Prostate Cancer Information
 
UPOINT System for the Clinical Phenotyping of Chronic Pelvic Pain (Chronic Prostatitis/Chronic Pelvic Pain Syndrome, Interstitial Cystitis, Painful Bladder Syndrome)
 
 

FAQ and Links of Interest

What is UPOINT?

UPOINT is a system to classify patients with chronic pelvic pain syndrome (category III prostatitis, CPPS, interstitial cystitis, painful bladder syndrome) according to 6 clinically defined areas or domains. It was developed in 2008 by Dr. Daniel Shoskes, a Urologist at The Cleveland Clinic Glickman Urological and Kidney Institute. It is based on the recognition that patients who suffer from these clinical syndromes often have very different etiologies and respond to different therapies. The hope is that using multimodal therapy guided by the UPOINT phenotype will lead to more effective therapy. The system is flexible so that as new biomarkers and treatments are validated, they can be incorporated. The following is a summary of our hypothesis for the development of the Chronic Pelvic Pain Syndromes. Local injury in the urinary tract may lead to local injury and inflammation, local muscle spasm and ultimately changes in the peripheral and central nervous system that can propagate symptoms even after the initiating injury is long resolved. Clearly patients with only local injury and inflammation can be treated differently from those with a chronic systemic neurologic condition.

Are there any published data on UPOINT?

The original paper describing the UPOINT system is Shoskes et al, Prostate Cancer Prostatic Dis. 2009;12(2):177-83. A subsequent paper correlated the UPOINT phenotype in men with Chronic Pelvic Pain Syndrome with symptom severity and duration. This study found that more positive domains correlated with worse symptoms and greater symptom duration. Furthermore, pain was most driven by the psychosocial, neurologic/systemic and tenderness domains (Shoskes et al, Urology. 2009 Mar;73(3):538-42). A third paper correlated the UPOINT phenotype with symptom severity in women with a diagnosis of interstitial cystitis (Nickel, Shoskes and Irvine-Bird, Journal of Urology. 2009 Jul;182(1):155-60). Prospective studies on the efficacy of multimodal therapy driven by the UPOINT phenotype are ongoing.

How can the UPOINT system guide therapy?

Patients are classified as yes/no for each of the six UPOINT domains. Each domain is associated with therapies that can be helpful for each specific problem. For instance, a man with CPPS who is positive for the Urinary, Organ Specific and Tenderness domains could be treated with an alpha blocker, quercetin and pelvic floor physical therapy. A women with Interstitial Cystitis who is positive for Urinary, Organ Specific, Infection and Neurologic/Systemic might be treated with an anti-muscarinic, dietary restrictions, PPS, an antibiotic (based on culture and sensitivities) and a neuroleptic durg (eg pregabalin). The UPOINT system can also help indicate which therapies are UNLIKELY to be beneficial. For instance, in the absence of positive cultures, the use of antibiotics is no more effective that placebo and should not be used, especially if there is no history of clinical benefit. Similarly, in a man with CPPS who has no voiding symptoms, alpha blockers are unlikely to help. Obviously the list of therapies needs to be tailored to the individual patient's clinical situation and should be modified by past treatment response, allergies, drug interactions and other comorbid conditions.

How is the UPOINT system different from current common medical practice?

The treatment of chronic pelvic pain can be difficult and no evidence based algorithms for therapy are validated. Unfortunately, most patients continue to receive antibiotics despite lack of culture evidence for infection. It is hoped that by using the UPOINT system, physicians might be open to considering other diagnostic and treatment approaches such as:



1. Only using antibiotics to treat documented infections

2. Palpating the pelvic floor muscles and consider physical therapy or medications to help with pelvic muscle spasm and trigger points

3. Asking about depression and catastrophizing (helplessness and hopelessness about their condition) which are common in chronic pain syndromes and which may be helped with the assistance of a psychologist or psychiatrist

4. Only using alpha blockers or antimuscarinics for documented urinary symptoms

5. Considering other systemic conditions which may be the cause of pelvic pain or associated with it and which may be helped by specific therapies (eg. vulvodynia, irritable bowel disease, fibromyalgia)

6. Considering the use of other organ specific therapies when symptoms or signs do point to bladder or prostate involvement but with negative cultures (eg. bioflavanoids, intravesical lidocaine)

How can I refer a patient for evaluation and treatment?

Dr. Shoskes sees patients at the Cleveland Clinic in Cleveland Ohio. No phone or email consultations are available, however patients unable to travel to Cleveland may use the Cleveland Clinic Remote Consult Service

Are there any links with more information on the urologic chronic pain syndromes?

The following links may be useful for patients. Inclusion in this list does not represent an endorsement of all information on these sites, nor does omission necessarily imply disagreement.



Textbook on Chronic Prostatitis/Chronic Pelvic Pain Syndrome by Dr. Shoskes (OK, I do fully endorse this one!)



Chronic Pelvic Pain Syndrome Network (includes a patient forum)



The Prostatitis Foundation



The Interstitial Cystitis Association



The Interstitial Cystitis Network



International Painful Bladder Foundation



"A Headache in the Pelvis", patient oriented book that describes pelvic floor physical therapy for pelvic floor spasm