Talk:Chronic prostatitis/chronic pelvic pain syndrome

Disambiguation

Could this page replace or be megered with the main proststits article?

- No, because it's a different thing — Preceding unsigned comment added by 77.225.149.15 (talk) 19:53, 6 April 2012 (UTC)

Major new overview study published in top journal

The Journal of Urology (known as "the white journal" by urologists since it is one of the top medical journals in the world) has just published a major new study that looks back over 30 years of research into this field. You can read it here. I think this should be used as a starting point for any further editing of the page. If there is no objection, I shall use it as a reference for a lot of future changes. ► RATEL ◄ 14:38, 28 April 2008 (UTC)

NIH alfusozin study

Objection to posting findings of the study because not yet published in a journal. This was a large, multi-center, NIH run study whose findings have a direct impact on patient care today. Abstract is published in the Journal of Urology AUA edition. Not reasonable to wait on every bit of medical evidence to go through the 6-12 months it takes to be published in a journal if level of quality (patient numbers, study design, track record of investigators) is strong enough. Is this not more important than a list of famous dead people who may have had prostatitis based on newspaper accounts? I completely agree that minor abstracts should not be given the weight of peer reviewed journal articles and that not all journal articles are of equal weight. I would also support removing the information if no article is forthcoming. Nevertheless, I believe that deleting this edit sets the bar too high, and would call into question some of the other more speculative parts of the CPPS wiki entry. Wlosy (talk) 15:32, 21 May 2008 (UTC)

• Please read rules for reliable sources for medical articles. Thank you and keep contributing. ► RATEL ◄ 15:36, 21 May 2008 (UTC)

Failure of alfusozin does not mean other alpha blockers will fail also. Alfusozin is relatively selective for the alpha1a receptor subtype. Alpha receptors that control pain in the spinal cord may be other subtypes. Note that studies of less selective alpha blockers in CPPS (Cardura, Hytrin) while smaller in numbers, were all positive studies. Wlosy (talk) 22:03, 26 May 2008 (UTC)

Actually, the abstract ends with the conclusion:

This large NIH/NIDDK sponsored multicenter randomized placebo controlled North American trial will provide an evidence based foundation to help physicians decide whether or not to prescribe alpha-blockers for men with newly diagnosed CP/CPPS.

The inference that the study relates to all alpha blockers may justifiably be drawn. However, I see no problem leaving the edit you made, for now.► RATEL ◄ 22:40, 26 May 2008 (UTC)

Mepartricin

Im surprised this article doesnt mention this drug (and the [Mepartricin] article only describes it as a stomatological preparation). It has shown to be effective in treating CPPS and I can only confirm that from my personal experience. Evidence: http://www.goldjournal.net/article/S0090-4295%2803%2900885-9/abstract —Preceding unsigned comment added by 80.188.222.34 (talk) 16:45, 15 April 2010 (UTC)

==Name== I have never seen a page named like this chronic prostatitis and chronic pelvic pain syndrome are synonyms. Usually we use one or the other not both.Doc James (talk · contribs · email) 11:24, 29 May 2010 (UTC)

Recent changes

There are some SPA editors making huge changes, mostly deletions of long-standing sourced content, without reason, and simultaneous addition of unsourced material that amounts to SPAM while failing the tests of wikipedia is not a crystal ball and rules for sourcing of data in medical articles. The SPAs are Noodlebike (talk · contribs · deleted contribs · page moves · block user · block log) and Arkaroola (talk · contribs · deleted contribs · page moves · block user · block log). I notice the rules on edit warring were also breached. TickleMeister (talk) 09:03, 19 August 2010 (UTC)

Recent review

Review [1] Doc James (talk · contribs · email) 22:17, 25 January 2011 (UTC)

Unfortunately, because this field has seen quite large advances in knowledge in the last 12 years, a review that starts at 1974 will come up with some strange results. The finding that antibiotics are the most effective treatment, for instance, flies in the face of recent research that recommends against their use, since they are found to be no better than placebo (PMID 14550427 et al). See also PMID 18472971 PMID 17954024 and many more like them. RxWatch (talk) 00:24, 26 January 2011 (UTC)

Merge with Chronic prostatitis

Neither ICD 9 or 10 use this term. We routinely refer to the condition as chronic prostatitis.--Doc James (talk · contribs · email) 22:27, 25 January 2011 (UTC)

Chronic prostatitis is shorthand for CP/CPPS, and redirects to this article. RxWatch (talk) 00:25, 26 January 2011 (UTC)

You are correct. Thus I propose we move it to Chronic prostatitis as this is the ICD 9 term and both terms are frequently used interchangeably in reviews.--Doc James (talk · contribs · email) 00:34, 26 January 2011 (UTC)

ICD 9 is a little behind the terms the urological profession and researchers are using (see Table 2 here). But I don't have an objection to the name change, as long as we ripple it all over the database. RxWatch (talk) 00:46, 26 January 2011 (UTC)

Medline plus uses the term "Chronic nonbacterial prostatitis" That might work even better. Then change Chronic prostatitis to a disambig that lists these two terms? Doc James (talk · contribs · email) 01:09, 26 January 2011 (UTC)

Chronic nonbacterial prostatitis — gee, that's an oldie that nobody uses anymore. Do we have to conform to medline or ICD9, and can't we just stick to the NIDDK's definition? RxWatch (talk) 01:33, 26 January 2011 (UTC)

