain (p≤0.0001) over time was also noted (Table 2). In terms of treatment modalities, there was an increased prevalence of use of alpha-blockers (p≤0.0001), neuromodulation (p≤0.0001), and phytotherapy (p=0.0001) with time, while the use of antibiotics — which ranged from 20.5–27.2% among the cohorts — did not change significantly with time (Table 2). There was little variation in age, CPSI scores, and pain locations over time.

Table 2.

Trends observed over time in 1310 CP/CPPS patients stratified by time of initial presentation to chronic prostatitis clinic

1998–2001 2002–2005 2006–2009 2010–2014 p
n=195 n=387 n=357 n=371
 Age 42.1 (±11.3) 44.9 (±12.3) 45.8 (±13.2) 44.9 (±15.3) 0.0185
 CPSI pain 11.1 (±4.6) 10.6 (±4.6) 10.2 (±5.1) 10.7 (±5.0) 0.2000
 CPSI urination 4.5 (±2.9) 5.1 (±3.0) 4.6 (±3.1) 5.0 (±3.3) 0.0564
 CPSI QoL 7.8 (±3.0) 7.7 (±3.0) 7.8 (±3.1) 8.2 (±3.2) 0.2272
 CPSI total 23.4 (±8.3) 23.4 (±8.8) 22.7 (±9.2) 23.8 (±9.3) 0.3599
UPOINT
 U 144 (73.8%) 291 (75.2%) 250 (70.0%) 256 (69.0%) 0.0636
 P 45 (23.1%) 94 (24.3%) 94 (26.3%) 128 (34.5%) 0.0009
 O 67 (34.4%) 175 (45.2%) 224 (62.7%) 194 (52.3%) <0.0001
 I 116 (59.5%) 140 (36.2%) 90 (25.2%) 94 (25.3%) <0.0001
 N 88 (45.1%) 115 (29.7%) 95 (26.6%) 104 (28.0%) 0.0003
 T 55 (28.2%) 173 (44.7%) 156 (43.7%) 260 (70.1%) <0.0001
Pain locations
 Perineum 138 (70.8%) 230 (59.4%) 210 (58.8%) 210 (56.6%) 0.0049
 Testicular 95 (48.7%) 215 (55.6%) 163 (45.7%) 185 (49.9%) 0.3924
 Tip of penis 57 (29.2%) 137 (35.4%) 115 (32.2%) 132 (35.6%) 0.3195
 Pubic/bladder 121 (62.1%) 246 (63.6%) 217 (60.8%) 214 (57.7%) 0.1456
 Dysuria 92 (47.2%) 165 (42.6%) 146 (40.9%) 150 (40.4%) 0.1368
 Ejaculation 104 (53.3%) 182 (47.0%) 165 (46.2%) 164 (44.2%) 0.0591
Treatment by referring physician*
 Alpha-blockers 64 (32.8%) 244 (63%) 263 (73.7%) 235 (63.3%) <0.0001
 Neuromodulation 16 (8.2%) 45 (11.6%) 79 (22.1%) 95 (25.6%) <0.0001
 Phytotherapy 62 (31.8%) 139 (35.9%) 204 (57.1%) 159 (42.9%) 0.0001
 Physiotherapy 13 (6.6%) 21 (5.4%) 13 (3.6%) 36 (9.7%) 0.1078
 Antibiotics 53 (27.2%) 82 (21.2%) 82 (23%) 76 (20.5%) 0.1759
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Discussion

We describe the change in specific CP/CPPS symptoms (CPSI scoring), clinical phenotypes (as expressed by UPOINT), and the correlation between these parameters over time in this retrospective study of 1310 CP/CPPS patients presenting to a single clinic over a 16-year period. The analysis confirmed that an increased number of UPOINT domains was associated with increased CPSI scores, as previously suggested by Shoskes et al.12 It further showed that referring physicians tailored treatments to clinical presentation before UPOINT was described. It appears that both before and after UPOINT introduction, physicians were treating patients with urinary symptoms (U domain) with alpha-blockers, using antidepressants with secondary pain modulation in patients with psychological problems (P domain), neuromodulatory medications (gabapentinoids) for neurogenic pain (N domain), and increasing use of physiotherapy for pelvic floor pain (T domain). Although many patients, particularly in the earlier cohorts, were identified with infection at some time in their past (I domain), our observation of a trend of less antibiotics being employed over time for these patients was compatible with increased understanding of the inappropriateness of antimicrobial therapy in the majority of CP/CPPS patients.

