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Keywords:

  • prostatitis;
  • adolescent;
  • catastrophizing;
  • quality of life

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECT AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

OBJECTIVE

To estimate the prevalence and examine the extent that pain, urinary symptoms, depression and pain catastrophizing predict the quality of life (QoL) in Canadian male adolescents, as the prevalence and impact of chronic prostatitis (CP)-like symptoms in adolescents is unknown.

SUBJECTS AND METHODS

Participants completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the Patient Health Questionnaire-depression screen (PHQ-D), and the Pain Catastrophizing Scale (PCS). CP-like case identification was based on NIH-CPSI report of pain/discomfort in perineum and/or with ejaculation and NIH-CPSI total pain score (0–20) of ≥4 (mild) and ≥8 (moderate-severe). The point prevalence was estimated and regressions used to examine predictors of diminished QoL gathered from the NIH-CPSI.

RESULTS

The prevalence of at least mild CP-like symptoms in 264 Canadian adolescents aged 16–19 years (mean age 17.5, sd 1.1) was 8.3%, with 3% reporting moderate-severe CP-like symptoms. Pain, urinary symptoms, depression and catastrophizing were correlated with diminished QoL. Additionally, catastrophizing predicted diminished QoL when the variance of pain, urinary symptoms and depression were simultaneously considered in the analysis.

CONCLUSIONS

Similar to that reported by older cohorts, these data provide the first point-prevalence estimate of CP-like symptoms in adolescents. These findings suggest increased vigilance to a potential diagnosis of adolescent CP syndrome and indicate that psychological features (i.e. catastrophizing) are significant in diminished QoL. Adolescent male chronic pelvic pain is an important and understudied area for future investigations.


Abbreviations
QoL

quality of life

CP

chronic prostatitis

NIH-CPSI

National Institutes of Health Chronic Prostatitis Symptom Index

PHQ(-D)

Patient Health Questionnaire (depression)

PCS(-R

-M, -H) Pain Catastrophizing Scale (Rumination, Magnification, Helplessness subscales)

STI

sexually transmitted infection.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECT AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Prostatitis is a urogenital syndrome associated with pelvic and genital pain/discomfort and variable voiding and sexual complaints. The prevalence in North American adults indicates that 4–16% men report either a physician or self-reported diagnoses of prostatitis [1–4], with community samples reporting chronic prostatitis (CP)-like symptoms in 6.5–12%[5–7].

There are greater odds of CP-like symptoms in middle-aged than in older men [2], with symptoms reported most often in men aged 35–65 years [8], but there is reason to speculate that these symptoms are also prevalent in adolescents. Using a case identification based on the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) [9], ≈10% of North American men aged 20–29 years were identified by a community survey [6]. Ku et al.[10] also described a case-identified CP-like prevalence of 6% in 20-year-old South Korean men. Further, Li et al.[11] described a small sample of 10 adolescent males with voiding complaints as having prostatitis, but their definition of CP was inaccurate because the primary symptom of pelvic pain [9] was not collected. Currently, there are no prevalence and quality of life (QoL) studies for CP-like symptoms in males aged <20 years.

CP is a syndrome that is difficult to manage, and is associated with significant pain [12] and diminished QoL [13–15], both of which have been predicted by the dysfunctional pain-related coping style of ‘catastrophizing’[12,15]. The persistence of pain and urinary symptoms is of concern for adolescents identified with CP-like symptoms because under-treated long-standing pain in adolescents is associated with negative physical and psychological outcomes later in life [16]. Perhaps earlier identification and multi-professional treatment in adolescence might reduce symptoms, to aid in better patient adjustment over time, but first the initial evidence for the occurrence and impact of CP-like symptoms is required, as has been documented in older men. In the present study we aimed to estimate the prevalence of CP-like symptoms in community adolescent males (aged 16–19 years), and to examine associations of biopsychosocial factors like age, pain, urinary symptoms (pain/urinary), depression [14] and catastrophizing [13,16].

SUBJECT AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECT AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Subjects were adolescents recruited from a university and high-school community population. Eligible subjects had to be male, North American citizens, read and write English, and be aged 16–19 years; the Queen’s University review board approved this study.