If you look at Pubmed there are recent reviews 2009 that use the term. I had never heard of CP/CPPS until I realised that it was the same as chronic prostatitis. Doc James (talk · contribs · email) 02:47, 26 January 2011 (UTC)

You are right that CP/CPPS is used more. It is just such a combersum term. Will leave it where it is per NIDDK. Doc James (talk · contribs · email) 02:51, 26 January 2011 (UTC)

I have noticed an unfortunate trend to longer (and more inclusive) names for diseases, institutions, departments of institutions, etc., necessitating an ever-increasing use of opaque initialisms.  :-( 108.48.209.190 (talk) 22:20, 3 March 2013 (UTC)

female prostate

This page is heavily geared towards men with chronic prostatis. I would create a separate page for chronic pelvic pain syndrome as it pertains to women. — Preceding unsigned comment added by Mjams (talk • contribs) 14:55, 1 October 2016 (UTC)

ummm see Skene's gland and articles linked at Skene's_gland#Clinical_significance Jytdog (talk) 18:42, 1 October 2016 (UTC)

New ref

seems good: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30503-1/pdf%7C Best Regards, Barbara (WVS) (talk) 19:36, 6 November 2016 (UTC)

Brain

I have put the brain research section under the heading Research. This is an enigmatic syndrome and finally there is light at the end of the tunnel with this NIH/NIDDK funded research, so excluding it all would be stupid. Ratel (talk) 07:07, 26 March 2017 (UTC)

There are two issues with this. First, you have synthesized a mini-review here in WP, which you do not have the right to do as a Wikipedia editor. Second, if there are no reviews discussing this, it is UNDUE. If there are reviews, please summarize them here in WP, giving appropriate WEIGHT to various perspectives on this. The funding has nothing to do with it. Please also see User:Jytdog#NPOV_part_1:_secondary_sources. Jytdog (talk) 12:18, 26 March 2017 (UTC)

Not a synthesis, no attempt to make an argument or draw it all together, simply stating the individual findings in precis form. Perhaps you should re-look at what synthesis means?

Is WP really forbidden from enumerating research directions in conditions, especially conditions about which the medical profession openly acknowledges it knows almost nothing? I would expect a good encyclopedia to outline the directions of further research, not only into the brain but elsewhere too. This is groundbreaking research, reviews have not caught up yet; there are however these reviews PMID 26905019 PMID 27922040 and PMID 2692001 but I would expect more to be published soon. In summary, I will insert the material on the brain again, once I have access to the full paper PMID 26905019 as a source (which should occur soon).Ratel (talk) 22:18, 26 March 2017 (UTC)

Per WP:NPOV which is policy, we give WEIGHT per secondary sources. I went looking and found some brief discussions of this and will add some content based on those reviews. But WP is not cutting edge - our mission is "accepted knowledge" (per WP:NOTEVERYTHING, which is policy); "accepted knowledge" is not at all the same thing as "cutting edge", which we don't do in WP. Jytdog (talk) 22:44, 26 March 2017 (UTC)

Oh please, covering research in a condition with unknown etiology is hardly "cutting edge". Facepalm. Ratel (talk) 23:16, 26 March 2017 (UTC)

• The conclusion of PMID 26905019 is interesting and some of it could go into our article (my emphasis):

The neuroanatomical route of bladder pain is complex. Although the peripheral nervous system is responsible for the initial response to noxious stimuli, the CNS is responsible for the affective and autonomic disturbances that accompany bladder pain. In chronic diseases such as IC/BPS the CNS undergoes molecular, physiological and structural changes that result in pain despite a lack of noxious input from the periphery. Investigating these supraspinal changes will identify new therapeutic strategies to help patients with IC/BPS and other chronic pelvic diseases.

The fact that the brain can continue the pain independently is novel and important. Ratel (talk) 20:36, 27 March 2017 (UTC)

Section deleted with comment "source poor"

The section on pelvic floor musculature was deleted with the words "source poor". However, the source in question frequently cites primary sources, is a reliable secondary source, and is written by one of the leading researchers in this area at Stanford University.

You can see his publications about this issue here: https://profiles.stanford.edu/rodney-anderson?tab=publications

Furthermore, if there are other sources you prefer, go ahead and add them, but please don't just delete the whole section. This is a major theory of CPPS causation which was scarcely mentioned in the page until now. We cannot just delete all mention of it.

There are other theories of causation in the article now. Some of those theories ("food allergies") were developed on message boards and have little or no academic support. If we delete this section, then the most prominent and well-supported theories of causation will be removed from the article when fringe or unsupported theories remain.

The reliable sources policy appears to favor citing secondary sources, which is why I included that one. WP:MEDRS does not stipulate that the source must be a primary source.

Thomas pow s (talk) 18:43, 8 March 2019 (UTC)

Looking at this text. Harmony books is NOT a medical publisher. This is not a medical textbook. It is popular press. We need sources that meet WP:MEDRS. Also you need to provide page numbers, year of publication, Etc. But the first thing is a proper source. Doc James (talk · contribs · email) 04:35, 9 March 2019 (UTC)

User:Thomas pow s you need to use proper sources and get consensus. Doc James (talk · contribs · email) 06:07, 9 March 2019 (UTC)

Hi Doc James. You were just asked not to blank the entire section and delete the most prominent and well-reserached theory, while leaving fringe theories intact. You have not responded in any meaningful way to any of the material that was presented to you.