We were surprised that patient-identified pain locations (CPSI) did not necessarily correlate with total CPSI score, UPOINT domains, or treatment. This is in keeping with a large, multinational study of 1563 CP/CPPS patients by Wagenlehner et al,10 where they found that pain severity and frequency were more important than pain location. CP/CPPS is a heterogeneous disease, and pain location may not be overly useful in helping direct treatment, i.e., pain is pain, regardless of location.

We observed a number of trends in UPOINT domain prevalence over time, specifically an increase over time in the P and T domains. This likely does not reflect a change in patient population presenting characteristics, but rather our referring physicians’ understanding of the importance of identifying these domains for better treatment outcomes. In fact, it appears that the patients are not changing over time. The age, CPSI score (and pain, urinary, and impact/QoL subscores), and pain locations did not appreciably change from 1998–2014.

The low use of antibiotics (22.4% overall) was interesting to note, given that current guidelines, acknowledging the generally poor evidence for use in Category III CP/CPPS patients, recommend or suggest consideration of a course of antimicrobial therapy as a first-line treatment option.15–17 Although no trends in antibiotic use were seen over time, their relatively low usage as a treatment modality may reflect an increased attention to antimicrobial stewardship among general practitioners. This is in contrast to the increased trend over time in usage of neuromodulation and phytotherapy. This could similarly reflect an increased comfort among general practitioners with neuromodulatory medication prescribing, while increased use of phytotherapy may illustrate a patient population increasingly interested in seeking alternative health strategies and natural products.

While it is encouraging to note that referring physicians appeared to be embracing specific treatments towards identified phenotypes prior to referral to our specialty clinic, it is difficult to know if this has made a significant difference to patient outcome. Certainly, even with the described treatment identified in this referral population, baseline symptoms were similar to those of patients being enrolled in clinical treatment trials.11 Further research will attempt to determine whether identification of specific phenotypes, along with assessment of failed therapies, resulted in therapeutic strategies that provided favourable patient outcomes by examining this same patient population one year after the first clinic assessment described in the present study.

Conclusion

The increased recognition of the UPOINT P and T domains by referring physicians may be responsible for the changing clinical face of CP/CPPS. This increased recognition of specific domains coincides with increased use of their associated therapies. However, there was little change in pain or urinary symptom patterns and QoL over the 16 years of assessment. The more things “appear” to change, the more they stay the same.

Supplementary materials

Supplementary Table 1.

UPOINT associations in 1310 CP/CPPS patients treated at a single outpatient clinic from 1998–2014

