Stesura Seveso Archivio Italiano di Urologia e Andrologia 2024; 96(1):12452 1 ORIGINAL PAPER symptoms, sexual and psychosocial disturbances (1). The importance of recognizing the psychological impact of CP/CPPS has been taken into primary consideration by the UPOINT phenotyping and therapeutic algorithm (2), which rates a specific “Psychosocial” domain in the frame of the work-up of chronic prostatitis (CP) patients. It is sug- gested to use self-administered questionnaires to assess depression and anxiety and to measure negative thoughts associated with pain. The implementation of the UPOINT system with the eval- uation of a sexual domain (“S”) has further extended the evaluation of patients with CP/CPPS who frequently pres- ent with significant rates of erectile and orgasmic dys- function (3). The aim of this study was an in-depth assessment of the complex correlations between somatic, psychological, and sexual disorders in CP/CPPS patients. METHODS Study design and endpoints We performed a cross-sectional study on a cohort of patients with CP-CP/CPPS, consecutively enrolled among patients attending two outpatient clinics. The study was ethically approved by the local Ethics Committee of Tzaneio Hospital (protocol 8295/05-05-2022) and complied with the requirements of the Helsinki declaration. The primary endpoint of the study was the association between the total and subdomain scores (pain, voiding symptoms, quality of life) of the National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) (4), and the total score of the Patient Health Questionnaire-9 (PHQ-9), a self-administered tool focusing on the pres- ence and severity of depression (5). Secondary endpoints of the study included the assessment of an association between the scores (i) of the NIH-CPSI questionnaire, (ii) of the International Prostate Symptom Score (IPSS) (6), (iii) of the erectile function domain of the International Index of Erectile Function (IIEF) (7), and (iv) of the Premature Ejaculation Diagnostic Tool (PEDT) (8) (inde- pendent variables), and the scores of the following psycho- social tests: (i) the PHQ-9 questionnaire (5), (ii) the Purpose: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by a multiform clinical presentation requiring a differentiated treatment based on different phenotypes including the psychoso- cial and sexual domains. The aim of this study was assessing the complex correlations between somatic, psychological, and sexual symptoms of CP/CPPS patients. Materials and methods: We performed a cross-sectional study on patients attending a Prostatitis Clinic. Patients were adminis- tered the following questionnaires: National Institutes of Health- Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF), Premature Ejaculation Diagnostic Tool (PEDT), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-item (GAD-7), Oxford Happiness Questionnaire (OHQ), and Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A). Results: Linear regression analyses show highly significant cor- relations between scores of the NIH-CPSI and the scores of the GAD-7, PHQ-9 and OHQ psychometric questionnaires. IPSS scores correlate significantly with the psychometric scores only when a non-parametric analysis is performed. IIEF and PEDT sexual function scores did not correlate with any of the psycho- metric tests. NIH-CPSI scores correlate positively with most of the TEMPS-A profiles but the hyperthymic profile correlated negatively with the total and QoL NIH-CPSI and with PEDT scores. Conclusions: Scores measuring anxiety, depression, and psycho- logical well-being in patients with CP/CPPS are strictly