Editorial comment: Associations of pain in young men presenting with lower urinary tract symptoms

This is a thought-provoking observational study assessing the presence of pain in young males presenting with lower urinary tract symptoms (LUTS). Several key points should be considered while interpreting the results of this paper. The incidence of pain in young men with LUTS is a little higher than what is perceived by a practicing urologist. Nonetheless, it is essential to note that this is a subset of young men (<40 years) who are referred to a urology clinic for advice regarding urinary symptoms. Pain could be a surrogate attention-seeking symptom when asked about, rather than a presenting symptom, which, obviously, in this subgroup, was LUTS. It has been mentioned that bladder pain was identified using the Interstitial Cystitis Symptom Index (ICSI Q4).[1] ICSI was designed as a symptom-scoring system to be used in the diagnosed cases of interstitial cystitis (IC) and not for the diagnosis of IC. ICSI Q4 is indeed a good question to be used for assessing pain or burning in the bladder. However, it falls short in defining the phenotype of pain, as is known in the contemporary literature.[2] Pain with bladder filling is perceived to be originating from the bladder as in IC, whereas pain that commences with urination can be associated with an inflamed prostatic urethra, suggesting a diagnosis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)[3] The pain, therefore, needs to be phenotyped further. CP/CPPS is defined by the National Institutes of Health (NIH) as “the presence of genitourinary pain in the absence of uropathogenic bacteria detected by standard microbiological methodology.”[4] In men, unfortunately, conventionally the focus has been on the prostate rather than the bladder, and thus the diagnosis of CP/CPPS is made more often than IC There is a very fine line between the pain of IC and that of CPPS. In the NIH-sponsored MAPP (Multidisciplinary Approach to the Prevention and Treatment) study, approximately 75% of male participants with Urological Chronic Pelvic Pain Syndrome (UCPPS) reported painful bladder filling and/or painful urinary urgency.[5] This article points out the prevalence of pain in young men with LUTS. This opens up the possibility of identifying young men with a diagnosis that might be primarily the one associated with pain (CP or IC), and LUTS may just be secondary. The authors have correctly mentioned that this study was meant to look at young men with LUTS rather than men with pain. Practicing urologists may want to change the way they look at young men with LUTS in their clinic and start exploring the possibilities of unreported pain. This may alter the direction of the working diagnosis, leading to better outcomes. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.