U P O I N T
n=941 n=361 n=660 n=440 n=402 n=644
 Age 44.8 (±13.3) 44.1 (±13.0) 44.8 (±13.4) 45.9 (±12.4) 43.5 (±12.6) 43.6 (±13.5)
 CPSI pain 11.2 (±4.8) 10.8 (±5.1) 11.0 (±4.8) 10.5 (±4.7) 11.0 (±4.9) 11.5 (±4.7)
 CPSI urination 6.3 (±2.3) 5.2 (±3.0) 4.9 (±3.2) 4.5 (±3.1) 5.1 (±3.1) 5.1 (±3.2)
 CPSI QoL 8.2 (±2.9) 8.4 (±3.1) 8.1 (±3.1) 7.8 (±3.0) 7.9 (±3.2) 8.3 (±8.8)
 CPSI total 25.8 (±8.2) 24.4 (±9.1) 24.1 (±9.0) 22.8 (±8.8) 24.0 (±9.3) 24.9 (±8.0)
Pain location
 Perineum 575 (61.1%) 223 (61.8%) 418 (63.3%) 274 (62.3%) 262 (65.2%) 443 (68.8%)
 Testicular 503 (53.5%) 191 (52.9%) 344 (52.1%) 217 (49.3%) 223 (55.5%) 356 (55.3%)
 Tip of penis 348 (37.0%) 113 (31.3%) 226 (34.2%) 153 (34.8%) 132 (32.8%) 225 (34.9%)
 Pubic/bladder 629 (66.8%) 226 62.6%) 416 (63.0%) 255 (58.0%) 269 (66.9%) 423 (65.7%)
 Dysuria 454 (48.2%) 156 (43.2%) 294 (44.5%) 194 (44.1%) 182 (45.3%) 293 (45.5%)
 Ejaculation 473 (50.3%) 177 (49.0%) 316 (47.9%) 218 (49.5%) 211 (52.5%) 324 (50.3%)
Treatment by referring physician*
 Alpha-blockers 659 (70.0%) 235 (65.1%) 445 (67.4%) 240 (54.5%) 247 (61.4%) 422 (65.5%)
 Antidepressants 150 (15.9%) 105 (29.1%) 109 (16.5%) 54 (12.3%) 65 (16.2%) 121 (18.8%)
 Quercetin 304 (32.3%) 115 (31.9%) 244 (37.0%) 158 (35.9%) 151 (37.6%) 227 (35.2%)
 QUrol 87 (9.2%) 41 (11.4%) 57 (8.6%) 25 (5.7%) 32 (8.0%) 68 (10.6%)
 Gabapentinoids 61 (6.5%) 37 (10.2%) 43 (6.5%) 19 (4.3%) 20 (5.0%) 52 (8.1%)
 Acupuncture 8 (0.9%) 8 (2.2%) 5 (0.8%) 3 (0.7%) 2 (0.5%) 5 (0.8%)
 Physiotherapy 20 (2.1%) 13 (3.6%) 14 (2.1%) 6 (1.4%) 9 (2.2%) 27 (4.2%)
 Antibiotics 216 (23.0%) 72 (19.9%) 167 (25.3%) 113 (25.7%) 100 (24.9%) 144 (22.4%)
 Prostate massage 22 (2.3%) 10 (2.8%) 24 (3.6%) 24 (5.5%) 12 (3.0%) 18 (2.8%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Supplementary Table 2.

Associations of number of UPOINT domains in 1310 CP/CPPS patients treated at a single outpatient clinic from 1998–2014

