Clinical Utility of the UPOINT Phenotype System in Chinese Males with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS): A Prospective Study
Zeng G (2013) Clinical Utility of the UPOINT Phenotype System in Chinese Males with Chronic Prostatitis/Chronic Pelvic Pain
Syndrome (CP/CPPS): A Prospective Study. PLoS ONE 8(1): e52044. doi:10.1371/journal.pone.0052044
Clinical Utility of the UPOINT Phenotype System in Chinese Males with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS): A Prospective Study
Zhigang Zhao 0
Jingwei Zhang 0
Jun He 0
Guohua Zeng 0
Praveen Thumbikat, Northwestern University, United States of America
0 Department of Urology & Andrology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical College, Guangdong Provincial Key Laboratory of Urology , Guangzhou, Guangdong Province , China
Background: Recent data showed that a six-domain UPOINT is a flexible and responsive new classification system that has the clinical applicability in CP/CPPS. However, the utility of UPOINT algorithm in men in China with CP/CPPS has not been comprehensively studied. For international validation and adoption, we evaluated this clinical phenotype system for a large cohort of Chinese CP/CPPS patients and correlated it with patient symptoms and erectile dysfunction (ED). We also investigated the addition of an ED domain in regard to symptom correlation. Methods: A total of 389 Chinese males with CP/CPPS were prospectively collected and classified in each domain of the UPOINT system. Symptom severity was measured using the NIH-CPSI and IPSS. The erectile function was evaluated using the IIEF-5. Clinically relevant associations were calculated. Results: The percentage of patients positive for each domain was 54.0%, 42.1%, 41.9%, 20.8%, 26.7%, and 40.4% for the Urinary, Psychosocial, Organ-specific, Infection, Neurological/systemic, and Tenderness, respectively. There were significant correlations between the number of positive UPOINT domains and total NIH-CPSI (r = 0.706, p,0.001), IPSS (r = 0.682, p,0.001) and IIEF-5 scores (r = 0.631, P = 0.007) in Chinese cohort. Except for patients age, symptom duration was associated with a significantly greater number of positive domains (r = 0.638, P = 0.005). After adding an ED domain to create a modified UPOINT system, the correlation between the number of phenotypic domains and symptom severity was improved (0.706 to 0.844, p,0.001). Conclusions: The clinical applicability of using UPOINT phenotyping system has been validated in the Chinese patients with CP/CPPS. In our cohort, the number of positive domains was also correlated with ED symptoms and the significant association between the number of UPOINT domains and NIH-CPSI scores was further refined by adding a domain for ED. Our findings presented here support the utility of using ED as a stand-alone item in the UPOINT domain.
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is
a common yet poorly understood condition, with significant
economic costs and severe impact on the quality of life of
diagnosed patients [1,2]. The prevalence was estimated between
2.2% and 13.8% [3,4]. A population-based survey has shown the
prevalence of CP/CPPS-like symptoms to be 4.5% in China .
Symptoms of this condition include chronic pain, voiding
symptoms, and pelvic, sexual and psychosocial disturbances,
among others . To date, no single specific therapy is effective
in all patients. The major reason for this is that patients with CP/
CPPS are not a homogenous group with a single disease process
who respond in the same way to specific medications, but rather a
heterogeneous group of unique individuals with widely different
etiological mechanism(s), disease characteristics, symptom
complexes, and progression trajectories. It is therefore rational to
evaluate CP/CPPS patients as individuals with differing clinical
phenotypes. However, no validated predictors or biomarkers are
currently available that help classify those patients in a way that
could guide therapy. In 2009, Shoskes et al  developed a
6point clinical phenotyping system called UPOINT to classify
patients with CPPS and interstitial cystitis and subsequently direct
appropriate therapy. The clinical domains are urinary symptoms,
psychosocial dysfunction, organ specific findings, infection,
neurological/systemic, and tenderness of muscles. Each domain has
been clinically defined, linked to specific mechanisms of symptom
production or propagation, and associated with specific therapy.
This phenotype is qualitative, with each domain scored as yes or
no. The major finding of the first UPOINT retrospective study
was the strong correlation between the number of UPOINT
positive domains and the NIH-CPSI total score in each patient
, which was further verified by other studies [9,10]. More
recently, the UPOINT-guided multimodal therapy has been
shown to significantly improve symptoms .
