UCPPS - Prostatitis, Interstitial Cystitis Forum

Monday, 25 February 2008 - DAVOS - Urologic chronic pelvic pain syndromes were on J. Curtis Nickel’s mind giving a state of the art-lecture on the occasion of the European Urology Forum 2008 in Davos, Switzerland. "Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and interstitial cystitis/painful bladder syndrome (IC/PBS, also termed bladder pain syndrome or BPS) are now referred to as urologic pelvic pain syndrome (UCPPS)," Nickel defined at the beginning of his lecture.

From his point of view, it became evident that “only some, certainly not all patients appear to be at risk (anatomic, metabolic and/or genetic predisposition) to develop and then maintain the chronic disease and then again a further subgroup progress on to a more generalized symptom complex”.

Read full article at Urosource

What time frame does he consider "early stage" and "late stage"?

This tells me nothing at all. Can anyone let me understand why this is good?

Fascinating article, Dr. Nickel's doing great work, and getting it out there in the public eye! I think I understood most everything on that very useful graphic,

1) Cognitive behavioral therapy: Pretty classic approach, right? "Classic" meaning under the new paradigm.
2) Physical therapy: See #1 above.
3) Gene therapy: This would be the future fruits of what Dr. Dimitrakov is studying now, right, and would likely be something pharmacological?
4) Neuromodulation: TENS/SANS (Dr. Stoller's work) and all that, if I understand correctly, but some could be as "simple" as certain lifestyle changes, right?
5) Immunomodulation: Largely pharmocological, if I understand correctly ( http://en.wikipedia.org/wiki/Immunomodulator ), but again, lifestyle could perhaps play a role, right?

except for

6) What does Dr. Nickel mean by the "The 3 A's - Repetitive Initiator Stimuli?" Is this something like the "self-feeding cycle of tension, anxiety, and pain" that Dr. Wise talks about? ( http://209.85.173.104/search?q=cache:d9 ... cd=2&gl=us ) CPPS as learned dysfunction?

I don't know the answer to that, and the article is cryptic. But maybe Dr Dimitrakov can answer this. I have also invited Dr Nickel to join the forum.

Guessing wildly here about the "The 3 A's" (and I'm certainly NOT a doctor): Maybe allodynia and (hyper)algesia (which Dr. Nickel's model seem to have responding to neuromodulation), and ... anxiety (responding to CBT)? Not the easiest thing to understand, hope someone will have some insight to offer...

The three A's: Antibiotics, alpha-blockers, anti-inflammatories.

http://pubmed.ncbi.nlm.nih.gov/1561 ... d_RVDocSum

A-ha! Thanks, Kevin- you're on the ball!

webslave wrote:I don't know the answer to that, and the article is cryptic. But maybe Dr Dimitrakov can answer this. I have also invited Dr Nickel to join the forum.

I just noted this thread. Not familiar with Dr. Nickel's lecture. Let me review and offer my thoughts

Best,
JD

neis wrote:What time frame does he consider "early stage" and "late stage"?

There is an abstract presentation coming at the AUA on this topic. We will be discussing this on May 17 at 3:30-5:30 in Orlando, FL.

Best,
JD

boulder wrote:Fascinating article, Dr. Nickel's doing great work, and getting it out there in the public eye! I think I understood most everything on that very useful graphic,
3) Gene therapy: This would be the future fruits of what Dr. Dimitrakov is studying now, right, and would likely be something pharmacological?
====Yes, we are working on gene therapy. However, it involves more than drugs. The idea is that we can identify triggring factors that work on genes and then induce epigenetic changes (these changes are not inhereted but are acquired during our individual lives). Pretty much, the aim here is to identify potential factor (s) that act to induce CPPS at the genomic and proteomic level in a fashion similar to smoking inducing lung cancer

>snip for brevity<

except for

6) What does Dr. Nickel mean by the "The 3 A's - Repetitive Initiator Stimuli?" Is this something like the "self-feeding cycle of tension, anxiety, and pain" that Dr. Wise talks about? ( http://209.85.173.104/search?q=cache:d9 ... cd=2&gl=us ) CPPS as learned dysfunction?

=====I think you are correct about the 3 A's

Hope this is helpful

Best,
JD

Many (belated) thanks for your reply, Dr. Dimitrakov! It was very helpful indeed- and hopeful! It's nice to know that the gene therapy you're working on "involves more than drugs". I'm intrigued! Forgive me if this is a stupid question, but am I correct in my (wishful?) thinking that this could be ameliorative/curative as well as preventative?

I'm also happy to see that your paper "Management of chronic prostatitis/chronic pelvic pain syndrome: an evidence-based approach" is available online for free: http://pubmed.ncbi.nlm.nih.gov/16698346

Kevin pointed out that "the 3 A's" are Dr. Nickel's shorthand for antibiotics, alpha-blockers, and anti-inflammatories. These have been considered "first-line" treatments against "prostatitis," but as I understand it, they don't offer much promise for chronic cases. However, as alpha-blockers go, am I correct in my impression that alfuzosin is the most promising, if not for us long-term cases, then at least for alpha-blocker naive men in the early stages of CPPS?

I found a paper (again, free online- this is such a great resource for those of us with limited means!) in which Dr. Nickel describes very well "Repetitive Initiator Stimuli," and, really, the whole new paradigm of CPPS:

http://pubmed.ncbi.nlm.nih.gov/17592539

It is now apparent that the condition occurs in anatomically and/or genetically susceptible men who suffer from some initiator factor (usually repetitive). These initiators can be infection (urethritis, cystitis, prostatitis), dysfunctional high-pressure voiding (bladder neck, prostate, sphincter, or urethral pathology), failure to relax the pelvic floor muscles at rest or during voiding, trauma (bicycle seat, prolonged sitting), or allergic phenomenon. This can lead to a self-perpetuating immunologic inflammatory state and/or neurogenic injury, creating acute and then chronic pain. Peripheral and then central nervous system sensitization involving neuroplasticity may lead to a centralized neuropathic pain state, further modulated by upper central nervous system centers.

New avenues of therapy will involve novel diagnostic strategies leading to neuromodulatory, physical, and cognitive-behavioral therapies. Such treatment trials are already ongoing and hold promise for better management of CP/CPPS.

(Figure 1 in that paper is quite illuminating for the visually-minded. I can't recall if Webslave included it in his excellent collection of diagrams a while back, nor can I find the appropriate thread to link to- sorry Webslave!)

Well, I'm still exactly not sure why Dr. Nickel had an arrow going from "the 3 A's" to "Repetitive Initiator Stimuli" in that diagram- I guess because "the 3 A's" sometimes work for men in early stages of this condition?

The exciting thing is that it really sounds to me like Drs. Anderson, Berger, Dimitrakov, Nickel, Shoskes, et al. (our heroes here at the forum!) are all working from pretty much the same concept of CPPS, but each studying it from their own angle, bringing their own strengths to the table. It's great to see this come together. While I don't feel lucky that I got CPPS, I'm certainly glad I have it at a time when all the above are doing such great work to figure it out! Thank you again for your tireless efforts, and best of luck to you all!

Just thought I'd note what appears to be a slight shift in Dr. Nickel's ideas about CPPS: While he wrote in 2007 that "the condition occurs in anatomically and/or genetically susceptible men," he now says that predispositions can be "anatomic, metabolic and/or genetic," that "only some, certainly not all patients appear to be at risk ... to develop and then maintain the chronic disease and then again a further subgroup progress on to a more generalized symptom complex." Maybe I'm parsing this too closely (all bold print and italics are mine), but I thought that was interesting.

Great comments, boulder!