CPPS) in men -- a systematic review.

Journal of Psychosomatic Research 77 (2014) 333–350

Contents lists available at ScienceDirect

Journal of Psychosomatic Research

Review

Assessing psychological factors, social aspects and psychiatric co-morbidity associated with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) in men — A systematic review☆ Björn Riegel a,⁎,1, Christian A. Bruenahl a,1, Sascha Ahyai b, Ulrike Bingel c, Margit Fisch b, Bernd Löwe a a b c

Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf and Schön Klinik Hamburg Eilbek, Hamburg, Germany Department of Urology, University Medical Centre Hamburg-Eppendorf, Germany Department of Neurology, University Medical Centre Hamburg-Eppendorf, Germany

a r t i c l e

i n f o

Article history: Received 18 June 2014 Received in revised form 17 September 2014 Accepted 21 September 2014 Keywords: Chronic prostatitis with Chronic pelvic pain syndrome Mental disorder Psychosocial aspects Quality of life Systematic review

a b s t r a c t Objective: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a chronic pain disease with high prevalence rates and substantial health care costs. An interdisciplinary classification system is commonly used (UPOINT) which includes psychosocial factors. Nevertheless, psychosocial influences on CP/CPPS only recently became a research focus. Therefore, we aimed to synthesize the existing data and to identify further research topics. Then, based on our results, diagnosis and treatment can be improved. Methods: In a systematic review conducted according to the PRISMA reporting guidelines we searched different databases (MEDLINE, EMBASE, PsychINFO) using the broad search terms “chronic pelvic pain syndrome AND men”. Two raters independently screened the literature and assessed the risk of bias. Results: We included 69 original research articles which considered psychosocial variables. We found studies investigating different psychosocial factors (pain catastrophizing, stress, personality factors, social aspects), co-morbid psychiatric disorders (depression, anxiety and trauma-related disorders, somatization disorder, substance abuse) and Quality of Life (QoL). In addition, there is a high risk of bias in most studies e.g. concerning the study design or the measures. Conclusions: There is evidence suggesting that psychological factors are important in understanding CP/CPPS. However, research concentrated on a few aspects while the others were not covered adequately. We found evidence of a higher number of psychosocial factors and psychiatric co-morbidities than is currently included in the UPOINT system. More high quality research is needed to understand the interplay of psychosocial factors in CP/CPPS. Furthermore, these factors should be incorporated into treatment approaches. © 2014 Elsevier Inc. All rights reserved.

Introduction It is well known that prostatitis symptoms incur substantial health care costs [1,2] but only 5–10% can be explained by bacterial infection [3]. According to the NIH consensus, one subgroup of prostatitis (nonbacterial, main symptom: pain [4]) is classified as Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), category IIIA/

☆ Review registration number: PROSPERO CRD42013003160. ⁎ Corresponding author at: Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Tel.: +49 40 7410 52997; fax: +49 7410 4975. E-mail address: [email protected] (B. Riegel). URL: http://www.uke.de (B. Riegel). 1 Both authors contributed equally to this work.

http://dx.doi.org/10.1016/j.jpsychores.2014.09.012 0022-3999/© 2014 Elsevier Inc. All rights reserved.

IIIB, and can be used for both genders [5]. Although the understanding of the underlying mechanisms in both genders is lacking [6–8], this paper will focus on CP/CPPS in men diagnosed according the NIH-definition [5]. Despite epidemiological data suggesting a high point prevalence of CP/CPPS in men in the general population varying worldwide between 2% in Australia [9] and 12% in Nigeria [10], a high percentage of primary care physicians are not familiar with CP/CPPS [11,12]. Given the heterogeneity and variance of symptom development in CP/CPPS, the UPOINT system with its six domains (Urinary, Psychosocial, Organ-specific, Infection, Neurologic/Systemic and Tenderness) has been established [13]. The rating of the “Psychosocial” domain of the UPOINT system has been operationalized in different ways (e.g. psychometric instruments, medical history, assessment by a psychiatrist or self-report). Patient reported depression and/or

334

B. Riegel et al. / Journal of Psychosomatic Research 77 (2014) 333–350

pain catastrophizing cognitions are required for the psychosocial domain to be rated positive [13]. Using this definition, two studies classified 37% of patients as being positive in the “P-domain” [13,14]. However, the impact of this classification on specific psychological treatment was low [14]. Despite the useful definition of symptoms, the classification system and a common measurement instrument (NIH-CPSI) [15], there is a lack of research regarding psychosocial factors in CP/CPPS compared to other chronic pain conditions. Given the heterogeneity of the syndrome, a deeper understanding of the associated psychological and social mechanisms is crucial to improve treatment approaches for CP/CPPS patients. This systematic review will summarize and synthesize the current research to outline the role of psychosocial factors in the development and maintenance of CP/CPPS. As the focus is limited to depression and pain catastrophizing cognitions in the “Psychosocial” domain of the UPOINT system, our review aims to expand the scope of this domain. Furthermore, specific psychotherapeutic treatments for CP/CPPS patients have been developed [16–18] but we need more knowledge about the psychosocial factors involved in CP/CPPS to increase the effectivity of these approaches. The review only included data since the NIH-CPSI was established as standard measurement in 1999 [15]. We grouped results into different clusters based on the presence of different psychological and social factors and psychiatric co-morbidities to give an insight into their impact on patients with CP/CPPS. Furthermore, we included data on Quality of Life (QoL). Methods The MEDLINE, EMBASE and PsychINFO databases were searched with the broad search terms “chronic pelvic pain syndrome AND men”. In addition, the reference lists of included studies were screened by hand. The last update of our search was performed on the 15th of May 2014. PRISMA criteria [19] were used as reporting guidelines and the review was registered in an international systematic review registry: PROSPERO (CRD42013003160). The following inclusion criteria were defined: Only original quantitative research published from 1999 until present in the English or German language was included. To minimize a potentially misleading heterogeneity of diseases related to the pelvic area, we decided to only include studies based on the standardized NIH-Classification (category IIIA/B) [5]. Studies meeting these criteria were screened for data related to the following predefined categories: the UPOINT psychological factors (depression, pain catastrophizing cognitions, stress, maladaptive psychological responses) [13] given our aim to improve the understanding of the “P-domain” in the UPOINT-system. Secondly, we included the psychological factors mentioned in the European Association of Urology (EAU) guidelines which have an association with quality of life (anxiety, distress in relationships, sexual abuse and trauma) [20]. In summary, we predefined the categories “psychosocial factors” (pain catastrophizing cognitions, stress, personality factors, social aspects/relationship functioning), “psychiatric co-morbidity” (any psychiatric diagnosis according DSM-IV/ ICD-10 or self report questionnaires measuring psychopathology) and “quality of life”. Two researchers (BR, CB) then conducted the search, evaluated whether the study should be included according to the abovementioned criteria and rated the content and risk of bias according to the “Cochrane Risk of Bias Tool” [21] independently. Disagreement was resolved by a consensus decision. The “Cochrane Risk of Bias Tool” [21] was adapted for evaluation studies. In particular, this included a judgment of: (1) Sampling bias which describes whether the sample selection was appropriate (recruitment of subjects, inclusion criteria, sample size), (2) Attrition bias (handling of missing and dropout data), (3) Reporting bias (risk of selective, incomplete reporting of outcome data), and

(4) Other bias which includes all risk of bias that is not mentioned above, especially inappropriate ways of measurement or diagnostic techniques, risk of bias regarding the study design or neglect of possible covariates. Results Using the criteria described above, the final number of included studies was 69 out of 662 search results (Fig. 1). To synthesize the current body of knowledge regarding psychological and social factors, psychiatric co-morbidity and QoL associated with CP/CPPS, we organized the different categories into sub-categories. A comprehensive overview of all studies is given in Table 1. In Table 2, the presence of psychosocial aspects and psychiatric co-morbidities in each study is listed. Psychosocial factors We identified studies belonging to the following four psychosocial factors: pain catastrophizing cognitions (1), stress (2), personality factors (3) and social aspects/ relationship functioning (4). (1) Pain catastrophizing cognitions The impact of pain catastrophizing cognitions in CP/CPPS was reported in 8 studies. Using the UPOINT classification system, 25% of patients felt helpless or hopeless [22]. In contrast to this study, the following studies used the standardized Pain Catastrophizing Scale [23] to measure patients' cognitive style. In a cluster analysis, two out of seven clusters were characterized by high catastrophizing thoughts [24]. Data showed that untreated pain catastrophizing cognitions are stable at a two year follow-up [25] but such cognitions can be reduced by a cognitive behavioral intervention [26]. Furthermore, pain catastrophizing predicted mental QoL [27] and pain intensity [28]. Only one study [24] categorized the patients according to Sullivan's cut-off score [29]; the others used a continuous score. In addition, two studies [30,31] employed the Coping Strategies Questionnaire [32] to classify CP/CPPS patients with high catastrophizing cognitions. Again, these data revealed an association between catastrophizing and pain intensity but the high risk of bias must also be considered. (2) Stress There are other data regarding the influence of stress on the development and maintenance of CP/CPPS as reported in six studies. In a psychobiological experiment, CP/CPPS patients had less emotional negativity in comparison to healthy controls and showed altered hormonal responses following a standardized stressor [33]. The authors concluded that these differences are due to a neuropsychological adjustment to chronic pain but reported the opposite results in another publication [34]. Korean researchers found an elevated level of stress perception in CP/CPPS patients, but no difference in the type of stressful events [35]. These data suggest the assumption of a deficiency in CP/CPPS patients concerning the handling of stressful situations. In a prospective cohort study, half of the patients believed that stress worsened pain. Nevertheless, their coping strategies did not differ from the general population [36]. Another investigation showed the long-term influence of stressful living conditions on CP/CPPS: The more stress patients perceived during the first 6 months after a health care visit, the more pain and disability were reported after 12 months [37]. In another observational study, enhanced pain and lower QoL were associated with a higher level of stress [38]. (3) Personality factors There has been early research investigating the association between personality factors and CP/CPPS, but we only found one study published after 1999. The only association between the “Big Five” factors and CP/CPPS was with neuroticism [39]. Patients scoring high on neuroticism showed a poorer treatment response and higher severity of depression and somatization. (4) Social aspects/relationship functioning Additional social aspects were assessed in 6 studies. Low social support appears to be predictive of poor mental QoL [27]. A solicitously responding partner has a negative impact on the feeling of disability due to pain [40]. In addition, there was an association between severe pain and low satisfaction with relationships, mediated by lower sexual functioning [41]. In contrast, another study failed to show social support or a specific spousal response as predictors of pain [28]. Moreover, CP/CPPS patients have a greater number of sexual relationships with more than one partner compared to healthy controls [42]. Finally, lower levels of education predicted pain severity [43]. Psychiatric co-morbidity Besides the aforementioned psychosocial factors, there is a growing body of evidence regarding psychiatric co-morbidities in CP/CPPS. CP/CPPS patients had significantly higher psychological distress compared to healthy controls [33,34] as measured by the Brief Symptom Inventory [44]. In addition, the results of two case–control studies revealed a significantly higher rate of lifetime psychiatric conditions in CP/CPPS patients compared to healthy controls [45,46]. CP/CPPS patients also consumed a higher amount of medication for anxiety, depression or stress [45]. We identified studies belonging to the following


335

Fig. 1. PRISMA flow diagram. The number of studies included in each part of the review process.

four psychiatric co-morbidities: depression (I), anxiety and trauma-related disorders (II), somatization disorder (III) and substance abuse (IV). (I) Depression Depression severity as measured by standardized psychometric questionnaires (most commonly the well-validated CES-D questionnaire [47]), or the clinical diagnosis of depression according DSM-IV/ICD-10 was reported in 15 studies. Compared to control groups, CP/CPPS patients showed elevated CES-D scores [25,48]. In contrast, one study reported a CES-D mean score that was below the cut-off score for clinically relevant depression but the authors only reported data from the responder sample [36]. The same study stated an association between depression and sexual function [36] in addition to an increase in the perception of pain and enhanced pain catastrophizing [28]. In a case–control-study employing the PHQ-9 questionnaire [49], 12% of the CP/CPPS patient sample was diagnosed with a depressive disorder (control group: 3%) [45]. In fact, a recent analysis found that 24% of patients had clinically relevant depression [22]. Furthermore, the degree of depression significantly predicted CP/CPPS symptom severity [43,50] and patients' QoL [50]. Again, one study revealed an only slightly elevated PHQ-9 mean score suggestive of mild depressive symptoms but did not use a categorical score to diagnose depression [51]. In a Chinese sample of CP/CPPS patients [52] 6.5% had depression as assessed by the HADS questionnaire [53] (control group: 5.4%; significant difference). Similarly, a Korean study showed that CP/CPPS patients had an elevated HADS score compared to healthy controls [35]. In summary, all but one of the included studies revealed an association between depression and CPPS.