If the date of publication is missing, then fill it in, but do not just ignore what you were asked and then blank the entire section, and remove the most well-researched theory because of a missing date etc.

WP:MEDRS does not require a medical textbook.

Are you suggesting that this theory is fringe or unscientific? Did you click the link and read the research publications that I presented to you? If you think that the secondary source is not good enough, then can we use other sources you would find more acceptable? Would you like me to help you find those sources?

Answer these questions please, and do not just delete the entire section because of a missing date. Also, if you feel that WP:MEDRS absolutely requires a medical textbook, could you point out where that is indicated?

Thomas pow s (talk) 06:17, 9 March 2019 (UTC)

As the person who wishes to add the content in question, you need to come forwards with a decent reference. You have not done so. You have not even supplied sufficient details in the current reference to verify it. Doc James (talk · contribs · email) 06:29, 9 March 2019 (UTC)

Okay, let's take this one point at a time. Is this reference bad because the book publisher (Harmony) is unacceptable to you? If I fill in the date and page numbers, would it make any difference, or is anything published by Harmony unacceptable? There is no point in doing those things if the source is unacceptable anyway.

How about a bunch of primary sources, like the ones listed in the link I provided above, in addition to the book? Would that be okay?

Thomas pow s (talk) 06:38, 9 March 2019 (UTC)

Also, you are asking for consensus, but do you have consensus yourself? Can you point out where you obtained consensus? If I am violating consensus, then I apologize, and please point out where consensus was obtained.

Also, are these standards applied to all the other theories indicated in that section? Why are you deleting the most-supported theory, while fringe theories have been in the page for years while you've been editing and have entire sections devoted to them? I noticed that one of the major theories presented here has no sources whatsoever, has no relevant research, and indicates "Studies are lacking in this area". Why would we delete the best-supported theories while keeping that one? Thomas pow s (talk) 06:28, 9 March 2019 (UTC)

You need to use proper references per WP:MEDRS. Best Doc James (talk · contribs · email) 06:34, 9 March 2019 (UTC)

Doc James, you are offering flippant responses, while not responding at all to what was just said to you.

If I included a bunch of primary sources as well, as per above, would that be acceptable to you?

Thomas pow s (talk) 06:46, 9 March 2019 (UTC)

How about this source as well? It's a meta-analysis by the same author, published in the journal Urology. Would that be acceptable? Thomas pow s (talk) 07:27, 9 March 2019 (UTC)

That source is much better. It is a pubmed indexed secondary source in a reputable journal. Doc James (talk · contribs · email) 08:05, 9 March 2019 (UTC)

agree w/ Doc James on Meta/analysis--Ozzie10aaaa (talk) 12:02, 9 March 2019 (UTC)

Hi Ozzie, you say "agreed w/ Doc James", but the changes you made to the article were not what was agreed upon. Furthermore, there is a consensus, and someone wrote below that the inclusion of the book as well is acceptable. But then you deleted that source entirely, right after it was agreed that the inclusion of that source as well is acceptable.

Furthermore, I do not see why we would remove this section from where it was, and put it where you put it. I don't understand your reason for that.

This is the best-supported theory on the causation of CPPS. Why would we remove all mention of it from the "Cause" section? And leave the other theories of causation, some of which are fringe, obscure, supported by only a single source, and so on? Why would we remove all mention of the best-supported theory and leave the fringe or obscure theories intact? Readers will now get a drastically incorrect impression that the major theories of CPPS causation involve climate and food allergies (!!). I don't understand your reasoning here.

The very first sentence of WP:RS reads: "Wikipedia articles should be based on reliable ... sources, making sure that all majority and significant minority views in those sources are covered". However, you have just removed the most supported theory from the "causes" section, and left the fringe ones. Could you elaborate on why we should do that?

Thomas pow s (talk) 19:22, 9 March 2019 (UTC)

Im agreeing w/ the use of... Anderson, Rodney U.; Wise, David; Nathanson, Brian H. (October 2018). "Chronic Prostatitis and/or Chronic Pelvic Pain as a Psychoneuromuscular Disorder-A Meta-analysis". Urology. 120: 23–29. doi:10.1016/j.urology.2018.07.022. ISSN 1527-9995. Retrieved 9 March 2019.….--Ozzie10aaaa (talk) 19:52, 9 March 2019 (UTC)

Hi Ozzie, I asked you why you removed the best supported theory from the causes section while leaving the fringe theories intact. If you have no significant reason for this, then I will re-add something to the cause section.

Thomas pow s (talk) 19:59, 9 March 2019 (UTC)

as long as the text is supported by MEDRSWikipedia:Identifying_reliable_sources_(medicine),thank you--Ozzie10aaaa (talk) 20:21, 9 March 2019 (UTC)

Do you object if I also include the book reference, in addition to the agreed-upon source? Thomas pow s (talk) 22:19, 9 March 2019 (UTC)

book[2] does not conform to MEDRS...IMO--Ozzie10aaaa (talk) 23:07, 9 March 2019 (UTC)

(outdenting) Okay, great. I'll add that source to the section.

