Archivio Italiano di Urologia e Andrologia 2019; 91, 116 ORIGINAL PAPER The role of anticholinergic therapy based on the upoint system in the treatment of chronic prostatitis Kamil Fehmi Narter 1, Utku Can 2, Alper Coşkun 2, Kubilay Sabuncu 2, Fatih Tarhan 2 1 Acibadem Mehmet Ali Aydinlar University, Urology, Istanbul/Turkey; 2 Department of Urology, University of Health Sciences, Kartal Dr. Lütfi Kırdar Training and Research Hospital, Istanbul/Turkey. Objective: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common problem and severely impairs the quality of life (QoL). We aimed to investigate the effects of different treatment options on voiding symptoms and QoL in patients with urinary phenotype according to the UPOINT system. Matherial and methods: Ninety-six patients with NIH category II,III CP/CPPS were included in the study prospectively. After the diagnosis, the questionnaires including NIH Chronic prosta- titis Symptom Index (NIH-CPSI), International Prostate Symptom Score (IPSS), Overactive Bladder Screening Questionnaire (OAB-V8), and Beck depression inventory were filled by the patients. The patients with urinary phenotype were treated by alpha-blocker, antimuscarinic or both therapy modalities (combined) considering the specific therapy recom- mendations by UPOINT. The questionnaires applied on the first visit were reapplied after one month and treatment success was evaluated. Results: Seventy-three patients were included in ‘Urinary phe- notype’ group (76%) and 23 were included in ‘other phenotypes’ (24%) group of the patients according to the UPOINT classifi- cation. Significant improvements of symptoms were observed with the all treatment modalities when the NIH-CPSI, IPSS and OAB-V8 scores were compared before and after treatment in the ‘Urinary phenotype’ group. Significant differences in the percentage of change in values were obtained in the anticholin- ergic group for pain subdomain of NIH-CPSI and IPSS scores. Conclusion: U-POINT clasification is useful for deciding on the treatment modality in CP/CPSS patients. We showed anti- cholinergic therapy might be effective option. Addition to the symptomatic recovery, there is need more further studies about effectivity cholinergic system in the prostate tissue. KEY WORDS: Chronic prostatitis; Anticholinergic therapy, UPOINT system. Submitted 28 August 2018; Accepted 25 September 2018 Summary No conflict of interest declared. of this problematic disease is only on the basis of symp- toms such as pain/discomfort in the pelvic area or lower urinary tract symptoms (LUTS) like storage symptoms fre- quency and urgency (3, 4). Antibiotics, alpha-adrenergic blockers, and anti-inflammatory drugs may be chosen in the treatments for CP/CPSS, but anticholinergic treat- ment for CP/CPSS has not been preferable yet adequate- ly, and there are few references about this topic (5). According to the National Institutes of Health (NIH), inflammation of the prostate can be classified as acute bacterial prostatis (category I), chronic bacterial prostati- tis (category II), chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS, category III) and asymptomatic prostatitis (category IV) (6). CPSS are further subdivided by the presence of inflammation in the extraprostatic secretions or semen (category IIIa) or the absence of it (category IIIb). Although there is no symptoms of dis- ease, chronic prostatitis can be declared histologically on many prostate biopsy reports. The UPOINT system was described in 2008. Patient's symptoms were seperated into six phenotypes as (U)rinary symptoms, (P)sycho- logical dysfunction, (O)rgan specific symptoms, (I)nfec- tious causes, (N)eurologic dysfunction and (T)enderness of the pelvic floor muscles according to the this system (7). Moreover, comorbidities are often present along with CP/CPSS such as irritable bowel syndrome and fibromyalgia. Recently, a (S)exual dysfunction domain (UPOINT(S)) was