Beyond that, studies revealed only small treatment effects on depression. Neither the treatment with prednisolone [54] nor a physical activity training [55] was associated with changes in depression scores. Surprisingly, treatment with antidepressant drugs produced inconsistent results. While one CP/CPPS patient RCT (n = 14) investigating on the effects of sertraline on depression found no differences between the treatment and control groups [56], an observational study (n = 42) investigating the effects of fluoxetine showed a decrease in depression score after treatment [57].

(II) Anxiety and trauma-related disorders We found 11 studies which investigated the relationship between CP/CPPS and anxiety and trauma-related disorders. The general state of anxiety was higher in patients compared to their spouses and remained unchanged two years later [25]. In a Chinese sample, more than 60% of patients were diagnosed with an anxiety disorder using the HADS (control group: 15%) [52]. Elevated anxiety scores in CP/CPPS patients compared to healthy controls were also shown in another study which used the HADS [35] as well as in two studies [33,34] which used the Beck Anxiety Inventory [58]. A case–control-study reported a higher prevalence of any mental health diagnosis and a higher amount of prescribed medication for anxiety in CP/CPPS patients than in healthy controls [45]. Similarly, an additional study with a large sample investigated the existence of any anxiety disorder three years before CP/CPPS was diagnosed [59]. Anxiety disorders were 2.1 times more prevalent in patients than in controls. Another study [36] examined the association between CP/CPPS and traumatic experiences, but only a small number of participants reported any history of sexual or physical abuse. In contrast, a second study showed a high rate of abuse in child- and adulthood

336

Table 1 Overview of all included studies including study design, population and reported psychosocial factors Reference Author (year) number

Study design

Population

Psychosocial factor(s)a

Risk of bias: Detailsb

[71]

Giannantoni, Porena, Gubbiotti, Maddonni & Stasi (2014)

RCT, prospective sample

N = 38 Group 1 (age = 47.0 y); group 2 (age = 46.2 y)

Sampling (unclear): no data on a-priori-planning given Attrition (high): no data presented

[51]

Koh, Ko, Wang, Cho, Kim, Lee & Pae (2014)

12 weeks prospective observational study

N = 324 patients screened → n = 80 enrolled, n = 71 returned complete data; (mean age = 50 y)

[77]

Sung, Jung, Ryang, Kim & Kim (2014)

Retrospective review

[39]

Koh, Ko, Wang, Cho, Kim, Lee, Pae & Serretti (2014)

Prospective observational study: treatment with combination of alpha blocker, NSAID and antimicrobial agent

N = 111: n = 41 (IIIA), n = 71 (IIIB); (age IIIA = 54.9 y; age IIIB = 51.2 y) N = 66 (age range = 45 y–52 y)

(1) Tamsulosin + saw plamerto + duloxetine (2) Tamsulosin + saw plamerto for 16 weeks QoL [NIH-CPSI]: significantly reduced score Depression [HAM-D]: significantly reduced in group 1, but not in group 2 Anxiety [HAM-A]: significantly reduced in both groups (especially group 1) Medication: alpha-blockers, antimicrobials, antiinflammatories for 12 weeks Depression [PHQ-9] mild depression Somatization [PHQ-15] = mild symptoms QoL [EQ-5] lower than population norm Depression had a negative impact on treatment outcome, somatization had no significant influence Treatment using alfuzosin and levofloxacin for 6 weeks QoL [NIH-CPSI] decreased significantly in IIIA and IIIB

[89]

Vahdatpour, Alizadeh, Moayednia, Emadi, Khorami & Haghdani (2013)

RCT

[88]

Kim, Han, Cho, Lee, You, Park, Ryu & Lee (2013)

Prospective, open label, single arm study with 12 and 24 week follow-up

[25]

Tripp, Nickel, Shoskes & Koljuskov (2013)

Prospective study with 2 year follow-up

N = 44 (age 49 y, SD = 10) and their spouses (age = 48 y, SD = 11) →data from 21 completers were analyzed

[24]

Davis, Binik, Amsel & Carrier (2013)

Subgroup analysis

N = 171 (age = 44 y, SD = 14)

[66]

Davis, Binik, Amsel & Carrier (2013)

Prospective study

N = 162 (age = 44 y, SD = 14)

QoL [NIH-CPSI] reduced significantly in group 1 (but not in group 2) over time

Attrition (high): no data presented Other (high): inadequate measures were used Sampling (unclear): convenience sample with no control group Attrition (high): no data on nonresponder presented but high rate of refusals Other (unclear): data analysis unclear, a-priori-grouping may produce apparent differences Attrition (high): no data presented Other (high): inadequate measures were used

Sampling (unclear): it is not mentioned out of which population the sample was drawn Attrition (high): no data presented Physical HRQoL [SF-12] increased over time (p = .000) with Sampling (high): inclusion and exclusion criteria were not mentioned; unclear no differences between patients and spouses (p = .667) which patients were included. Mental HRQoL [SF-12] increased over time (.001) but patients report lower mental HRQoL than spouses (p = .05) Depressive symptoms [CES-D]: no changes over time (p = .256) but higher number of symptoms in patients (p = .054) Anxiety symptoms [STAI] were stable over time with more severe symptoms in patients (p = .34) Pain catastrophizing [PCS] was stable over time in patients (p = .47) Seven distinct clusters were defined — each with a different n.a. symptom presentation. Two clusters were characterized by high catastrophizing [PCS] and four clusters were characterized by poor mental QoL [SF36]. QoL [SF-36] was predicted by the psychosocial domain Attrition (unclear): n = 8 patients were (UPOINT; p b .001) and sexual domains (p b .05). excluded but their data were not reported Other (high): Psychosocial domain was rated “positive” when patients had a low SF-36 score, which was later used as a predictor variable. This leads to circular reasoning Extracorporeal magnetic stimulation QoL [NIH-CPSI]/QoL [IPSS] QoL significantly reduced/short and long terms


N = 40 Group 1 (intervention) (age = 35.4 y); group 2 (sham) (age = 37.0 y) N = 46 (age = 48.5 y; range = 26–74)

Neuroticism [BFI] may be the most important personality trait associated with treatment response Severity of depression [PHQ-9] and somatization [PHQ-9] depends on level of neuroticism

Sampling (unclear): convenience sample with no control group Attrition (high): no data on non-responder presented but high rate of refusals Other (unclear): parts of the data analysis may lead to circular reasoning

Sampling (unclear): sample consists of both patients with chronic symptoms and patients who have suffered for only a few weeks. Attrition (high): no data presented Other (high): diagnosis was given by one urologist, no quantification of a “positive” rating in the positive psychosocial domain n.a.

Zhao, Zhang, He & Zeng (2013)

Prospective study

N = 389 (age = 45 y, SD = 10)

Psychosocial domain (UPOINT) was rated positive in 42.4% of patients (complained of depression, catastrophizing or poor social interaction). QoL [NIH-CPSI] was low in the whole sample (8.42 SD = 2.38)

[59]

Chung & Lin (2013)

Case–control study

Diagnosis of an anxiety disorder [diagnosed by a psychiatrist] in the 3-year-anamnesis was 2.1 times higher in CPPS patients than in controls (p b .001)

[62]

Herati, Shorter, Srinivasan, Tai, Seideman, Lesser & Moldwin (2013)

Retrospective study

N = 32.352 (N = 8088 CPPS patients; N = 24,264 controls) (age range = 18–N70) N = 286 CPPS patients (age = 54 y; SD = 16)

[94]

Schneider, Tellenbach, Mordasini, Thalmann & Kessler (2013)

Prospective study with 5 year follow-up

N = 60 (age = 47 y)

Use of Transcutaneous electrical nerve stimulation improved QoL [NIH-CPSI] (p b .001)

[93]

Marx, Cimniak, Rütz & Resch (2013)

Randomized controlled trial

N = 19 (age range = 29–70)

QoL [NIH-CPSI] was improved (p b .005) in the treatment group (osteopathy) at 5 year follow-up

[61]

Lai, North, Andriole, Sayuk & Hong (2012)

Case–control study

n = 18 males (age = 44.8 y) and n = 13 controls (age = 45.7 y)

[81]

McLennan, Khourdaji, Killinger, Boura & Peters (2012)

Open-label, one-arm pilot study

[22]

Samplaski, Li & Shoskes (2012)

Review of clinical records of patients from a prospective database

N = 21 (screening) →n = 17 (beginning) →n = 13 (follow-up) (age = 48.2 y) N = 220 (age 44 y, SD = 13) →120 were categorized by UPOINT alone; 100 by UPOINT subdomain

DSM-IV Diagnosis of Somatization disorder was not comparatively more common in men with CPPS (but was in women) QoL [SF-12]: MCS/PCS remained unchanged Sampling (high): small sample size Attrition (high): no data on dropout patients (50% of the whole sample)

[35]

Ahn, Kim, Chung, Park, Cho & Kim (2012)

Prospective case–control study

[30]

Hedelin (2012)

Prospective study

[90]

Zeng, Liang & Ye (2012)


Increase in symptom severity was associated with increased consumption of alcohol (p b .010) except wine. Coffee consumption was not associated with a higher symptom severity [self-report questions]

Sampling (unclear): it is not mentioned out of which population the sample was drawn Attrition (high): no data presented Other (high): no quantification of rating for a positive psychosocial domain Sampling (high): restricted sample (young military personnel) Attrition (high): no data presented Other (high): inadequate measures were used

Sampling (unclear): restricted sample from general practitioners Other (high): diagnosis was given by one urologist; statistical analyses are not sufficient Other (high): inadequate measures were used (continued on next page)

337

The psychosocial domain in the UPOINT system was rated positive in 37.7% of the overall 220 patients. Analysis of 100 patients with subdomains shows 24% experienced depression [clinical diagnosis, current therapy] and 25% had pain catastrophizing cognitions [patients report feeling helpless/ hopeless] N = 55 (age = 23 y; SD = 3) and QoL [NIH-CPSI] was worse in patients compared to controls (p = .001). men without CPPS n = 58 Anxiety score [HAD] was higher in patients than in controls (age = 22 y; SD = 2) (p = .001). →Military personnel Depression score [HAD] was higher in patients than in controls (p = .013) Perceived stress [GARS] is higher in patients than in controls (p = .01) Stressful events [SRRS] did not occur more frequently in patients than in controls during the last year (p N .05) N = 61 (age = 46, SD 11) Pain catastrophizing: Based on the total score of the pain catastrophizing questionnaire [CSQ] patients were grouped as high or low catastrophizers. High catastrophizing patients showed a higher symptom score in the NIH-CPSI (p = 0.001) including a lower QoL [NIH-CPSI] (p = .02) N = 80 (age = 47 y) QoL [NIH-CPSI] was higher in the treatment group (extracorporeal shock wave; p b .001)

Sampling (high): no data on inclusion/ exclusion criteria. Composition of sample unclear Reporting (high): only parts of the data were presented Other (high): inadequate measures were used Attrition (high): no data presented on patients who refused to participate Other (high): inadequate measures were used Sampling (unclear): insufficient information given Attrition (unclear): only descriptive data were given Other (high): inadequate measures were used Sampling (high): small sample size


[64]

338

Table 1 (continued) Study design

Population



[96]

Gottsch, Yang & Berger (2011)