Do you think it's okay if I still include the book reference? It is by the same author. Thomas pow s (talk) 10:01, 9 March 2019 (UTC)

Of course it's okay to include the book reference, as it may help to verify the article content and provide a basis for further improvement; but it is vital that you supply the details of the book you are using – we need the page so that nobody has to read the whole book to verify the text, and we need the year to identify the edition because pagination often changes between editions. The only time you wouldn't need to provide an exact page number would be if you weren't using the book as a direct reference, but included it in a "Further reading" section. --RexxS (talk) 10:33, 9 March 2019 (UTC)

Harmony Books is not a suitable publisher. We should stick with high quality sources rather than that book. Doc James (talk · contribs · email) 03:11, 10 March 2019 (UTC)

If you are citing the most recent version of the book, then the citation should look like something like this:

Wise, David; Anderson, Rodney U (2018). A Headache in the Pelvis: The Wise-Anderson Protocol for Healing Pelvic Pain. New York. ISBN 9781524762049. OCLC 1000578441.{{cite book}}: CS1 maint: location missing publisher (link)

Whether a Random House imprint that focuses on self-care is appropriate depends upon exactly what sentence it follows.

I've left a blank to make it easy to fill in page numbers. "Page numbers" can be interpreted as the page range for whole chapters. A single sentence sometimes summarizes dozens of pages in a book. Also, if you are citing the book as a whole, which could happen for statements such as "Wise and Anderson published a book about their idea", then page numbers are not necessary, and it can be left blank. WhatamIdoing (talk) 19:49, 10 March 2019 (UTC)

Text in question

One theory is that CPPS is caused by chronic spasm in the pelvic floor musculature. This spasm causes tissue damage and sensitization of nearby nerves. The tissue damage cannot heal because the spasm is ongoing and prevents blood flow to the affected area, thereby preventing healing.

Treatment involves physical therapy to break the spasm, and also a program of "paradoxical relaxation" to prevent chronic tensing of the pelvic musculature which caused the spasm in the first place.

References

Were doe the ref support the text in question?

Not only do we need a decent reference which this is, the reference needs to actually support the text in question. I have read this reference and am not seeing the text that supports the following. User:Thomas pow s can you provide a direct quote from this source? Thanks Doc James (talk · contribs · email) 03:16, 10 March 2019 (UTC)

"One theory is that CPPS is caused by chronic tension in the pelvic floor musculature. This tension causes tissue damage and sensitization of nearby nerves. The tissue damage cannot heal because the tension is ongoing and prevents blood flow to the affected area, thereby preventing healing."

Anderson, RU; Wise, D; Nathanson, NH (October 2018). "Chronic Prostatitis and/or Chronic Pelvic Pain as a Psychoneuromuscular Disorder--A Meta-analysis". Urology. 120: 23–29. doi:10.1016/j.urology.2018.07.022. PMID 30056195.

Doc James, here is a verbatim quote from the paper in question: "prostatitis ... more accurately diagnosed [as] pelvic floor dysfunction. This alternative paradigm suggests pelvic pain arises from chronic pelvic floor irritation initiated by anxiety-provoked chronic muscular guarding of the pelvic floor leading to pelvic floor hypertonicity. This behavioral complex perpetuates a self-feeding cycle of pelvic tissue irritation, tension, pain...".

Here is another paper, entitled Patients with Pelvic Floor Muscle Spasm Have a Superior Response to Pelvic Floor Physical Therapy. Included in that paper is the following text: "Patients with chronic pelvic pain syndrome have a high incidence of pelvic floor spasm, which can be treated with pelvic floor physical therapy."

If I include both these sources, can I re-add the material to the "Causes" section? Thanks...

Thomas pow s (talk) 07:01, 10 March 2019 (UTC)

This paper is a primary source[3]

We have the review. Doc James (talk · contribs · email) 07:20, 10 March 2019 (UTC)

Hi Doc James,

I don't quite understand what you're saying here. I provided a verbatim quotation from the source, as you requested, in which it clearly supports the material in question. Did you see that quotation above? You responded with "we have the review". What does that mean?

Also, do you mean that the primary source is unacceptable? Are primary sources absolutely ruled out?

I'm sorry, but I just can't determine what you're getting at here.

Is it okay if I go ahead and re-add the material?

Thomas pow s (talk) 07:28, 10 March 2019 (UTC)

Yes I am reviewing. This would be the quote "This alternative paradigm suggests pelvic pain arises from chronic pelvic floor irritation initiated by anxiety-provoked chronic muscular guarding of the pelvic floor leading to pelvic floor hypertonicity. This behavioral complex perpetuates a self-feeding cycle of pelvic tissue irritation, tension, pain, and anxiety."

Doc James (talk · contribs · email) 07:32, 10 March 2019 (UTC)

So how about "One proposal is that CP/CPPS is a psychological as well as a neuromuscular disorder. The suggestion is that anxiety results in long term contraction of the pelvic floor muscles which results in pain." as a summary? Doc James (talk · contribs · email) 07:34, 10 March 2019 (UTC)

Frankly, I think it gives the wrong impression. The initial sentence indicates that it is a psychological disorder. The most obvious interpretation of calling it a psychological disorder is that it is imaginary or neurotic, like delusional parasitosis. The theory in question states that it is caused by pelvic floor muscular tension and spasm, which causes tissue irritation and damage. Granted, the spasm may originally have been caused by tension from anxiety, but that is not the same as saying it is a psychological disorder. As an analogy, if I crash my car and break my face on the windshield, it is not a psychological disorder even if my reckless driving ultimately had psychological causes.

Furthermore, I don't think the words "proposal" and "suggestion" should be used to describe the theory.

