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Articles
- Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes
- Clinical phenotyping of women with Interstitial Cystitis/Painful Bladder Syndrome: A Key to Classification and Potentially Improved Management
- UPOINT for Interstitial Cystitis
DA Shoskes1, JC Nickel2, RR Rackley1 and MA Pontari3
1Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA; 2Department of Urology, Queens University, Kingston, Ontario, Canada and 3Department of Urology, Temple University, Philadelphia, PA, USA
ABSTRACT
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.
Prostate Cancer and Prostatic Diseases advance online publication, 22 July 2008; doi:10.1038/pcan.2008.42
Keywords: chronic prostatitis; interstitial cystitis; chronic pain
Correspondence: Dr DA Shoskes, Glickman Urological and Kidney Institute, The Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
E-mail: dshoskes@gmail.com
Received 5 June 2008; accepted 26 June 2008
J. Curtis Nickel,*,† Daniel Shoskes‡ and Karen Irvine-Bird
From the Department of Urology, Queen’s University at Kingston, Kingston, Ontario, Canada, and the Department of Urology, Cleveland Clinic, Cleveland, Ohio
ABSTRACT
Purpose: We have proposed a clinical phenotype system (UPOINT) to classify patients with urological pelvic pain to improve the understanding of etiology and guide therapy. We examined the relationship between UPOINT and symptoms in patients with interstitial cystitis/painful bladder syndrome.
Materials and Methods: Patients with interstitial cystitis/painful bladder syndrome were classified in each domain of UPOINT, that is urinary, psychosocial, organ specific, infection, neurological/systemic and tenderness. Symptoms were assessed using the Interstitial Cystitis Symptom Index, Pain/Urgency/Frequency score and visual analogue scale for pain/urgency/frequency. Clinically relevant associations were calculated.
Results: The mean age of 100 consecutive patients with interstitial cystitis/ painful bladder syndrome was 48 years, median symptom duration was 7 years and median Interstitial Cystitis Symptom Index score was 12.8. The percent positive for each domain was urinary 100%, psychosocial 34%, organ specific 96%, infection 38%, neurological/systemic 45% and tenderness 48%. All patients were included in at least 2 domains, with 2 domains for 13%, 3 domains—35%, 4 domains—34%, 5 domains—13% and 6 domains—5%. The number of domains was associated with greater symptom duration (p _ 0.014) but not age. The number of domains was also associated with poorer general interstitial cystitis and pain symptoms (Interstitial Cystitis Symptom Index p _ 0.012, pain p _ 0.036) but not with frequency or urgency. The psychosocial domain was associated with increased pain, urgency and frequency, while tenderness was associated with increased Interstitial Cystitis Symptom Index score, pain/urgency/frequency score and urgency. The neurological/systemic domain was associated with increased Interstitial Cystitis Symptom Index score while the infection domain was not associated with any increased symptoms.
Conclusions: The UPOINT phenotyping system can classify patients with interstitial cystitis according to clinically relevant domains. Increased symptom duration leads to a greater number of domains, and domains that function outside of the bladder (psychosocial, neurological, tenderness) predict a significant impact on symptoms. We hypothesize that the UPOINT system can direct multimodal therapy and improve outcomes.
Key Words: cystitis, interstitial; phenotype; classification
Abbreviations and Acronyms
CP-CPPS _ chronic prostatitischronic pelvic pain syndrome
IC _ interstitial cystitis IC/PBS _ interstitial cystitis/ painful bladder syndrome
ICSI _ Interstitial Cystitis Symptom Index
MAPP _ Multidisciplinary Approach to Pelvic Pain
NIH _ National Institutes of Health
PUF _ Pain/Urgency/Frequency
UCPPS _ Urologic Chronic Pelvic Pain Syndromes
UPOINT _ urinary, psychosocial, organ specific, infection, neurogenic/systemic, tenderness
VAS _ visual analogue scale
Submitted for publication October 31, 2008.
* Correspondence: Department of Urology, Queen’s University, Kingston General Hospital, 76 Stuart St., Kingston, Ontario, Canada K7L 2V7 (telephone: 613-548-2497; FAX: 613-545-1970; e-mail: jcn@queensu.ca).
