I-STOP/PMP: A tool for monitoring prescription drug abuse in patients with chronic pain syndromes

Background:

Patients with chronic pain syndromes often require analgesics and muscle relaxants for symptom management. Unfortunately, many of these agents have abuse potential, and specific concerns have been raised with regard to drug-seeking behaviours that involve multiple clinicians dispensing similar, if not identical, agents. The Internet System for Tracking Over-Prescribing (I-STOP) is a newly implemented law targeted at monitoring the abuse and diversion of controlled substances in New York State. The purpose of this study is to describe the use and the potential for abuse of agents commonly used in the treatment of a variety of urological pelvic pain patients.

Materials and methods:

Clinical data from 397 patients with interstitial cystitis/bladder pain syndrome (IC/BPS), chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and pelvic floor dysfunction (PFD) were identified through medical record review over a consecutive 6-month period. These names were entered into the Prescription Monitoring Program (PMP) database to which all prescribers have access. I-STOP monitors prescription use over a prior 6-month interval from the date of access. Categoric data were compared with Fisher’s exact test and the chi-square test. Kaplan–Meier product limit curves were stratified by group and compared using the log-rank test.

Results:

In total, 397 patients with IC/BPS, CP/CPPS, and PFD were included; 14 patients (3.5%) had been prescribed duplicate medications by more than one practitioner. Of those patients who received duplicate prescriptions, 4 of 14 (29%) were for benzodiazepines, and 10 of 14 (71%) of duplicate medications prescribed were opioids.

Conclusions:

The implementation of the I-STOP/PMP registry provides an innovative way for practitioners to monitor prescribed controlled substances while allowing patients to receive necessary medications for symptom control.

Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment

PURPOSE

The purpose of this amendment is to provide an updated clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome based upon data received since the publication of original guideline in 2011.

MATERIALS AND METHODS

A systematic literature review using the MEDLINE(®) database (search dates 1/1/83-7/22/09) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of IC/BPS. This initial review yielded an evidence base of 86 treatment articles after application of inclusion/exclusion criteria. The AUA update literature review process, in which an additional systematic review is conducted periodically to maintain guideline currency with newly published relevant literature, was conducted in July 2013. This review identified an additional 31 articles, which were added to the evidence base of this Guideline.

RESULTS

Newly incorporated literature describing the treatment of IC/BPS was integrated into the Guideline with additional treatment information provided as Clinical Principles and Expert Opinions when insufficient evidence existed. The diagnostic portion of the Guideline remains unchanged from the original publication and is still based on Expert Opinions and Clinical Principles.

CONCLUSIONS

The management of IC/BPS continues to evolve as can be seen by an expanding literature on the topic. This document constitutes a clinical strategy and is not intended to be interpreted rigidly. The most effective approach for a particular patient is best determined by the individual clinician and patient. As the science relevant to IC/BPS evolves and improves, the strategies presented will require amendment to remain consistent with the highest standards of care.

Endoscopic lysis of bladder scar associated with Hunner's lesions: A new technique

Objective

Five to ten percent of interstitial cystitis/bladder pain syndrome (IC/BPS) patients have Hunner's lesions (HL), areas of non-specific inflammation and scarring. The poor quality of life of patients with HL is entwined in associated pain and loss of bladder capacity. Although the decrease in bladder capacity is usually dependent on pain, it may also be dependent upon scarring and associated compliance changes produced by the inflammatory process. This report reviews the potential role of endoscopic scar lysis using the holmium laser in the management of these patients whose only other therapeutic option is urinary diversion.

Methods

Two patients with HL and "end stage" bladders who underwent holmium laser division of bladder wall scar/tethering were identified. Clinical data were reviewed with emphasis on safety and efficacy.

Results

Both patients selected for this procedure underwent holmium laser lysis of known scar tissue in an effort to increase bladder capacity and improve symptoms of urinary frequency and pain with bladder filling. The median age of patients who underwent the procedure was 63 (59-67) years. Incisions were made with the holmium laser at frequencies of 3-10 Hz of 300-700 J along the region of scarring. All procedures were performed by the same practitioner. There was an increase in bladder capacity by 58.3% (50.0%-66.7%). During a mean follow-up of 4.2 years, there appeared to be a significant improvement with an increase in interval time between voids and a decrease in pain with bladder filling.

Conclusion

Patients with IC/BPS may be severely debilitated by a clinically significant decrease in their bladder capacity, especially in the face of HL. The use of the holmium laser to incise regions of scar and bladder wall tethering may produce a clinically significant and durable increase in bladder capacity. The use of this technique as a means of treating bladder scarring poses an excellent adjunct to existing treatment strategies.

Strange Vibes - Novel Presentation of Prostatitis

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has significant variability in its presentation.