correlat- ed with prostatitis-like symptoms although they are poorly cor- related with symptoms of prostatism, as measured by IPSS, and not correlated with scores of sexual dysfunctions, as measured by IIEF and PEDT. A hyperthymic temperament may tempera- ment may increase resilience against the disease. KEY WORDS: Chronic prostatitis; chronic pelvic pain syndrome; Depression; Anxiety; Affective temperaments. Submitted 3 March 2024; Accepted 7 march 2024 INTRODUCTION Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common clinical condition presenting with a variety of signs and symptoms including chronic pain, voiding Psychological and sexological assessment of patients with chronic prostatitis Konstantinos Stamatiou 1, Vittorio Magri 2, Margherita Trinchieri 3, Alberto Trinchieri 4, Gianpaolo Perletti 5 on behalf of Mediterranean study group for prostatitis and prostatic diseases 1 Department of Urology, Tzaneio Hospital, Pireus, Greece; 2 Urology Unit, ASST Fatebenefratelli Sacco, Milan, Italy; 3 Psichiatry Unit, ASST Rhodense, G. Salvini Hospital, Garbagnate (Milan), Italy; 4 School of Urology, University of Milan, Milan, Italy; 5 Department of Biotechnology and Life Sciences, Section of Medical and Surgical Sciences, University of Insubria, Varese, Italy. DOI: 10.4081/aiua.2024.12452 Summary Archivio Italiano di Urologia e Andrologia 2024; 96(1):12452 K. Stamatiou, V. Magri , M. Trinchieri, et al. 2 Generalized Anxiety Disorder 7-item questionnaire (GAD-7) (9), (iii) the Oxford Happiness Questionnaire (OHQ) (10), and (iv) the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A, 39-item short version), which includes 5 domains, focusing on the pres- ence of cyclotimic, depressive, irritable, hyperactive and anxious personalities (11). Patient selection criteria We included adult patients (>/= 18 years) who agreed to participate in the study, referring for long-standing (at least 18 months) documented signs and symptoms of cat- egory II CP or category III CP/CPPS assessed according to NIH criteria (12) after a thorough work up including clin- ical and laboratory assessments. Exclusion criteria were: signs and symptoms present for a period shorter than 6 months; recent (< 8 weeks) category I acute bacterial prostatitis; neoplasia, indwelling catheters; nephrostomy; any chronic and/or painful and/or disabling illness significantly affecting the quality of life, potentially generating anxiety or depression; recent events (< 3 months) that may have had a considerable impact on the psychological profile of patients, possibly acting as con- founders in this study (e.g., the loss of a child or spouse, divorce, loss of a job, other traumatic events). Data collection At referral, patients were informed about the aim of the study and reassured about the anonymous handling of their data. After signing an informed consent, patients underwent a thorough urological examination after being interviewed about their clinical history. Patients were also asked to fill the questionnaires listed above. Questionnaires were collected by the consulting urologist and uploaded in a study database. Personal data were ren- dered anonymous in such a manner that patients were no longer identifiable in the database. Data were analyzed by a member of the research group (GP) in a blinded fashion. Statistical analysis Median and interquartile range (IQR) or mean and standard deviation were used as measures of the central tendency and data dispersion of non-continuous and continuous variables, respectively. Simple linear regression Simple linear regression was performed to analyze the sig- nificance