† Financial interest and/or other relationship with Merck Frosst Canada, GlaxoSmithKline, Ortho-McNeil, Medtronic, Allergan, Farr Laboratories, Triton Pharma and Plethora Solutions. ‡ Financial interest and/or other relationship with Triurol.
UPOINT for Interstitial Cystitis
Lisa Richards
Nickel et al. have used their UPOINT system to characterize the wide range of clinical phenotypes of women presenting with interstitial cystitis (painful bladder syndrome). This classification method should help to individualize therapy for this difficult-to-treat condition.
“We believe that [urologic chronic pelvic pain] syndromes require multifactorial therapy targeted at the
Specific etiologies and symptoms that the patients have in order to be effective,” says co-researcher Daniel Shoskes, from the Cleveland Clinic, USA. “We developed the UPOINT clinical phenotype classification system as a potential technique to classify patients into clinically meaningful domains (urinary, psychosocial, organ [bladder/prostate] specific, infection, neurologic/systemic and tenderness of skeletal muscles), each associated with specific effective therapies.”
Previously validated in men with chronic prostatitis and chronic pelvic pain syndrome, a total of 100 women with interstitial cystitis (mean age 48 years, median duration of symptoms 7 years) were included in this new study of the UPOINT system. Symptoms were evaluated using the Interstitial Cystitis Symptom Index, as well as questionnaires and visual analogue scale measurements of pain, urgency and frequency.
As expected, Nickel and colleagues observed that 100% and 96% of the patients were positive for symptoms in the urinary and organ-specific domains, respectively. The percentages of patients positive for symptoms in the psychosocial, infection, neurological/systemic, and muscle tenderness domains were 34%, 38%, 45% and 48%, respectively. “The UPOINT system [classified] these women into distinct phenotypes, and a greater number of positive domains correlated with worse symptoms [as well as symptom duration],” Shoskes comments. Symptoms from at least two of the domains were noted in all of the patients, of whom 13% were positive for just two domains, 35% for three, 38% for four, 13% for five and 5% for all six.
Shoskes notes that although the bladder category is the main UPOINT domain for symptoms of interstitial cystitis, “non-urologic domains (psychosocial, tenderness) were major contributors to symptom severity.” this finding might explain why bladder-specific treatments often fail.
Specific etiologies and symptoms that the patients have in order to be effective,” says co-researcher Daniel Shoskes, from the Cleveland Clinic, USA. “We developed the UPOINT clinical phenotype classification system as a potential technique to classify patients into clinically meaningful domains (urinary, psychosocial, organ [bladder/prostate] specific, infection, neurologic/systemic and tenderness of skeletal muscles), each associated with specific effective therapies.”
Previously validated in men with chronic prostatitis and chronic pelvic pain syndrome, a total of 100 women with interstitial cystitis (mean age 48 years, median duration of symptoms 7 years) were included in this new study of the UPOINT system. Symptoms were evaluated using the Interstitial Cystitis Symptom Index, as well as questionnaires and visual analogue scale measurements of pain, urgency and frequency.
As expected, Nickel and colleagues observed that 100% and 96% of the patients were positive for symptoms in the urinary and organ-specific domains, respectively. The percentages of patients positive for symptoms in the psychosocial, infection, neurological/systemic, and muscle tenderness domains were 34%, 38%, 45% and 48%, respectively. “The UPOINT system [classified] these women into distinct phenotypes, and a greater number of positive domains correlated with worse symptoms [as well as symptom duration],” Shoskes comments. Symptoms from at least two of the domains were noted in all of the patients, of whom 13% were positive for just two domains, 35% for three, 38% for four, 13% for five and 5% for all six.
Shoskes notes that although the bladder category is the main UPOINT domain for symptoms of interstitial cystitis, “non-urologic domains (psychosocial, tenderness) were major contributors to symptom severity.” this finding might explain why bladder-specific treatments often fail.
Original article Nickel, J. C. et al. Clinical phenotyping of women with interstitial cystitis/painful bladder syndrome: a key to classification and potentially improved management.
J. Urol. 182, 155–160 (2009).
