Phenotypically directed AAPM The American Academy of Pain prostatitis by mikeholy


									Shoskes D, Robert D, Nickel C.
Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic
pain syndrome: a prospective study using upoint
105th Annual Meeting and Exhibition of the American Urological Association (AUA) (San
Francisco, CA: May 29, 2010)
Introduction and objectives: Chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS)
is likely multifactorial. Multi-center placebo controlled trials have failed their primary
endpoints using "one size fits all'' therapies. In order to phenotype CP/CPPS patients we
developed the UPOINT system with six yes/no domains (Urinary, Psychosocial, Organ
Specific, Infection, Neurologic/Systemic and Tenderness of muscles). We have shown a
direct correlation between domain number and symptom duration as well as NIH-Chronic
Prostatitis Symptom Index (CPSI) scores. In this study, we treated patients with
multimodal therapy based on the UPOINT phenotype (one therapy recommended for each
positive domain) and hypothesized that patients would have significant long term symptom
Methods: From March 2008 to April 2009, patients with CP/CPPS were classified
according to UPOINT and offered multimodal therapy based on the positive domains (eg.
Urinary: alpha blocker or antimuscarinic, Organ specific: quercetin; Neurologic:
pregabalin, Tenderness: physical therapy). One hundred patients agreed to therapy and
were re-examined at least 26 weeks later. Primary endpoint was a minimum 6 point drop in
total CPSI (90% power for a 1.2 point drop).
Results: Mean age was 46 years and median symptom duration was 24 months. A median
of 3 UPOINT domains were positive (range 1-5), the most common being Organ specific
(70%), Tenderness (64%) and urinary (59%). With a minimum follow up of 26 weeks and
median of 50 weeks, 84% had a 6 point or greater fall in total CPSI. Number of positive
domains and initial CPSI score did not predict treatment response. Average changes for the
CPSI subscores were pain 11.5+/-3.2 to 6.1 +/-3.9, urine 4.7+/-3.1 to 2.6+/-2.0, QOL 9.1+/-
2.3 to 4.5 +/-2.8 and total 25.2 +/-6.1 to 13.2+/-7.2 (all pairs p<0.0001). No individual
phenotype predicted symptom improvement, however use of quercetin was the only
individual therapy associated with a higher drop in total CPSI (8.47+/-6.4 vs 13.9 +/-6.2,
Conclusions: Phentoypically directed multimodal therapy using the UPOINT system leads
to significant improvement in symptoms and quality of life in men with CP/CPPS. While a
placebo controlled trial for every therapy combination is not feasible, the results using
UPOINT compare favorably to all large trials of monotherapy. This algorithmic technique
is simple to use ( and a major improvement over the status quo of
empiric therapy.
Source of funding: None
Author Affiliation: Kingston, Canada

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