+ The Emerging Biopsychosocial Model of a Male Chronic Pelvic Pain Syndrome Dean A. Tripp, PhD Departments of Psychology, Anesthesiology & Urology, Queen’s University, Canada + Acknowledgements CPS Michael JL Sullivan, Elizabeth VanDenKerkhof Queen’s Graduate students Annie Hsieh, Tara Haley, Jess Ginting, Mary Acreman Kelly Smith, Megan Davidson, Sam Waxman NIH CPPS group + Queen’s University J. Curtis Nickel, MD (PI), Dean A. Tripp, PhD Dale Ardern, RN, Janet Clark, ACP Joseph Downey, MSc University of Maryland Richard B. Alexander, MD (PI) Sathibalan Ponniah, PhD, C Lowder, MS, RN Kim Burton Northwestern University Anthony J. Schaeffer, MD (PI) Charles L. Bennett, MD, PhD Wade Bushman, MD, PhD Elizabeth A. Calhoun, PhD Alisa Erika Koch, MD, Robert B. Nadler, MD Mary Healy, RN, Marylin Dopona University of Mississippi Jackson E. Fowler, Jr., MD (PI) Rachael Tapley, RHIA, Anne Dautenhahn Brigham and Women’s Hospital Michael P. O’Leary, MD, MPH (PI) Debra Rhodes, MD, J Spolarich-Kroll, BA Alex Adler Massachusetts General Hospital Mary McNaughton Collins, MD, MPH Michael J. Barry, MD Cleveland Clinic, Fort Lauderdale Daniel Shoskes, MD (PI), Kim Thomas Martin Luther King Hospital Nand S. Datta, MD (PI) Mary Ellen Raimo, Kawajalen Mervin University of Arizona Craig V. Comiter, MD (PI), Pat Conrad Temple University Michel A. Pontari, MD (PI), Michael Ruggieri, PhD Linda Kish, BA, Sharon Filer-Maerten, BS University of Pennsylvania School of Medicine J. Richard Landis, PhD (PI) Kathleen J. Propert, ScD, John T. Farrar, MD Harold I. Feldman, MD, MS, Denise Cifelli, BS Stephen Durborow, BS, Lori Fanelli, BA Xueyou Hu, MS, Lee Randall, BA Jill S. Knauss, MS, Randy Hildebrand, MS Gina Norwood, BS, Marie Durborow Christopher Helker, RN, MPH University of California, Los Angeles Mark S. Litwin, MD, MPH (PI) Scott I. Zeitlin, MD, Yining Xie, MD Kellie Ma The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) John W. Kusek, PhD (Project Officer) Leroy M. Nyberg, PhD, MD University of Toronto Keith Jarvi, MD, Lori L. Burrows, PhD + WARNING There will be a quiz later in the talk… I am not kidding Sorry no prizes though! + CP/CPPS Prostatitis is a major health care burden 2 million office visits per year in the US alone NA Urologists see 100-150 per year, 33% new patients. Prevalence estimates for Dx of prostatitis (including CP/CPPS) between 11-16% for general population + CP/CPPS Cardinal Sx’s - Persistent Pain in the external genitalia, perineum, pelvis or suprapubic area Urinary symptoms (frequency, urgency, hesitancy of urination) CP/CPPS symptoms are common and recognized for their strong negative impact on patient QoL… comparable to Crohn’s disease, congestive heart failure and severe diabetes + CP/CPPS • Chronic Prostatitis is a Syndrome not a disease “British Pain Society Meeting” – Constellation of symptoms – Primary Sx is PAIN (>3 months) associated with variable degrees of voiding and / or sexual / ejaculatory disturbances + NIH Prostatitis Classification System Category I Acute bacterial prostatitis (acute infection of prostate) Category II Chronic bacterial prostatitis (recurrent infection of the prostate) Category III Chronic non-bacterial prostatitis/chronic pelvic pain syndrome (no demonstrable infection) Category IIIA Inflammatory (white blood cells in semen/EPS/VBU) Category IIIB Non-inflammatory (no white blood cells in the semen/EPS/BVU) Category IV Asymptomatic inflammatory prostatitis (no subjective symptoms detected either by prostate biopsy or the presence of