New Study on Pelvic Tenderness

[dshoskes]

Muscle Tenderness in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome: The Chronic Prostatitis Cohort Study.

J Urol. 2007 Dec 12;

Authors: Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S,

PURPOSE: Myofascial pain is a possible etiology for category III chronic prostatitis/chronic pelvic pain syndrome, either secondary to infection/inflammation or as the primary cause. We documented tenderness on physical examination in a large multicenter cohort of patients with chronic pelvic pain syndrome and compared to controls. MATERIALS AND METHODS: Data were reviewed from the National Institutes of Health Chronic Prostatitis Cohort study on 384 men with chronic pelvic pain syndrome and 121 asymptomatic controls who had complete unblinded physical examination data from 7 clinical centers between October 1998 and August 2001. Tenderness in 11 sites including prostate, genitals, abdomen and pelvic floor together with prostate size and consistency was evaluated. Data were correlated with cultures and symptoms. RESULTS: Overall 51% of patients with chronic pelvic pain syndrome and 7% of controls had any tenderness. The most common site was prostate (41% chronic pelvic pain syndrome, 5% controls), followed by external and internal pelvic floor (13% and 14% chronic pelvic pain syndrome, 0 controls) and suprapubic area (9% chronic pelvic pain syndrome, 0 controls). Of patients with chronic pelvic pain syndrome 25% had 1 tender site, 11% had 2 and 6% had 3 tender sites. Tenderness did not correlate with inflammation or infection in the prostate fluid. Prostate consistency was normal in 79% of patients with chronic pelvic pain syndrome and in 95% of controls, and did not correlate with symptom severity. Patients with chronic pelvic pain syndrome with any tenderness had significantly higher Chronic Prostatitis Symptom Index scores at baseline and at 1 year (24.1 vs 21.2 and 20.2 vs 17.5, p <0.0001) compared to patients without tenderness. CONCLUSIONS: Abdominal/pelvic tenderness is present in half of the patients with chronic pelvic pain syndrome but only 7% of controls. Extraprostatic tenderness may identify a cohort of patients with a neuromuscular source of pain.

PMID: 18082223 [PubMed - as supplied by publisher]

[webslave]

Abdominal/pelvic tenderness is present in half of the patients with chronic pelvic pain syndrome but only 7% of controls.

That's a remarkably high number for a retrospective review of NIH studies which only documented tender points as one of many parameters they were measuring. Also note that the people looking for tenderness are not trained to do this, and we know how many errors and overlooked trigger points that causes...

[dshoskes]

It WAS a prospective study (by definition all analysis is done after the fact)

[webslave]

Thanks for clarifying.

For those confused by this exchange on retrospective and prospective: a retrospective study is a study that looks backwards in time. For example, we find people that are already dead and try to figure out why they died. In contrast, a prospective study looks forward in time. For example, we select a group of subjects and sit around and watch them for a decade.

[Sleeper Service]

So about half of chronic prostatitis / chronic pelvic pain syndrome patients have pelvic tenderness? This is much lower than the figure of 90% I have seen used.

What's the difference due to?

[webslave]

IMO due to investigator error and perhaps bias. The high figure was from people who have specialised knowledge of neuromuscular pelvic pain and neurourology, like Dr Ragi Doggweiler, in this study.

More about Doggweiler:

Dr. Ragi Doggweiler was born in Switzerland and studied nursing in Florence, Italy. After working as a nurse for several years, she attended medical school in Florence and completed her residency in urology. She then moved to the United States and became a research fellow in neurourology at the University of Colorado Health Science Center in Denver. There, she worked extensively with Richard Schmidt, MD, a pioneer in the field of neurourology and sacral nerve stimulation implants. Since October 1998, she has been an Assistant Professor in the Department of Urology at the University of Tennessee in Knoxville.