The NIH-CPSI is a nine-item self-reported measure (score 0–43) assessing prostatitis-like symptoms and the impact on daily lives, and that is both reliable and validated [9]. Pain questions include location, frequency and severity of pain, and cab be summed as a total pain index score (range 0–21). Urinary symptoms include incomplete emptying and frequency of urination (range 0–10). Impact/QoL questions assess limitations of activities, psychological distress and overall QoL (range 0–12) [9]. Subjects were identified with CP-like symptoms if they reported perineal and/or ejaculatory pain/discomfort and their NIH-CPSI total pain score was ≥4 (0–21). This case definition has been empirically reported in community [6] and population [5] studies of symptom prevalence. Moderate to severe CP-like symptoms are identified as perineal and/or ejaculatory pain/discomfort and a total pain score of ≥8. To provide a more conservative prevalence estimation, subjects answering ‘yes’ to NIH-CPSI question 2a (pain or burning during urination), a potential indicator of sexually transmitted infection (STI), were removed as cases and values were reproduced.

The Patient Health Questionnaire (PHQ) [17] is a valid and reliable nine-item questionnaire assessing depressive symptoms [17], and that has been used in the study of adolescent depression. In the present study we summed the responses on the depressive symptoms section to create a depressive symptoms index of 0–27, with higher scores representing greater depressive symptoms.

The Pain Catastrophizing Scale (PCS) [18] is a 13-item self-reported measure used to assess catastrophizing cognitions about painful sensations in adolescents and adults. The PCS provides a total score and three scale scores of ‘rumination’, ‘magnification’ and ‘helplessness’. The PCS is reliable [18] and catastrophizing has been shown as a significant psychological predictor of both pain [12] and QoL [15] for adult patients with CP.

Recruitment was completed over a 5-week period using advertisements to students and by direct community recruitment (i.e. through public access recruitment areas: physician notice boards, YMCA, community bulletin boards, ad in local paper). Subjects were offered $5 as compensation. Eligible subjects completed the questionnaires in random order, with completion times of 15–20 min.

Data were examined for accuracy and total missing data were minimal (<10% on any scale). As they were random, missing items were replaced with the overall mean for each associated variable [19]. Prevalence rates of CP-like symptoms were produced with frequency analyses of the NIH-CPSI. Previously validated case identification was calculated using case-identification indicators from the NIH-CPSI. Zero-order correlations were examined, followed by hierarchical regressions examining the unique contributions of pain, urinary symptoms, depression and catastrophizing on QoL. A hierarchical regression tested whether depression and catastrophizing would predict QoL over and above urinary symptoms and pain, with significant variables with subscales followed by regression modelling decomposing potential subscale effects.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECT AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

In all, 246 Caucasian males aged 16–19 years (mean 17.58, sd 1.11) comprised the sample, meeting minimum sample size requirements for an estimated prevalence of 6%, a confidence level of 95% and a CI of 3% (i.e. prevalence can range from 3.2% to 9.5%) [19]. There were equitable representations across ages, with 21.6% (57) at 16 years, 25.8% (68) at 17, 25.4% (67) at 18, and 27.3% (72) at 19 years. Of the subjects, ≈130 reported attending University and 134 were high-school age; no subjects withdrew.

The distribution of NIH-CPSI items is shown in Table 1. These distributions indicate the number of subjects, as both a frequency and percentage, endorsing the NIH-CPSI items. For pain locations, 25.4% reported having pain or discomfort in one or more location(s) of the pelvic region. In particular, 15.5% of the subjects reported pain in one location only, 7.2% reported two painful locations, and 2.7% reported three or more painful locations. Scores for pain frequency showed 28.8% of the subjects rarely felt pain in the pelvic region over the last week, while 4.9% reported that they sometimes feel pain in the pelvic region, and 0.8% that they had pain often or usually. When rating the severity of pain on a scale of 0–10 (0, no pain; 10, pain as bad as you can imagine), 9.5% of subjects felt that they had more than the moderate rating of pain symptoms (score ≥4). Within the total sample of subjects, 4.2% reported that they could not fully empty their bladder while urinating about half or more than half of time. Finally, 0.8% felt this sensation at almost all times. For frequency of urination, 24.3% had to urinate again within 2 h from less than half the time to almost always. For the impact of symptoms on activity disability and psychological distress, 16.2% described only a little or some interference in daily activities and thoughts about their symptoms over the last week, while 1.5% of subjects described this inference as occurring ‘a lot’. The QoL question (i.e. NIH-CPSI item 9) concerning how subjects would feel if they were to spend the rest of their lives with their symptoms that they had reported for the past week, revealed that 19.8% of the subjects would feel mixed in reaction, mostly dissatisfied, unhappy, or terrible.