In this study, we present 2 novel cases of prostatitis in which “buzz” is described as the primary pain symptom. These cases describe patients with the primary complaint of “cell phone–like buzzing” within the perineum, with accompanying urinary symptoms consistent with prostatitis.

CP/CPPS is a multifactorial disease within which psychological, inflammatory, neurologic, and neuromuscular etiologies are at play. As in other disease descriptions, a buzzing sensation represents the interaction of multiple pathways that have significant overlay with CP/CPPS. As such, we believe buzzing might represent a new symptom of CP/CPPS.

Childhood sexual trauma in women with interstitial cystitis/bladder pain syndrome: a case control study

Background: The impact of early lifetime trauma on symptomseverity and quality of life of patients with interstitial cystitis/bladderpain syndrome (IC/BPS) has not been fully elucidated. Wewanted to determine and compare the prevalence and impact ofchildhood traumatic events, with an emphasis on childhood sexualabuse, on patient symptoms, quality of life and other biopsychosocialparameters.Methods: Subjects (female patients with IC/BPS and controls withoutIC/BPS) completed psychosocial phenotyping questionnaires,including a demographics/history form, and validated questionnairesfocused on presenting symptoms (IC symptom indices, pain),psychosocial parameters (depression, anxiety, pain catastrophizing,sexual functioning, social support) and quality of life. Participantsalso completed the Childhood Traumatic Events Scale.Results: Questionnaires were completed by 207 IC/BPS patientsand 117 controls matched for age, partner status and education. Itwas found that before 17 years of age, the IC/BPS cases reportedhigher prevalence of “raped or molested” compared to controls(24.0% vs. 14.7%; p = 0.047). Within the IC/BPS group, casesreporting previous sexual abuse endorsed greater sensory pain,depression and poorer physical quality of life at the present timecompared to IC cases without a sexual abuse history. In the controlsonly, those reporting previous sexual abuse endorsed more depression,anxiety, stress, social maladjustment poorer mental qualityof life in the present time. When the analysis was corrected forpotential multiple comparison error, none of the findings remainedsignificant in either the IC/BPS or control groups.Interpretation: Childhood traumatic events, in particular sexualabuse and extreme illness, are reported as more common in IC/BPS patients than controls. Early trauma, such as the occurrenceof sexual abuse, is associated with some differences in patientadjustment (e.g., pain, quality of life, depression) but this impactappears to be, at most, very modest.

Variability of transrectal ultrasound-guided prostate biopsy prophylactic measures

INTRODUCTION

To assess the variability of pre-prostate biopsy prophylaxis among American urologists.

MATERIALS AND METHODS

A survey was electronically mailed to 3355 urologists around the country. Urologists were surveyed on their antibiotic prophylaxis choice, the route and duration of antimicrobial prophylaxis. Additionally they were questioned about their knowledge of local antimicrobial resistance and if rectal enemas were routinely used.

RESULTS

There were 679 (21%) responses to the survey. The survey revealed differences in pre-prostate biopsy prophylaxis among urologists. Ten different classes of antibiotics were used orally, 4 classes intramuscular, 5 classes intravenous, and there was also 14 different duration regimens.

CONCLUSION

Despite the initiation of the 2008 American Urological Association Guidelines on this topic, there still is a lack of uniformity in prostate biopsy prophylaxis.

Childhood sexual trauma in women with interstitial cystitis/bladder pain syndrome: a case control study

BACKGROUND

The impact of early lifetime trauma on symptom severity and quality of life of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) has not been fully elucidated. We wanted to determine and compare the prevalence and impact of childhood traumatic events, with an emphasis on childhood sexual abuse, on patient symptoms, quality of life and other biopsychosocial parameters.

METHODS

Subjects (female patients with IC/BPS and controls without IC/BPS) completed psychosocial phenotyping questionnaires, including a demographics/history form, and validated questionnaires focused on presenting symptoms (IC symptom indices, pain), psychosocial parameters (depression, anxiety, pain catastrophizing, sexual functioning, social support) and quality of life. Participants also completed the Childhood Traumatic Events Scale.

RESULTS

Questionnaires were completed by 207 IC/BPS patients and 117 controls matched for age, partner status and education. It was found that before 17 years of age, the IC/BPS cases reported higher prevalence of "raped or molested" compared to controls (24.0% vs. 14.7%; p = 0.047). Within the IC/BPS group, cases reporting previous sexual abuse endorsed greater sensory pain, depression and poorer physical quality of life at the present time compared to IC cases without a sexual abuse history. In the controls only, those reporting previous sexual abuse endorsed more depression, anxiety, stress, social maladjustment poorer mental quality of life in the present time. When the analysis was corrected for potential multiple comparison error, none of the findings remained significant in either the IC/BPS or control groups.