It is widely acknowledged that CP/CPPS is associated with
significant sexual dysfunction [12,13]. Erectile dysfunction (ED),
defined as the consistent inability to obtain and/or maintain a
penile erection sufficient for adequate sexual performance, is the
most investigated sexual dysfunction in patients with CP/CPPS
[12,13]. The reported ED prevalence findings for CP/CPPS
sufferers ranged from 15.0% to 48.3% [14,15], varying with the
evaluation tools and populations. However, the original UPOINT
phenotype system did not include a domain for sexual dysfunction
or ED. A Swedish study recently showed that the number of
positive UPOINT domains was not correlated with ED severity in
CP/CPPS patients . The impact of adding a sexual dysfunction
or ED domain to the UPOINT system on patients symptoms is
also conflicting [10,16].
For international validation and adoption of this novel
UPOINT algorithm a prospective study was conducted in a
Chinese cohort of males with CP/CPPS. We sought to determine
the clinical phenotype of those Chinese CP/CPPS patients using
the UPOINT classification system and assessed the frequency of
individual domains and their effect on symptom severity and
erectile function. Also, we aimed to further investigate the impact
of adding an ED domain to create a modified UPOINT
phenotyping system on symptom severity of CP/CPPS patients.
Materials and Methods
The patient population included 389 consecutive male patients
with a diagnosis of CP/CPPS, who were prospectively evaluated
in our Clinic from November 2009 to June 2012, by 1 urologist (Z.
Z.). All patients were diagnosed according to the National
Institutes of Health (NIH) criteria , and assessed by a carefully
taken medical history that included a symptom and bother
assessment, a focused physical examination that included
premassage urine and expressed prostatic secretions or post-massage
urine analysis and culture, a digital rectal examination (DRE) of
the prostate and the pelvic floor muscles, and specifical questions
regarding the psychosocial problems. Each patient had their
symptom measured using the NIH Chronic Prostatitis Symptom
Index (NIH-CPSI) questionnaire, reported as the total score (043
points) and the NIH-CPSI subscores for pain (021 points),
urinary (010 points) and quality of life (QoL, 012 points) ,
and the international prostate symptom score (IPSS)
questionnaire. On the basis of the total NIH-CPSI score, patients were
stratified as having mild (015 points), moderate (1629 points), or
severe (.29 points) symptoms . The presence and severity of
ED was measured for each patient by using the 5-item
International Index of Erectile Function (IIEF-5) questionnaire
. Any patients with acute or chronic bacterial prostatitis, a
history of genitourinary cancer, previous prostate procedures or
surgery, and neurologic disease affecting the bladder were
excluded from the study.
The patients in this study were a mixture of newly diagnosed,
relatively treatment naive (usually antibiotics or anti-inflammatory
agents) and tertiary referral patients in whom multiple previous
therapies had failed. Prior to commencing this study, the approval
from the Ethics Review Board of Guangzhou Medical College was
granted, and the written informed consent was obtained from each
From the clinical data a yes/no classification for each of the six
UPOINT domains was made for each individual patient. For each
domain the same criteria as repored in the paper by Shoskes et al.
were used . In brief, the urinary domain was positive if patients
had a NIH-CPSI urinary score .4 and complained of bothersome
urgency, frequency, nocturia, or had a postvoid residual urine
volume of .100 ml. The psychosocial domain was positive if
patients complained of depression, poor coping or catastrophizing,
helplessness, hopelessness, or had a poor social interaction. The
organ specific domain was considered positive if patients had
tenderness localized to the prostate, leukocytosis in the prostatic
fluid, hematospermia, or extensive prostatic calcifications. The
infection domain was positive if gram-negative bacilli or Enterococcus
was localized to the prostatic fluid in the absence of a current or
previous urinary tract infection, or patients had a documented
successful response to antimicrobial therapy. The neurological/
systemic domain was considered positive if patients had a pain
experienced beyond the abdomen and pelvis, with the concurrent
diagnoses of irritable bowel syndrome, fibromyalgia, or chronic
fatigue syndrome. Finally, the tenderness domain was positive if
painful spasms or pelvic floor-related intra-rectal trigger points
In the present study, we adapted the validated IIEF-5
questionnaire to define patient erectile function phenotype, which
was added as an independent ED domain into the UPOINT to
create a modified UPOINT system. The ED domain was positive
if there was a IIEF-5 score ,22. Based on the IIEF-5 score, the
severity of ED was divided into five levels, i.e. normal (2225
points), mild (1721 points), mild to moderate (1216 points),
moderate (811 points), or severe (57 points) .
