The clinical syndomes called "prostatitis" are in fact many potentially overlapping illnesses of different causes and behaviors. Is there any system that would help doctors with prostatitis treatment selection such that this maximizes therapeutic effect?

In a study published in Urology, UPOINT, a clinical algorithm based upon the specific bedside findings relating to such measures as depression, infection, and/or pelvic muscle trigger points was tested.

The study relied upon 100 patients with an average age of 46 years and a median disease of 2 years. 73 patients had 3 or 4 coexisting types of complaints. 83 patients had had 3 or 4 therapies before enrolling in the study. There were the following numbers of specific types of prostatitis complaints:

• 59 Urinary
• 37 Psychosocial
• 70 Organ-specific
• 16 Infection
• 39 Neuromuscular/Systemic
• 64 Tenderness of muscles

The study defined a 6-point drop in the Chronic Prostatitis Symptom Index (CPSI) score as its outcome measure and found that the likelihood of reaching this outcome was not different across the number of complaints. Using this definition, the study found that treatment as directed by the algorithm failed to meet the specified outcome in 16% of the patients. Overall, the average change in the CPSI score was a drop from 25 before treatment to 13 after treatment. This drop compares favorably with historical comparisons of different patients in different trials.

The study suffers from a number of limitations, not least of which is lack of a placebo arm. This is important because other prostatitis treatment studies have shown mild symptomatic reductions in placebo groups, too. Given the relatively modest study outcome — 6-point drop in the CPSI — it may well be that a portion of the observed response was due to placebo effect. Other limitations include the fact that many of the patients were from remote locations and may have been lost to followup and that the algorithm is in its first iteration and may not yet be fully optimized.

The study raises questions:

• Do patients define outcomes the same way: Is a 6-point drop satisfying to most patients?
• What happens to patients who fail treatments by the standards defined here or by their own?

Overall, the study is aimed at a very important clinical obective: Targeting treatments. It is clear that prostatitis treatments have historically been very poorly targeted. For example, antibiotics are clearly used in excess relative to their clinical effectiveness. Moreover, patients suffer side effects from treatments that bring them no relief. As such, the approach outlined in this study has great merit and one can only hope that it will achieve the goal of helping doctors to more precisely target treatments for chronic prostatitis. 

Click below to hear Dr. Shoskes discuss the treatment algorithm; the video aired on http://cleveland.com on August 17.

Pelvic pain disorders in men: Part II