[garyholc]

Has a study been done anywhere on the average length of time it takes for prostatitis to resolve itself? I hear quite a lot on here about it being approx 3 years but just wondered if there has been any investigations into this, and in particular, what proportion of those people found it clearing without doing anything, and those who actually did some of the SP and relaxation techniques. Would be interesting to see the results if such a study has been done to see if SP patients found a quicker resolution of symptoms.

[graeme]

The difference is the protocol is to keep it at bay forever, I and others have had remissions after a few years of this in fact my remission lasted 4 years but guess what it came back

Dr Wise still does the relaxing even though he has been pain free many years and his symptoms have NOT returned

[Sleeper Service]

As I recall Dr Wise also had relapses and remissions as well though, Graeme. It is, however, clear that SP has worked very well for him and a number of other people. What attracts me to his work is that it's actually documented and published in peer reviewed journals. However, until a double blind study is conducted it remains unproven although highly likely.

Graeme - I would say that people who do something about it almost certainly get better quicker which is why it's important we look at every reasonable possibility. As for natural duration, this is unknown although a recent study in the UK showed most cases resolving within two weeks to three or so years although they lost contact with 35% of the study either due to resolution and non-return or people just giving up. I'm more inclined to believe it's the former in most cases as the people in the study were distributed right across the spectrum in terms of duration from a few weeks to over 10 years.

[Sleeper Service]

IMO due to investigator error and perhaps bias.

From: Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S

[webslave]

IMO due to investigator error and perhaps bias.

From: Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S

No, they just assembled and reviewed the findings of others:

Data were reviewed from the National Institutes of Health Chronic Prostatitis Cohort study on 384 men with chronic pelvic pain syndrome and 121 asymptomatic controls who had complete unblinded physical examination data from 7 clinical centers between October 1998 and August 2001.

It's also worthwhile noting the dates that these examinations of patients took place: 1998 - 2001, long before the neuromuscular theories and Stanford/Wise-Anderson Protocol got going in a big way.

[dshoskes]

No, they just assembled and reviewed the findings of others:

Again, don't want to split hairs, but WE did the study, this is not a review article or "meta-analysis" of works by others. This was a part of the CPCRN cohort study that we all were members of and myself, Dr. Zeitlin and the other PI's of the CPCRN (names listed in the actual paper) all had our fingers up the butts of patients and recorded the findings. The primary questions asked of the CPCRN was not pelvic tenderness, so the initial publications that followed the 3 year study had different focus (medical comorbidities, significance (or lack thereof) of cultures and prostatic WBC, responsiveness of the CPSI, placebo controlled trial of antibiotics and alpha blockers etc). At the end of the study period, we realized that there was still much valuable data that had not been analyzed and ideas were solicited to further explore the database. It was Dr. Berger's idea to focus on the physical exam data. Due to illness he could not continue the work, and I took over the primary analysis and writing of the paper (which is why I am first author).

As discussed in the actual paper, there is much room for bias in both directions. None of the PI's was hostile to the idea that chronic prostatitis / chronic pelvic pain syndrome patients may have muscle tenderness, and no center found tenderness sites in either everyone or nobody. There may have been bias to score "normal" controls as normal and patients complaining of pain as obviously abnormal. The fact remains that pelvic tenderness and "trigger points" is a subjective measure and until we have a truly objective measure of chronic muscle spasm and increased tone, all measurements will have observer bias intrinsic in the result.

[webslave]

I'd like to see that aspect of the study repeated as a primary focus and by investigators trained and alerted to the existence of tender points. As it stands, coming from 7+ years ago (pre-Stanford/Wise-Anderson Protocol) and from incidental findings, I still find the 51% figure remarkable.

[dshoskes]

I still find the 51% figure remarkable.

Pretty typical for my current general clinic chronic prostatitis / chronic pelvic pain syndrome population, with perhaps closer to a 60% tender 40% nontender split.

[webslave]

I am reminded of this thread about the difficulty of finding trigger points, or "tender points".
viewtopic.php?f=34&t=1778