described as an additional content to the clinical phenotyping of CP/CPPS (8). Until today, anticholinergic therapy for patients with CP/CPSS has been very few reported as a symptomatic treatment option for voiding problems. Our theory are based on cholinergic system effective on the infectious/inflammation process in the prostate tis- sue. So that, anticholinergic therapy can be a new alter- native and additional therapy option for these patients. Many patients with CP/CPSS may have LUTS and geni- tal/pelvic pain. It depend on this, new individualized treatment modalities for patients with CP/CPPS has been considered as a multimodal therapy based on UPOINT sysytem. For this reason, we aimed to classify patients with CP/CPSS according to the UPOINT system and investi- gate the effects of different treatment modalities such as anticholinergic treatment on voiding symptoms and quality of life in a prospective clinical trial. DOI: 10.4081/aiua.2019.1.16 INTRODUCTION Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disease especially seen in men younger than 50 years old. Its prevalence was reported from 2 to 16% in the male population (1, 2). CP/CPPS has a sig- nificant negative impact on quality of life and it may cause depresssion and anxiety due to pyschological effects. This syndrome has not been well described yet and its optimal treatment is not clear. Moreover, there is no standard diagnostic test for CP/CPPS. The diagnosis Narter_Stesura Seveso 25/03/19 17:14 Pagina 16 17Archivio Italiano di Urologia e Andrologia 2019; 91, 1 Anticholinergic therapy for chronic prostatitis MATERIALS AND METHODS Ninety-six patients with symptoms of CP/CPPS who were referred to our outpatient clinic between March 2014 and May 2015 were enrolled in this prospective study. All patients were evaluated with a detailed medical history, physical examination, and laboratory tests (urine analysis, two glass test, urinary sonographic evaluation, uroflowmetry, and postvoid residual urine volume-PVR). All patients were also asked to fill out National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) (9), International Prostate Symptom Score (IPSS) (10), Overactive Bladder Screening Qustionare version 8 (OAB- V8) (11), and Beck depression inventory (12). Validated Turkish versions of these all questionnaries are used in the study. NIH categories was designated by the number of leucocytes and culture analysis in the expressed prostate secretion (EPS) examination (modified Meares and Stamey test/two glass test-1968). National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score (IPSS), Overactive Bladder Screening Questionnaire version 8 (OABV8), and Beck depression inventory were used to grade the symptoms. Patients aged 20 to 50 years and patients with CP/CPSS (NIH catego- ry II, IIIa and IIIb) with pelvic pain/discomfort for 3 or more months, negative urine culture, maximum urinary flow rate of 15 ml/sec or greater were included to study. Patients with medical history of pelvic surgery/previous prostate surgery, benign prostate hyperplasia (BPH), urinary obstruction or high postvoid residual volume (> 100 cc), urinary tract infection, prostatic cancer, urethral stricture, diabetes mellitus, neurogenic lower urinary tract dysfunc- tion and patients who had 5-alpha reductase inhibitors or anticholinergics were excluded from the study. After the NIH-CPSI, IPSS, OAB-V8 and Beck depression inventory evaluations, patients were clinically classified as ‘urinary phenotype’ or ‘other phenotypes’ according to UPOINT system. Alpha blocker (silodosin 8 mg/daily), antimuscarinic (propiverin 30 mg/daily), or combination therapies have been ordered for patients with urinary phe- notype, taking into consideration failure of treatments and allergy records in medical history. All patients were classi- fied into the treatment groups as patients with high void- ing subdomain of IPSS score were treated with the alpha