Assuming a two-sided significance test with significance level
a = 0.05 for the current study, with our sample size of 389 cases,
the estimated power was of 90%. For descriptive statistics, the data
are presented as the mean6standard deviation (SD) and medians
with interquartile range for continuous variables and counts or
frequencies with percentages or proportions for categorical
variables. Analysis of variance was used for comparison between
multiple groups, and Bonferronis multiple comparison test was
then used to compare pairs of groups. For comparison of
categorical data, the nonparametric Kruskall-Wallis test was used.
Correlations of the number of positive domains with symptom
severity and ED were evaluated by using the Spearmans
coefficient of rank correlation. Intergroup differences between
NIH-CPSI or IIEF-5 scores in patients positive or negative for
each domain were analyzed by using the non-paired,
nonparametric Mann-Whitney test. Correlation coefficients were also
calculated using nonparametric tests. In the study, all analyses
were performed with the Statistical Package for the Social Sciences
(SPSS) statistical software package version 16.0 for Windows
(SPSS, Chicago, IL).
Patient Clinical Presentation
Patient age, diagnosis, and the results of the NIH-CPSI, IPSS
and IIEF-5 scores and the 6 UPOINT domains in the Chinese
cohort are listed in Table 1. The 389 men had a median age of 43
years (range 1973), with a median duration of symptoms of 9.3
months (range 1156). The median total NIH-CPSI score was
23.7 (range 643), and the median total number of UPOINT
positive domains was 3 (range 16). The number of patients
Duration of symptoms (month)
CP/CPPS diagnosis, n (%)
NIH-CPSI scores, mean6sd (range)
IPSS scores, mean6sd (range)
Symptom severity, n (%)
IIEF-5 scores, mean6sd (range)
Positive UPOINT domains, n (%)
Eligible patients (n = 389)
having positive domains was 21 (5.4%) for 1 domain, 123 (31.6%)
for 2 domains, 167 (42.9%) for 3 domains, 51 (13.1%) for 4
domains, 20 (5.1%) for 5 domains, and 7 (1.8%) for 6 domains. No
patient had zero positive domains. The majority had positive
scores between 2 and 3, and one-fifth had a score $4.
Correlation between the UPOINT Phenotyping Domain
and Patients Symptoms
To validate the original findings of Shoskes et al , we
calculated the correlation between the number of positive
UPOINT domains and the NIH-CPSI total scores and
NIHCPSI pain, voiding and QoL impact subscores in Chinese cohort
of patients with CP/CPPS. Analysis was also extended to the IPSS
scores and to the IIEF-5 scores. The results revealed that there was
a strong and significant correlation between the number of positive
domains and the NIH-CPSI total score (Spearman r = 0.706,
p,0.001) and the IPSS score (Spearman r = 0.682, p,0.001). The
number of positive UPOINT domains was also strongly correlated
with the NIH-CPSI QoL subscore (Spearman r = 0.650, p,0.001)
and pain subscore (Spearman r = 0.643, p = 0.004), but not with
the urinary subscore (Spearman r = 0.328, p = 0.140). The
correlation between age and NIH-CPSI scores was nonsignificant
(Spearman r = 0.136, P = 0.547), however, symptom duration was
found to be associated with a significantly greater number of
positive domains (Spearman r = 0.638, P = 0.005).
As seen in Figure 1A, a stepwise increase was found in the total
NIH-CPSI score as the number of positive domains increased
from a mean of 16.8562.11 for patients with 1 positive domain to
34.0763.16 for those with 6 positive domains (P,0.001, analysis
of variance). Stratifying patients by the total NIH-CPSI score as
having mild, moderate, or severe symptoms revealed that, as the
symptom severity increased, so did the number of positive domains
(mild 1.5460.18, moderate 2.4260.20, and severe 3.7760.25;
P,0.001, Kruskall-Wallis test). In addition, when the total
NIHCPSI score was compared for the presence of each phenotypic
domain, significantly increased symptom scores were seen in all
Figure 2. Comparison of NIH-CPSI symptom scores between patients with and without each UPOINTS domain. Mean total NIH-CPSI
symptom scores were compared between patients with and without each urinary (U), psychosocial (P), organ specific (O), infection (I), neurological/
systemic (N), tenderness (T), and sexual dysfunction (S) UPOINTS domain, respectively. Significant difference was seen in each domain between no
and yes (*P,0.05).
UPOINT domains, including the added sexual dysfunction S
domain (no vs. yes for each domain, all P,0.05, Figure 2).