of associations between baseline scores of the NIH-CPSI, IPSS, IIEF (short version) and PEDT question- naires (independent variables), and the scores of the PHQ- 9, GAD-7, OHQ and TEMPS-A (39-item short version) questionnaires (dependent variables in the present predic- tion model). Both nonparametric (Kendall’s rank coefficient ‘tau’) and parametric (Pearson’s product-moment ‘rho’) correlation coefficients were calculated, to take into account the exis- tence of non-linear relationships between the bivariates. Sample size calculation To estimate the effect size for sample size calculation, we referred to the Koh et al. (13) trial, reporting a significant correlation between the NIH-CPSI and PHQ-9 scores (p = 0.009), resulting in a Spearman’s coefficient (r) equal to 0.307. Sample size calculations was performed using the G*Power 3.1.3 software (14). We computed that a sample of 127 patients was required to analyze by simple linear regression (one predictor) the primary endpoint of the study, namely, the correlation between the NIH-CPSI total score and the PHQ-9 depression score, with 95% power, a 5% alpha error probability, a f^2 effect size of 0.104 and a f^2 coefficient equal to 0.0942. Logistic regression analysis Simple binary logistic regression analysis was performed to ascertain the goodness of fit of models whereby the increasing symptom scores of tests (e.g., the NIH-CPSI) showing significant linear correlation with psychometric scores, would be significant predictor of dichotomized psychometric outcomes (e.g., no depression vs. moder- ate-to-severe depression). The null hypothesis for the logistic regression was the absence of an association between the symptom score pre- dictor and the psychologic condition dichotomic outcome. The coefficients of the logistic functions, the intercepts, the odds ratios, and the confidence intervals related to the odds ratios (95%CI) were calculated. The statistical sig- nificance of the model was evaluated by means of the Wald test and the likelihood ratio test. The Hosmer/Lemeshow test was performed to evaluate the goodness-of-fit of the models, and the Nagelkerke- R^2 value was be calculated. For the Hosmer and Lemeshow test, the null hypothesis was that the number of expected dichotomic psychological disturbances – when the entire patient cohort is divided into 10 groups of approximately similar size – is not significantly differ- ent from the same outcomes observed in the overall logis- tic model. Values > 0.05 of the probability associated with the zero hypothesis indicated an acceptable good- ness-of-fit. For statistical analysis only two-tailed tests were per- formed, 95% confidence intervals were calculated, and the conditional probability of a type I error, in the pres- ence of a true null hypothesis, was set at < 0.05. Statistical softwares Statistical analysis of linear and logistic regressions was carried out in the “R” software environment for statistical computing and graphics (https://www.r-project.org/). Logistic regression analysis was performed using the car and lmtest packages. The Hosmer and Lemeshow goodness-of-fit test was per- formed with the Resource Selection package, whereas the Nagelkerke pseudo (y)-R2 was calculated using the rcom- panion package. Odds ratios and 95% CIs for the model were calculated using the epiDisplay package. Intergroup differences between questionnaire scores were analyzed with the two-tailed Mann-Whitney-Wilcoxon test, using the R platform. RESULTS One hundred and forty-one consecutive patients were prospectively enrolled for the study between January 1st and November 30th, 