blocker, patients with high OAB-V8 score were treated with the anticholinergic or patients with both criteries were treated with the alpha blocker and anticholinergic in com- bined group. Addition to these cut off (IPSS ≥ 8 and OAB- V8 ≥ 8) values, for the patients with modest and severe depression, cut off value of Beck Depression Inventory was accepted 17 or higher. NIH-CSPI score was evaluated as a succesful with at least a 6-point improvement and experi- enced improvements in every domain. When similar ques- tionnaire results were obtained, treatment option were selected according to preference of clinician. One month later, all patients were recalled for control, then all ques- tionnaires were applied again and effectiveness of treat- ment was evaluated. This study was approved by our Instutional Review Board (03.06.2014/8) and was conduct- ed according to the Declaration of Helsinki. All patients gave informed consent. Data were presented as median + standard deviation (SD). Stastical analysis was performed by Mann-Whitney U, Kruskal-Wallis and Wilcoxon tests with SPSS 12.0 (SPSS Inc. Chicago, IL, USA) and p < 0.05 was considered to indicate significance. The difference in values before and after treatments was defined as ‘∆’ and (∆/value before treatment) x100 was defined as ‘% change’. RESULTS Based on the U-POINT scoring system, patients were classified as ‘urinary phenotype’ (n: 73, 76%) and ‘other phenotypes’ (n: 23, 24%). The mean age, duration of symptoms, voiding volume and prostate volume were similar between two groups. LUTS were found to be more frequent in the group of ‘urinary phenotype’. Maximum flow rate at voiding in the ‘urinary phenotype’ group was significant lower than the ‘other phenotypes’. NIH-CPSI, IPSS and OAB-V8 scores were statistically sig- nificant higher in the ‘urinary phenotype’ group (p < 0.001). Stastistically difference was obtained in urinary and QoL subdomain of NIH-CPSI, except pain subdo- main between urinary and other phenotypes group. Significant differences were also obtained in IPSS subdo- main between ‘urinary phenotype’ and ‘other pheno- types’. But Beck depression inventory scores were similar between two groups (Table 1). Three patients with positive prostatic secretion culture (Category II) were treated with antibiotics and the remain- ing 73 patients with non-bacterial prostatitis (25 patients with category IIIa, 48 patients with category IIIb) were treated with appropriate medical agents. Moreover, alpha- blockers (n: 19), anticholinergics (n: 16) and combination therapies (n: 38) were initiated to patients in the ‘urinary phenotype’ group, while psychotherapy or physiothera- phy (n: 6) and food supplements contain quercetin (n: 13) were preferred in the group of ‘other phenotypes’. Lifestyle changing and dietery modifications was recommended for all patients (Table 2). Table 1. Evaluation of clinical and demographic data of patients with and without predominant urinary symptoms according to U-POINT score. U-POINT Urinary Other P* phenotype (n = 73) phenotypes (n = 23) median + SD median + SD Age 37 + 9.6 36.5 + 9 0.708 Duration of symptoms (months) 12 + 47 12 + 15.5 0.235 Qmax 21 + 8 27 + 6.3 0.002 Prostate volume (cc) 22 + 7.5 20 + 8.1 0.860 NIH-CPSI 24 + 7.3 19 + 5.8 < 0.001 Pain 10.5 + 4.9 10 + 4.3 0.45 Urinary 7 + 2.7 2 + 1.4 < 0.001 QoL 8 + 2.3 6 + 2 0.002 IPSS IPSS 15.5 + 8.1 5.5 + 5.9 < 0.001 QoL 5 + 2.3 3 + 1.3 < 0.001 OAB-V8 18 + 8.4 7 + 5.6 < 0.001 BECK 8.5 + 8.1 9..5 + 7.1 0.968 *Mann-Whitney U. Narter_Stesura Seveso 25/03/19 17:14 Pagina 17 Archivio Italiano di Urologia e Andrologia 2019; 91, 1 K. Fehmi Narter, U. Can, A. Coşkun, K. Sabuncu, F. Tarhan 18 Significant improvements were observed in the three treatment groups (alpha blockers, anticholinergic and combined) when comparing the pre and post treatment values of the NIH-CPSI, IPSS and OAB-V8 scores in the ‘Urinary phenotype’ group. Recovery in all three groups was