Pilot study; randomization of intervention vs. placebo

Botulinum toxin A vs. placebo QoL [NIH-CPSI] was slightly reduced in both groups

[80]

Chen, Wu, Liu, Tang, Zhao & Zhang (2011)

RCT, multicenter

N = 29: n = 13 (intervention) (age = 54 y; range = 25–80) n = 16 (placebo) (age = 47 y; range = 25–77) N = 100 (age (1) = 35.6 y; age (2) = 33.3 y)

[40]

Ginting, Tripp & Nickel (2011)

Prospective cohort study

N = 188 from the NIH CPC (age 49 y, SD = 11)

Spousal response [MPI] affected the impact of pain on disability: solicitous spousal response increase negative impact; distracting spousal response decreased the impact of pain on disability

[26]

Tripp, Nickel & Katz (2011)

Pilot study

N = 11 (age 51 y, SD = 12)

[52]

Zhang, Bai, Xu & Wang (2011)

Case–control-study

N = 77 patients (age 35 y, SD = 16) and 44 controls (age 33 y, SD = 14)

[57]

Xia, Wang, Chen, Wang & Jiang (2011)

Prospective pilot study

N = 42 (age = 35 y; SD = 8)

[76]

Nickel, O'Leary, Lepor, Caramelli, Thomas, Hill & Hoel (2011)

Double-blind placebo controlled Phase-II study

[72]

Kim, Kyung, Woo, Chang & Kim (2011)

Single-blinded, prospective study

N = 153 randomized → n = 52 Silodosin 4 mg (age = 49; SD = 13); n = 45 Silodosin 8 mg (age = 47; SD = 16); n = 54 Placebo (age = 49; SD = 12) N = 96 (age range = 20–49)

[83]

Pontari, Krieger, Litwin, White, Anderson, McNaughton-Collins, Nickel, Shoskes, Alexander, O'Leary, Zeitlin, Chuai, Landis, Cen, Propert, Kusek, Nyberg & Schaeffer (2010)

RCT, double blind, multi center study

Treatment protocol to reduce pain catastrophizing cognitions Pain catastrophizing [PCS] continuously decreased after session 4 (p = .039). QoL score [NIH-CPSI] decreased from baseline to follow-up (p = .013) QoL [NIH-CPSI] was lower in patients than in controls (6.5 vs. 1.3; p = .01) Anxiety [HADS] was higher in patients than in controls (10.3 vs. 3.5; p = .01); 62.3% clinically relevant Depression [HADS] was higher in patients than in controls (5.2 vs. 2.5; p = .05); 6.5% clinically relevant At follow-up after 12 weeks, QoL score [NIH-CPSI] and depression [BDI] decreased following a treatment with antidepressant fluoxetine QoL [NIH-CPSI] improved after 12 weeks in one treatment group (Silodosin 4 mg) compared to placebo (p = .001). Another QoL measure [SF-12] showed no differences in mental QoL between the groups (p = .62/.72) but a higher physical QoL in one treatment group (Silodosin 4 mg) compared to placebo (p = .049). QoL [NIH-CPSI, IPSS] increased over time in the first (ciprofloxacin) and in the second (ciprofloxacin + solifenacin) groups, but there were no significant differences between the groups. Pregabalin vs. placebo QoL [NIH-CPSI]/QoL [SF-12] QoL significantly reduced in both groups as measured by NIH-CPSI but not by SF-12

Sampling (high): small sample size Attrition (high): no data presented Other (high): inadequate measures were used Attrition (high): no intention-to-treat analysis Other (high): inadequate measures were used Sampling (high): inclusion and exclusion criteria were not mentioned; unclear which patients were included from the greater NIH-sample. Attrition (high): no data of nonresponders presented Sampling (high): small sample size Attrition (high): no intention-to-treat analysis

[14]

Shoskes, Nickel & Kattan (2010)

Review of clinical records of patients from a prospective database

[69]

Zhao, Yue, Yang, Wang, Wu & Li (2010)


N = 324: n = 218 (Pregabalin group; age = 48 y; 21–78); n = 106 (placebo; age = 42 y; range = 19–76) N = 100 split according to UPOINT subdomains (age 46 y, range 18–71)

N = 268 patients and n = 364 randomly approached persons from the general population (no mean of age presented, range 20–59)

Tamsulosin vs. placebo QoL [NIH-CPSI] slightly reduced in both groups

Patients were offered a treatment based on each positive UPOINT subdomain Psychosocial: patients were referred to a psychiatrist or psychologist for depression and stress management: 10 of 37 patients decided to use these treatment methods. QoL (NIH-CPSI) improved from 9.1 to 4.5 points. QoL was measured with two different instruments [EQ-5, SF-6D] showing a significantly better QoL in the general population compared to the patient sample (ps b .001)

Sampling (unclear): restricted sample (data of patients from one hospital; inclusion post-hoc) Attrition (high): no data presented

Sampling (unclear): insufficient information given Attrition (high): no data presented n.a.

Sampling (unclear): insufficient information given Attrition (high): no data presented n.a.

Attrition (high): no intention-to-treat analysis Other (high): inadequate measures were used; all patients diagnosed by one researcher Sampling (high): control group is not suitable. CPPS population is not as representative as other publications in the field Attrition (high): no data presented Other (high): inadequate measures and statistical analyses were used


Reference Author (year) number

QoL [NIH-CPSI] was improved (p b .001) with acupuncture. Follow-up was after 24 weeks

Tugcu, Tas, Eren, Bedirhan, Karadag & Tasci (2010)


N = 97 (no sample description available)

[91]

Zimmermann, Cumpanas, Miclea & Janetschek (2009)

Placebo controlled prospectively randomized double-blind phase 2 study

QoL [NIH-CPSI] decreased after extracorporeal shock wave N = 60 (age 42 y, range 22 to 52 in verum group; age 43 y, range 34 therapy, but data were only presented for the NIH-CPSI complete sumscore to 61 in placebo group)

[33]

Anderson, Orenberg, Morey, Chavez & Chan (2009)

Experimental study

N = 60 patients (age 43 y, range 20–76) and 30 controls (age 42 y, range 23–66)

[92]

Marx, Cimniak, Beckert, Schwerla & Resch (2009)


N = 35 (age range = 29–70)

[31]

Hedelin (2009)

Evaluation of clinical data

N = 50 (age 46 y, range = 26–71)

[95]

Wagenlehner, Schneider, Ludwig, Schnitker, Brähler & Weidner (2009)

N = 139 (age = 39 y; SD = 8)

[78]

Zhao, Zhang, Li, Yu, Rui, Li & Ding (2009)

Randomized, prospective, double-blind, placebocontrolled study Randomized, placebocontrolled trial

[34]

Anderson, Orenberg, Chan, Morey & Flores (2008)

Experimental study

N = 45 patients (age 43 y, range 21–70) and 20 controls (age 44 y, range 23–66)

[45]

Clemens, Brown & Calhoun (2008)

Case–control-study

N = 174 (age 52 y, range 24–90) and 72 controls (age 68 y, range 34–91); the two groups differed significantly in age (p = .0001)

N = 64 (age range 18 y to 58 y)

QoL [NIH-CPSI] lower in patient than in controls (9 vs. 0.5; p = .001) Anxiety [BAI] was higher in patients than in controls (9.5 vs. 2; p = .001) General psychological state [BSI] was worse in patients than in controls in the global score (94th vs. 49th percentile; p = .001) as well as every subdomain Patients showed an altered response to acute stress. The total response curve for the endocrine variables suggested a 30% lower response in patients compared to controls (p = .038) QoL was improved [NIH-CPSI] (p b .0005) in the treatment group (osteopathy) at an 18 month follow-up The psychosocial domain of the UPOINT system was rated positive in 36% of the sample. Pain catastrophizing [CSQ] and the total symptom score [NIH-CPSI] were linked (r = .61)

Sampling (unclear): it is not mentioned out of which population the sample was drawn; no patient flow chart Attrition (high): no intention-to-treat analysis; only complete cases were used Other (high): inadequate measures were used Sampling (unclear): it is not mentioned out of which population the sample was drawn; no patient flow chart Attrition (high): no data presented Reporting (high): incomplete and insufficient data analysis. Conclusions were drawn without presenting sufficient data. Other (high): inadequate measures were used n.a.

Other (high): inadequate measures used

Sampling (unclear): selected sample from general practitioners Attrition (high): no data presented Reporting (unclear): incomplete reporting of data/statistical analysis Other (high): diagnosis was given by one urologist; statistical analyses are not sufficient QoL (NIH-CPSI) improved in both groups with a significantly Other (high): inadequate measures used higher impact in the treatment group (pollen extract) after 12 weeks of treatment QoL (NIH-CPSI) increased during treatment (Celecoxib) but Sampling (unclear): insufficient decreased after the end of treatment. information given Other (high): inadequate measures were used Anxiety [BAI] was higher in patients than in controls (p = .0004) Attrition (unclear): no data on patients presented who did not agree to General psychological state [BSI] was worse in patients than in controls in the global score (93rd vs. 48th percentile; p = .0001) participate. Other (unclear): there was no adequate as well as every subdomain Patients perceived themselves as having more stress compared to control of time and method of patients self administered daily saliva sample controls (p = .0004). The awaking cortisol response was significantly increased in patients (p = .05) Depression [PHQ-9] was diagnosed more often in patients than in Attrition (high): no data presented Other (unclear): no validation of controls (12% vs. 8%; p = .02) Panic disorder [PHQ] was not diagnosed significantly more in one diagnosis besides screening of both groups (p = .18) Patients were more often likely to be diagnosed with any mental health disorder compared to controls (13% vs. 4%; p = .03) Patients consumed more medication for anxiety, depression or

339

(continued on next page)


[87]

340

Table 1 (continued) Study design

Population

[36]

Aubin, Berger, Heiman & Ciol (2008)


N = 72 patients (age 41 y, range SD = 10). There was a control group but no comparison of psychosocial variables was reported.

[27]

Prospective cohort study Nickel, Tripp, Chuai, Litwin, McNaughton-Collins, Landis, Alexander, Schaeffer, O'Leary, Pontari, White, Mullins, Nyberg, Kusek & NIH-Study-Group (2008)

N = 253 from the NIH CPC study (age 45 y, SD = 11)

[42]

Bartoletti, Cai, Mondaini, Dinelli, Pinzi, Pavone, Gontero, Gavazzi, Giubilei, Prezioso, Mazzoli, Boddi, Naber & IPSG (2007)

Case–control observational study

N = 764 CPPS patients (age 35 y, range 24–43) and 152 controls (age 36 y, range 28–41); both groups were urological hospital outpatients

[63]

Hedelin & Jonsson (2007)

Prospective study

N = 48 (age 50 y range 27–70)

[60]

Hu, Link, McNaughton-Collins, Barry & McKinlay (2007)

Population based, random sample epidemiological survey (BACH study)

N = 2301 (sample was recruited stratified by age 30 y–79 y, gender and ethnicity)

[41]

Smith, Tripp, Pukall & Nickel (2007)


N = 38 patients (age 49 y, SD = 9.6) and their partners (age 47 y, SD = 11)

[48]

Smith, Pukall, Tripp & Nickel (2007) →same sample as in Smith, Tripp, Pukall & Nickel (2007)


N = 38 patients (age 49 y, SD = 9.6) and their partners (age 47 y, SD = 11)