2022. The median age of patients Archivio Italiano di Urologia e Andrologia 2024; 96(1):12452 3 Psychosexologic assessment in prostatitis was 48 (IQR, 18). The median year of first diagnosis of CP was 2018. Baseline clinical and psychological symptoms are shown in Table 1. Linear regression Table 2 shows the results of linear regression analyses comparing the scores of the NIH-CPSI, IPSS, IIEF and PEDT questionnaires with the GAD-7, PHQ-9 and Oxford questionnaires. The results show highly significant correlations between all domains (pain, voiding, quality of life impact and total scores) of the NIH-CPSI test and the scores of the GAD- 7, PHQ-9 and Oxford psychometric questionnaires. Conversely, the IPSS, IIEF and PEDT tests correlate poor- ly and, in most cases, not significantly with any of the psychometric tests, except for IPSS, whose scores corre- late significantly with the scores of the GAD-7, PHQ-9 and Oxford tests only when a non-parametric analysis is performed (The Kendall’s Tau). Temperament profiling Table 3 shows the results of linear regression analyses comparing the scores of the NIH-CPSI, IPSS, IIEF and PEDT questionnaires with the scores of basic patient tem- perament profile, measured with the TEMPS-A test. Highly significant correlations were found between NIH- CPSI scores (total score and pain, voiding and QoL sub- scores) with most of the TEMPS-A profiles. An exception was the hyperthymic profile, which correlated signifi- cantly and negatively with the total and QoL NIH-CPSI scores. In other words, a less severe impact of prostatitis on total and QoL NIH-CPSI correlated with higher hyper- thymic scores. Conversely, the IPSS, IIEF and PEDT tests correlate poor- ly and in almost all cases not significantly with any of the TEMPS-A profile scores. Exceptions were the significant correlation of the IPSS scores with the TEMPS-A depres- sive profile and the significant negative correlation of PEDT scores with the hyperthymic TEMPS-A profile. Logistic regression models We tested the NIH-CPSI and the IPSS interval scores as predictors versus dichotomized outcomes of the GAD-7, PHQ-9 and Oxford happiness scores. Dichotomization was as follows: for the GAD-7 test, a score equal or higher than 5 predicted mild to severe anx- iety according to Spitzer et al. (2006) (9); for the PHQ-9 test a score equal or higher than 10 predicted moderate to severe depression according to Kroenke et al. (2001) (5), and for the Oxford happiness test a score equal to 3.5 was the cutoff to discriminate between happy or unhappy responses (Hills & Argyle, 2002)(15). Table 1. Baseline scores of clinical symptom tests and psychological questionnaires. Test Median score Interquartile range NIH-CPSI (total) 18 16 NIH-CPSI (pain domain) 9 9 NIH-CPSI (voiding domain) 3 4 NIH-CPSI (QoL impact domain) 6 5 IPSS 7 9 IIEF 26 8.5 PEDT 4 5.5 GAD-7 7 7.25 PHQ-9 6 5 Mean score Standard deviation TEMPS-A Cyclothymic 0.38 0.29 TEMPS-A Depressive 0.32 0.30 TEMPS-A Irritable 0.21 0.24 TEMPS-A Hyperthymi 0.53 0.28 TEMPS-A Anxious 0.33 0.38 Oxford Happiness 3.68 0.54 NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Score (QoL, impact of the disease on the quality of life). IPSS: International Prostate Symptom Score. IIEF (1-5,15), Short International Index of Erectile Function (sum of questions 1, 2, 3, 4, 5, 15). PEDT: Premature Ejaculation Diagnostic Tool. GAD-7: General Anxiety Disorder-7. PHQ-9, Patient Health Questionnaire-9. TEMPS-A: Temperament Evaluation of Memphis, Pisa, Paris and San Diego - Auto-questionnaire version. Table 2. Psychological profiling of chronic prostatitis patients included in