1 2 3 4 5 6
n=249 n=408 n=368 n=192 n=39 n=7
 Age 45.3 (±14.1) 44.5 (±12.7) 44.3 (±13.2) 44.7 (±13.1) 43.8 (±13.8) 49.4 (±3.3)
 CPSI pain 9.2 (±4.6) 10.6 (±4.6) 11.1 (±4.9) 11.6 (±5.2) 11.8 (±4.3) 14.3 (±2.8)
 CPSI urination 3.4 (±2.9) 4.6 (±3.1) 5.7 (±3.0) 6.3 (±2.5) 5.4 (±2.8) 6.3 (±1.1)
 CPSI QoL 6.9 (±3.1) 7.9 (±3.0) 8.3 (±3.0) 8.4 (±3.1) 8.4 (±2.9) 10.9 (±1.1)
 CPSI total 19.5 (±8.2) 23.2 (±8.4) 25.1 (±8.8) 26.4 (±9.1) 25.6 (±8.1) 31.4 (±6.0)
UPOINT
 U 118 (47.4%) 287 (70.3%) 311 (84.5%) 181 (94.3%) 35 (89.7%) 7 (100%)
 P 11 (4.4%) 63 (15.4%) 128 (34.8%) 119 (62.0%) 33 (84.6%) 7 (100%)
 O 45 (18.1%) 169 (41.4%) 252 (68.5%) 148 (77.1%) 37 (94.9%) 7 (100%)
 I 44 (17.7%) 129 (31.6%) 143 (38.9%) 86 (44.8%) 29 (74.4%) 7 (100%)
 N 33 (13.3%) 103 (25.2%) 123 (33.4%) 106 (55.2%) 27 (69.2%) 7 (100%)
 T 62 24.9%) 160 (39.2%) 227 (61.7%) 153 (79.7%) 34 (87.2%) 7 (100%)
Pain locations
 Perineum 125 (50.2%) 243 (59.6%) 241 (65.5%) 123 (64.1%) 30 (76.9%) 4 (57.1%)
 Testicular 108 (43.4) 192 (47.1%) 203 (55.2%) 104 (54.2%) 24 (61.5%) 5 (71.4%)
 Tip of penis 74 (29.7%) 146 (35.8%) 128 (34.8%) 65 (33.9%) 16 (41.0%) 1 (14.3%)
 Pubic/bladder 130 (52.2%) 242 (59.3%) 243 (66.0%) 132 (68.8%) 24 (61.5%) 7 (100%)
 Dysuria 85 (34.1%) 166 (40.7%) 177 (48.1%) 91 (47.4%) 23 (59.0%) 3 (42.9%)
 Ejaculatory 101 (40.6%) 185 45.3%) 187 (50.8%) 106 (55.2%) 18 (46.2%) 4 (57.1%)
Treatment by referring physician*
 Alpha-blockers 128 (51.4%) 236 (57.8%) 265 (72.0%) 125 (65.1%) 30 (76.9%) 6 (85.7%)
 Antidepressants 23 (9.2%) 53 (13.0%) 70 (19.0%) 37 (19.3%) 12 (30.8%) 2 (28.6%)
 Quercetin 83 (33.3%) 139 (34.1%) 137 (37.2%) 62 (32.3%) 11 (28.2%) 3 (42.9%)
 QUrol 18 (7.2%) 33 (8.1%) 38 (10.3%) 18 (9.4%) 5 (12.8%) 0 (0%)
 Gabapentinoids 13 (5.2%) 17 (4.2%) 25 (6.8%) 16 (8.3%) 5 (12.8%) 1 (14.3%)
 Acupuncture 1 (0.4%) 2 (0.5%) 3 (0.8%) 3 (1.6%) 1 (2.6%) 0 (0%)
 Physiotherapy 6 (2.4%) 8 (2.0%) 9 (2.4%) 7 (3.6%) 1 (2.6%) 0 (0%)
 Antibiotics 48 (19.3%) 98 (24.0%) 84 (22.8%) 48 (25.0%) 8 (20.5%) 2 (28.6%)
 Prostate massage 8 (3.2%) 19 (4.7%) 10 (2.7%) 5 (2.6%) 1 (2.6%) 0 (0%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Supplementary Table 3.

Associations of pain locations in 1310 CP/CPPS patients treated at a single outpatient clinic from 1998–2014