Psychosocial factor(s)a stress than controls (18% vs. 7%, p = .03) Physical component score and mental component score of HrQoL [SF-16] were slightly lower than the normative data (44 points both) Mean depression score [CES-D] is below the threshold score for depression (mean score = 14) Half of the sample believed that stress worsened pain, but coping strategies did not differ from normative data Reported sexual or physical abuse in history was minimal (8 and 6 points respectively) Poor physical HRQoL [SF-12] was predicted by worse urinary functioning (p = .001) and more pain contingent resting (p = .026). Mean QoL-score in patients was slightly lower than in the general population (47.4 compared to 50) Poor mental HRQoL [SF-12] was predicted by greater pain catastrophizing, especially helplessness (p = .002) and low social support, especially from family and friends (p = .001). Mean QoL-score was slightly lower than in the general population (45.7 compared to 50) Mean depression score [CES-D] of 13.9 is comparable to the psychiatric norm sample (13.5) and is higher than in the general population (9.3) Cigarette smoking was more common in patients than in controls (p = .004) Alcohol consumption was similar in both groups (p = .52) Patients had a higher intake of unhealthy food (p = .001) and a lower intake of fruits and vegetables (p = .001) Patients had a higher rate of having sexual relationship with more than one partner (p = .001). QoL was impaired in patients as measured by two instruments [NIH-CPSI: 7.2 vs. 0.2, p = .001; IPSS: 3.6 vs. 0.9, p = .001] QoL [NIH-CPSI] was decreased in 42% of the sample (score N 4). Age was a predictor of QoL (t = −2.2, p = .0036) with higher age being associated with a higher QoL

Sexual/physical/emotional abuse in childhood was associated with increased odds of having symptoms suggestive of CPPS (OR = 1.75 CI = .92–3.26/1.97 CI = 1.14–3.41/2.19 CI = 1.15–4.16) Adult Sexual/physical/emotional abuse was associated with increased odds of having symptoms suggestive of CPPS (OR = 1.89 CI = .93–3.83/3.29 CI = 1.81–5.98/2.60 CI = 1.37–4.95). The higher the number of different types of abuse, the more increased was the OR for having CPPS An increase in pain severity predicted sexual function. A decrease in sexual function predicted sexual dissatisfaction [GRISS]. Relationship adjustment [DAS] was predicted by sexual functioning and the level of satisfaction of the couple. Mean depression score [CES-D] in patients was 15.2 and was significantly greater than in male controls (7.9, p = .001) Symptoms of depression moderated sexual dysfunction


Sampling (high): subgroup out of larger observational study but inclusion criteria are not stated Attrition (high): no intention-to-treat analysis

Sampling (high): subgroup out of larger study but inclusion criteria are not stated (only 52% of the original sample is included)

n.a.

Sampling (unclear): selected sample from general practitioners Attrition (high): no data presented Other (high): no validation of diagnosis; statistical analyses are not sufficient; inadequate measures were used n.a.

Sampling (high): small sample, no control group Attrition (high): no data presented

Sampling (high): small sample, no control group Attrition (high): no data presented


Reference Author (year) number

Bates, Hill, Anderson, Chapple, Spence, Ryan & Talbot (2007)

[55]

Giubilei, Mondaini, Minervini, Saieva, Lapini, Serni, Randomized controlled Bartoletti & Carini (2007) trial

N = 231 (age range = 20–50)

[84]

Capodice, Jin, Bemis, Samadi, Stone, Kapan & Katz (2007)

Pilot study

N = 10 (median age = 36; range = 29 to 63)

[28]

Tripp, Nickel, Wang, Litwin, McNaughton-Collins, Landis, Alexander, Schaeffer, O'Leary, Pontari, Fowler, Nyberg, Kusek & NJI-CPCRN study group (2006)


N = 253 from the NIH CPC study (age 45 y, SD = 11)

[43]

Clemens, Brown, Kozloff & Calhoun (2006)

Retrospective cohort study

[68]

Propert, McNaughton-Collins, Leiby, O'Leary, Kusek, Litwin & CPCRN study group (2006)

[97]

Leippold, Strebel, Huwyler, John, Hauri & Schmid (2005)

Prospective longitudinal study with 1 year and 2 year follow-ups Pilot study

N = 174 from the database of a tertiary care facility (age = 52 y, range 23–89) N = 293 (age = 42 y, SD = 11) Only patients who completed follow-up of the NIH CPC-study N = 14 (age = 49 y, range = 26–65)

[73]

Randomized controlled Nickel, Forrest, Tomera, Hernandez-Graulau, Moon, Schaeffer, Krieger, Zeitlin, Evans, Lama, Neal trial & Sant (2005) Case control study Pontari, McNaughton-Collins, O'Leary, Calhoun, Jang, Kusek, Landis, Knauss, Litwin & CPCRN study group (2005)

N = 100 (age range = 18–50)

[37]

Ullrich, Turner, Ciol & Berger (2005)

Longitudinal study

N = 224 (age = 47 y, SD = 10)

[56]

Lee, West & Wilson (2005)


N = 14 (age range = 18–65)

[86]

Honjo, Kamoi, Naya, Ukimura, Kajima, Kitakoji & Miki (2004)

Pilot study

N = 10 (age 32 y, SD 10)

N = 463 No other details provided

Female partners also showed higher depression scores than female controls (12.6 vs. 6.6; p = .01) There were no significant differences found in anxiety and depression [HADS] as well as in QoL [NIH-CPSI] between treatment (prednisolone) and control groups at 3 and 12 month follow-up.

Physical activity increased QoL [NIH-CPSI] in the treatment group (aerobic exercise) after 18 weeks (p = .02). There were no differences found in anxiety [SAI-Y] and depression scores [BDI]. QoL [NIH-CPSI] increased from baseline to follow-up after 12 weeks following six weeks of acupuncture. Scores in half of all scales of the QoL instrument [SF-36] increased but not the subset mental health (p = .066). Overall pain was predicted by depression [CES-D] (β = .24; p = .002) and helplessness catastrophizing [PCS] (β = .26; p = .001). Social support [MSPPS] and solicitous responses from others [MPI] showed no influence on pain (MSPPS: β = −.05; p = .546/MPI: β = .07; p = .228) Symptom severity was predicted by higher depression [PHQ-9] (β = .19; p = .004) and lower education (β = −.17; p = .007) QoL score [NIH-CPSI; SF-12] increased slightly over time but no statistical comparison was reported QoL [NIH-CPSI] did not improve during treatment. Only descriptive statistics were reported.

QoL [NIH-CPSI] was increased in the treatment group (Pentosan Polysulfate Sodium; p = .031) from baseline compared to 16 week follow-up. CPPS patients were more likely to drink alcohol (p = .02) and caffeinated beverages (p b .001) than controls but did not smoke more cigarettes (p = .37) (self-report questions). Furthermore, they reported having more psychiatric conditions (p b .001) Greater perceived stress [PSS] predicted higher pain intensity (PSS; p = .03) and higher pain-related disability (p = .003) at 12 months. Depression [HADS] scores did not differ between the treatment (antidepressant sertraline) and control groups (p = .3) QoL score [NIH-CPSI] decreased from 7.6 before treatment (acupuncture) to 4.6 one week after treatment (p = .001);

Sampling (unclear): it is not mentioned out of which population the sample was drawn; small sample size Attrition (high): no intention-to-treat analysis Reporting (high): Follow-up was not reported. Only mean scores, no diagnosis of depression/anxiety Other (high): inadequate measures were used. Attrition (high): no intention-to-treat analysis

Sampling (high): small sample size

n.a.

Sampling (high): retrospective measures with only 35% responders Attrition (high): no data presented Attrition (high): no intention-to-treat analysis, but withdrawals revealed higher symptom scores Sampling (high): it is not mentioned out of which population the sample was drawn; small sample size Attrition (high): no data presented Other (high): inadequate measures were used. Other (high): inadequate measures were used.


[54]

[46]


Healthy control participants: n = 37 (age 45 y SD = 8) and their partners (age 43 y, SD = 7) N = 21 (age = 41 y, age range = 18–65)

Attrition (high): no data presented

n.a.

Sampling (high): small sample size

Sampling (high): it is not mentioned out of which population the sample was drawn; small sample size Attrition (high): no data presented Other (high): inadequate measures were used. 341

(continued on next page)

342

Table 1 (continued) Reference Author (year) number

Study design

Population


N = 463 (range = 20–83)

Symptom severity was predicted by higher depression [questionnaire not mentioned] (p b .001).

N = 58 (age = 41 y; range = 21 to 56) N = 12 (age 42 y; range 26 to 57)

QoL [NIH-CPSI] improved (p = .02) in the treatment group (alpha antagonist) QoL score [NIH-CPSI] decreased from 8.8 before treatment (acupuncture) to 2.3 approximately 33 weeks after treatment (p = .001);

Tripp, Nickel, Landis, Wang, Knauss & CPCRN study Retrospective study group (2004)

Attrition (high): no data presented Other (high): depression was measured with one question; parts of the data analysis may lead to circular reasoning Patients who reported ejaculatory pain symptoms in each of Attrition (high): no data presented N = 486 from the NIH CPC-study the 3 monthly follow-up contacts showed lower QoL [SF-12] (average ages for the 4 subgroups ranged between 40.3 y and 46.9 y) than those with no ejaculatory pain (p b .001) N = 196 (age = 45 y; SD = 6.2) No differences in QoL [SF-12, NIH-CPSI] between treatment n.a. (ciprofloxacin or tamsulosin) and control groups at baseline and after 6 weeks.

[70]

Shoskes, Landis, Wang, Nickel, Zeitlin, Nadler & CPCRN study group (2004)

Longitudinal cohort study

[79]


[75]

Alexander, Propert, Schaeffer, Landis, Nickel, O'Leary, Pontari, McNaughton-Collins, Shoskes, Comiter, Datta, Fowler, Nadler, Zeitlin, Knauss, Wang, Kusek, Nyberg, Litwin & CPCRN research group (2004) Nickel, Narayan, McKay & Doyle (2004)

[85]

Chen & Nickel (2003)

Randomized controlled trial Pilot study

[98]

Hochreiter, Danuser, Weidner & Studer (2003)

Prospective study

N = 104 (age = 44 y, range = 23–71)

There was no difference found in QoL [NIH-CPSI] between CPPS IIIa and IIIb patients.

[82]

Mehik, Alas, Nickel, Sarpola & Helström (2003)

Prospective, randomized, double-blind, placebocontrolled pilot study

N = 70 (age range = 20 to 70)

Neither after 6 months of treatment (alfuzosin) nor after 6 months follow-up, did QoL [NIH-CPSI] change significantly in any group (p N .05).

[38]

Turner, Hauge, Von Korff, Saunders, Lowe & Berger Prospective cohort study (2002)

N = 357 (age range = 18–65)

QoL [SF-36] was lower in CPPS patients compared to the reference sample (p b .001). CPPS patients showed less perceived stress [PSS; p values not mentioned]

[67]

Mc Naughton Collins, Pontari, O'Leary, Calhoun, Santanna, Landis, Kusek & Litwin (2001)

CPS-study: cohort study →Data from the first 278 pt.

N = 278 (age = 42.4 y)

QoL [SF-12] PCS predicted by symptoms QoL [SF-12] MCS predicted by pain/urinary/history of psychiatric disease QoL [NIH-CPSI predicted by education, income, pain disease in history]

[74]

Nickel, Johnston, Downey, Barkin, Pommerville, Gregoire & Ramsey (2000)

Prospective, open-label, multicenter phase II pilot study

N = 32 → n = 28 evaluated → (age of N = 32 participants = 45.5 y)

QoL [NIH-CPSI]: 54% improved QoL N 25%

Other (high): inadequate measures were used. Sampling (high): it is not mentioned out of which population the sample was drawn; small sample size Attrition (high): no data presented Other (high): inadequate measures were used. Sampling (unclear): insufficient information given Attrition (high): no data presented Reporting (unclear): insufficient information on data collection Other (high): inadequate measures were used. Sampling (unclear): consecutive sample without a-priori-power-analysis Attrition (high): no intention-to-treat analysis Other (high): inadequate measures and statistical procedures were used. Sampling (high): retrospective measures with 37% refusals. Included patients had low rate of chronic symptoms Attrition (high): no data presented Sampling (high): subgroup out of larger study but inclusion criteria are not state (only 50% of the original sample included without stating the inclusion criteria) Attrition (high): no data presented Other (high): inadequate measures

Note: QoL (NIH-CPSI) = high score indicates low QoL. Mean age is presented in years (y). n.a. = not applicable. Abbreviations of instruments: NIH-CPSI = National Institutes of Health Chronic Prostatitis Symptom Index; SF-36/SF-12/SF-6D = Short Form Health Survey; CES-D = Center for Epidemiologic Studies Depression Scale; STAI = State-Trate Anxiety Inventory; PCS = Pain Catastrophizing Scale; CSQ = Coping Strategies Questionnaire; MPI = Multidimensional Pain Inventory; HADS/HAD = Hospital Anxiety and Depression Scale; BDI = Beck Depression Inventory; IPSS = International Prostate Symptom Score; EQ-5 = EuroQol; BAI = Beck Anxiety Inventory; BSI = Brief Symptom Inventory; PHQ-9 = Patient Health Questionnaire (Depression); PHQ-15 = Patient Health Questionnaire (Somatization); GRISS = Golombok-Rust Inventory of Sexual Satisfaction; DAS = Dyadic Adjustment Scale; SAI-Y = State Anxiety Inventory-Y; PSS = Perceived Stress Scale; MSPPS: Multidimensional Scale of Perceived Social Support; GARS = Global Assessment of Recent Stress; SRRS = Social Readjustment Rating Scale; BFI = Big Five Inventory; HAM-D = Hamilton Rating Scale for Depression; Ham-A = Hamilton Rating Scale for Anxiety. a Measurement instrument(s) in brackets. b Only high or unclear risk of bias in each category (sampling, attrition, reporting, other) is presented.