our study according to the GAD-7, PHQ-9 and Oxford Happiness questionnaires. Scores are analyzed by linear regression against the total or subdomain scores of the NIH_CPSI, IPSS, IIEF and PEDT tests. Correlation coefficients are shown. Statistically significant differences are shown in bold. NIH-CPSI, Total Score NIH-CPSI, Pain domain NIH-CPSI, Voiding domain NIH-CPSI, QoL domain Kendall’s Tau (P) Pearson's r (P) Kendall’s Tau (P) Pearson's r (P) Kendall’s Tau (P) Pearson's r (P) Kendall’s Tau (P) Pearson's r (P) GAD-7 0.285 (< 0.0001) 0.413 (< 0.0001) 0.316 (< 0.0001) 0.439 (< 0.0001) 0.188 (0.0023) 0.271 (0.0011) 0.283 (< 0.0001) 0.407 (< 0.0001) PHQ-9 0.365 (< 0.0001) 0.464 (< 0.0001) 0.392 (< 0.0001) 0.475 (< 0.0001) 0.218 (0.0004) 0.290 (0.0004) 0.375 (< 0.0001) 0.469 (< 0.0001) Oxford Happiness Score -0.230 (0.002) -0.335 (0.001) -0.229 (0.002) -0.335 (0.001) -0.1 (0.20) -0.21 (0.043) -0.21 (0.005) -0.288 (0.006) IPSS IIEF (1-5,15) PEDT GAD-7 0.170 (0.026) 0.191 (0.075) -0.129 (0.094) -0.119 (0.27) 0.09 (0.25) 0.179 (0.096) PHQ-9 0.198 (0.009) 0.267 (0.012) -0.077 (0.32) -0.052 (0.63) 0.085 (0.27) 0.114 (0.29) Oxford Happiness Score -0.168 (0.024) -0.17 (0.102) 0.138 (0.067) 0.189 (0.078) -0.097 (0.20) -0.131 (0.22) NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Score. IPSS: International Prostate Symptom Score. IIEF (1-5,15): Short International Index of Erectile Function (sum of questions 1, 2, 3, 4, 5, 15). PEDT: Premature Ejaculation Diagnostic Tool. GAD-7: General Anxiety Disorder-7. PHQ-9, Patient Health Questionnaire-9. Archivio Italiano di Urologia e Andrologia 2024; 96(1):12452 K. Stamatiou, V. Magri , M. Trinchieri, et al. 4 Bivariate analysis comparing all NIH-CPSI scores (pain, micturition, impact on QoL and total scores) with GAD-7. PHQ-9 and Oxford Happiness resulted in significant pre- diction models (Table 4). The only exception was the model comparing the voiding NIH-CPSI domain with the Oxford test of happiness. Analysis of the predictor significance and goodness-of-fit of all models showed statistical significance in all cases, apart from the comparison of the voiding NIH-CPSI domain with the Oxford test of happiness (Table 5). Conversely, logistic regression models comparing IPSS predictor scores against dichotomized anxiety (GAD-7), depression (PHQ-9) or happiness (Oxford) outcomes were found to be not statistically significant (Table 4). This was confirmed by the predictor significance and goodness-of-fit parameters shown in Table 5. Severity of CP symptoms in patients showing various degrees of happiness, depression and anxiety We investigated whether any significant difference could be observed by dichotomizing our population into two cohorts. Cohorts included patients with moderate/severe Table 3. Temperament profiling of chronic prostatitis patients included in our study according to the Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto-questionnaire (TEMPS-A). TEMPS-A scores are analyzed by linear regression against the total or subdomain scores of the NIH_CPSI, IPSS, IIEF and PEDT tests. Statistically significant differences are shown in bold. NIH-CPSI, Total NIH-CPSI, Pain domain NIH-CPSI, Voiding domain NIH-CPSI, QoL domain Kendall’s Tau (P) Pearson's r (P) Kendall’s Tau (P) Pearson's r (P) Kendall’s Tau (P) Pearson's r (P) Kendall’s Tau (P) Pearson's r (P) TEMPS-A Cyclothymic 0.411 (< 0.0001) 0.590 (< 0.0001) 0.433 (< 0.0001) 0.612 (< 0.0001) 0.206 (0.0009) 0.344 (< 0.0001) 0.369 (< 0.0001) 0.512 (< 0.0001) Depressive 0.367 (< 0.0001) 0.503 (< 0.0001) 0.362 (< 0.0001) 0.479 (< 0.0001) 0.257 (< 0.0001) 0.361 (< 0.0001) 0.355 (< 0.0001) 0.468 (< 0.0001) Irritable 0.366 (< 0.0001) 0.485 (< 0.0001) 0.402 (< 0.0001) 0.512 (< 0.0001) 0.216 (0.001) 0.296 (0.0003) 0.310 (< 0.0001) 0.390 (< 0.0001) Hyperthymic -0.115 (0.058) -0.172 (0.042) -0.944 (0.127) -0.132 (0.12) -0.051 (0.42) -0.075 (0.37) -0.132 (0.03) -0.186 (0.02) Anxious 0.288 (< 0.0001) 0.393 (< 0.0001) 0.326 (< 0.0001) 0.421 (< 0.0001) 0.184 (0.006) 0.237 (0.004) 0.222 (0.0008) 0.302 (0.0002) IPSS IIEF (1-5,15) PEDT Cyclothymic 0.126 (0.11) 0.147 (0.17) -0.10 (0.20) -0.166 (0.12) -0.026 (0.74) 0.044 (0.68) Depressive 0.233 (0.004) 0.294 (0.005) -0.06 (0.45) -0.006 (0.94) 0.076 (0.36) 0.126 (0.24) Irritable 0.11 (0.24) 0.049 (0.65) 0.116 (0.18) 0.123 (0.25) -0.032 (0.71) -0.06 (0.55) Hyperthymic -0.051 (0.51) -0.84 (0.44) 0.143 (0.071) 0.20 (0.059) -0.199 (0.012) -0.263 (0.013) Anxious 0.067 (0.43) 0.11 (0.31) -0.15 (0.078) -0,138 (0.19) -0.0042 (0.96) -0.0065 (0.95) NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Score. IPSS: International Prostate Symptom Score. IIEF (1-5,15): Short International Index of Erectile Function (sum of questions 1, 2, 3, 4, 5, 15). PEDT: Premature Ejaculation Diagnostic Tool. TEMPS-A: Temperament Evaluation of Memphis, Pisa, Paris and San Diego - Auto-questionnaire version. Table 4. Logistic regression models for Generalized Anxiety Disorder (GAD-7 test), depression (PHQ-9 test), or degree of happiness (Oxford test) as function of the score of the NIH-CPSI test (total score and pain, voiding symptoms and impact on the quality of life subdomains) and of the IPSS test. Significant results are shown in bold. Psychometric test Logistic Model Prostatitis/Prostate Symptom Scores (predictor) (outcome) Parameters NIH-CPSI, Total Score NIH-CPSI, Pain domain NIH-CPSI, Voiding domain NIH-CPSI, QoL domain IPSS GAD-7 Intercept ± SE -0.356 ± 0.37 -0.435 ± 0.31 0.285 ± 0.29 -0.56 ± 0.39 0.101 ± 0.37 Corfficient ± SE (P) 0.073 ± 0.020 (0.0003) 0.142 ± 0.034 (< 0.0001) 0.141 ± 0.07 (0.05) 0.220 ± 0.059 (0.0002) 0.045 ± 0.033 (0.183) Odds Ratio (96% CI) 1.08 (1.03-1.12) 1.15 (1.08-1.23) 1.15 (1-1.33) 1.25 (1.11-1.4) 1.05 (0.98-1.12) EL50 4.88 3.07 2.03 2.58 2.23 PHQ-9 Intercept ± SE -2.93 ± 0.54 -2.717 ± 0.49 -1.96 ± 0.36 -2.79 ± 0.57 -1.131 ± 0.39 Corfficient ± SE (P) 0.093 ± 0.021 (< 0.0001) 0.159 ± 0.030 (< 0.0001) 0.218 ± 0.072 (0.002) 0.227 ± 0.067 (0.0007) 0.014 ± 0.033 (0.668) Odds Ratio (96% CI) 1.1 (1.05-1.15) 1.17 (1.09-1.27) 1.24 (1.08-1.43) 1.26 (1.1-1.43) 1.01 (0.95 to 1.08) EL50 31.65 17.06 8.99 12.31 78.21 Oxford Happiness Score Intercept ± SE 2.09 ± 0.52 2.29 ± 0.51 1.51 ± 0.42 1.92 ± 0.52 1.741 ± 0.51 Corfficient ± SE (P) -0.075 ± 0.026 (0.0038) -0.155 ± 0.05 (0.0023) -0.201 ± 0.11 (0.072) -0.177 ± 0.074 (0.014) -0.999 ± 0.051 (0.051) Odds Ratio (96% CI) 0.93 (0.88-0.98) 0.86 (0.77-0.95) 0.82 (0.66-1.02) 0.84 (0.73-0.97) 0.9 (0.82-1) EL50 27.76 14.74 7.51 10.85 17.42 NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Score (QoL, impact of the disease on the quality of life of patients). IPSS: International Prostate Symptom Score. IIEF (1-5,15): Short International Index of Erectile Function (sum of questions 1, 2, 3, 4, 5, 15). GAD-7: General Anxiety Disorder-7. PHQ-9: Patient Health Questionnaire-9. SE: Standard Error. 