How about: "One theory is that CPPS is caused by chronic tension in the pelvic floor musculature. Long-term contraction of the pelvic floor muscles results in tissue irritation, spasm, damage, and pain. This chronic tension of the pelvic floor muscles is often the result of muscular guarding, caused by anxiety. It can become a self-reinforcing cycle, whereby pain and anxiety caused by the condition can cause further pelvic floor muscle tension, thereby worsening the condition."

Would that be okay?

I also think we should include the other reference I provided. WP:MEDRS explicitly says: "Primary sources may be presented together with secondary sources."

Thomas pow s (talk) 08:28, 10 March 2019 (UTC)

Furthermore, I think we should re-add the section formatting which was deleted. That way, the format of the text will match the format for all the other theories in the section.

Thomas pow s (talk) 08:44, 10 March 2019 (UTC)

It is not accepted that psychological disorders are "imaginary".

The question is how should we summarize "This alternative paradigm suggests pelvic pain arises from chronic pelvic floor irritation initiated by anxiety-provoked chronic muscular guarding of the pelvic floor leading to pelvic floor hypertonicity. This behavioral complex perpetuates a self-feeding cycle of pelvic tissue irritation, tension, pain, and anxiety."

It states that it starts with "anxiety provoked chronic muscular guarding" so we should start with that. Doc James (talk · contribs · email) 06:43, 11 March 2019 (UTC)

It is not accepted that psychological disorders are imaginary

That's not at all what I said. The example I gave was delusional parasitosis. The parasites are imaginary, not the psychological disorder. In this case, it's a physical illness with tissue damage causing the symptoms. That's what I meant.

It states that it starts with "anxiety provoked chronic muscular guarding" so we should start with that.

That is already present in the proposed summary above, in the third sentence. Do you mean it must be the first sentence? That doesn't read well, in my opinion.

You and I are just going back and forth now. Maybe we should get a few other people involved. Ratel, what do you think? Do you think the text should be as I suggested above? Do you have a better suggestion? What does everyone else think? I'll reproduce the proposed text here: "One theory is that CPPS is caused by chronic tension in the pelvic floor musculature. Long-term contraction of the pelvic floor muscles results in tissue irritation, spasm, damage, and pain. This chronic tension of the pelvic floor muscles is often the result of muscular guarding, caused by anxiety. It can become a self-reinforcing cycle, whereby pain and anxiety caused by the condition can cause further pelvic floor muscle tension, thereby worsening the condition."

Thomas pow s (talk) 22:44, 11 March 2019 (UTC)

This is a key point in the article and so quite important. Can we see competing texts here please? Use a table for greater clarity, as in:

Psychoneuromuscular Theory

Source	Thomas Pow	Doc James
"prostatitis [is] more accurately diagnosed [as] pelvic floor dysfunction. This alternative paradigm suggests pelvic pain arises from chronic pelvic floor irritation initiated by anxiety-provoked chronic muscular guarding of the pelvic floor leading to pelvic floor hypertonicity. This behavioral complex perpetuates a self-feeding cycle of pelvic tissue irritation, tension, pain, and anxiety."	One theory is that CPPS is caused by chronic tension in the pelvic floor musculature. Long-term contraction of the pelvic floor muscles results in tissue irritation, spasm, damage, and pain. This chronic tension of the pelvic floor muscles is often the result of muscular guarding, caused by anxiety. It can become a self-reinforcing cycle, whereby pain and anxiety caused by the condition can cause further pelvic floor muscle tension, thereby worsening the condition.	One proposal is that CP/CPPS is a psychological as well as a neuromuscular disorder. The suggestion is that anxiety results in long term contraction of the pelvic floor muscles which results in pain. The pain results in further anxiety and thus worsening of the condition.

Copy and paste the table text into your replies. Thank you. Ratel (talk) 01:19, 12 March 2019 (UTC)

Okay, I copied it into the table. Thomas pow s (talk) 03:32, 12 March 2019 (UTC)

I've added in Doc James' text (I think). He is welcome to change it. On the face of it, perhaps it's too short? Ratel (talk) 11:59, 12 March 2019 (UTC)

I have added the source. The "irritation" being described is not something that is visible in a microscope as far as I am aware. Doc James (talk · contribs · email) 12:13, 12 March 2019 (UTC)

I will briefly re-iterate my concerns with the alternative text. First, we cannot call the condition a "psychological disorder", because it is not a psychological disorder. As an analogy, consider the example a person whose depression drives him to drink, and he eventually develops cirrhosis of the liver. The cirrhosis is not a psychological disorder, even if the patient would never have had it but for behavior driven by a psychological disorder.

Second, we should not describe this theory using terms like "suggestion" and "proposal". This is by far the best supported theory on this condition. At worst we should use neutral terms (like "theory") to describe it.

Finally, I don't think that my proposed text should be re-ordered so the statement about anxiety comes first. I want a topic sentence for the paragraph which is concise, and which immediately describes the distinguishing characteristics of this disorder. In this kind of paragraph, the sentences should be arranged in descending order of importance, not chronological order ("it all starts with anxiety..."). Any more than an article about cirrhosis should start with material about how patients have had addiction problems for years. Note that the meta-analysis article does not start with statements about anxiety; it first describes the condition as "pelvic floor dysfunction" and then goes into anxiety later. The text I proposed does describe the anxiety and muscular guarding in the third sentence, so that material is not omitted or hidden.