[50]



343

Table 2 Distribution of psychosocial factors and psychiatric co-morbidities in each study. Author (year) [number in references]

1. Psychological aspects

2. Psychiatric co-morbidity

3. Quality of Life

(2) Stress (3) Personality (4) Social (I) Depression (II) Anxiety (III) Somatization (IV) substance (1) Pain factors aspects Disorders Disorder abuse catastrophizing cognitions Giannantoni et al. (2014) [71] Koh et al. (2014) [51] Sung et al. (2014) [77] Koh et al. (2014) [39] Vahdatpour et al. (2013) [89] Kim et al. (2013) [88] Tripp et al. (2013) [25] Davis et al. (2013) [24] Davis et al. (2013) [66] Zhao et al. (2013) [64] Chung & Lin (2013) [59] Herati et al. (2013) [62] Schneider et al. (2013) [94] Marx et al. (2013) [93] Lai et al. (2012) [61] McLennan et al. (2012) [81] Samplaski et al. (2012) [22] Ahn et al. (2012) [35] Hedelin (2012) [30] Zeng et al. (2012) [90] Gottsch et al. (2011) [96] Chen et al. (2011) [80] Ginting et al. (2011) [40] Tripp et al. (2011) [26] Zhang et al. (2011) [52] Xia et al. (2011) [57] Nickel et al. (2011) [76] Kim et al. (2011) [72] Pontari et al. (2010) [83] Shoshkes et al. (2010) [14] Zhao et al. (2010) [69] Tugcu et al. (2010) [87] Zimmermann et al. (2009) [91] Anderson et al. (2009) [33] Marx et al. (2009) [92] Hedelin (2009) [31] Wagenlehner et al. (2009) [95] Zhao et al. (2009) [78] Anderson et al. (2008) [34] Clemens et al. (2008) [45] Aubin et al. (2008) [36] Nickel et al. (2008) [27] Bartoletti et al. (2007) [42] Hedelin et al. (2007) [63] Hu et al. (2007) [60] Smith et al. (2007) [41] Smith et al. (2007) [48] Bates et al. (2007) [54] Giubilei (2007) [55] Capodice (2007) [84] Tripp et al. (2006) [28] Clemens et al. (2006) [43] Propert et al. (2006) [68] Leippold et al. (2005) [97] Nickel et al. (2005) [73] Pontari et al. (2005) [46] Ullrich et al. (2005) [37] Lee et al. (2005) [56] Honjo et al. (2004) [86] Tripp et al. (2004) [50] Shoskes et al. (2004) [70] Alexander et al. (2004) [79] Nickel et al. (2004) [75] Chen & Nickel (2003) [85] Hochreiter et al. (2003) [98] Mehik et al. (2003) [82] Turner et al. (2002) [38] McNaughton -Collins et al. (2001) [67] Nickel et al. (2000) [74]

✓ ✓

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

✓

✓ ✓

✓

✓

✓ ✓ ✓ ✓ ✓ ✓ ✓

✓ ✓

✓

✓

✓

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

✓

✓ ✓ ✓ ✓ ✓ ✓ ✓

✓

✓ ✓ ✓ ✓ ✓

✓

✓ ✓ ✓ ✓ ✓ ✓

✓ ✓

✓ ✓ ✓

✓ ✓

✓

✓ ✓ ✓ ✓

✓ ✓ ✓ ✓ ✓ ✓

✓ ✓

✓ ✓

✓ ✓ ✓

✓ ✓ ✓ ✓ ✓ ✓

✓ ✓ ✓ ✓

✓

✓ indicates that the effect of this psychosocial factor above was investigated in the publication.

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

344


Fig. 2. Complete overview of “risk of bias” (n = 69 studies): Proportion of studies with high (red), low (green) or unclear (yellow) risk of bias.

in CP/CPPS patients [60]. Symptoms suggestive of CP/CPPS were more likely to be present when any abuse was reported. Only 6% of CP/CPPS patients in a case–control study were found to have panic disorder, which was not statistically significantly different compared to healthy controls [45]. Only two treatment studies measured the level of anxiety as an outcome. Neither prednisolone [54] nor physical activity training [55] was associated with a decrease in anxiety. (III) Somatization disorder There was only one study which investigated somatization disorder and another one focused on somatization in CP/CPPS. A case–control-study revealed no higher rates of somatization disorder in CP/CPPS patients compared to age matched non-CP/CPPS controls [61]. The second study employed the somatization module of the Patient Health Questionnaire and revealed a mean score indicative of mild somatization symptoms [51]. The level of somatization was associated with the level of neuroticism [39]. (IV) Substance abuse Only 3 studies referred to substance consumption. CP/CPPS patients used more alcohol and caffeine [46] compared to controls. Consistent with that, higher symptom severity was associated with increased consumption of alcohol and coffee [62]. Results about cigarette consumption were inconsistent [42,46]. Quality of Life A common factor associated with CP/CPPS was low Quality of Life (QoL) and it was investigated in 49 publications. QoL was defined and measured in different ways. Most often patient's subjective lower QoL was measured using the QOL items from the NIH-CSPI [34,35,42,52,63,64]. While this is a simple measure of QoL, other studies employed more sophisticated definitions and operationalized them with generic instruments: A recent evaluation used the SF-36 [65] and found a rate of 44% of patients complaining of low wellbeing [66]. Other studies using the SF-36/SF-12 reported slightly lower QoL scores in patients than the general population [27,36,38,67]. Results of two studies with a 2year-follow-up suggested an increase of QoL over time [25,68], but the increase in mental QoL was lower in patients compared to their spouses [25]. Results of two studies using different QoL measures suggested a greater impairment in CP/CPPS patients' QoL compared to healthy controls and compared to the general population [67,69]. Furthermore, CP/CPPS and post-ejaculatory pain were associated with low QoL [70]. In addition, a clusteranalysis of different types of patients found that four out of seven clusters were defined by poor QoL [24]. All of the aforementioned results suggest that CP/CPPS is associated with a remarkable impairment in QoL. An increase in QoL is, therefore, an important therapeutic goal: Research on antibiotics, adrenoceptor antagonists, anti-inflammatory drugs, sodium, alpha-receptor antagonists and SSRI shows an increased QoL after treatment [57,71–78]. The effect was not, however, always stable over time without treatment. Previous drug studies did not show an increase in QoL after treatment with medications including glucocorticoids, antibiotics and alpha-receptor antagonists [54,79–82]. In addition, one study

revealed different outcomes depending on how QoL was measured: while the QoL score of the NIH-CPSI increased with treatment, the SF-12 score remained unchanged on a low level [83]. Other treatment options, like psychotherapy [14,26], acupuncture [84–87], extracorporeal shock waves [88–91], osteopathy [92,93], electrical nerve stimulation [94], physical activity [55] or pollen extract [95], also showed a positive effect on QoL. In contrast, the injection of botulinum toxin A had a small effect on QoL [96] and sacral magnetic stimulation [97] was not shown to increase QoL. All in all, there is strong evidence of an association between QoL and symptom severity, however, there was no evidence of differences between CP/CPPS patients with categories IIIA and IIIB [98]. Assessment of bias The included 69 studies revealed a considerably high risk of bias. Only ten studies were rated as having a low risk of bias in all categories (sampling bias, attrition bias, reporting bias and other bias) [24,28,33,37,42,59,60,76,79,83]. Main shortcomings were found in the recruitment of the study samples, e.g. the selection of patients remains unclear or was very specific. Furthermore, most authors did not report how they dealt with missing or dropout data. A major shortcoming has also been found in the measurements. Most often, QoL was only assessed with few questions from the NIH-CPSI instead of using a comprehensive QoL instrument. Another risk of bias evolved from the use of non-validated diagnosis, i.e. only by questionnaires. A summary of the overall rating of the “risk of bias” across all studies is depicted in Fig. 2. The risk of bias for each study is shown in Table 3 (Figs. 3–5).

Discussion To our knowledge, our review is the first to give a comprehensive overview of the current body of work investigating psychosocial factors in CP/CPPS. Altogether we included 69 studies and by systematically reviewing their results, their study design and risk of bias we provide a current literature synthesis. One of the major results is that the current literature emphasizes the association between psychological aspects (pain catastrophizing, stress and personality factors) and social aspects (namely relationship functioning) and CP/CPPS. For example, there is strong evidence that pain catastrophizing has an influence on symptom severity. In accordance with that data, pain catastrophizing is already included in the EAU guidelines [20] and a specific cognitive–behavioral treatment has been developed [17]. In contrast, data on the influence of stress on CP/CPPS are inconsistent. In addition, spousal response and social


345

Table 3 Summary of risk ratings for each included study. Risk of each type of bias is shown by a + (low risk), ? (unclear risk) or - (high risk), representing the risk rating. Author (year) [number in references]

Sampling Bias

Attrition Bias

Reporting Bias

Other Bias

Giannantoni et al. (2014) [71] Koh et al. (2014) [51] Sung et al. (2014) [77] Koh et al. (2014) [39] Vahdatpour et al. (2013) [89] Kim et al. (2013) [88] Tripp et al. (2013) [25] Davis et al. (2013) [24] Davis et al. (2013) [66] Zhao et al. (2013) [64] Chung & Lin (2013) [59] Herati et al. (2013) [62] Schneider et al. (2013) [94] Marx et al. (2013) [93] Lai et al. (2012) [61] McLennan et al. (2012) [81] Samplaski et al. (2012) [22] Ahn et al. (2012) [35] Hedelin (2012) [30] Zeng et al. (2012) [90] Gottsch et al. (2011) [96] Chen et al. (2011) [80] Ginting et al. (2011) [40] Tripp et al. (2011) [26] Zhang et al. (2011) [52] Xia et al. (2011) [57] Nickel et al. (2011) [76] Kim et al. (2011) [72] Pontari et al. (2010) [83] Shoshkes et al. (2010) [14] Zhao et al. (2010) [69] Tugcu et al. (2010) [87] Zimmermann et al. (2009) [91] Anderson et al. (2009) [33] Marx et al. (2009) [92] Hedelin (2009) [31] Wagenlehner et al. (2009) [95] Zhao et al. (2009) [78] Anderson et al. (2008) [34] Clemens et al. (2008) [45] Aubin et al. (2008) [36] Nickel et al. (2008) [27] Bartoletti et al. (2007) [42] Hedelin et al. (2007) [63] Hu et al. (2007) [60] Smith et al. (2007) [41] Smith et al. (2007) [48] Bates et al. (2007) [54] Giubilei (2007) [55] Capodice (2007) [84] Tripp et al. (2006) [28] Clemens et al. (2006) [43] Propert et al. (2006) [68] Leippold et al. (2005) [97] Nickel et al. (2005) [73] Pontari et al. (2005) [46] Ullrich et al. (2005) [37] Lee et al. (2005) [56] Honjo et al. (2004) [86] Tripp et al. (2004) [50] Shoskes et al. (2004) [70] Alexander et al. (2004) [79] Nickel et al. (2004) [75] Chen et al. (2003) [85] Hochreiter et al. (2003) [98] Mehik et al. (2003) [82] Turner et al. (2002) [38] McNaughton-Collins et al. (2001) [67] Nickel et al. (2000) [74]