96% CI: 95% Confidence Interval. EL50: median effective level, i.e., symptom score associated with 50% probability of the psychometric test outcome. Archivio Italiano di Urologia e Andrologia 2024; 96(1):12452 5 Psychosexologic assessment in prostatitis versus absent or very mild anxiety or depression. The Oxford score was also used to distinguish patients showing a happiness versus little or no happiness. Dichotomization thresholds are indicated in the previous paragraph. Table 6 shows that the pain, quality of life impact, and total scores of the NIH-CPSI test are significantly higher in patients with moderate to severe depression or anxiety and in patients with a poor Oxford happiness score. A significantly higher NIH-CPSI voiding score was related to moderate to severe depression, but no difference was observed between patients with or without symptoms of anxiety and between patients reporting or not psycholog- ical well-being. The IPSS score was significantly higher in patients show- ing a poor Oxford happiness score. DISCUSSION The bidirectional relationship between psychological dis- turbances and prostatitis is complex, with several factors interacting or interfering with each other (16). Our findings can be divided into two sections, the first eval- uating correlations between measures of anxiety, depres- sion, and psychological well-being and the scores of symp- toms associated with CP/CPPS as measured with NIH-CPSI and questionnaires evaluating sexual function (IIEF or Table 5. Predictor significance and goodness-of-fit parameters of the logistic regression models shown in Table 3. Psychometric test Test Prostatitis/Prostate Symptom Scores (predictor) (outcome) NIH-CPSI, Total Score NIH-CPSI, Pain domain NIH-CPSI, Voiding domain NIH-CPSI, QoL domain IPSS GAD-7 Wald c2 = 12.86, P = 0.00035 c2 = 17.11, P < 0.0001 c2 = 3.75, P = 0.05 c2 = 13.63, P = 0.00022 𝜒2 = 1.77, P = 0.18 Likelihood Ratio c2 = 14.91, P = 0.0001 c2 = 20.16, P < 0.0001 c2 = 4.06, P = 0.043 c2 = 15.50, P < 0.0001 𝜒2 = 1.87, P = 0.17 Hosmer & Lemeshow 𝜒2 = 19.24, P = 0.013 𝜒2 = 4.22, P = 0.83 𝜒2 = n.a. 𝜒2 = 1.62, P = 0.99 𝜒2 = 35.93, P < 0.0001 Nagelkerke 𝜓R2 = 0.364 𝜓R2 = 0.652 𝜓R2 = 0.318 𝜓R2 = 0.701 𝜓R2 = 0.078 PHQ-9 Wald c2 = 17.76, P < 0.0001 c2 = 16,49, P < 0.0001 c2 = 9.20, P = 0.0024 c2 = 11.38, P = 0.00074 𝜒2 = 0.18, P = 0.67 Likelihood Ratio c2 = 21.93, P < 0.0001 c2 = 20.02, P < 0.0001 c2 = 9.54, P = 0.002 c2 = 13.20, P = 0.00027 𝜒2 = 0.18, P = 0.67 Hosmer & Lemeshow 𝜒2 = 5.87, P = 0.661 𝜒2 = 1.66, P = 0.98 𝜒2 = 0.85, P = 0.99 𝜒2 = 1.87, P = 0.98 𝜒2 = 5.01, P = 0.75 Nagelkerke 𝜓R2 = 0.469 𝜓R2 = 0.648 𝜓R2 = 0.591 𝜓R2 = 0.645 𝜓R2 = 0.0081 Oxford Happiness Score Wald c2 = 8.36, P = 0.038 c2 = 9.27, P = 0.023 𝜒2 = 3.21, P = 0.072 c2 = 5.99, P = 0.014 𝜒2 = 3.80, P = 0.051 Likelihood Ratio c2 = 9.34, P = 0.022 c2 = 10.73, P = 0.0011 𝜒2 = 3.28, P = 0.069 c2 = 6.50, P = 0.011 c2 = 3.91, P = 0.047 Hosmer & Lemeshow 𝜒2 = 6.83, P = 0.55 𝜒2 = 6.94, P = 0.54 𝜒2 = 3.22, P = 0.919 𝜒2 = 0.83, P = 0.999 𝜒2 = 7.77, P = 0.45 Nagelkerke 𝜓R2 = 0.293 𝜓R2 = 0.485 𝜓R2 = 0.315 𝜓R2 = 0.412 𝜓R2 = 0.201 NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Score (QoL, impact of the disease on the quality of life of patients). IPSS: International Prostate Symptom Score. IIEF (1-5,15): Short International Index of Erectile Function (sum of questions 1, 2, 3, 4, 5, 15). GAD-7: General Anxiety Disorder-7. PHQ-9: Patient Health Questionnaire-9. SE: Standard Error. 96% CI: 95% Confidence Interval. P: statistical probability of an alpha error. EL50: median effective level, i.e., symptom score associated with 50% probability of the psychometric test outcome. n.a.: not available. Table 6. Severity of CP symptoms in patients showing various degrees of happiness, depression and anxiety. Statistically significant differences are shown in bold. GAD-7 0-4 GAD-7 5-21 P PHQ-9 1-9 PHQ-9 10-27 P Oxford Oxford P median (IQR) median (IQR) (Mann-Whitney) median (IQR) median (IQR) (Mann-Whitney) happiness >3.5 happiness