observed according to Beck depression scale, but it was not statistically significant difference in anticholiner- gic group (p = 0.387). The best improvement in the pain subdomain of NIH-CPSI and IPSS scores were obtained from the anticholinergic group compared to the others (Table 3). DISCUSSION The prostate is innervated by rich supply of mixed autonomic post- ganglionic neurons that arise from the pelvic (inferior hypogastric) and the preganglionic parasympathetic neurons joining the pelvic plexus from the pelvic nerve arising from the sacral spinal cord segment (13). Cholinergic innervation is found in the both stromal and glandular epithelial areas of the human prostate for secretion and contrac- tion (14). The prostate secretes many substances into the seminal plasma that includes PSA (serine protease), zinc, citric acid, magne- sium, spermine, prostatic acid phos- phatase calcium, and accounts for approximately 15% of volume of the normal human ejaculate. Moreover, in vitro contraction of iso- lated prostate can be inhibited by muscarinic receptor antagonists in the human (15-17). Recently, anti- cholinergic (antimuscarinic) treat- ment has become more actual for treatment of male LUTS because such drugs work not only bladder but also on the prostate (18). Muscarinic receptors are intensely represented, especially those belong- ing to the M1 subtype, on glandular epithelial cells whereas M2 subtype receptors are more represented on the stromal cells. Animal data sug- gest that muscarinic receptors may be important in the genesis of pro- static secretions (19), smooth mus- cle contraction of the prostatic cap- sule (15, 17) and prostatic growth (18, 20). Cholinergic fibres were found in various regions of the prostate including the anterior cap- sule, peripheral zone, proximal and distal central zones and their density was more than adrenergic fibers (21). Moreover, muscarinic recep- tors with binding characteristics of Table 3. Assessment of pre and post treatment NIH-CSPI, IPSS, OAB-V8 and BECK depression inventory scores according to the treatment groups in ‘urinary phenotype’ group. Table 2. Treatment chart for patients with and without predominant urinary symptoms according to U-POINT score. U-POINT Treatment Urinary phenotype (n = 73) Other phenotypes (n = 23) n (%) n (%) Antibiotics 0 3 (13) Alpha blocker 19 (26) 0 Anticholinergic 16 (22) 1 (4) Combined 38 (52) 0 Quercetin 0 13 (57) Others 0 6 (26) Total 73 (100) 23 (100) NIH-CSPI Total Pretreatment Posttreatment Δ * % Change* 1P Pain Pretreatment Posttreatment Δ * % Change* 1P Urinary Pretreatment Posttreatment Δ * % Change* 1P QoL Pretreatment Postreatment Δ * % Change* 1P IPSS Pretreatment Posttreatment Δ * % Change* 1P OAB-V8 Pretreatment Posttreatment Δ * % Change* 1P BECK Pretreatment Posttreatment Δ * % Change* 1P Alpha blocker n = 19 20.9 + 6.6 15.6 + 5.1 -5.3 + 5 -12.2 + 11.6 < 0.001 8.4 + 5.2 6.3 + 3.8 -2.1 + 2.2 -9.8 + 10.7 0.002 6.2 + 2.9 4.6 + 2.2 -1.5 + 2.2 -15.3 + 22.2 0.012 6.4 + 2.3 4.7 + 2 -1.7 + 2.2 -14 + 18 0.003 14.8 + 7.2 11.3 + 6.5 -3.6 + 4.2 -10.2 + 11.9 0.003 13.5 + 8 9.7 + 6 -3.8 + 3.6 -10.5 + 10.1 0.001 9.5 + 6.4 6.3 + 4.8 -3.2 + 2.9 -5 + 4.6 0.001 Antimuscarinic n = 16 27.2 + 7.5 20.1 + 6.3 -7.1 + 5.8 -16.6 + 13.5 0.001 11.8 + 5.2) 8 + 3.6 -3.8 + 3 -18.1 + 14.5 0.001 7.3 + 2.8 5.5 + 2.6 -1.8 + 2 -17.5 + 19.8 0.003 8.1 + 1.5 6.6 + 2.1 -1.6 + 2.6 -13 + 21.9 0.008 16.4 + 8.7 10.5 + 6.3 -5.9 + 4.9 -17 + 14 0.001 20 + 6 14.8 + 6.2 -5.3 + 4.5 -14.6 + 12.5 0.001 11 + 8.8 9.4 + 8.7 -1.6 + 5.1 -2.5 + 8.1 0.387 Combined n = 37 25.1 + 7.3 20 + 7.3 -5.1 + 6.2 -11.8 + 14.3 < 0.001 9.8 + 4.5 8.1 + 3.4 -1.8 + 2.9 -8.5 + 13.7 < 0.001 7.1 + 2.6 5.3 + 2.8 -1.9 + 2.2 -18.6 + 22.1 < 0.001 8.1 + 2.2 6.7 + 2.6 -1.4 + 2.6 -11.7 + 18.8 0.001 16.8 + 8.6 13.9 + 7.7 -2.9 + 3.8 -8.3 + 10.9 < 0.001 19.7 + 8 16.9 + 7.4 -2.8 + 4.1 -7.9 + 11.4 < 0.001 11.6 + 8.7 8 + 6.4 -3.7 + 6.1 -5.8 + 9.6 < 0.001 2P 0.267 0.031** 0.894 0.858 