Perineum pain Testicular pain Tip of penis pain Pubic/bladder pain Dysuria Ejaculatory pain
n=788 n=658 n=441 n=798 n=553 n=615
 Age 43.9 (±13.0) 43.9 (±12.8) 44.4 (±13.8) 44.1 (±13.6) 44.5 (±13.6) 42.8 (±12.6)
 CPSI pain 12.3 (±3.9) 12.8 (±3.7) 13.1 (±3.7) 12.4 (±3.8) 13.0 (±3.8) 12.8 (±3.8)
 CPSI urination 5.1 (±3.1) 5.3 (±3.1) 5.6 (±3.1) 5.5 (±3.0) 5.9 (±3.0) 5.4 (±3.1)
 CPSI QoL 8.6 (±2.7) 8.7 (±2.7) 8.9 (±2.4) 8.8 (±2.6) 8.8 (±2.6) 8.8 (±2.6)
 CPSI total 26.0 (±7.8) 26.9 (±7.5) 27.6 (±7.2) 26.7 (±7.4) 27.6 (±7.5) 27.0 (±7.5)
UPOINT
 U 575 (73.0%) 503 (76.4%) 348 (78.9%) 629 (78.8%) 454 (82.1%) 473 (76.9%)
 P 223 (28.3%) 191 (29.0%) 113 (25.6%) 226 (28.3%) 156 (28.2%) 177 (28.2%)
 O 418 (53.0%) 344 (52.3%) 226 (51.2%) 416 (52.1%) 294 (53.2%) 316 (51.4%)
 I 274 (34.8%) 217 (33.0%) 153 (34.7%) 255 (32.0%) 194 (35.1%) 218 (35.4%)
 N 262 (33.2%) 223 (33.9%) 132 (29.9%) 269 (33.7%) 182 (32.9%) 211 (34.3%)
 T 443 (56.2%) 356 (54.1%) 225 (51.0%) 423 (53.0%) 293 (53.0%) 324 (52.7%)
Pain locations
 Perineum 788 (100%) 479 (72.8%) 296 (67.1%) 524 65.7%) 362 (65.5%) 424 (68.9%)
 Testicular 479 (60.8%) 658 (100%) 257 (58.3%) 483 (60.5%) 323 (58.4%) 359 (58.4%)
 Tip of penis 296 (37.6%) 257 (58.3%) 441 (100%) 308 (38.6%) 280 (50.6%) 263 (42.8%)
 Pubic/bladder 524 (66.5%) 483 (73.4%) 308 (69.8%) 798 (100%) 398 (72.0%) 418 (68.0%)
 Dysuria 362 (45.9%) 323 (49.1%) 280 (63.5%) 398 (49.9%) 553 (100%) 347 (56.4%)
 Ejaculatory 424 (53.8%) 359 (54.6%) 263 (59.6%) 418 (52.4%) 347 (62.7%) 615 (100%)
Treatment by referring physician*
 Alpha-blockers 502 (63.7%) 412 (62.6%) 303 (68.7%) 529 (66.3%) 386 (69.8%) 402 (65.4%)
 Antidepressants 136 (17.3%) 108 (16.4%) 72 (16.4%) 140 (17.5%) 98 (17.7%) 103 (16.7%)
 Quercetin 311 (39.5%) 242 (36.8%) 168 (38.1%) 298 (37.3%) 210 (38.0%) 239 (38.9%)
 QUrol 77 (9.8%) 59 (9.0%) 51 (11.6%) 71 (8.9%) 53 (9.6%) 62 (10.1%)
 Gabapentinoids 55 (7.0%) 49 (7.4%) 35 (7.9%) 55 (6.9%) 44 (8.0%) 43 (7.0%)
 Acupuncture 7 (0.9%) 4 (0.6%) 2 (0.5%) 6 (0.8%) 4 (0.7%) 6 (1.0%)
 Physiotherapy 27 (3.4%) 22 (3.3%) 17 (3.9%) 28 (3.5%) 19 (3.4%) 14 (2.3%)
 Antibiotics 183 (23.2%) 142 (21.6%) 88 (20.0%) 179 (22.4%) 121 (21.9%) 138 (22.4%)
 Prostate massage 35 (4.4%) 22 (3.3%) 17 (3.9%) 22 (2.8%) 20 (3.6%) 18 (2.9%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Acknowledgements

Dr. Nickel is supported by grants from the CIHR and NIH/NIDDK.

Footnotes

Competing interests: Dr. Nickel has been a consultant for Astellas, Auxillium, Eli Lilly, Farr Labs, Ferring, GSK, Pfizer, Redleaf Pharma, Taris Biomedical, Tribute, and Trillium Therapeutics; a lecturer for Astellas and Eli Lilly; and has participated in clinical trials supported by Eli Lilly, GSK, J&J, Pfizer, and Taris Biomedical. The remaining authors report no competing personal or financial interests related to this work.

This paper has been peer-reviewed.

References

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table 1.