Table 1.  The distribution of each item in the NIH-CPSI
ScorePainIncomplete emptyingFrequency of urinationImpactQoL
LocationsFrequencySeverity
  1. Values are n (%) of 264 subjects.

Items  1,2  3  4  5  6  7,8  9
0197 (74.6)173 (65.5)159 (60.2)156 (59.1) 76 (28.8)217 (82.2)125 (47.3)
1 41 (15.5) 76 (28.8) 31 (11.7) 82 (31.1)124 (47.0) 26 (9.8) 59 (22.3)
2 19 (7.2) 13 (4.9) 30 (11.4) 13 (4.9) 41 (15.5) 17 (6.4) 28 (10.6)
3  6 (2.3)  1 (0.4) 19 (7.2) 10 (3.8) 20 (7.6)  3 (1.1) 26 (9.8)
4  1 (0.4)  1 (0.4)  7 (2.7)  1 (0.4)  1 (0.4)  1 (0.4) 17 (6.4)
5  0  0  8 (3.0)  2 (0.8)  2 (0.8)  0  6 (2.3)
6  0   4 (1.5)    0  3 (1.1)
7    1 (0.4)    0 
8    3 (1.1)    0 
9    2 (0.8)    
10    0    

The NIH-CPSI total pain scores distribution is shown in Fig. 1. Overall, 25.4% (67) subjects reported a total pain score of ≥4, while 6.9% (18) reported a score of ≥8. The prevalence of CP-like symptoms showed that 8.3% (22) adolescents reported perineal and/or or ejaculatory pain/discomfort and a total pain score of ≥4, with a mean (sd) pain score of 6.95 (2.72). In all, 3% (eight) subjects reported moderate to severe CP-like symptoms (perineal or ejaculatory pain/discomfort, total pain index ≥8), with a mean (sd) total pain score of 10.12 (1.25). To control for possible inflation in values caused by STI, subjects with positive responses for item 2a were removed and the prevalence analyses repeated. With item 2a removed, 6.8% (18) adolescents reported perineal or ejaculatory pain/discomfort and a pain score of ≥4. Further, 1.9% (five) reported perineal or ejaculatory pain/discomfort and an index pain of ≥8.

image

Figure 1. Frequency distribution of NIH-CPSI scores in men aged 16–19 years.

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Correlations between age, pain/discomfort, urinary symptoms, depressive symptoms, QoL and catastrophizing are shown in Table 2. There were no correlations between age and pain/discomfort, urinary symptoms, QoL, or depression. However, older adolescents reported more catastrophizing. Pain was associated with urinary symptoms, diminished QoL, depression and greater catastrophizing. Also, urinary symptoms were associated with diminished QoL, depressive symptoms and catastrophizing. Further, diminished QoL was associated with depression and catastrophizing. Finally, depression was associated with greater catastrophizing.

Table 2.  Intercorrelations between age, pain, urinary symptoms, depression and catastrophizing
VariableNIH-CPSIPHQ-DPCS
PainUrinaryQoL
  • *

    P < 0.05;

  • P < 0.01.

Age−0.040.02−0.030.120.29
NIH-CPSI     
 Pain0.290.590.290.13*
 Urinary 0.440.310.20
 QoL  0.330.28
PHQ-D   0.44

Hierarchical regression examined pain, urinary symptoms, depressive symptoms and catastrophizing on QoL (Table 3); age was excluded because it was not correlated with QoL. Pain and urinary symptoms were entered first, depression and catastrophizing followed in a second-step modelling QoL. Step 1 accounted for significant variability in QoL (R2 = 0.42; adjusted R2 = 0.42, F2,261 = 95.44, P < 0.001) where pain and urinary symptoms were associated with diminished QoL. In step 2, depression and catastrophizing were significant in QoL after controlling for pain and urinary scores (R2 change = 0.03, F2,259 = 53.07, P < 0.001). Pain, urinary symptoms and catastrophizing predicted QoL in the final model. Depression did not predict QoL in the final model, making catastrophizing the unique psychological predictor of diminished QoL. Follow-up analysis was conducted predicting QoL from the catastrophizing subscales (i.e. rumination, magnification, and helplessness; Table 3). This model was significant (R2 = 0.10; adjusted R2 = 0.09, F3,260 = 9.93, P < 0.001) with the catastrophic magnification of pain uniquely associated with diminished QoL. No violations of statistical assumptions were manifest in these analyses [19].