0.053 0.190 0.223 1 Wilcoxon 2 Kruskal Wallis *Δ : The difference in values before and after treatments **% Change: Percentage of change in values before and after treatments; (Δ /the maximum score of relevant questionnaire) x100 Narter_Stesura Seveso 25/03/19 17:14 Pagina 18 19Archivio Italiano di Urologia e Andrologia 2019; 91, 1 Anticholinergic therapy for chronic prostatitis the M3 subtype are predominant in the rat ventral prostate (22), and M1 subtype is dense in the rabbit vas deferens (23). Despite of the only small acute urinary retention risk, muscarinic antagonists may be helpful in men with LUTS as well as overactive bladder (OAB). The expression of muscarinic receptors can be correlated with CP/CPSS. Recently, a possible etiological pathway has been described. According to this mechanism, an unfavorable event as trauma or infection leads to an injury-response of the tissue. Inflammation and upregulation of cytokines may lead to additional organ damage involving nerves, blood vessels, smooth muscles, and the loss of urothelium integrity. As we well know, urothelium is a whole unit especially in the trigonum and prostatic ürethra, and some muscle fibers in detrusor and sphinc- ter region continue in the prostatic area, so that it is a functional and anatomic whole unit. The resulting pain may produce contraction of pelvic smooth and skeletal muscles, finally leading to LUTS, ejaculatory pain or pain in other regions such as back and abdomen. Prolonged pain may sensitize central and peripheral nervous sys- tems and finally cause hyperalgesia and allodynia. For this reason, the primary symptoms of CP/CPPS can be pelvic pain and frequency and few physicians prefer anti- cholinergics empirically for treatment, and there are only hints of treatment with anticholinergics in some of the guidelines (9). In our study, anticholinergic therapy improved the pain subdomain score associated with CP/CPSS more than the others (p = 0.031). According to this result, anticholin- ergic therapy is the best succesful option for treatment of pain subdomain of NIH-CPSI. In some actual studies, muscarinic receptors have also been suggested to be implicated in the control of inflam- mation, cell growth and proliferation (24, 25). The mus- carinic receptors are also present in the urethra, but their function have not been clarified adequately. The urethral sphincter tone is predominantly regulated by adrenergic nerves, but muscarinic receptors also modulate the tone (26). Muscarinic receptor mediates contraction of the proximal urethra whilst mediating relaxation of the dis- tal urethra (27). All muscarinic receptor subtypes (M1-5) are located on the urinary system, especially M2 recep- tors mostly occur in the circular muscle layers, and mus- carinic M3 receptors in the longitudinal layer. During inflammation expression of muscarinic M5 receptors is increased, especially in the epithelium and cholinergic induced production of nitric oxide (NO) increase (28). We chose propiverine as an anticholinergic in this study because of it is a competitive antagonist with similar affinity for all muscarinic receptor subtypes (29). Kim et al. presented their results about efficacy of anticholinergics for CP/CPSS at American Urological Association's (AUA) 2010 Annual Meeting and then con- firmed this finding with a prospective study in 2011 (30, 31). In that study, ninety six patients with CP/CPPS were randomly assigned in a single-blind fashion and received either ciprofloxacin or ciprofloxacin and solife- nacin (5 mg/d) for 2 months. IPSS, NIH-CPSI, IIEF-5 questionnaires and assessment of QoL were used in that study. According to the results of the study, 67% of patients had urinary symptoms. Similarly, in our study 76% of patients showed urinary phenotype. On the other hand, the IPSS assessment appears to be a good indicator follow-up in the management of CP/CPPS especially in many patients with severe