UPOINT associations in 1310 CP/CPPS patients treated at a single outpatient clinic from 1998–2014

U P O I N T
n=941 n=361 n=660 n=440 n=402 n=644
 Age 44.8 (±13.3) 44.1 (±13.0) 44.8 (±13.4) 45.9 (±12.4) 43.5 (±12.6) 43.6 (±13.5)
 CPSI pain 11.2 (±4.8) 10.8 (±5.1) 11.0 (±4.8) 10.5 (±4.7) 11.0 (±4.9) 11.5 (±4.7)
 CPSI urination 6.3 (±2.3) 5.2 (±3.0) 4.9 (±3.2) 4.5 (±3.1) 5.1 (±3.1) 5.1 (±3.2)
 CPSI QoL 8.2 (±2.9) 8.4 (±3.1) 8.1 (±3.1) 7.8 (±3.0) 7.9 (±3.2) 8.3 (±8.8)
 CPSI total 25.8 (±8.2) 24.4 (±9.1) 24.1 (±9.0) 22.8 (±8.8) 24.0 (±9.3) 24.9 (±8.0)
Pain location
 Perineum 575 (61.1%) 223 (61.8%) 418 (63.3%) 274 (62.3%) 262 (65.2%) 443 (68.8%)
 Testicular 503 (53.5%) 191 (52.9%) 344 (52.1%) 217 (49.3%) 223 (55.5%) 356 (55.3%)
 Tip of penis 348 (37.0%) 113 (31.3%) 226 (34.2%) 153 (34.8%) 132 (32.8%) 225 (34.9%)
 Pubic/bladder 629 (66.8%) 226 62.6%) 416 (63.0%) 255 (58.0%) 269 (66.9%) 423 (65.7%)
 Dysuria 454 (48.2%) 156 (43.2%) 294 (44.5%) 194 (44.1%) 182 (45.3%) 293 (45.5%)
 Ejaculation 473 (50.3%) 177 (49.0%) 316 (47.9%) 218 (49.5%) 211 (52.5%) 324 (50.3%)
Treatment by referring physician*
 Alpha-blockers 659 (70.0%) 235 (65.1%) 445 (67.4%) 240 (54.5%) 247 (61.4%) 422 (65.5%)
 Antidepressants 150 (15.9%) 105 (29.1%) 109 (16.5%) 54 (12.3%) 65 (16.2%) 121 (18.8%)
 Quercetin 304 (32.3%) 115 (31.9%) 244 (37.0%) 158 (35.9%) 151 (37.6%) 227 (35.2%)
 QUrol 87 (9.2%) 41 (11.4%) 57 (8.6%) 25 (5.7%) 32 (8.0%) 68 (10.6%)
 Gabapentinoids 61 (6.5%) 37 (10.2%) 43 (6.5%) 19 (4.3%) 20 (5.0%) 52 (8.1%)
 Acupuncture 8 (0.9%) 8 (2.2%) 5 (0.8%) 3 (0.7%) 2 (0.5%) 5 (0.8%)
 Physiotherapy 20 (2.1%) 13 (3.6%) 14 (2.1%) 6 (1.4%) 9 (2.2%) 27 (4.2%)
 Antibiotics 216 (23.0%) 72 (19.9%) 167 (25.3%) 113 (25.7%) 100 (24.9%) 144 (22.4%)
 Prostate massage 22 (2.3%) 10 (2.8%) 24 (3.6%) 24 (5.5%) 12 (3.0%) 18 (2.8%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Supplementary Table 2.

Associations of number of UPOINT domains in 1310 CP/CPPS patients treated at a single outpatient clinic from 1998–2014

1 2 3 4 5 6
n=249 n=408 n=368 n=192 n=39 n=7
 Age 45.3 (±14.1) 44.5 (±12.7) 44.3 (±13.2) 44.7 (±13.1) 43.8 (±13.8) 49.4 (±3.3)
 CPSI pain 9.2 (±4.6) 10.6 (±4.6) 11.1 (±4.9) 11.6 (±5.2) 11.8 (±4.3) 14.3 (±2.8)
 CPSI urination 3.4 (±2.9) 4.6 (±3.1) 5.7 (±3.0) 6.3 (±2.5) 5.4 (±2.8) 6.3 (±1.1)
 CPSI QoL 6.9 (±3.1) 7.9 (±3.0) 8.3 (±3.0) 8.4 (±3.1) 8.4 (±2.9) 10.9 (±1.1)
 CPSI total 19.5 (±8.2) 23.2 (±8.4) 25.1 (±8.8) 26.4 (±9.1) 25.6 (±8.1) 31.4 (±6.0)
UPOINT
 U 118 (47.4%) 287 (70.3%) 311 (84.5%) 181 (94.3%) 35 (89.7%) 7 (100%)
 P 11 (4.4%) 63 (15.4%) 128 (34.8%) 119 (62.0%) 33 (84.6%) 7 (100%)
 O 45 (18.1%) 169 (41.4%) 252 (68.5%) 148 (77.1%) 37 (94.9%) 7 (100%)
 I 44 (17.7%) 129 (31.6%) 143 (38.9%) 86 (44.8%) 29 (74.4%) 7 (100%)
 N 33 (13.3%) 103 (25.2%) 123 (33.4%) 106 (55.2%) 27 (69.2%) 7 (100%)
 T 62 24.9%) 160 (39.2%) 227 (61.7%) 153 (79.7%) 34 (87.2%) 7 (100%)
Pain locations
 Perineum 125 (50.2%) 243 (59.6%) 241 (65.5%) 123 (64.1%) 30 (76.9%) 4 (57.1%)
 Testicular 108 (43.4) 192 (47.1%) 203 (55.2%) 104 (54.2%) 24 (61.5%) 5 (71.4%)
 Tip of penis 74 (29.7%) 146 (35.8%) 128 (34.8%) 65 (33.9%) 16 (41.0%) 1 (14.3%)
 Pubic/bladder 130 (52.2%) 242 (59.3%) 243 (66.0%) 132 (68.8%) 24 (61.5%) 7 (100%)
 Dysuria 85 (34.1%) 166 (40.7%) 177 (48.1%) 91 (47.4%) 23 (59.0%) 3 (42.9%)
 Ejaculatory 101 (40.6%) 185 45.3%) 187 (50.8%) 106 (55.2%) 18 (46.2%) 4 (57.1%)
Treatment by referring physician*
 Alpha-blockers 128 (51.4%) 236 (57.8%) 265 (72.0%) 125 (65.1%) 30 (76.9%) 6 (85.7%)
 Antidepressants 23 (9.2%) 53 (13.0%) 70 (19.0%) 37 (19.3%) 12 (30.8%) 2 (28.6%)
 Quercetin 83 (33.3%) 139 (34.1%) 137 (37.2%) 62 (32.3%) 11 (28.2%) 3 (42.9%)
 QUrol 18 (7.2%) 33 (8.1%) 38 (10.3%) 18 (9.4%) 5 (12.8%) 0 (0%)
 Gabapentinoids 13 (5.2%) 17 (4.2%) 25 (6.8%) 16 (8.3%) 5 (12.8%) 1 (14.3%)
 Acupuncture 1 (0.4%) 2 (0.5%) 3 (0.8%) 3 (1.6%) 1 (2.6%) 0 (0%)
 Physiotherapy 6 (2.4%) 8 (2.0%) 9 (2.4%) 7 (3.6%) 1 (2.6%) 0 (0%)
 Antibiotics 48 (19.3%) 98 (24.0%) 84 (22.8%) 48 (25.0%) 8 (20.5%) 2 (28.6%)
 Prostate massage 8 (3.2%) 19 (4.7%) 10 (2.7%) 5 (2.6%) 1 (2.6%) 0 (0%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

Supplementary Table 3.

Associations of pain locations in 1310 CP/CPPS patients treated at a single outpatient clinic from 1998–2014