? ? + ? + ? − + + ? + − + ? − − ? − ? + − + − − ? ? + ? + + − ? ? + + ? + ? + + − − + − + − − − + − + − + − + + + − − + + + + − ? ? − − +

− − − − − − + + ? − + ? − ? + − − − + + − − − − − − + − + − − − − + + − + + ? − − + + − + − − − − + + − − − + − + + − − − + + − − − − − +

+ + + + + + + + + + + − + + + + + + + + + + + + + + + + + + + + − + + ? + + + + + + + + + + + − + + + + + + + + + + + + + + + + ? + + + +

+ ? − ? − + + + − − + − − − + + − − − − − − + + + + + + + − − − − + − − − − ? ? + + + − + + + − + + + + + − − + + + − − + + − − − − + + −

interaction play an important role, e.g. concerning the subjective feeling of disability. Consistent with other research about the influence of spousal response on pain [99,100], a solicitously responding partner seems

to have a negative impact on pain. Since 1999, surprisingly little research has been done on the association between personality factors and CP/CPPS. It would be useful to examine this area further in men as

346


Fig. 3. Overview of “risk of bias” for category, “psychosocial factors”. Given there is only one study included the sub-category “personality factors” is omitted.

there is promising research regarding potential deficits in the psychic structure of female CP/CPPS patients such as poor experiences with bonding in early childhood and resulting problems in the ability to mentalize [101,102]. In the past, some efforts were made to determine whether personality pathologies in women [103] as well as in men [104] are underlying pathogenic mechanisms in CP/CPPS. Moreover, incidents of incest or other sexual assaults in child- or adulthood have been shown to be an important variable in the development of personality pathology [103,105]. In particular, the examination of the impact of personality factors (e.g. neuroticism, affect regulation), experienced abuse, social interaction (e.g. spousal response) and stress on CP/CPPS patients needs more attention. In addition to the adaption of pain specific treatment approaches [18] on CP/CPPS patients, the improvement of stress management could also be a possible goal in therapy. Another important result of our review is the examination of the role of psychiatric co-morbidities. The majority of the included studies show evidence of an elevated prevalence of depression and general anxiety in CP/CPPS patients compared to controls but this is not true for panic disorders. Results regarding the impact of traumatic experiences (e.g. physical or sexual abuse) are inconsistent. Other possible co-morbidities are somatoform type disorders, but only one study addressed this question. Unlike female patients, where this question arose already some years ago [106], clinicians and researchers should pay more attention to somatoform disorders as a possible explanation in subgroups of male CP/CPPS patients. Furthermore, the small numbers of results regarding the relationship between substance abuse and CP/CPPS symptoms are both partly inconsistent and associated with a high risk of bias (e.g. sampling and measures). Altogether, the existing data suggests a high importance of psychiatric diseases which are not currently reflected in treatment approaches. Surprisingly, nearly none of the employed non-psychiatric treatment strategies were able to reduce the elevated level of depression and

anxiety. Specific treatment approaches are needed that address the aforementioned psychosocial deficiencies and focus on co-morbid psychiatric disorders. This leads to the assumption that more research with large samples and adequate methods of diagnosis is necessary to gain greater insight into co-morbidities and to tailor psychological and psychiatric interventions accordingly. Furthermore, the causality of these psychiatric symptoms has not yet been investigated. Only one study was able to show a higher rate of anxiety in the years before CP/CPPS was diagnosed compared to healthy controls. Therefore, research should also concentrate on clarifying whether psychiatric diseases occur first or are the result of the burden of CP/CPPS symptoms. Most of our included studies reported consistently low levels of QoL in CP/CPPS patients. This might change when patients undergo treatment. Consistent with our results, a recent meta-analysis on the efficacy of different drug treatments for the management of CP/CPPS revealed a modest to low effect on patients' QoL [107]. The low QoL of CP/CPPS patients is an important issue that should be addressed by an interdisciplinary approach. A great number of studies revealed a considerably high risk of bias, especially with respect to the sampling of patients and the quality of the applied measures. Another widespread risk of bias was reported in a study about socially desirable responding [108]. The authors observed the tendency that men want the clinician to understand their suffering by presenting more severe symptoms which ultimately results in higher NIH-CPSI scores. Our review provides a comprehensive overview of the current literature regarding possible psychological and social factors, psychiatric comorbidities and quality of life. Considering our results, we recommend extending the “Psychosocial” UPOINT domain. While the psychological aspects – except the personality factors – are already addressed, psychiatric co-morbidities should also be properly considered. There is a need for a better diagnosis of highly prevalent co-morbidities beyond


347

Fig. 4. Overview of “risk of bias” for the category, “psychiatric co-morbidity”.

depression, namely anxiety, somatization disorders and substance abuse. In addition, the role of prior traumatic experiences as a possible way of understanding the underlying mechanism of CP/CPPS in men has also been neglected. In conclusion, a broader approach to rate the “P-domain” is necessary to guide patients in specifically tailored treatment approaches according to the relevant psychological factors and psychiatric co-morbidities. In summary, the influence of psychological and social aspects as well as psychiatric co-morbidities in the course of CP/CPPS seems to be underestimated and underrepresented in current research. Therefore, it is critical that high quality research is conducted in the future which focuses on these aspects employing systematic recruitment strategies and validated psychometric instruments.

Finally some limitations of our study have to be mentioned. We decided to use a broad search strategy and impose limits based on the year of publication. This was due to our goal to include publications with the consistent diagnosis of CP/CPPS according to the NIHstandard. Using more search terms, for example, “chronic prostatitis” may have produced not only a higher number of publications, but also a greater variety in sample composition. Furthermore, we excluded sexual dysfunction as an outcome measurement although, in some cases, it is a mental disorder. We investigated this subject from a psychological point of view and given that sexual disorders incorporate a substantial part of the suffering of CP/CPPS patients, it should be fully addressed elsewhere. A final limitation is the basis of the different clusters of psychiatric diseases and psychosocial aspects. We treated every psychiatric/psychosocial variable in our included publications as independent main outcomes, although they were just secondary outcomes in most of the original research. Most of the studies were not originally designed to investigate these aspects. In conclusion, our review underlines the importance of psychosocial aspects to understand CP/CPPS and to optimize current treatment approaches. It is necessary to conduct more studies with psychosocial outcome variables. Furthermore, we need more data on specific subgroups of CP/CPPS patients with psychosocial impairments. Promising attempts [22] need to be extended.

Acknowledgments

Fig. 5. Complete overview of “risk of bias” (n = 49 studies): Proportion of studies with the high (red), low (green) or (yellow) risk of bias.

We gratefully acknowledge Alexandra Murray, DPhil, University Medical Center, Hamburg-Eppendorf, Germany, for her critical proofreading and valuable comments on the manuscript. The review is a result of an interdisciplinary research project on Chronic Pelvic Pain Syndrome funded by the PRANA foundation in the “Stifterverband für die Deutsche Wissenschaft”. The PRANA foundation had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision

348


to submit the article for publication. The authors have no competing interests to report. References [1] Turner JA, Ciol MA, Von Korff M, Rothman I, Berger RE. Healthcare use and costs of primary and secondary care patients with prostatitis. Urology 2004;63:1031–5. http://dx.doi.org/10.1016/j.urology.2004.01.042. [2] Calhoun EA, McNaughton Collins M, Pontari MA, O'Leary M, Leiby BE, Landis RJ, et al. The economic impact of chronic prostatitis. Arch Intern Med 2004;164: 1231–6. http://dx.doi.org/10.1001/archinte.164.11.1231. [3] Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol 1998;159:1224–8. [4] Nickel JC, Nyberg LM, Hennenfent M. Research guidelines for chronic prostatitis: consensus report from the First National Institutes of Health International Prostatitis Collaborative Network. Urology 1999;54:229–33. http://dx.doi.org/10.1016/S00904295(99)00205-8. [5] Krieger JN, Leroy Nyberg J, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999;282:236–7. http://dx.doi.org/10.1001/pubs.JAMA-ISSN0098-7484-282-3-jac90006. [6] Pontari MA. Chronic prostatitis/chronic pelvic pain syndrome. Urol Clin N Am 2008;35:81–9. http://dx.doi.org/10.1016/j.ucl.2007.09.005 [vi]. [7] Khastgir J, Dickinson AJ. Where do we stand with chronic prostatitis? An update. Hosp Med 2003;64:732–6. [8] Konkle KS, Clemens JQ. New paradigms in understanding chronic pelvic pain syndrome. Curr Urol Rep 2011;12:278–83. http://dx.doi.org/10.1007/s11934011-0185-1. [9] Ferris JA, Pitts MK, Richters J, Simpson JM, Shelley JM, Smith AM. National prevalence of urogenital pain and prostatitis-like symptoms in Australian men using the National Institutes of Health Chronic Prostatitis Symptoms Index. BJU Int 2010;105:373–9. http://dx.doi.org/10.1111/j.1464-410X.2009.08708.x. [10] Ejike CECC, Ezeanyika LUS. Prevalence of chronic prostatitis symptoms in a randomly surveyed adult population of urban-community-dwelling Nigerian males. Int J Urol 2008;15:340–3. http://dx.doi.org/10.1111/j.1442-2042.2008. 02003.x. [11] Calhoun EA, Clemens JQ, Litwin MS, Walker-Corkery E, Markossian T, Kusek JW, et al. Primary care physician practices in the diagnosis, treatment and management of men with chronic prostatitis/chronic pelvic pain syndrome. Prostate Cancer Prostatic Dis 2009;12:288–95. http://dx.doi.org/10.1038/pcan.2009.9. [12] McGowan L, Escott D, Luker K, Creed F, Chew-Graham C. Is chronic pelvic pain a comfortable diagnosis for primary care practitioners: a qualitative study. BMC Fam Pract 2010;11:7. http://dx.doi.org/10.1186/1471-2296-11-7. [13] Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology 2009;73:538–42. http://dx.doi.org/10.1016/j.urology.2008.09. 074. [14] Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. Urology 2010;75:1249–53. http://dx.doi.org/10.1016/j.urology.2010.01. 021. [15] Litwin MS, McNaughton-Collins M, Fowler Jr FJ, Nickel JC, Calhoun EA, Pontari MA, et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999;162:369–75. [16] Baranowski AP, Mandeville AL, Edwards S, Brook S, Cambitzi J, Cohen M. Male chronic pelvic pain syndrome and the role of interdisciplinary pain management. World J Urol 2013;31:779–84. http://dx.doi.org/10.1007/s00345-013-1083-6. [17] Nickel JC, Mullins C, Tripp DA. Development of an evidence-based cognitive behavioral treatment program for men with chronic prostatitis/chronic pelvic pain syndrome. World J Urol 2008;26:167–72. http://dx.doi.org/10.1007/s00345008-0235-6. [18] Sattel H, Lahmann C, Gündel H, Guthrie E, Kruse J, Noll-Hussong M, et al. Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial. Br J Psychiatry 2012;200:60–7. http://dx. doi.org/10.1192/bjp.bp.111.093526. [19] Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. http://dx.doi.org/10.1371/journal.pmed.1000097. [20] European Association of Urology (EAU). Guidelines on chronic pelvic pain. n.d. [21] Higgins JPT, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343. http://dx.doi.org/10.1136/bmj.d5928 [d5928–d5928]. [22] Samplaski MK, Li J, Shoskes DA. Clustering of UPOINT domains and subdomains in men with chronic prostatitis/chronic pelvic pain syndrome and contribution to symptom severity. J Urol 2012;188:1788–93. http://dx.doi.org/10.1016/j.juro. 2012.07.036. [23] Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:524. [24] Davis SNP, Binik YM, Amsel R, Carrier S. A subtype based analysis of urological chronic pelvic pain syndrome in men. J Urol 2013;190:118–23. http://dx.doi.org/ 10.1016/j.juro.2013.01.020. [25] Tripp DA, Nickel JC, Shoskes D, Koljuskov A. A 2-year follow-up of quality of life, pain, and psychosocial factors in patients with chronic prostatitis/chronic pelvic pain syndrome and their spouses. World J Urol 2013. http://dx.doi.org/10.1007/ s00345-013-1067-6.