INTERPRETATION

Childhood traumatic events, in particular sexual abuse and extreme illness, are reported as more common in IC/BPS patients than controls. Early trauma, such as the occurrence of sexual abuse, is associated with some differences in patient adjustment (e.g., pain, quality of life, depression) but this impact appears to be, at most, very modest.

Mapping of pain phenotypes in female patients with bladder pain syndrome/interstitial cystitis and controls

BACKGROUND

Many bladder pain syndrome/interstitial cystitis (BPS/IC) patients report multiple pain locations outside the pelvis. No research has examined pain using a whole-body diagram, pain-associated adjustment factors, or the impact of pain in multiple body areas on patients' quality of life (QoL).

OBJECTIVE

Compare and contrast pain in BPS/IC patients and controls using a whole-body diagram (visible body areas). Examine the association between patient adjustment factors and greater number of body pain areas (pain phenotypes).

DESIGN, SETTING, AND PARTICIPANTS

Validated questionnaires were collected from diagnosed, tertiary-care, outpatient, female BPS/IC patients (n=193) and age-matched controls (n=115). Scales included a body pain area diagram, demographics/history, pain severity, BPS/IC symptoms, pain, depression, catastrophizing, and QoL.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cross-tabulation and analysis of variance models addressed the patient and control differences.

RESULTS AND LIMITATIONS

Patients reported more pain than controls in all reported body areas. Four pain phenotypes were created based on increasing counts of body locations (BPS/IC only, BPS/IC+plus 1-3 additional locations, BPS/IC plus 4-9, BPS/IC ≥ 10). Patients reported more body pain locations, pain, urinary symptoms, depression, catastrophizing, and diminished QoL than controls. The increased-pain phenotype was associated with poorer psychosocial adjustment and diminished physical QoL, but catastrophizing and low scores for mental QoL remained stable across all patient groups. This study was cross-sectional, relying on correlation-based analyses, thus causality cannot be established.

CONCLUSIONS

Patients reported numerous systemic pain symptoms outside the areas associated with the bladder/pelvic region, and increased numbers of body pain sites were associated with poorer patient outcomes (ie, pain severity, depression). This study illustrates the significant negative impact of pain on patient adjustment in BPS/IC. These findings suggest that clinicians carefully consider pain location distributions and the potential impact of body pain phenotypes during patient evaluation and treatment planning.

Psychosocial phenotyping in women with interstitial cystitis/painful bladder syndrome: a case control study

PURPOSE

We characterized and compared psychosocial phenotypes in a female interstitial cystitis/painful bladder syndrome cohort and an age matched cohort without that diagnosis.

MATERIALS AND METHODS

Female patients with interstitial cystitis/painful bladder syndrome and controls without the condition completed a psychosocial phenotyping questionnaire battery, including a demographics/history form and validated questionnaires focused on a range of presenting symptoms, psychosocial parameters and quality of life. Specific measures included interstitial cystitis symptom and problem index, McGill Pain Questionnaire, Medical Outcomes Study Sleep Scale, Center for Epidemiological Studies Depression Scale, State-Trait Anxiety Inventory, Pain Catastrophizing Scale, Female Sexual Functioning Index and Multidimensional Scale of Perceived Social Support and Medical Outcomes Study Short Form-12 quality of life. Direct comparisons and correlations were made to establish group differences and the strength of associations for psychosocial parameters in patients with interstitial cystitis/painful bladder syndrome.

RESULTS

Questionnaires completed by 207 patients with interstitial cystitis/painful bladder syndrome were compared to those of 117 controls matched for age, partner status and education. Compared to controls patients reported significantly more pain (total, sensory and affective), worse physical quality of life, increased sleep dysfunction, depression, catastrophizing, anxiety, stress and moderately more sexual/social function problems. These suffering, coping and social parameters correlated with the degree of general pain but stress, anxiety, depression and catastrophizing further correlated with IC specific symptoms and strongly with decreased quality of life. Pain was strongly associated with physical quality of life, while depression, catastrophizing and stress, and to a lesser extent social support were associated with poor mental quality of life.

CONCLUSIONS

Patients with interstitial cystitis/painful bladder syndrome have significant cognitive and psychosocial alterations compared to controls.

Interstitial cystitis: bladder pain and beyond

BACKGROUND

Interstitial cystitis is characterized by over 6 months of chronic pain, pressure and discomfort felt in the lower pelvis or bladder. It is often relieved with voiding, along with daytime frequency and nocturia in the absence of a urinary tract infection. Interstitial cystitis occurs primarily in females including adolescents and its diagnosis is still one of exclusion. It is now recognized as a serious medical condition associated with significant disability.

OBJECTIVE

The aim of this paper was to review the pathogenesis and treatment of interstitial cystitis with emphasis on new pathogenetic trends and therapeutic modalities.