Perineum pain Testicular pain Tip of penis pain Pubic/bladder pain Dysuria Ejaculatory pain
n=788 n=658 n=441 n=798 n=553 n=615
 Age 43.9 (±13.0) 43.9 (±12.8) 44.4 (±13.8) 44.1 (±13.6) 44.5 (±13.6) 42.8 (±12.6)
 CPSI pain 12.3 (±3.9) 12.8 (±3.7) 13.1 (±3.7) 12.4 (±3.8) 13.0 (±3.8) 12.8 (±3.8)
 CPSI urination 5.1 (±3.1) 5.3 (±3.1) 5.6 (±3.1) 5.5 (±3.0) 5.9 (±3.0) 5.4 (±3.1)
 CPSI QoL 8.6 (±2.7) 8.7 (±2.7) 8.9 (±2.4) 8.8 (±2.6) 8.8 (±2.6) 8.8 (±2.6)
 CPSI total 26.0 (±7.8) 26.9 (±7.5) 27.6 (±7.2) 26.7 (±7.4) 27.6 (±7.5) 27.0 (±7.5)
UPOINT
 U 575 (73.0%) 503 (76.4%) 348 (78.9%) 629 (78.8%) 454 (82.1%) 473 (76.9%)
 P 223 (28.3%) 191 (29.0%) 113 (25.6%) 226 (28.3%) 156 (28.2%) 177 (28.2%)
 O 418 (53.0%) 344 (52.3%) 226 (51.2%) 416 (52.1%) 294 (53.2%) 316 (51.4%)
 I 274 (34.8%) 217 (33.0%) 153 (34.7%) 255 (32.0%) 194 (35.1%) 218 (35.4%)
 N 262 (33.2%) 223 (33.9%) 132 (29.9%) 269 (33.7%) 182 (32.9%) 211 (34.3%)
 T 443 (56.2%) 356 (54.1%) 225 (51.0%) 423 (53.0%) 293 (53.0%) 324 (52.7%)
Pain locations
 Perineum 788 (100%) 479 (72.8%) 296 (67.1%) 524 65.7%) 362 (65.5%) 424 (68.9%)
 Testicular 479 (60.8%) 658 (100%) 257 (58.3%) 483 (60.5%) 323 (58.4%) 359 (58.4%)
 Tip of penis 296 (37.6%) 257 (58.3%) 441 (100%) 308 (38.6%) 280 (50.6%) 263 (42.8%)
 Pubic/bladder 524 (66.5%) 483 (73.4%) 308 (69.8%) 798 (100%) 398 (72.0%) 418 (68.0%)
 Dysuria 362 (45.9%) 323 (49.1%) 280 (63.5%) 398 (49.9%) 553 (100%) 347 (56.4%)
 Ejaculatory 424 (53.8%) 359 (54.6%) 263 (59.6%) 418 (52.4%) 347 (62.7%) 615 (100%)
Treatment by referring physician*
 Alpha-blockers 502 (63.7%) 412 (62.6%) 303 (68.7%) 529 (66.3%) 386 (69.8%) 402 (65.4%)
 Antidepressants 136 (17.3%) 108 (16.4%) 72 (16.4%) 140 (17.5%) 98 (17.7%) 103 (16.7%)
 Quercetin 311 (39.5%) 242 (36.8%) 168 (38.1%) 298 (37.3%) 210 (38.0%) 239 (38.9%)
 QUrol 77 (9.8%) 59 (9.0%) 51 (11.6%) 71 (8.9%) 53 (9.6%) 62 (10.1%)
 Gabapentinoids 55 (7.0%) 49 (7.4%) 35 (7.9%) 55 (6.9%) 44 (8.0%) 43 (7.0%)
 Acupuncture 7 (0.9%) 4 (0.6%) 2 (0.5%) 6 (0.8%) 4 (0.7%) 6 (1.0%)
 Physiotherapy 27 (3.4%) 22 (3.3%) 17 (3.9%) 28 (3.5%) 19 (3.4%) 14 (2.3%)
 Antibiotics 183 (23.2%) 142 (21.6%) 88 (20.0%) 179 (22.4%) 121 (21.9%) 138 (22.4%)
 Prostate massage 35 (4.4%) 22 (3.3%) 17 (3.9%) 22 (2.8%) 20 (3.6%) 18 (2.9%)
Open in a new tab
*

Treatment provided by referring physician prior to or at time of evaluation of presentation to chronic prostatitis clinic.

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; CPSI: chronic prostatitis symptom index; QoL: quality of life; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurogenic (N), and tenderness (T).

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