LUTS. Statistically significant differences in the total score, the pain and sub-domain scores of NIH-CPSI and total score and storage domain score of IPSS were reported accord- ing to Kim’s research. Moreover, they reported a statisti- cally non significant increase of the total score of IIEF-5 and no statistically significant difference in residual urine. As a result of the study, the efficacy of anticholin- ergic treatment in CP/CPPS was demonstrated by the improvements in the NIH-CPSI and IPSS total and stor- age scores. Similar to the results of that study, the NIH- CPSI and IPSS total and storage scores improved signifi- cantly in the anticholinergic treatment group for patients with CP/CPSS in our study (p = 0.053). More than 90% of cases of CP are not associated with a significant bacteriuria, a condition referred to as chronic pelvic pain syndrome (CPPS) and may not respond to antibiotics or other classical treatment options. Many hypotheses have been suggested for the physiopathology of CP/CPSS including infection, inflammation, autoim- munity, neuromuscular spasm or intraprostatic urinary reflux. CP/CPSS is a syndrome, not a disease and patients may have a wide array of symptoms. For this reason, symptomatic treatment is essential for these patients. Symptom severity should be assessed using the NIH Chronic prostatitis symptom index (CPSI), which is a vali- dated nine question survey that covers the three domains of pain, urinay symptoms and quality of life (32). The UPOINT system was developed to identify clinical phe- notypes according to the symptoms and decide for com- bined multimodal treatment strategies. The UPOINT sys- tem (www.upointmd.com) was validated in several clin- ical trials (33-35). In this system each category has its own treatment. Use of this treatment strategy is starting to become more widespread and is proving its effective- ness. A strong correlation between the number of posi- tive UPOINT domains and the worse total score of the CPSI measured in patients was shown (36). Shoskes et al demostrated that a majority (84%) of patients treated based on the UPOINT phenotype had a clinical improvement of CP/CPSS symptoms measured by an at least a 6-point or greater decrease in NIH-CPSI score (33, 34, 37). Another study about UPOINT clinical phenotyping reported that 75% of patients had at least a 6-point improvement in CPSI and experienced improve- ments in every domain (38). In our study, many patients with CP/CPSS had LUTS and we evaluated to all patients according to UPOINT classification. In addition to the correlation between the UPOINT and CP/CPSS, sexual dysfunction (ED) was added as a specific domain to create UPOINT(S) (12). In this study, the authors suggested that adding sexual dysfunction to the domain system may be helpful, as a sexual dysfunction is a frequent complaint of patients suffering from CP/CPSS. According to this study, the prevalence of sexual dys- function is 65% in these patients. Multimodality treatment strategies that provides superi- or outcomes over other treatment strategies for this dis- Narter_Stesura Seveso 25/03/19 17:14 Pagina 19 Archivio Italiano di Urologia e Andrologia 2019; 91, 1 K. Fehmi Narter, U. Can, A. Coşkun, K. Sabuncu, F. Tarhan 20 ease and it aims to offer a personalized combination ther- apy. At least combined therapy may show synergistic effects in the management of CP/CPPS. In our study, NIH-CPSI, IPSS and OAB-V8 scoring values were calcu- lated at statistically significant higher level in the ‘urinary phenotype’ group (p < 0.001). We found statistically sig- nificant differences between the two groups in the total score and urinary domain of the NIH-CPSI and the total score and storage symptom score of the IPSS. As a result of NIH-CPSI, IPSS and OAB-V8’s data, we can suggest that CP/CPSS is a complex problem and it can effect bladder, prostate and lower urinary tract functions as a whole system. However to prove