METHODS

About 713 mostly original papers were reviewed in Medline from 1990 to August. 2008. All authors independently reviewed the literature. Large, double-blind, placebo-controlled, clinical trials were few and the medical histories of the patients used varied considerably making conclusions difficult. Promising pilot trials turned out mostly negative on follow-up.

RESULTS

Increasing evidence of co-morbid diseases, neurogenic inflammation and the effect of stress are promising as new targets for pathophysiology. No new effective treatments have emerged. Oral pentosanpolysulfate, amitriptyline, hydroxyzine and quercetin, as well as intravesical heparin/bicarbonate/lidocaine solutions, are still used with variable success. Some pilot open-label trials presented encouraging findings.

CONCLUSION

Interstitial cystitis contributes substantially to chronic pelvic pain and to poor quality of life. Oral or intravesical administration of solutions containing sodium hyaluronate, chondroitin sulfate and quercetin to both reduce bladder inflammation and 'replenish' the glycosaminoglycan layer should be tried. There is a clear need for therapeutic modalities. New potential translational research areas are suggested.

Diagnostic options for early identification and management of interstitial cystitis/painful bladder syndrome

AIMS

The aims of this article were to discuss options for diagnosing interstitial cystitis (IC), to compare approaches and to encourage early diagnosis of this disorder in the primary care setting.

METHODS

Experts discussed the tools available to diagnose IC and the advantages and disadvantages of each approach. Treatment options, both pharmacological and non-pharmacological, were also discussed. The importance of patient follow-up was emphasised.

RESULTS

Diagnostic options for IC include a thorough history and physical examination, laboratory evaluations, symptom screening tools, cystoscopy with hydrodistention, bladder biopsy, potassium sensitivity testing, intravesical anaesthetic challenges, urodynamics and urinary markers. Treatment options include oral and intravesical medications, dietary modification and physical therapy. Patient follow-up can be an opportunity to educate and empower patients to participate in their treatment.

DISCUSSION

A thorough patient history, physical examination and laboratory evaluations are keys to the diagnosis of IC. Optional diagnostic approaches may help increase physician confidence in prescribing therapy for this disorder. Multimodal therapy with an emphasis on patient education can help ensure success in treating IC.

CONCLUSION

Understanding the options available to diagnose IC may result in earlier identification and treatment for some patients.

Myofascial dysfunction associated with chronic pelvic floor pain: Management strategies

Myofascial pain as a cause of chronic pelvic pain with or without pelvic organ pathology is well-documented in the literature. Causes of this pain are multifactorial, including specific pelvic organ pathologies, neuromuscular disorders, and psychologic causes. Management of this myofascial component of chronic pelvic pain involves a multidisciplinary approach including physicians, physical therapists, neurologists, and psychiatrists. Treatment strategies, including behavioral management, medications, physical therapy, trigger point injections, neuromodulation, botulinum toxin injection, and other lesser known treatment modalities, are discussed in detail in this article.

The role of the bladder surface in interstitial cystitis/painful bladder syndrome

INTRODUCTION

Interstitial cystitis (IC) is a potentially severe and debilitating condition of the bladder. Numerous factors have been implicated in its pathogenesis.

MATERIALS AND METHODS

A literature review was conducted on the following topics: urothelium, mucosal lining, interstitial cystitis, bladder, and glycosaminoglycans.

RESULTS

A commonly proposed cause for IC is a defect or alteration in the bladder surface leading to increased permeability to noxious urinary solutes and ultimately to tissue inflammation and neurogenic upregulation. Support for this concept is drawn from studies of the structure, function, and composition of the bladder surface. The cause(s) of this alteration is not known, although recent research has implicated changes in the levels of growth factors and/or compounds that protect against irritants and potentially "toxic" factors. The etiology of IC is likely multifactorial.

CONCLUSIONS

Alterations of the bladder surface are observed in IC, and may play an important role in the etiology of this condition.

Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature

Compression of the left renal vein between the aorta and the superior mesenteric artery has been termed the nutcracker syndrome. Obstruction of left renal vein outflow results in venous hypertension with the formation of intra- and extrarenal collaterals and/or the development of gonadal vein reflux. To date, a variety of clinical symptoms due to mesoaortic compression of the left renal vein (nutcracker syndrome) have been described. It is not known what pathophysiological variables play a role in the different clinical manifestations of nutcracker syndrome. We report two patients representing the two different forms of the condition. In the first, hematuria and left flank pain resolved in a young man after successful renocaval reimplantation. In the second, symptoms of pelvic congestion due to pelvic varices improved in a middle-aged woman after successful embolization of the gonadal vein and pelvic collaterals. This report reviews the pathophysiology, presentation, diagnosis including radiographic findings, management options, as well as the current literature on nutcracker syndrome.