Shoskes article on IC/CPPS phenotyping

[kevin]

Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes.
Shoskes DA, Nickel JC, Rackley RR, Pontari MA.

Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA.

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.

http://pubmed.ncbi.nlm.nih.gov/18645581

This is quite a neat article. I agree that a better classification system for IC/CPPS patients is needed. Hopefully this phenotyping system will be adopted by clinicians and researchers so that treatments can be better tailored to the individual. Additionally, it might be easier to find an IC/CPPS biomarker if we study more homogeneous subgroups of patients.

By the way, the "UCPPS" name looks like it may be gaining momentum.

[webslave]

Dr Shoskes is one of the few innovators on the CPPS scene, so I always await his new ideas with anticipation and pleasure.

From the paper, the clinical phenotype system for UCPPS contains 6 domains scored as positive or negative based on clinical criteria. The mnemonic is UPOINT:

1. Urinary symptoms
2. Psychosocial (Depression, Catastrophizing)
3. Organ specific (evidence of prostate or bladder pathology: hematospermia, heavy inflammation, Hunner'c ulcers etc)
4. Infection (atypical organisms in bladder in IC, bugs in EPS only)
5. Neurologic (pain outside the pelvis, CFS, IBD, Fibromyalgia)
6. Tenderness of pelvic muscles

Phenotype classification is great, and may be all we can hope for if no biomarkers are found that reliably indicate CPPS. Not sure the infection thing belongs in there, but I know he has published supportive papers showing that small minority have concurrent infections, so it's understandable.

According to this way of thinking, once a patient is phenotypically classified, they can then receive multimodal therapy based on the phenotype. One patient may need stress reduction and trigger point massage. Another may need tamsulosin, quercetin and Lyrica. A third may need all of the above.

Of course, the effectiveness of that will have to be shown. I'm skeptical that it'll work out neatly, but always ready to be pleasantly surprised.

The NIDDK has already said that the first mission of the MAPP (Multi-disciplinary Approach to the Study of Chronic Pelvic Pain) will be to develop a clinically relevant phenotypic classification and this work by Shoskes may do an end run around them. Anything that leaves the NIDDK for dead gets my vote. I wish him luck with this.

I am a little concerned that there is no slot for cortisol exhaustion (chronic stress-induced hypocortisolism), based on the recent work by Anderson and Dimitrakov. I have an intuition that this HPA axis stuff is a key to much of what is happening. The issue is whether it helps to phenotype patients and whether those patients respond differently to therapy. I suppose that's what would be required to get into the classification.

[webslave]

Just to clarify what Dr S is saying about infection in his paper, here is the infection section quoted in full:

Infection.
In both CPPS and IC/PBS, empiric antibiotic therapy is both overused and ineffective. Nevertheless there are patients whose symptoms and culture results place them within the syndrome of UCPPS, but who nevertheless have an infection which may respond to antimicrobial therapy. These include uropathogens (Gram-negative bacilli and Gram-positive Enterococcus) found in the mid-stream urine at low counts or localized to EPS or post-massage urine in men with no history of recurrent or documented UTI. It may include other Gram-positive bacteria found in completely antibiotic naive patients. It can also include other atypical organ- isms in the urethra or urine of men and women (for example, Ureaplasma, Chlamydia, Mycoplasma). Certainly a number of prospective clinical trials have indicated that some patients with chronic prostatitis who do not have typical uropathogen localization and women with IC-like symptoms do respond to antimicrobial regimes. Male patients would be identified be documenting any organism localized to the prostate-specific specimens, whereas women may be identified with organisms (atypical or low ‘insignificant count of uropathogens) cultured in midstream urine. It may be inferred that patients may be included in this group if they have never had a documented UTI but have a history of favorable response to antibiotics in past. Therapy for these culture positive patients would ideally be antibiotics selected on the basis of bacterial culture sensitivity or known sensitivity patterns (in the case of atypical organisms). However, practically, the antibiotics are usually prescribed empirically. A caveat however is that if patients do not respond to adequate antibiotic therapy, no further antimicrobial treatment should be initiated