[26] Tripp DA, Nickel JC, Katz L. A feasibility trial of a cognitive–behavioural symptom management program for chronic pelvic pain for men with refractory chronic prostatitis/chronic pelvic pain syndrome. Can Urol Assoc J 2011;5:328–32. http://dx. doi.org/10.5489/cuaj.10201. [27] Nickel JC, Tripp DA, Chuai S, Litwin MS, McNaughton-Collins M, Landis JR, et al. Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2008;101:59–64. http://dx.doi.org/10. 1111/j.1464-410X.2007.07196.x. [28] Tripp DA, Nickel JC, Wang Y, Litwin MS, McNaughton-Collins M, Landis JR, et al. Catastrophizing and pain-contingent rest predict patient adjustment in men with chronic prostatitis/chronic pelvic pain syndrome. J Pain 2006;7:697–708. http:// dx.doi.org/10.1016/j.jpain.2006.03.006. [29] Sullivan Michael. The Pain Catastrophizing Scale — user manual; 2009. [30] Hedelin H. The chronic prostatitis/chronic pelvic pain syndrome and pain catastrophizing: a vicious combination. Scand J Urol Nephrol 2012:1–6. http://dx. doi.org/10.3109/00365599.2012.669403. [31] Hedelin HH. Evaluation of a modification of the UPOINT clinical phenotype system for the chronic pelvic pain syndrome. Scand J Urol Nephrol 2009;43: 373–6. http://dx.doi.org/10.3109/00365590903164514. [32] Burckhardt CS, Henriksson C. The Coping Strategies Questionnaire — Swedish version: evidence of reliability and validity in patients with fibromyalgia. Scand J Behav Ther 2001;30:97–107. http://dx.doi.org/10.1080/02845710108559239. [33] Anderson RU, Orenberg EK, Morey A, Chavez N, Chan CA. Stress induced hypothalamus–pituitary–adrenal axis responses and disturbances in psychological profiles in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol 2009;182: 2319–24. http://dx.doi.org/10.1016/j.juro.2009.07.042. [34] Anderson RU, Orenberg EK, Chan CA, Morey A, Flores V. Psychometric profiles and hypothalamic–pituitary–adrenal axis function in men with chronic prostatitis/ chronic pelvic pain syndrome. J Urol 2008;179:956–60. http://dx.doi.org/10.1016/ j.juro.2007.10.084. [35] Ahn SG, Kim SH, Chung KI, Park KS, Cho SY, Kim HW. Depression, anxiety, stress perception, and coping strategies in Korean military patients with chronic prostatitis/chronic pelvic pain syndrome. Korean J Urol 2012;53:643–8. http://dx.doi. org/10.4111/kju.2012.53.9.643. [36] Aubin S, Berger RE, Heiman JR, Ciol MA. The association between sexual function, pain, and psychological adaptation of men diagnosed with chronic pelvic pain syndrome type III. J Sex Med 2008;5:657–67. http://dx.doi.org/10.1111/j.1743-6109. 2007.00736.x. [37] Ullrich PM, Turner JA, Ciol M, Berger R. Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain. Ann Behav Med 2005;30:112–8. http://dx.doi.org/10.1207/s15324796abm3002_3. [38] Turner JA, Hauge S, Von Korff M, Saunders K, Lowe M, Berger R. Primary care and urology patients with the male pelvic pain syndrome: symptoms and quality of life. J Urol 2002;167:1768–73. [39] Koh JS, Ko HJ, Wang S-M, Cho KJ, Kim JC, Lee S-J, et al. The association of personality trait on treatment outcomes in patients with chronic prostatitis/chronic pelvic pain syndrome: an exploratory study. J Psychosom Res 2014;76:127–33. http://dx.doi. org/10.1016/j.jpsychores.2013.11.004. [40] Ginting JV, Tripp DA, Nickel JC. Self-reported spousal support modifies the negative impact of pain on disability in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 2011;78:1136–41. http://dx.doi.org/10.1016/j.urology.2011. 03.073. [41] Smith KB, Tripp D, Pukall C, Nickel JC. Predictors of sexual and relationship functioning in couples with chronic prostatitis/chronic pelvic pain syndrome. J Sex Med 2007;4:734–44. http://dx.doi.org/10.1111/j.1743-6109.2007. 00466.x. [42] Bartoletti R, Cai T, Mondaini N, Dinelli N, Pinzi N, Pavone C, et al. Prevalence, incidence estimation, risk factors and characterization of chronic prostatitis/chronic pelvic pain syndrome in urological hospital outpatients in Italy: results of a multicenter case–control observational study. J Urol 2007;178:2411–5. http://dx.doi. org/10.1016/j.juro.2007.08.046 discussion 2415. [43] Clemens JQ, Brown SO, Kozloff L, Calhoun EA. Predictors of symptom severity in patients with chronic prostatitis and interstitial cystitis. J Urol 2006;175:963–6. http://dx.doi.org/10.1016/S0022-5347(05)00351-4 [discussion 967]. [44] Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med 1983;13:595–605. [45] Clemens JQ, Brown SO, Calhoun EA. Mental health diagnoses in patients with interstitial cystitis/painful bladder syndrome and chronic prostatitis/chronic pelvic pain syndrome: a case/control study. J Urol 2008;180:1378–82. http://dx.doi.org/10. 1016/j.juro.2008.06.032. [46] Pontari MA, McNaughton-Collins M, O'Leary MP, Calhoun EA, Jang T, Kusek JW, et al. A case–control study of risk factors in men with chronic pelvic pain syndrome. BJU Int 2005;96:559–65. http://dx.doi.org/10.1111/j.1464-410X.2005. 05684.x. [47] Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. http://dx.doi.org/10.1177/ 014662167700100306. [48] Smith KB, Pukall CF, Tripp DA, Nickel JC. Sexual and relationship functioning in men with chronic prostatitis/chronic pelvic pain syndrome and their partners. Arch Sex Behav 2007;36:301–11. http://dx.doi.org/10.1007/s10508-0069086-7. [49] Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders Patient Health Questionnaire. JAMA 1999;282:1737–44. [50] Tripp DA, Curtis Nickel J, Landis JR, Wang YL, Knauss JS. Predictors of quality of life and pain in chronic prostatitis/chronic pelvic pain syndrome: findings from the


[51]

[52]

[53] [54]

[55]

[56]

[57]

[58] [59]

[60]

[61]

[62]

[63]

[64]

[65]

[66]

[67]

[68]

[69]

[70]

[71]

[72]

[73]

[74]

National Institutes of Health Chronic Prostatitis Cohort Study. BJU Int 2004;94: 1279–82. http://dx.doi.org/10.1111/j.1464-410X.2004.05157.x. Koh JS, Ko HJ, Wang S-M, Cho KJ, Kim JC, Lee S-J, et al. The impact of depression and somatic symptoms on treatment outcomes in patients with chronic prostatitis/chronic pelvic pain syndrome: a preliminary study in a naturalistic treatment setting. Int J Clin Pract 2014;68:478–85. http://dx.doi.org/10.1111/ ijcp.12340. Zhang G, Bai W, Xu T, Wang X. A preliminary evaluation of the psychometric profiles in Chinese men with chronic prostatitis/chronic pelvic pain syndrome. Chin Med J 2011;124:514–8. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–70. Bates SM, Hill VA, Anderson JB, Chapple CR, Spence R, Ryan C, et al. A prospective, randomized, double-blind trial to evaluate the role of a short reducing course of oral corticosteroid therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2007;99:355–9. http://dx.doi.org/10.1111/j.1464-410X. 2007.06667.x. Giubilei G, Mondaini N, Minervini A, Saieva C, Lapini A, Serni S, et al. Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments — could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study. J Urol 2007;177: 159–65. http://dx.doi.org/10.1016/j.juro.2006.08.107. Lee RA, West RM, Wilson JD. The response to sertraline in men with chronic pelvic pain syndrome. Sex Transm Infect 2005;81:147–9. http://dx.doi.org/10.1136/sti. 2004.010868. Xia D, Wang P, Chen J, Wang S, Jiang H. Fluoxetine ameliorates symptoms of refractory chronic prostatitis/chronic pelvic pain syndrome. Chin Med J Beijing 2011; 124:2158. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988;56:893–7. Chung S-D, Lin H-C. Association between chronic prostatitis/chronic pelvic pain syndrome and anxiety disorder: a population-based study. PLoS ONE 2013;8: e64630. http://dx.doi.org/10.1371/journal.pone.0064630. Hu JC, Link CL, McNaughton-Collins M, Barry MJ, McKinlay JB. The association of abuse and symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome: results from the Boston Area Community Health survey. J Gen Intern Med 2007;22:1532–7. http://dx.doi.org/10.1007/s11606-007-0341-y. Lai HH, North CS, Andriole GL, Sayuk GS, Hong BA. Polysymptomatic, polysyndromic presentation of patients with urological chronic pelvic pain syndrome. J Urol 2012;187:2106–12. http://dx.doi.org/10.1016/j.juro.2012.01.081. Herati AS, Shorter B, Srinivasan AK, Tai J, Seideman C, Lesser M, et al. Effects of foods and beverages on the symptoms of chronic prostatitis/chronic pelvic pain syndrome. Urology 2013;82:1376–80. http://dx.doi.org/10.1016/j.urology.2013.07.015. Hedelin H, Jonsson K. Chronic prostatitis/chronic pelvic pain syndrome: symptoms are aggravated by cold and become less distressing with age and time. Scand J Urol Nephrol 2007;41:516–20. http://dx.doi.org/10.1080/00365590701428517. Zhao Z, Zhang J, He J, Zeng G. Clinical utility of the UPOINT phenotype system in Chinese males with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a prospective study. PLoS ONE 2013;8:e52044. http://dx.doi.org/10.1371/journal. pone.0052044. Brazier JE, Harper R, Jones NM, O'Cathain A, Thomas KJ, Usherwood T, et al. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ 1992;305:160–4. Davis SNP, Binik YM, Amsel R, Carrier S. Is a sexual dysfunction domain important for quality of life in men with urological chronic pelvic pain syndrome? Signs “UPOINT” to yes. J Urol 2013;189:146–51. http://dx.doi.org/10.1016/j.juro.2012.08.083. McNaughton Collins M, Pontari MA, O'Leary MP, Calhoun EA, Santanna J, Landis JR, et al. Quality of life is impaired in men with chronic prostatitis: the Chronic Prostatitis Collaborative Research Network. J Gen Intern Med 2001;16:656–62. Propert KJ, McNaughton-Collins M, Leiby BE, O'Leary MP, Kusek JW, Litwin MS. A prospective study of symptoms and quality of life in men with chronic prostatitis/ chronic pelvic pain syndrome: the National Institutes of Health Chronic Prostatitis Cohort study. J Urol 2006;175:619–23. http://dx.doi.org/10.1016/S0022-5347(05) 00233-8 [discussion 623]. Zhao F-L, Yue M, Yang H, Wang T, Wu J-H, Li S-C. Health-related quality of life in Chinese patients with chronic prostatitis/chronic pelvic pain syndrome. Qual Life Res 2010;19:1273–83. http://dx.doi.org/10.1007/s11136-010-9697-2. Shoskes DA, Landis JR, Wang Y, Nickel JC, Zeitlin SI, Nadler R. Impact of post-ejaculatory pain in men with category III chronic prostatitis/chronic pelvic pain syndrome. J Urol 2004;172:542–7. http://dx.doi.org/10.1097/01.ju.0000132798.48067.23. Giannantoni A, Porena M, Gubbiotti M, Maddonni S, Di Stasi SM. The efficacy and safety of duloxetine in a multidrug regimen for chronic prostatitis/chronic pelvic pain syndrome. Urology 2014;83:400–5. http://dx.doi.org/10.1016/j.urology.2013. 09.024. Kim DS, Kyung YS, Woo SH, Chang YS, Kim H-J. Efficacy of anticholinergics for chronic prostatitis/chronic pelvic pain syndrome in young and middle-aged patients: a single-blinded, prospective, multi-center study. Int Neurourol J 2011; 15:172. http://dx.doi.org/10.5213/inj.2011.15.3.172. Nickel JC, Forrest JB, Tomera K, Hernandez-Graulau J, Moon TD, Schaeffer AJ, et al. Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicentre, randomized, placebo controlled study. J Urol 2005;173:1252–5. http://dx.doi.org/10.1097/01.ju.0000159198.83103.01. Nickel JC, Johnston B, Downey J, Barkin J, Pommerville P, Gregoire M, et al. Pentosan polysulfate therapy for chronic nonbacterial prostatitis (chronic pelvic pain syndrome category IIIA): a prospective multicenter clinical trial. Urology 2000;56: 413–7.