Correlation between the UPOINT Phenotyping Domain
In the study, we also investigated the correlation between the
number of positive UPOINT domains and the presence and
severity of ED. Our data showed that there was a significant
inverse correlation between the number of positive UPOINT
domains and IIEF-5 scores (Spearman r = 0.631, P = 0.007). As
the number of positive domains increased, the IIEF-5 scores
reduced from a mean of 21.0465.16 for patients with 1 positive
domain to 6.5962.14 for those with 6 positive domains (P,0.001,
Kruskall-Wallis test, Figure 3). Stratifying patients by the IIEF-5
score as having no ED, or mild, mild to moderate, moderate, or
severe ED revealed that, as the ED severity increased, so did the
number of positive domains (normal 0.5660.15, mild 1.5460.22,
mild to moderate 2.6060.37, moderate 3.7460.52, and severe
5.0560.71; P,0.001, Kruskall-Wallis test).
As shown in Figure 4, the presence or absence of ED had a
significant effect on the total NIH-CPSI score (25.6567.10 vs.
21.7365.94, P,0.001) and its QoL subscore (8.4162.26 vs.
5.7861.79, P,0.001), but not on its urinary (4.3862.24 vs.
4.6162.32, P = 0.517) and pain subscores (10.7563.22 vs.
10.3663.05, P = 0.328). When the total IIEF-5 score was
compared for the presence of each phenotypic domain of the
UPOINT, significantly reduced IIEF-5 scores were seen in
patients positive for the psychosocial, organ specific and skeletal
muscle tenderness domains (no vs. yes for each domain, all
P,0.05, Figure 5).
Effect of Adding a Domain for ED to Create a Modified
UPOINT on Symptoms
To evaluate the impact of adding a domain related to ED on
symptom severity, we analyzed the correlation between the
number of positive phenotypic domains and the NIH-CPSI or
IPSS scores in a modified UPOINT system. After adding the ED
domain, the correlation between the number of the modified
UPOINT domains and the NIH-CPSI total score was significantly
improved in our cohort of CP/CPPS patients (correlation
coefficient r from 0.706 to 0.844, p,0.001, Figure 1B). Intergroup
variance also became significant (Mann-Whitney test, p,0.001).
Furthermore, adding an ED phenotype to the original UPOINT
significantly improved the correlation between the number of
UPOINT domains and the NIH-CPSI pain and QoL subscores
(correlation coefficient r from 0.643 to 0.772, p,0.001 and from
0.650 to 0.794, p,0.001, respectively). Similarly, we did not note
a significant correlation between the NIH-CPSI voiding subscore
and the number of domains of this modified UPOINT domains.
It has become increasingly clear that each patient with CP/
CPPS represents a distinct etiological and symptom profile,
resulting in a unique clinical phenotype that may be clinically
directive, involving clearly identifiable symptom domains to define
a heterogeneous population of unique individuals [7,8]. Classifying
patients according to the clinical phenotype will allow for helping
determine effective therapy for CP/CPPS . The UPOINT
Figure 4. Correlation between NIH-CPSI symptom scores and ED. Total NIH-CPSI symptom score and its urinary, pain and QoL subscores
were compared between CP/CPPS patients with and without ED. The presence of ED had a significant effect on the total NIH-CPSI score and its QoL
subscore, but not on its urinary and pain subscores (*P,0.05).
clinical phenotyping system, developed by Shoskes et al , has
been recently evaluated and validated in the American and
European populations of CP/CPPS . For international
validation and adoption of this novel algorithm, we applied the
original UPOINT phenotype domains prospectively to a large
population of Chinese males consecutively diagnosed with CP/
CPPS and evaluated its clinical utility. Our results presented here
showed that most patients can be typically categorized with
multiple domains and the increasing number of positive UPOINT
domains characterizing the clinical phenotype in each patient
strongly and significantly correlated with severity of symptoms as
measured using the NIH-CPSI or IPSS total scores. The results
are consistent with the major findings of the four separate studies
that have now examined the UPOINT system in CP/CPPS, in
1469 patients . Taken together, those data demonstrate that
the UPOINT phenotyping system can identify CP/CPPS patients
into relevant domains using standard clinical assessment and that
the phenotypes yielded by this novel classification system show a
heterogeneity for individual domains and the number of positive
domains in CP/CPPS. The prevalence and distribution of positive
UPOINT domains observed in Chinese patients is remarkably
similar to the ones recorded in European or North-American
subjects . In our cohort, the NIH-CPSI values are also
strikingly similar to the ones described in the studies of Shoskes
et al  and Magri et al . These worldwide similarities
demonstrate the robustness of both NIH-CPSI and UPOINT
systems. Concordantly with the results of the first UPOINT
retrospective study , we found that the duration of symptoms
but not age is significantly associated with an increase in the
number of UPOINT domains a patient is identified with,
suggesting a progression of multiple domains as the duration of
symptoms increased. These results also supported the hypothesis
that ongoing local tissue injury and inflammation can lead to local
muscle spasm, central and peripheral neurologic changes
(allodynia, hyperalgesia), and psychosocial changes that can maintain the
clinical syndrome years after the initiating injury has resolved .