the effective of anti- cholinergics in CP/CPPS decrease of absolute values between two groups should be considered during the study. Our data suggest that anticholinergics are effective in the management of CP/CPSS, especially for the treat- ment of storage symptoms. In our study, total and storage scores of NIH-CPSI and IPSS improved significantly in the anticholinergic treat- ment group for patients with CP/CPSS (p = 0.053). As we well know, UPOINT system may recommends all treatment options for ‘urinary phenotype’ according to patient’s symptoms and preference of the clinician. According to our results, anticholinergics may be a treat- ment option for many patients with CP/CPSS who have high IPSS scores with modarate or severe LUTS symp- toms. Moreover, this effect of antimuscarinics may be explain by the influence of anticholinergic system on the prostate tissue. Many treatment options for this disease have been used such as alpha blockers, antibiotic therapy, anti-inflam- matory drugs and analgesics, antispasmodics, 5-alpha reductase inhibitors (5-ARI), lifestyle changing, psy- chotherapy, physiotheraphy, local thermotherapy, neu- roleptics and anti-anxiolitics, narcotics, acupuncture, extracorporeal shockwave therapy, myofascial trigger point release, biofeedback, food supplements (quercetin, zinc etc), phytotherapy (bioflavonoids), botulinum toxin A injection or occasionally surgical therapy. There have been few studies of the efficacy of anticholinergics for these patients. At least for a symptomatic relief of com- plaints, anticholinergic treatment may be tried according to the results of our study. But there is a need for a long term, randomized, controlled study to confirm the effi- cacy of this treatment. The limitations of the our study are the lack of a ques- tionnaire to assess the sexual performance of the patients such as IIEF-5 and of an evaluation of long-term treat- ment outcomes. Furthermore, our study was not a large scale and long term research. So that, more randomized, controlled, long-term and large-scale clinical trials are needed. On the contrary, our study was the first to include Beck depression scale together with UPOINT system in patients with CP/CPSS. Although there was a decrease in Beck score after treatment in patients treated with anticholinergics, the change was not significant (p = 0.387). This positive but statistically insignificant result can be pioneer for entegration of Beck depression scale and UPOINT system that could be named as UPOINT(D; depression) similarly to UPOINT(S) modification. CONCLUSIONS As we well know, CP/CPPS is a common, worrisome problem especially for the young men population. Until today, anticholinergic therapy is not a choice for the treatment of this problem according to classical treat- ment algorithms, but after the introduction of UPOINT system this option has been considered, especially for patients belong urinary phenotype based on UPOINT system. If patients with CP/CPSS according to subgroup of the NIH categorization have lower urinary symptoms (LUTS) such as urgency, frequency, nocturia, increased postvoid residual urine, dysuria, they have to be evaluat- ed with UPOINT system and they are best candidate for anticholinergic treatment. In this study, we showed that anticholinergic therapy was an effective and preferable option for these patients. In the near future anticholinergic treatment of patients with CP/CPSS will be accepted and take a place in classical treatment algorithms. 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Murat apt. 24/15 Kadikoy 34724 Istanbul (Turkey) Utku Can, MD utkucan99@yahoo.com Alper Coşkun, MD dr.alper05@gmail.com Kubilay Sabuncu, MD kubilaysabuncu@yahoo.com Fatih Tarhan, MD, Assoc Prof tarhanf@yahoo.com Department of Urology, University of Health Sciences, Kartal Dr. Lütfi Kırdar Training and Research Hospital, Istanbul (Turkey) Narter_Stesura Seveso 25/03/19 17:14 Pagina 21