white blood cells in EPS during evaluation for other disorders) + CP/CPPS Prevalence + Understanding Pain & QoL? NIH working all curative avenues… – Bacteria / microorganisms – Anatomic (bladder neck hyperplasia) – Interstitial Cystitis similarities – Neurologic / immunologic Patient Management + Looking for answers Models of chronic pain - from a biomedical focus to a broader biopsychosocial approach Research suggests 3 categories of psychosocial variables important in chronic pain… Cognitions Cognitions Coping Coping Responses Responses Environment Environment Variables Variables Catastrophizing Catastrophizing PerceivedControl Control Perceived Paincontingent contingent Pain Rest&&inactivity inactivity Rest SocialSupport Support Social SolicitousRes Res Solicitous + Series of Studies 2004 QoL Impact Study 2006 Biopsychosocial Pain Study 2007 Biopsychosocial QoL Study 2008 CP/CPPS Couple Longitudinal Study 2008 Prevalence in Adolescent Males Studies + Predictors of Quality Of Life and Pain in CP/CPPS: The NIH Chronic Prostatitis Cohort Study Tripp DA, Nickel JC, Landis R, Wang Y, Knauss JL, & the CPCRN Study Group. British Journal of Urology, 2004 + Sample N=463 men from NIH baseline cohort study aged 20–83 years (M = 52). Caucasian (83%) >85% reporting college education >65% reported living with a partner >83% employed Mean household income was just above US$ 50,000 + QoL + Pain + Conclusions Ok, it’s a start! Depressive symptoms, urinary Sx’s, pain predict poor QoL in CP/CPPS (independent of partner status, age) Pain - most robust predictor of poorer QoL Further pain and psychological factors for CP/CPPS needed for pain and its impact on QoL + Catastrophizing and Pain-Contingent Rest Predict Adjustment in Men with CP/CPPS Tripp DA, Nickel JC, Wang Y, Litwin MS, McNaughtonCollins M, Landis JR, Alexander RB, Schaeffer AJ, O'Leary MP, Pontari MA, Fowler J, Nyberg L, Kusek J & the NIH-CPCRN Study Group. Journal of Pain, 2006 + Sample 253 men recruited from NIH Chronic Prostatitis Cohort (CPC) Study - 7 NA tertiary care centers (6 U.S., 1 Canada) 45 years (SD = 11.3); > 50% high school; 36% reported some college/university Most living with a partner (70%) White 88%, 5% African American, 3% Hispanic/Latino, 2% Asian, 1% American Indian + Pain + Disability + Conclusions Now we are on to something! Cognitive/behavioral factors such as helplessness catastrophizing and pain-contingent rest may have significant roles in patient adjustment Reality is… Pain programs or psychological issues are not highly prioritized in CP/CPPS management + Psychosocial Parameters Impact Quality of Life in Men Diagnosed with CP/CPPS Nickel JC, Tripp DA, Chuai S, Litwin MS, McNaughtonCollins M, Landis JR, Alexander RB, Schaeffer AJ, O'Leary MP, Pontari MA, White P, Nyberg L, Kusek J, Mullins C & the NIH-CPCRN Study Group. British Journal Of Urology, 2007 + Sample 240 men recruited from NIH Study - 7 NA tertiary care centers (6 U.S., 1 Canada) 45 years (SD = 11.3); > 50% high school; 36% reported some college/university Most living with a partner (70%) White 88%, 5% African American, 3% Hispanic/Latino, 2% Asian, 1% American Indian + + Conclusions Specific coping and environmental factors (Catastrophizing, Resting, Social Support) are significant in understanding patient adjustment in CP/CPPS “Specific” cognitive-behavioural programs for men with CP/CPPS refractory to standard medical therapy + Longitudinal Changes in Relationship Issues in Men with CP/CPPS Tripp In DA, Nickel JC, NIH group progress + Aim Examine changes contrasting patient/spousal reports at baseline, 6 months, 1 year, & 2 years where applicable Remember… Remember… SF12 SF12 population population score score is is 50 50 Physical Physical Comp Comp Score Score -- SF12 SF12 Sig Sig changes changes overtime; overtime; No No couples couples differences; differences; No No interaction interaction Mental Mental Comp Comp Score Score -- SF12 SF12 Sig Sig changes changes overtime; overtime; Sig Sig couples couples differences; differences; No No interaction interaction Anxiety Anxiety Scores Scores Sig Sig couples couples differences; differences; Non Non sig sig changes changes over over time; time; No No interaction interaction Depression Depression Score Score Sig Sig couples couples differences; differences; Sig Sig increases increases overtime; overtime; No No interaction interaction Marital Marital Adjustment Adjustment Scores Scores –– non non sig sig differences differences between between patients patients and and spouse; spouse; non non sig sig changes changes over over time; time; no no interaction interaction Values Values did did not not differ differ overtime. overtime. Without Without intervention intervention pain, pain, disability, disability, and and catastrophizing catastrophizing did did not not decline decline in in these these men. men. + Conclusions CP/CPPS couples suffer together! Longitudinal data show patients worse Mental QoL, Depression and Anxiety than spouses but ALSO spouses report stable Depression and Anxiety Catastrophizing, Pain, Disability do not reduce over 2 year period + Quiz #1 What have we now learned about CP/CPPS? + CP/CPPS symptoms in African and Canadian Males aged 16-19 years Tripp DA, Nickel JC, Ross S, Mullins C, Pickard J, Stechyson N, Hsieh A. Journal of Urology, under review + Background & Aims ≈10% of North American males aged 20-29 yrs report symptoms similar to those with CP/CPPS Prevalence of 6% in 20-year-old South Korean males Recent data suggested “pubertal prostatitis” 1) Prevalence in community adolescent males for CP/CPPS-like symptoms, 2) QoL, 3) Crosscultural differences in symptom report + African Sample (Kenya) 166 African males aged 16-19 Yrs (M=17.5, SD=1.1) School districts in Migori and Nairobi Province, 42% Rapogi, 34% Kibera, 25% Kahawa + African Sample (Kenya) Inequitable representations of age + Total CPSI PAIN Score (0-21) 7% Pain ≥ 8 25.4% Pain ≥ 4 + Prevalence of CP/CPPS ; 13.3 ; 9 ; 5.4 ; 2.4 + QoL + Canadian Sample 264 Caucasian males aged 16-19 Yrs (M=17.5, SD=1.1) Equitable representations of age + Total CPSI PAIN Score (0-21) 6.9% Pain ≥ 8 25% Pain ≥ 4 + Prevalence of CP/CPPS ; 8.3 ; 6.8 ; 3.0 ; 1.9 + Prediction of poorer QoL + Quiz #2 What have we now learned? + Conclusions Adolescents report symptoms similar to older cohorts including significant negative impact on their QoL! Regardless of Country! We should be uneasy about the possible progression into adult CP/CPPS! Adolescent population is an important and understudied area for future investigations… these initial data warrant concern! + General Conclusions Psychosocial factors cannot be ignored Catastrophizing has particular role in CP/CPPS adjustment (Pain, QoL) Symptoms do not change without treatment CP/CPPS age cohort data indicate catastrophizing is varied and perhaps developmental? + Ongoing / Future studies Full epidemiology CP/CPPS study CP/CPPS & IC/PBS pain symptom comparison study IC/PBS phenotype study CP/CPPS vs IC/PBS social support behaviour study + Thank you