Table 3.  Summary of hierarchical regression analysis for depressive symptoms and catastrophizing predicting QoL when controlling for pain and urinary symptoms, and a subscale analysis
QoL modelVariableβTP
  1. β, standardized β coefficient.

Step 1NIH-CPSI Pain0.5010.23<0.001
NIH-CPSI Urinary0.295.98<0.001
Step 2NIH CPSI Pain0.489.77<0.001
NIH-CPSI Urinary0.265.15<0.001
PHQ-D0.040.750.451
PCS0.152.940.004
PCS subscales-R0.020.170.860
-M0.323.510.001
-H−0.01−0.090.930

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECT AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

This is the first study to estimate the prevalence of CP-like symptoms in male adolescents, and to show the impact of pain, urinary symptoms, depression and catastrophizing on QoL. CP-like symptoms were reported by 8.3% of adolescents, which is comparable to reports from 20-year-old Korean men [10], and from older men in the same geographical area [6]. There was a 3% prevalence of moderate-severe symptoms, compared with 6.6% in older men (20–74 years) [6]. The removal of item 2a (i.e. dysuria, conceivably associated with STIs) resulted in a slightly more conservative but meaningful estimate of symptoms, at 6.8% and moderate/severe symptoms at 1.9%.

CP-like symptoms are associated with a negative impact on QoL in adolescence. Greater pain and urinary symptoms were associated with diminished QoL, and depression and catastrophizing predicted diminished QoL even when pain and urinary symptoms were considered. Furthermore, catastrophic magnification, which is an exaggeration of the threat value of pain sensations, was a unique predictor of diminished QoL. Interestingly, pain and urinary symptoms are similarly associated with diminished QoL for men aged 20 and 30–54 years [10,13], and in older men depression was associated with diminished QoL in those aged 20–83 years [14]. Furthermore, Nickel et al.[15] recently reported that catastrophic helplessness (i.e. thoughts that you can do little to manage your pain) and low social support predicted poorer QoL in men with CP-like symptoms, even when pain and urinary symptoms were included in the same analysis.

It is possible that the symptoms associated with chronic prostatitis (urogenital pain, voiding, sexual complaints) and catastrophizing might negatively affect adolescent socio-sexual maturation, especially if unmanaged [16]. Indeed, Merlijn et al.[20] reported that catastrophizing predicted poorer QoL, even when controlling for pain characteristics amongst 12–18-year-olds with pain for ≥3 months. The present findings are comparable with those of Merlijn et al.[20], in that adolescents reporting pain tend to catastrophize and report diminished QoL. Interestingly, the different catastrophizing subscales that predicted QoL, magnification in this adolescent sample vs helplessness in an older sample [15], might highlight specific targets for cognitive intervention across age groups in multidisciplinary settings. The varied catastrophizing and QoL association might also reveal a progression based on age and continuity of CP-like symptoms. In particular, magnification is often reported when the pain duration is short, while helplessness tends to be reported with longer pain duration [18].

A primary limitation to the current study on the adolescent prevalence of CP-like symptoms is sample characteristics. In particular, data are from Caucasian males and thus cannot be generalized to other ethnicities. However, as the Boston Area Community Health Survey (BACH) study [5] illustrates, there might be little difference in rates across ethnic groups (i.e. African-Americans and Caucasian). Future research could examine the prevalence in other adolescent ethnic groups as a check on data compatibility with that reported in older men with CP-like symptoms. Another issue is that the prevalence was determined solely by responses on the NIH-CPSI, with no clinical diagnostic confirmation from a urologist. When considering this limitation, a diagnostic evaluation is not logistically viable in large samples, and the NIH-CPSI and the case-identification used here was also used in most of the major epidemiological publications in community samples [6,7,10], including the recent large BACH study [5]. Finally, regression analyses cannot be used to infer causality in the relationships described here.

In conclusion, the prevalence of CP-like symptoms and their impact on QoL in males in early life is significant and compares with that in older men. Furthermore, catastrophizing is significant in predicting diminished QoL even when pain, urinary and depression effects are considered. Identifying CP-like symptoms in males before 20 years old might be useful in guiding symptom-management treatments to maximize both physical and psychological adjustment. Further prospective study is required to determine if early identification and treatment in adolescence is beneficial to QoL.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECT AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES