AUA 2020, some interesting studies

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webslave
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AUA 2020, some interesting studies

Post by webslave »

As you probably know, the American Urological Association Meeting for 2020 (AUA 2020) was cancelled due to COVID-19.

However, some interesting abstract were lodged. Bear in mind these are not yet published studies, so grain of salt etc.
Pain Catastrophizing Affects the Outcomes of Pelvic Floor Physical Therapy
Danielle Wang, Stephanie Goldstein, Kate Kunkle, Jennifer Fariello, Robert Moldwin
Smith Institute for Urology, Northwell Health, Sacramento, California

Introduction: Chronic pelvic pain and pelvic floor myalgia is still underrecognized and true incidence is unknown. Higher pain catastrophizing scores have been correlated to worse health outcomes. We studied the impact of pain catastrophizing behavior upon the effectiveness of specialized pelvic floor physical therapy (PT).

Methods: A retrospective chart review was conducted among patients receiving pelvic floor PT as part of their pelvic pain treatment. Patients are given validated survey instruments at initial evaluation, 6-week follow up, and 12-week follow up. These three instruments are the 6-item short form Pain Catastrophizing Scale (PCS), Genitourinary Pain Index (GUPI), and Pelvic Floor Disability Index (PFDI-20). Patients were separated into non-catastrophizing or catastrophizing cohort if their PCS scores were >20 at any time point. Patients' changes on their GUPI and PFDI scores were compared utilizing two sample t-test, mixed-effects ANOVA, and non-parametric test.

Results: Catastrophizing patients (n=9, 28%) had a mean of 5 comorbidities while non-catastrophizing patients (n=23, 72%) had a mean of 6.13 comorbidities. After 12 weekly PT sessions, 74% of non-catastrophizing patients saw improvement in their GUPI and PFDI scores while only 44% of catastrophizing patients saw improvements. Non-catastrophizing patients showed a mean decrease of 14.96% (GUPI) and 20.80% (PDFI) at 3 months. Conversely, catastrophizing patient showed a mean decrease of 4.44% (GUPI) and 4.21% (PFDI) (see a_image). Factors which were not predictive of PT outcomes include comorbidities, pain medications, gender, and past abdominal or genitourinary surgeries.

Conclusions: This is the first study evaluating catastrophizing behavior and how it affects pelvic floor PT outcomes. The preliminary data suggests that pain catastrophizing negatively affects pelvic floor PT outcomes as assessed by GUPI and PFDI-20.
My comment: more evidence that catastrophizing makes for a poor prognosis
Detection of Bacteria by Next Generation Sequencing in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Incidence, Correlation to Conventional Culture and Impact on Symptoms
Nicholas Farber, Paige Gotwald, Daniel Shoskes
Cleveland Clinic Foundation, Somerset, NJ

Introduction: Chronic prostatitis/Chronic pelvic pain syndrome (CPPS) is a syndrome that shares clinical features with urinary infections and a certain subset of patients improve with antibiotics. However, traditional cultures of urine and expressed prostatic secretions often fail to identify an organism. Next-generation sequencing (NGS) analyzes microbial DNA and can identify organisms that fail to grow in traditional cultures. We sought to compare traditional cultures with NGS in men with CPPS and examine the impact on symptoms and treatment response.

Methods: 25 men with a clinical diagnosis of CPPS underwent both traditional cultures and NGS (MicroGen Dx) of urine and expressed prostatic secretions (EPS). NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) and UPOINT domains were evaluated. Patients with negative traditional cultures and positive NGS were offered antibiotic therapy.

Results: Urine cultures were negative in all CPPS patients, while 8% (2/25) had a positive EPS culture. NGS identified these organisms in one patient and failed to detect it in the other. In culture negative patients, NGS identified at least one organism in EPS in 70% (16/23), though only 30% (7/23) were for established uropathogens. Patients with positive and negative NGS had similar mean NIH-CPSI scores of 23.3 +/- 6.8 and 20.5 +/- 6.9, respectively (p=0.44).

Organisms of questionable pathogenicity in EPS found by NGS included vaginal flora (Prevotella spp., Sneathia amnii), anaerobes, and fungi. In the subset of 6/25 (24%) men with systemic symptoms suggestive of infection, all had negative EPS cultures but NGS identifying a uropathogen in 50% (3/6). 4 were treated with antibiotics based on the sensitivity gene panel but only 1 patient (25%) resolved their symptoms.

Conclusions: NGS detected a variety of microorganisms not found by conventional culture in urine and EPS. In men with systemic symptoms suggestive of infection, NGS found a pathogen missed by culture in 50%. The presence of vaginal flora, anaerobes, and yeast is novel but the clinical significance is unclear and the value of prolonged antimicrobial treatment of these organisms is not proven. Based on our data, NGS may help identify pathogenic organisms in men with CPPS who have symptoms suggestive of true infection, however men should still be offered multimodal therapy based on their clinical phenotype to maximize the chance for symptom resolution.
My comment: NGS is useless in CPPS, in my estimation. If it identified a stealthy bug that could then be treated leading to resolution, then yes, but as you can see from the highlighted text above, it doesn't. The one patient who resolved symptoms was most likely reacting to the well-known anti-inflammatory effects of certain antibiotics (one wonders which antibiotic was used on that patient, and whether that patient had a follow-up test to see if the bug was eradicated). Microgen Dx is a sure money spinner, a new iteration of an old racket. It's marketed aggressively, so hold on to your wallets.
Clinical and Pathologic Relevance of a Prostate MRI Diagnosis of "Prostatitis"
Sij Hemal, Lewis Thomas, Daniel Shoskes
Cleveland Clinic Foundation, Cleveland, OH

Introduction: Non-malignant abnormalities in the peripheral zone are common in prostate mpMRI. Such findings include decrease in T2-weighted signal, decrease in diffusion coefficient or enhancement in a diffuse or linear pattern. These abnormalities are often reported as “prostatitis” and lead to patient anxiety and treatment referral. However, the relationship between these MRI findings and clinical prostatitis is unknown. We investigated the relationship between MRI evidence of prostatitis with clinical symptoms and pathology.

Methods: Retrospective review of patients undergoing prostate mpMRI (2016-2017) was performed, and patients were divided into two groups based on the presence of either “prostatitis” or “inflammation” in the radiology report. Patients with prior prostate cancer treatment were excluded. Clinical characteristics included age, PSA, biopsy/intervention history, lower urinary tract symptoms (LUTS), pain, use of urologic medications for LUTS, urinary findings of pyuria or leukocyte esterase positivity), prostate volume, and PIRADS score. Pathologic finding of inflammation on either prior biopsies or biopsy within 6 months was also recorded. Groups were compared using chi-square for dichotomous variables and t-tests for continuous variables. P<0.05 was considered significant.

Results: 104 patients were identified with “prostatitis/inflammation” and 119 without. Report of any LUTS was high in both groups (57% and 60% for prostatitis and no prostatitis respectively, p = 0.69), though report of moderate/severe LUTS (physician description or IPSS of 8-19 and 20+) was more common in the no prostatitis group (8% vs 17%, p=0.038). Use of urologic meds was similar between the two groups (66% and 55% for prostatitis and no prostatitis respectively, p = 0.074). Any biopsy finding of inflammation was more common in the prostatitis group (57% vs 35% p =0.002). Reports of pelvic/perineal pain, chronic dysuria, or urinary findings of inflammation/infection were uncommon in both groups (<5% for pain/dysuria and <10% for urinalysis findings in both groups)

Conclusions: MRI findings of prostatitis may be associated with a pathologic finding of inflammation on biopsy, however, such findings did not correlate to reported LUTS, pelvic pain or use of urologic medications. While mpMRI findings of prostatitis may indicate NIH Category IV prostatitis, there is no evidence of correlation with categories I, II or III prostatitis nor with symptomatic LUTS and patients should be reassured that further investigation or treatment is not warranted.
My comment: many men with CPPS have MRIs, and it looks like it could be a waste of money.
Exercise modulates neuronal activation in the micturition circuit of chronically stressed rats: A multidisciplinary approach to the study of urologic chronic pelvic pain (MAPP) research network study
Larissa Rodriguez, Zhuo Wang, Yumei Guo, Melissa Sanford, Jihchao Yeh, Jackie J. Mao, Rong Zhang, Daniel Philipp Holschneider
University of Southern California

Introduction: Rats exposed to water avoidance stress (WAS) show increased urinary frequency, increased somatosensory nociceptive reflex responses, as well as altered brain responses to bladder distension, analogous to similar observations made in patients with urologic chronic pelvic pain syndrome (UCPPS). Exercise has been proposed as a potential treatment option for patients with chronic urinary frequency and urgency. We examined the effects of exercise on urinary voiding parameters and functional brain activation during bladder distension in rats exposed to WAS.

Methods: Adult, female Wistar Kyoto rats were exposed to 10 days of WAS and thereafter randomized to either voluntary exercise (WAS/EX) for 3 weeks or sedentary groups (WAS/no-EX). Voiding parameters were assessed at baseline, post-WAS, and weekly for 3 weeks. Thereafter, cerebral blood flow (CBF) mapping was performed during isotonic bladder distension (20 cm H2O) after intravenous bolus injection of [14C]-iodoantipyrine. Regional CBF was quantified in autoradiographs of brain slices and analyzed in 3-D reconstructed brains by statistical parametric mapping. Functional connectivity was examined between regions of the micturition circuit through interregional correlation analysis.

Results: WAS exposure in sedentary animals (WAS/no-EX) increased voiding frequency and decreased urinary volumes per void. Exercise exposure in WAS animals (WAS/EX) resulted in a progressive decline in voiding frequency back to the baseline, as well as increased urinary volumes per void. Within the micturition circuit, WAS/EX compared to WAS/no-EX demonstrated a significantly lower rCBF response to passive bladder distension in Barrington’s nucleus that is part of the spinobulbospinal voiding reflex, as well as in the periaqueductal gray (PAG) which modulates this reflex. Greater rCBF was noted in WAS/EX animals broadly across corticolimbic structures, including the cingulate, medial prefrontal cortex (prelimbic, infralimbic areas), insula, amygdala, and hypothalamus, which provide a ‘top-down’ decision point where micturition could be inhibited or triggered. WAS/EX showed a significantly greater positive brain functional connectivities compared to WAS/no-EX animals within regions of the extended reflex loop (PAG, Barrington’s nucleus, intermediodorsal thalamic nucleus, pons), as well as within regions of the corticolimbic decision-making loop of the micturition circuit, with a strikingly negative correlation between these pathways. Urinary frequency was positively correlated with rCBF in the pons, and negatively correlated with rCBF in the cingulate cortex.

Conclusions: Our results suggest that chronic voluntary exercise may decrease urinary frequency at two points of control in the micturition circuit. During the urine storage phase, it may diminish the influence of the reflex micturition circuit itself, and/or it may increase corticolimbic control of voiding. Exercise may be an effective adjunct therapeutic intervention for modifying the urinary symptoms in patients with UCPPS.
My comment: many forum members have commented that exercises help lessen symptoms.
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Redub
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Re: AUA 2020, some interesting studies

Post by Redub »

I was too lazy to read anything but the red text and your input. I wonder if a big reason why exercise work is that the more you exercise the more your body learns to ignore certain pain signals. If you don't run much and start running your going to get aches and pains all over but they tend to go away as you run and tend not to come back the more you run.
Age:37 | Onset Age:36 | Symptoms: Constant urinary urge(8-10/10, various pain in pubic and perineum area(4/10) | Helped By: Heat, standing, paradoxical relaxation| Worsened By: sitting, laying down, diet soda, coffee, LSD, magic mushrooms| Other comments:
ppp
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Re: AUA 2020, some interesting studies

Post by ppp »

Agreed regarding exercise. It might distract and reduce anxiety, and blood flow (positive), but it also puts stress on the muscles and nerves. I personally have that mixed experience.

Regarding the catasrophising study. I really have no idea how such a small sample could be meaningful. In my field the paper will be rejected without reading. I also have not read the details.

I am very sad every time I read the state of the research. I have been waiting for 15 years now.
But I agree with Webslave, it is a complex syndrome and we are unlikely to have a silver bullet.
Age: 33| Onset Age: 24 | Symptoms: dull ache in pelvic area, tension, feeling the need to urinate, frequency, dribbling after urination, ED symptoms started 6 moths after the onset wrecking my life since, abdominal tension, tension in my thighs. | Helped By: stretching/massage , benzos | Worsened By: Mainly sex, but also sitting and anxiety| Other comments: I have seen periods of substantially less flare-ups, but now I am at a steady state where it comes back almost always after sex.
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