An examination of psychosocial barriers in the management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) : informing psychosocial interventions

Background: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common, but poorly understood, chronic pain condition in men. CP/CPPS is generally defined as persistent pain in the pelvic area for at least three months and is usually associated with urinary difficulties. CP/CPPS can affect men of any age, and from different national backgrounds, with estimated prevalence rates ranging from 2.2% to 16 % worldwide. Currently, the aetiology of this condition is unclear, and men with CP/CPPS often show heterogeneous presentations. The current literature indicates that, apart from biological symptoms, men with CP/CPPS also experience varying psychosocial difficulties, significantly impairing their quality of life (QoL) and sexual functioning. Treatment for CP/CPPS remains suboptimal, with a predominant focus on mono-pharmacological treatment instead of multimodal biopsychosocial management, as recommended by current clinical guidelines. Barriers may exist in the management of CP/CPPS, which hinder professionals and patients from applying the biopsychosocial approach to managing this complex condition. However, few studies have examined these barriers in CP/CPPS management.
Aims: This thesis aimed to investigate the available psychological intervention options for CP/CPPS, and to explore and identify potential barriers that healthcare practitioners and patients face when managing this pain syndrome. The information obtained from this thesis may aid in the development of intervention programs that address psychosocial difficulties coexisting with pelvic pain in men, suggesting more treatment options for practitioners and patients.
Methods: This thesis includes three related studies and a proposed study protocol. Study 1 (Chapter 5) was a systematic review of relevant literature on psychological interventions for CP/CPPS. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020) guidelines. Seven relevant articles were identified, and narrative data analysis was performed according to the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Study 2 (Chapter 6) was a qualitative study that interviewed 12 healthcare practitioners across disciplines. Purposive sampling and semi-structured interview methods were employed, and interview data were analysed using reflexive thematic analysis to reveal the barriers healthcare practitioners encounter when treating men with CP/CPPS. Study 3 (Chapter 7) included a cross-sectional survey investigating the role of different social factors in CP/CPPS populations, including residential status, healthcare service availability, perceived access difficulty to healthcare services, socioeconomic status (SES), and relationship functioning. This study also examined the moderating effects of social factors on the relationship between psychological factors and CP/CPPS-related health outcomes. Thirty-one men with self-diagnosed CP/CPPS or CP/CPPS-like symptoms were recruited through advertisements on social media, online support groups, pelvic pain/persistent pain clinics, non?profit organisations, and professional networks. Data were analysed using regression and moderation analyses. Based on the findings of the three studies, this thesis proposed an intervention study protocol (Chapter 8) with a single-case experimental design. This protocol is to examine the clinical utility and benefits of remotely-delivered Acceptance and Commitment Therapy (ACT) for Chronic Primary Pelvic Pain Syndrome (CPPPS) in men.
Results: Study 1 provided preliminary evidence supporting three types of psychological interventions for CP/CPPS, showing the clinical benefits of reducing pain and psychological symptoms, and improving quality of life. However, only a small number of relevant articles were identified, and the evidence from these studies was subject to a high risk of bias owing to mixed methodologies and outcome measures. Therefore, the benefits of psychological interventions are unclear, and only limited options are available. Study 2 found that with the unstandardised terminology for diagnosing male pelvic pain and unclear referral or management pathways, practitioners often feel uncertain about planning treatment for male patients presenting with pelvic pain. In addition, practitioners reported limited resources, services, and training available specifically for men with pelvic pain, which further hinders treatment planning and clinical decision-making. As such, practitioners often feel uncertain in assessing and treating men with pelvic pain and may not prioritise attending to this pain syndrome. Practitioners also recognised the gender-related stigma towards men with pelvic pain. This stigma likely worsens negative emotions and prevents men from proactively seeking the appropriate treatment. Study 3 revealed that most men with CP/CPPS primarily used medical treatment or received no active treatment. Notably, psychological therapy was not reported in the participants’ management plans despite most participants reporting higher levels of psycho?cognitive symptoms and impaired QoL. There was also a significant difference in service availability between medical and allied health services, which was more apparent in rural areas than in urban areas. The findings indicated that perceived access difficulty was a significant moderator in the relationship between catastrophising cognitions and CP/CPPS symptom severity. SES was also a significant moderator between catastrophising cognitions and symptom severity/mental health-related QoL. Unexpectedly, high SES enhanced the impact of catastrophising cognitions on CP/CPPS symptom severity, whereas medium SES mitigated the impact of catastrophising cognitions on mental health-related QoL. This unexpected result may be related to the conceptualisation of social identity and masculinity.
Conclusion: The evidence base and available options for psychological interventions in men with CP/CPPS are relatively limited. Healthcare practitioners also recognise a lack of resources to target psychosocial symptoms in CP/CPPS populations. In addition, unstandardised terminology, limited availability of allied health services, difficulty accessing healthcare services, gender-related stigma, and social identity/masculinity are potential barriers contributing to suboptimal management and unsatisfactory treatment outcomes. Arguably, these barriers are manageable, and expanding resources for psychological interventions for men with chronic pelvic pain is urgently needed. Increasing evidence supports online therapy for chronic pain management, increasing treatment accessibility and availability. In addition, ACT-based interventions are comparable to CBT in chronic pain management, and growing evidence demonstrates their clinical benefit in reducing self-stigma associated with various health-related issues. Also, the terminology – chronic primary pelvic pain syndrome (CPPPS) is recommended by updated clinical guidelines to reduce confusion between biomedical and biopsychosocial pelvic pain syndromes. Therefore, this thesis proposed an intervention study protocol. The protocol described a single-case experimental design, a rigorous research method alternative to the randomised control trial method, to examine the clinical utility of remotely delivered ACT for men with CPPPS.