Figure 5. Comparison of IIEF-5 scores between patients with and without each UPOINT domain. Mean IIEF-5 scores were compared
between patients with and without each urinary (U), psychosocial (P), organ specific (O), infection (I), neurological/systemic (N), and tenderness (T)
UPOINT domain. Significant difference was seen in psychosocial, organ specific, and tenderness domains between no and yes (*P,0.05).
Furthermore, we noted that all six domains of the original
UPOINT system did exert a significant effect on both the total
NIH-CPSI score and its QoL section subscore in Chinese cohort
of patients with CP/CPPS. Thus, it is not surprising that the
symptom impact should be more severe if more than one of the
domains is involved in the individual patient.
Interestingly and importantly, we found a significant inverse
correlation between the number of positive domains and IIEF-5
scores. In our cohort of 389 CP/CPPS patients, as the number of
domains increased, the severity of ED measured by the IIEF-5
questionnaire was significantly associated with the number of
domains patients experienced. This was not in accordance with
the recent finding of Hedelin et al. , where no correlation
between the number of positive domains and the IIEF-5 scores
was observed. This discrepancy may be related to the differences
in the sample size, the different criteria used for the UPOINT
domains, and the geographic or racial/ethnic dissimilarities. A
cohort of 50 patients in the study of Hedelin et al.  might be a
relatively small-sized sample. In the same study, the criteria used
for the UPOINT domains were modified. In their organ specific
and infection domains, transrectal ultrasound of the prostate and
microscopic examination and cultures of the prostatic fluid were
all omitted, that could be considered as a flaw. In the absence of an
appropriate LUT segmented test to obtain prostate-specific
specimens, a diagnosis of prostatitis is only tentative, and nothing
can be said about positivity or negativity of the I domain. ED is
apparently quite common among men with CP/CPPS seeking
medical care, and men with CP/CPPS are more likely to
experience ED than age-matched controls [13,22,23]. Most
recently, a case-control study by using a population-based dataset
in Taiwan of China showed that cases with ED were more likely to
have had a previous CP/CPPS (odd ratio: 3.62, 95% confidence
interval: 3.074.26) after adjusting for the patients
sociodemographic characteristics, comorbidities, obesity, and alcohol
abuse/alcohol dependence syndrome status, when compared with
controls . In the current study, ED is present in 31.1% of
Chinese patients with CP/CPPS. These findings demonstrated a
significant association between CP/CPPS and ED in China. As
noted by Lee et al. , we further observed that ED had an
adverse impact on Chinese males with CP/CPPS, who had worse
total NIH-CPSI score and QoL subscore than men without ED
(p,0.001). Thus, men with CP/CPPS and ED have been shown a
tendency to experience substantially worse symptoms, particularly
QoL, than other patients with CP/CPPS. In the study, we found
that three of the six domains, psychosocial, organ specific and
tenderness of skeletal muscle, did exert a significant effect on the
IIEF-5 score, suggesting that both organic and extraprostatic
factors are all associated with the development of ED in CP/CPPS
patients. Although the underlying mechanisms that exist between
CP/CPPS and ED remains unclear, many factors can impact
erectile functioning, including vascular deficiency, neuromuscular
damage, and psychosocial difficulties [24,25]. It has been
suggested that CP/CPPS impairs patients quality of life and
causes mental distress, such as depression, that may be in turn the
trigger for ED [26,27]. Using penile Doppler ultrasonography,
Gonen et al  demonstrated that none of the men with CP/
CPPS and ED showed evidence of vascular deficiency that would
interfere with the ability to get an erection, suggesting that
psychogenic causes, mainly depression, were the main reasons for
the development of ED in CP/CPPS. Several studies have
suggested that ED and CP/CPPS may be linked by a shared
inflammatory process originating from a prostatic source .