349

[75] Nickel JC, Narayan P, McKay J, Doyle C. Treatment of chronic prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial. J Urol 2004;171:1594–7. http://dx.doi.org/10.1097/01.ju.0000117811.40279.19. [76] Nickel JC, O'Leary MP, Lepor H, Caramelli KE, Thomas H, Hill LA, et al. Silodosin for men with chronic prostatitis/chronic pelvic pain syndrome: results of a phase II multicenter, double-blind, placebo controlled study. J Urol 2011;186:125–31. http://dx.doi.org/10.1016/j.juro.2011.03.028. [77] Sung YH, Jung JH, Ryang SH, Kim SJ, Kim KJ. Clinical significance of national institutes of health classification in patients with chronic prostatitis/chronic pelvic pain syndrome. Korean J Urol 2014;55:276–80. http://dx.doi.org/10.4111/kju. 2014.55.4.276. [78] Zhao WP, Zhang ZG, Li XD, Yu D, Rui XF, Li GH, et al. Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA). Braz J Med Biol Res 2009;42:963–7. http://dx.doi.org/10.1590/S0100-879X2009005000021. [79] Alexander RB, Propert KJ, Schaeffer AJ, Landis JR, Nickel JC, O'Leary MP, et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann Intern Med 2004;141:581–9. http://dx.doi.org/10.7326/0003-4819-141-8-200410190-00005. [80] Chen Y, Wu X, Liu J, Tang W, Zhao T, Zhang J. Effects of a 6-month course of tamsulosin for chronic prostatitis/chronic pelvic pain syndrome: a multicenter, randomized trial. World J Urol 2011;29:381–5. http://dx.doi.org/10.1007/s00345010-0537-3. [81] McLennan GP, Khourdaji I, Killinger KA, Boura JA, Peters KM. Apremilast in the treatment of chronic prostatitis/chronic pelvic pain syndrome: a pilot study. LUTS Lower Urinary Tract Symptoms 2012;4:140–3. http://dx.doi.org/10.1111/j.17575672.2012.00150.x. [82] Mehik A, Alas P, Nickel JC, Sarpola A, Helström PJ. Alfuzosin treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, doubleblind, placebo-controlled, pilot study. Urology 2003;62:425–9. http://dx.doi.org/ 10.1016/S0090-4295(03)00466-7. [83] Pontari MA, Krieger JN, Litwin MS, White PC, Anderson RU, McNaughton-Collins M, et al. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: a randomized controlled trial. Arch Intern Med 2010;170: 1586–93. http://dx.doi.org/10.1001/archinternmed.2010.319. [84] Capodice JL, Jin Z, Bemis DL, Samadi D, Stone BA, Kapan S, et al. A pilot study on acupuncture for lower urinary tract symptoms related to chronic prostatitis/chronic pelvic pain. Chin Med 2007;2:1. http://dx.doi.org/10.1186/1749-8546-2-1. [85] Chen R, Nickel JC. Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 2003;61:1156–9 discussion 1159. [86] Honjo H, Kamoi K, Naya Y, Ukimura O, Kojima M, Kitakoji H, et al. Effects of acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion: preliminary results. Int J Urol 2004;11:607–12. http://dx.doi.org/10.1111/j.14422042.2004.00868.x. [87] Tugcu V, Tas S, Eren G, Bedirhan B, Karadag S, Tasci A. Effectiveness of acupuncture in patients with category IIIB chronic pelvic pain syndrome: a report of 97 patients. Pain Med 2010;11:518–23. http://dx.doi.org/10.1111/j.1526-4637.2009.00794.x. [88] Kim TH, Han DH, Cho WJ, Lee HS, You HW, Park CM, et al. The efficacy of extracorporeal magnetic stimulation for treatment of chronic prostatitis/chronic pelvic pain syndrome patients who do not respond to pharmacotherapy. Urology 2013;82: 894–8. http://dx.doi.org/10.1016/j.urology.2013.06.032. [89] Vahdatpour B, Alizadeh F, Moayednia A, Emadi M, Khorami MH, Haghdani S. Efficacy of extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome: a randomized, controlled trial. ISRN Urol 2013;2013:972601. http://dx. doi.org/10.1155/2013/972601. [90] Zeng XY, Liang C, Ye ZQ. Extracorporeal shock wave treatment for noninflammatory chronic pelvic pain syndrome: a prospective, randomized and sham-controlled study. Chin Med J 2012;125:114–8. [91] Zimmermann R, Cumpanas A, Miclea F, Janetschek G. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study. Eur Urol 2009;56:418–24. http://dx.doi. org/10.1016/j.eururo.2009.03.043. [92] Marx S, Cimniak U, Beckert R, Schwerla F, Resch KL. Chronische Prostatitis/ chronisches Beckenschmerzsyndrom. Urologe 2009;48:1339–45. http://dx.doi. org/10.1007/s00120-009-2088-z. [93] Marx S, Cimniak U, Rütz M, Resch KL. Langzeiteffekte osteopathischer Behandlungen bei chronischer Prostatitis/chronischem Beckenschmerzsyndrom. Urologe 2013;52:384–90. http://dx.doi.org/10.1007/s00120-012-3075-3. [94] Schneider MP, Tellenbach M, Mordasini L, Thalmann GN, Kessler TM. Refractory chronic pelvic pain syndrome in men: can transcutaneous electrical nerve stimulation help? BJU Int 2013;112:E159–63. http://dx.doi.org/10.1111/bju.12005. [95] Wagenlehner FME, Schneider H, Ludwig M, Schnitker J, Brähler E, Weidner W. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis–chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol 2009;56:544–51. http://dx.doi.org/10. 1016/j.eururo.2009.05.046. [96] Gottsch HP, Yang CC, Berger RE. A pilot study of botulinum toxin A for male chronic pelvic pain syndrome. Scand J Urol Nephrol 2011;45:72–6. http://dx.doi.org/10. 3109/00365599.2010.529820. [97] Leippold T, Strebel RT, Huwyler M, John HA, Hauri D, Schmid DM. Sacral magnetic stimulation in non-inflammatory chronic pelvic pain syndrome. BJU Int 2005;95: 838–41. http://dx.doi.org/10.1111/j.1464-410X.2005.05412.x. [98] Hochreiter DWW, Hruz P, Danuser H, Weidner W, Studer UE. Symptomevaluation beim chronischen Beckenschmerzsyndrom des Mannes. Urologe [A] 2003;42: 38–40. http://dx.doi.org/10.1007/s00120-002-0264-5. [99] Rosen NO, Bergeron S, Leclerc B, Lambert B, Steben M. Woman and partnerperceived partner responses predict pain and sexual satisfaction in provoked

350

[100]

[101] [102]

[103] [104]

B. Riegel et al. / Journal of Psychosomatic Research 77 (2014) 333–350 vestibulodynia (PVD) couples. J Sex Med 2010;7:3715–24. http://dx.doi.org/10. 1111/j.1743-6109.2010.01957.x. Rosen NO, Bergeron S, Glowacka M, Delisle I, Baxter ML. Harmful or helpful: perceived solicitous and facilitative partner responses are differentially associated with pain and sexual satisfaction in women with provoked vestibulodynia. J Sex Med 2012;9:2351–60. http://dx.doi.org/10.1111/j.1743-6109.2012.02851.x. Fischer-Kern M, Mikutta C, Kapusta ND, Hörz S, Naderer A, Thierry N, et al. The psychic structure of chronic pain patients. Z Psychosom Med Psychother 2010;56:34–46. Leithner-Dziubas K, Blüml V, Naderer A, Tmej A, Fischer-Kern M. Mentalization and bonding in chronic pelvic pain patients: a pilot study. Z Psychosom Med Psychother 2010;56:179–90. Gross RJ, Doerr H, Caldirola D, Guzinski GM, Ripley HS. Borderline syndrome and incest in chronic pelvic pain patients. Int J Psychiatry Med 1980;10:79–96. Keltikangas-Järvinen L, Ruokolainen J, Lehtonen T. Personality pathology underlying chronic prostatitis. Psychother Psychosom 1982;37:87–95. http://dx.doi.org/ 10.1159/000287558.

[105] Walker EA, Katon WJ, Hansom J, Harrop-Griffiths J, Holm L, Jones ML, et al. Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics 1995;36:531–40. http://dx.doi.org/10.1016/S0033-3182(95)71608-5. [106] Ehlert U, Heim C, Hellhammer DH. Chronic pelvic pain as a somatoform disorder. Psychother Psychosom 1999;68:87–94. [107] Anothaisintawee T, Attia J, Nickel JC, Thammakraisorn S, Numthavaj P, McEvoy M, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAMA 2011;305:78–86. http://dx.doi.org/10. 1001/jama.2010.1913. [108] Aavik T, Aavik A, Punab M. Are self-reported symptoms in chronic pelvic pain syndrome contaminated by socially desirable responding? J Men's Health 2013; 10:134–8. http://dx.doi.org/10.1089/jomh.2013.0015.

Predicting low testosterone in aging men: a systematic review.

Treatment of Men for "Low Testosterone": A Systematic Review.

CPPS) on Erectile Function: A Systematic Review and Meta-Analysis.

Human papillomavirus and vaccine-related perceptions among men who have sex with men: a systematic review.

Systematic review of interventions to reduce problematic alcohol use in men who have sex with men.

CPPS) on semen parameters in human males: a systematic review and meta-analysis.

Effective Factors in Marital Satisfaction in Perspective of Iranian Women and Men: A systematic review.

Osteoporosis in men: a review.

Oral Human Papillomavirus Infection in Men Who Have Sex with Men: A Systematic Review and Meta-Analysis.

A systematic review of osteoporosis medication adherence and osteoporosis-related fracture costs in men.

A systematic review of literature on psychosocial aspects of gynecomastia in adolescents and young men.

Men at higher risk of groin injuries in elite team sports: a systematic review.

Human papillomavirus prevalence among men in sub-Saharan Africa: a systematic review and meta-analysis.

The cortical sensory representation of genitalia in women and men: a systematic review.

Associations between intimate partner violence and health among men who have sex with men: a systematic review and meta-analysis.

Hard-to-reach populations of men who have sex with men and sex workers: a systematic review on sampling methods.

Factors Associated with Colorectal Cancer Screening among Younger African American Men: A Systematic Review.

Masculinity, Racism, Social Support, and Colorectal Cancer Screening Uptake Among African American Men: A Systematic Review.

Human papillomavirus infection by anatomical site among Greek men and women: a systematic review.

A systematic review of sexual dysfunction measures for gay men: how do current measures measure up?

Psychosocial interventions for men with prostate cancer: a Cochrane systematic review.

A systematic review of weight loss, physical activity and dietary interventions involving African American men.

The correlates of chronic disease-related health literacy and its components among men: a systematic review.

Systematic Review and Meta-Analysis of Doxycycline Efficacy for Rectal Lymphogranuloma Venereum in Men Who Have Sex with Men.