Thomas pow s (talk) 20:29, 13 March 2019 (UTC)

I think both versions do convey the idea theory pretty well. It is, after all, almost certainly a psychoneuromuscular condition, an interplay between brain, muscles and peripheral nerves. The Thomas Pow version is a bit more descriptive and less tentative, so I guess I'd support that. Ratel (talk) 22:07, 13 March 2019 (UTC)

It is not really a "Pelvic floor muscular disorder" all by itself. The theory is that it involves an interplay of factors. Doc James (talk · contribs · email) 09:31, 14 March 2019 (UTC)

Are you objecting to the section title here? What section title do you prefer? How about "neuromuscular disorder"? How about "pelvic floor neuromuscular disorder"?

The first sentence of the quotation from the review says: "more accurately diagnosed [as] pelvic floor dysfunction.". Can we call it "pelvic floor dysfunction"?

Personally, I vote for "pelvic floor dysfunction" since that is what the first sentence of the review article says when discussing the cause.

Thomas pow s (talk) 09:48, 14 March 2019 (UTC)

Okay added that heading Doc James (talk · contribs · email) 12:00, 14 March 2019 (UTC)

Doc James, thanks for the agreement on the section title. I'm glad we were able to reach an agreement upon that.

However, the text itself must match what was decided upon by consensus above during discussion.

I am definitely willing to discuss this issue further and compromise, if you feel there is something wrong with that text or some change should be made to it. However, I think we would need to reach a new consensus here before deleting the text which has been inserted.

Thomas pow s (talk) 20:34, 14 March 2019 (UTC)

Were was "the text itself ... decided upon by consensus above during discussion"? Doc James (talk · contribs · email) 08:03, 15 March 2019 (UTC)

Just above, I asked for other editors' input. Ratel set up a table then voted as follows: "The Thomas Pow version is a bit more descriptive and less tentative, so I guess I'd support that". That is two votes in favor of one version, and one vote in favor of yours. It is about half a page above. The edit is entitled "pow version yes" in the edit history.

I am quite willing to discuss this issue further and compromise. However, you need to explain why you do not want the version I proposed, which changes you'd like made to it, and why. You should also respond to the objections I put to you above, if you still prefer your version.

Please do not just revert the agreed upon text without discussing it here and obtaining a new consensus.

Thomas pow s (talk) 09:39, 15 March 2019 (UTC)

That is not a consensus. We can try a WP:RfC. Doc James (talk · contribs · email) 10:19, 15 March 2019 (UTC)

(outdenting) Hi Doc James. I am asking you again to participate in the discussion and provide some kind of meaningful response or objection. I am trying repeatedly to engage you in some kind of compromise or discussion.

Thomas pow s (talk) 10:24, 15 March 2019 (UTC)

Additional primary source for the pelvic floor muscular section

Does anyone object if I add this source to that section as well? WP:MEDRS says: "Primary sources may be presented together with secondary sources."

Thomas pow s (talk) 09:26, 14 March 2019 (UTC)

There are lots of reviews. No we do not need to use primary sources. Doc James (talk · contribs · email) 09:32, 14 March 2019 (UTC)

agree, primary sources should not be added--Ozzie10aaaa (talk) 14:45, 14 March 2019 (UTC)

RfC regarding summary of one theory

The following discussion is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

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The source says "prostatitis [is] more accurately diagnosed [as] pelvic floor dysfunction. This alternative paradigm suggests pelvic pain arises from chronic pelvic floor irritation initiated by anxiety-provoked chronic muscular guarding of the pelvic floor leading to pelvic floor hypertonicity. This behavioral complex perpetuates a self-feeding cycle of pelvic tissue irritation, tension, pain, and anxiety."

Proposal 1

One proposal is that CP/CPPS is a psychological as well as a neuromuscular disorder. The suggestion is that anxiety results in long term contraction of the pelvic floor muscles which results in pain. The pain results in further anxiety and thus worsening of the condition.

Proposal 2

One theory is that CPPS is caused by chronic tension in the pelvic floor musculature. Long-term contraction of the pelvic floor muscles results in tissue irritation, spasm, damage, and pain. This chronic tension of the pelvic floor muscles is often the result of muscular guarding, caused by anxiety. It can become a self-reinforcing cycle, whereby pain and anxiety caused by the condition can cause further pelvic floor muscle tension, thereby worsening the condition.

10:22, 15 March 2019 (UTC)

Support 1

• Support this is more chronological in order. The source says "initiated by anxiety-provoked chronic muscular guarding" so anxiety first, muscle guarding second. Doc James (talk · contribs · email) 10:22, 15 March 2019 (UTC)
• support ordering events in accordance with time sequence is important ...IMO--Ozzie10aaaa (talk) 10:42, 15 March 2019 (UTC)
• support together with the improvements suggested below I came in late,but don't have a lot more to offer than the apparent preference for the wording some folks proposed. — Preceding unsigned comment added by JonRichfield (talk • contribs) 15:37, 4 April 2019 (UTC)

Support 2

• Support First, we cannot call the condition a "psychological disorder", because it is not a psychological disorder. It involves spasm and damage of the pelvic floor musculature, with consequent neuropathic pain. As a result, it's not a psychological disorder, even if anxiety drove a behavior which caused the muscular damage. As an analogy, consider the example a person whose depression drives him to drink, and he eventually develops cirrhosis of the liver. The cirrhosis is not a psychological disorder, even if the patient would never have had it but for behavior driven by a psychological disorder.

Second, we should not describe this theory using terms like "suggestion" and "proposal". This is by far the best supported theory on this condition, with an extensive review article and many studies on this theory. It is not at all just a "suggestion". At worst we should use neutral terms (like "theory") to describe it.