It may be possible that such prostatic inflammation affects smooth
muscle relaxation and impair microvascularization of the prostate
, thus decreasing the ability of penile tissue to fill with blood
and maintain an erection . Also, inflammation of the prostate
might impair chemokine, nitric oxide synthase and
cyclooxygenase-2 production, and impaired nitric oxide disponibility has been
associated with ED . Furthermore, the inflammation and
edema of the prostate might impinge on the surrounding
neurovascular bundle leading to the onset of ED . Recently,
Shoskes and his colleagues demonstrated in a casecontrol study
that men with CP/CPPS were more likely to have abnormalities in
their peripheral arterial tone than asymptomatic control patients
. The extrinsic compression from pelvic floor spasm could be
related to the poor arterial inflow, and therapy with myofascial
release can lead to significant improvement in ED symptoms .
It appears especially important to detect ED with its deleterious
effect on symptoms and quality of life in patients with CP/CPPS.
Therefore, we believed that ED merited consideration as a
potential unique clinical phenotype domain of CP/CPPS.
However, ED or sexual dysfunction was not one of the domains
included in the initial UPOINT system. In the present study, when
a seventh domain for ED was added into the original UPOINT
system, the correlation between the number of this modified
UPOINT domains and the NIH-CPSI total score was significantly
improved and all 7 domains of the modified UPOINT system
showed significantly higher symptom scores. Furthermore, when
the ED phenotype was added, patients showing a positive ED
domain were characterized by significantly worse NIH-CPSI
symptoms. Our results are consistent with those from a large
European study by Magri et al. , where the 15-item IIEF
questionnaire was adapted to define the sexual function phenotype
of patients in the frame of a modified UPOINTS domain, and
the improved correlation occurred not only when the sexual
dysfunction domain was defined by the single ED question
(16item questionnaire) but also when orgasmic dysfunction and
impaired libido were added to the sexual dysfunction phenotype
(17 and 18-item questionnaires). However, our results are
inconsistent with those from a recently retrospective study of 100
patients by Samplaski et al. , where they did not find
improvement in the correlation after adding a seventh domain
for ED. The reason for the discrepancy could have had several
causes, including patient selection, methodologic differences, and
geographic or racial/ethnic dissimilarities. Except for its
retrospective nature, a significant limitation of Samplaskis study 
was that they did not use a validated questionnaire such as the
IIEF to assess for sexual dysfunction. Instead, a yes or no answer to
the question do you have problems achieving or maintaining an
erection? was subjective and insufficient to exhaustively describe
the ED profile of a patient. Taken together with the results of
Magri et al. , those findings suggest that inclusion of the ED or
sexual dysfunction domain to the UPOINT phenotype may enable
better characterization of the symptom profile in patients with
CP/CPPS. Therefore, we propose that an ED domain should be
standed-alone in the UPOINT phenotyping system, and currently
in our clinical practice we have simulated in our patient cohorts
the inclusion of an independent ED item in the UPOINT
domains. Additionally, in our cohort a stepwise increase was also
found in the NIH-CPSI pain and QoL subscores, but not in the
voiding subscore, as the number of positive domains increased.
This association hold true when adding an ED domain to create a
modified UPOINT system. Absence of correlation with the
NIHCPSI voiding subscore was also shown in the European validation
paper by Magri et al. . The poor correlation between voiding
symptoms and positive UPOINT domains may be related to the
low responsiveness of the NIH-CPSI voiding subscore .
A limitation of our study was that we did not account for
confounding risk factors for ED. Comorbidites, including diabetes,
peripheral vascular disease, and coronary artery disease, can all
also contribute to ED, and these were not specifically evaluated in
this study. In addition, the fact that the patients were examined
and diagnosed by a single physician in the study carries with it a
risk for inclusion bias, but it may contribute to the homogeneity of
the studied population.
The utility of the UPOINT classification scheme in
discriminating clinical phenotypes has been validated in the Chinese
cohort of CP/CPPS, with the number of positive domains shown
to strongly correlate not only with the duration and severity of
prostatitis symptoms but also with the ED symptoms. Adding an
ED domain restored a significant association between the number
of a modified UPOINT domains and the NIH-CPSI scores.
Although the correlation between ED and the UPOINT domains
still needs confirmation in extensive clinical trials, our prospective
analyses demonstrate that ED is an important component of the
clinical phenotype of CP/CPPS and the addition of an ED
domain to the UPOINT system adds a value to the clinical
assessment of CP/CPPS symptom severity. The results presented
here support the utility of using ED as an independent UPOINT
Conceived and designed the experiments: ZZ GZ. Performed the
experiments: JZ JH GZ. Analyzed the data: GZ. Wrote the paper: ZZ.
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