Third, I don't think the text should be re-ordered so the statement about anxiety comes first. I want a topic sentence for the paragraph which is concise, and which immediately describes the distinguishing characteristics of this disorder. In this kind of paragraph, the sentences should be arranged in descending order of importance, not chronological order ("it all starts with anxiety..."). Any more than an article about cirrhosis should start with material about how patients had an abusive childhood and subsequent addiction problems for years, which would be chronological but not the most pertinent. The text I proposed does describe the anxiety and muscular guarding in the third and fourth sentences, so that material is not omitted or hidden. Thomas pow s (talk) 10:40, 15 March 2019 (UTC)

• This or the original source phrasing are better. The other selection is incorrectly saying “psychological disorder”, indicating the pain is imaginary. While the cause may be anxiety and tension, the expressed dysfunction is not psychological. It is also improper paraphrase to say ‘disorder’ instead of ‘dysfunction’. The source is not indicating an irrational fear, but rather an unusual result of anxiety or possibly a factor of physical guarding in some cases leading to the issue. That seems similar to favoring one knee causes back pain, or limiting back movement causes back issues. Those would lead to physical therapist prescriptions, not psychologist referrals. Cheers Markbassett (talk) 14:25, 13 April 2019 (UTC)

Discussion

• My comment is I would support Doc James' version if:

1. he could work the word "psychoneuromuscular" into the description (a word used in one of the studies, so not a neologism, see PMID 30056195 ).
2. remove the wording "The suggestion is ..." because (a) unnecessary (b) there is enough support for this theory to be less tentative and (c) it serves to caste doubt on the theory by implying complete empiricism (words like "claims" is a loaded term eschewed for the same reason).

I don't support the use of the word "damage" in Thomas Pow's version, because I am unaware of any study showing actual physical damage to muscles, nerves or prostate (beyond inflammation).

I would like to see the word "stress" introduced as well. Some men who develop this condition do so not because of anxiety but because of the level of stress they experience due to work conditions, or life experiences (marriage breakup or infidelity, for instance). Stress is mentioned in numerous review studies e.g. PMID 25300538 and PMID 23740129 and PMID 15310980 etc Ratel (talk) 16:01, 15 March 2019 (UTC)

The term is short form for "psychological, neurological, and muscular"

The best avaliable sources say the cause is unknown. This is a theory in that it is tentative.

User:Ratel the one under it discuses nerves and stress. So it is already there. Doc James (talk · contribs · email) 08:01, 16 March 2019 (UTC)

I certainly don't mind dropping the word "damage". I added that because Shoskes and others describe active and ongoing pelvic floor spasm, there are dead white blood cells, and several of the studies done on this use the word "injury". However, perhaps "damage" is too strong a word and I don't mind dropping it.Thomas pow s (talk) 18:41, 15 March 2019 (UTC)

Dead white blood cells (pus cells) are due to inflammation. Ratel (talk) 23:12, 15 March 2019 (UTC)

• An additional comment, directed mostly at Doc James, is that the Wise-Anderson psychoneuromuscluar theory first appeared in 2006 (PMID 15947608 ), whereas the "competing" theory in our article, as written currently, (Nerves, stress and hormones) is a grab-bag of theories based on the Pontari 2008 review (that ignored the Wise/Anderson study, strangely), combined with a brain-bladder review study that does not actually offer a causation theory, merely noting a link, and then there is the Theoharides work from 2003-6 that points to mast cells, HPA-axis, and neurogenic inflammation. Theoharides has mostly stopped publishing in this area (last study was in 2011 I think). He was very good on pointing out that stress can activate pelvic nerves, which in turn cause peptide hormones to be released at the end of the nerves that in turn activate local mast cells (causing degranulation), which in turn causes pain and inflammation. Sequence clearly shown in feline and murine models. The first domino in that sequence is stress (or anxiety), so this is what links his work to the Wise-Anderson theories, although the explicit commonality and linkage of these theories has never been published AFAIK. But you can work it out yourself just by comparing the two theories. The W-A theory posits stress/anxiety leading to pelvic muscle dysfunction and pain with trigger points, but ignores the cytokine profiles of bladder/prostate that do indicate inflammation (ignoring the less subtle WBCs), whereas the Theoharides theory ignores the muscles and trigger points, concentrating on the sequence stress ► nerve activation ► mast cell activation ► inflammation + pain. Both theories tell some of the story, but not all of the story. Now you may claim that this is WP:OR, but it's also fairly obvious. How do we respond? IMO, we should write the section in such a way that the two theories are not shown as competing with each other, because they dovetail logically. In essence, both main theories entail:

1. the brain ("stress" "anxiety" "CNS" "HPA-axis dysfunction" "psychological" etc)
2. the local nerves ("trigger points" (that are caused by nerves of course), "neurogenic inflammation" etc)

Where they differ is that one theory emphasizes muscle spasm and trigger points and calls for psychological training to intervene, combined with muscle spasm treatment, and ignores the mast cell/nerve interactions in the target organs adjacent to the muscles (that are inflamed due to nerve cross-talk) whereas the other ignores the muscles and emphasizes stress and mast cells. Unfortunately it's a complex medical problem, so you can see why it remains a contentious area. Ratel (talk) 01:00, 16 March 2019 (UTC)

It appears this discussion has stalled. Nobody has showed up or responded to the Rfc other than the people who were here before. No activity or discussion has occurred in some time.

I have a proposed compromise. How about we use Doc James' version, but with the wording changes which Ratel and I think would be appropriate. As follows:

"One theory is that CP/CPPS is a psychoneuromuscular disorder. The theory is that anxiety results in long term contraction of the pelvic floor muscles which results in pain. The pain results in further anxiety and thus worsening of the condition."

This is Doc James' version, except the words "suggestion" and "proposal" are replaced by "theory", and the words "psychoneuromuscular disorder" replace the terms "psychological disorder" and "neuromuscular disorder". Would that be okay?

Thomas pow s (talk) 04:01, 28 March 2019 (UTC)

I'll agree to that. Let's make the changes and move on. Ratel (talk) 05:25, 28 March 2019 (UTC)

Would be good to simplify "psychoneuromuscular disorder" as "psychological, neurological, and muscular disorder".

"Posits" would be better as "proposed". This is just to make it more accessible to a general audience. Doc James (talk · contribs · email) 14:24, 6 April 2019 (UTC)

Three editors have already agreed to the compromise text I proposed above, and there has been no activity for a long time. I think we should just go with the text agreed upon at this point. I see your point, but this discussion has stalled and I think we should go with what we agreed upon.

Thomas pow s (talk) 19:25, 30 April 2019 (UTC)

• Someone should close this RfC Ratel (talk) 22:35, 14 April 2019 (UTC)

The discussion above is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

Gluten and cold weather

It's a pity we have lost some data on gluten, and all the data on cold weather. There is very suggestive evidence that cold weather exacerbates symptoms (to take just one source: PMID 22452545 ), and gluten is a big suspect: [4] and PMID 11975966 (female case). I also thought the page at the Prostatitis Network was worth including because of the unique content, despite the ads. Sadly, review studies do not mention cold or gluten .... thus far. So I am not arguing with the exclusions, but I do regret seeing any relevant data on this enigmatic condition being excluded, perhaps because I see Wikipedia as a source readers may turn to for help. Ratel (talk) 05:41, 10 March 2019 (UTC)

I don't think the web page is an acceptable source. It appears to be random speculation from the owner of a website.

However, I agree with you that the information on climate should remain somewhere in the article. There appear to be a few sources which support the idea that cold temperatures exacerbate the condition. It is not a well-supported theory, but we must keep in mind that this is a poorly-understood and obscure condition. All significant minority views found in the literature should be represented here, in my opinion.

Thomas pow s (talk) 07:09, 10 March 2019 (UTC)

None of the source meet WP:MEDRS Doc James (talk · contribs · email) 07:21, 10 March 2019 (UTC)

I know that. However, when we are faced with a mysterious condition like CP/CPPS, I'd like to see more leeway to include primary studies that may indicate ideas for future research. The medical profession is stumped on this one, and the review studies mostly admit that. Ratel (talk) 10:20, 10 March 2019 (UTC)

Academic papers about future research directions are welcome sources in any disease-related article. A well-constructed ==Research directions== section, based on what researchers recommend, could give people (including patients, biotech investors, government research funders, etc.) ideas about what to realistically expect in the coming years. "In 2016, the Expert Committee recommended that research focus on X and Y" is much more valuable than something that amounts to "Some guy on the internet speculated about Z". WhatamIdoing (talk) 19:58, 10 March 2019 (UTC)

This is a good summary. The cause is unknown. https://www.cochrane.org/CD012551/PROSTATE_intervention-treating-chronic-prostatitis-and-chronic-pelvic-pain-men Doc James (talk · contribs · email) 07:02, 11 March 2019 (UTC)

Non-medication and medication based additions

I added additional information to both medication and non-medication treatments to broaden the scope of the treatment options listed in this article. The information cited comes from a set of Cochrane reviews relating to this condition. --Gsom12812 (talk) 20:07, 27 February 2021 (UTC)

I have some problems with this edit. The Cochrane review is not high quality. Coming from Argentina, it talks about things like physical activity as a treatment, this is something I have never heard being prescribed by any urologist (and I know a lot about this topic). It discusses "Prostatic massage" as a treatment, again not used by urologists in the West (was found to make no difference PMID 16566972 ). And also Transurethral microwave thermotherapy, not used as a treatment by any uro in the US or UK. I would describe this Cochrane review as very low quality. While purporting to cover non-pharma treatments, it completely ignores psychological treatments (e.g. progressive relaxation and cognitive therapy), physical therapy (now almost universally recommended as a first line treatment), and phytotherapy, the big new treatments in the US and Europe. And it fails to delineate what "lifestyle changes" it's talking about. Just a very poor paper. And the other Cochrane paper cited, used as support for things like antibiotics (already known to be ineffective PMID 14550427 ), is from the same South American team, and also contains information that is not quite right. I don't have time to correct all this, but I suggest reversing these edits. Ratel 🌼 (talk) 21:21, 27 February 2021 (UTC)

Thank you for your feedback. I fully agree that the evidence was inserted without an adequate context on the clinical aspects of this condition. I, therefore, added more information from EAU Guidelines regarding pain education, physical therapy and psychotherapy and organised the contents so they can be read more clinically. Please, feel free to add more information about the different types of psychological therapies in this section. I don't think that the evidence part needs to be reverted, though.Jvaf85 (talk) 21:11, 28 February 2021 (UTC)

@Jvaf85: Thanks for improving it. Much better now. Ratel 🌼 (talk) 10:21, 1 March 2021 (UTC)