EAU guidelines on chronic pelvic pain

Chronic pelvic pain in women: an epidemiological perspective

Chronic pelvic pain (CPP) is common in women of reproductive age and has a significant impact on quality of life, work efficiency and healthcare utilization. CPP can be a manifestation of many different, often multifactorial conditions, and in the absence of an identified cause, the management can be particularly challenging. High quality epidemiological studies would improve the understanding of CPP and identify risk factors which may be targeted for the development of appropriate management strategies. This review focuses on what is known about the prevalence, risk factors, individual and societal burden of CPP and outlines important management strategies.

Novel Treatment of Chronic Bladder Pain Syndrome and Other Pelvic Pain Disorders by OnabotulinumtoxinA Injection

Chronic pelvic pain (CPP) is defined as pain in the pelvic organs and related structures of at least 6 months' duration. The pathophysiology of CPP is uncertain, and its treatment presents challenges. Botulinum toxin A (BoNT-A), known for its antinociceptive, anti-inflammatory, and muscle relaxant activity, has been used recently to treat refractory CPP with promising results. In patients with interstitial cystitis/bladder pain syndrome, most studies suggest intravesical BoNT-A injection reduces bladder pain and increases bladder capacity. Repeated BoNT-A injection is also effective and reduces inflammation in the bladder. Intraprostatic BoNT-A injection could significantly improve prostate pain and urinary frequency in the patients with chronic prostatitis/chronic pelvic pain syndrome. Animal studies also suggest BoNT-A injection in the prostate decreases inflammation in the prostate. Patients with CPP due to pelvic muscle pain and spasm also benefit from localized BoNT-A injections. BoNT-A injection in the pelvic floor muscle improves dyspareunia and decreases pelvic floor pressure. Preliminary studies show intravesical BoNT-A injection is useful in inflammatory bladder diseases such as chemical cystitis, radiation cystitis, and ketamine related cystitis. Dysuria is the most common adverse effect after BoNT-A injection. Very few patients develop acute urinary retention after treatment.

Intraprostatic injection of botulinum toxin-A in patients with refractory chronic pelvic pain syndrome: The transurethral vs. transrectal approach

OBJECTIVE

To evaluate the outcome of an intraprostatic injection of botulinum toxin-A (BTX-A) in men with refractory chronic prostatitis-associated chronic pelvic-pain syndrome (CP/CPPS) and to compare the efficacy of the transurethral and transrectal routes.

PATIENTS AND METHODS

In an uncontrolled randomised clinical trial conducted in men with refractory CP/CPPS, the patients were classified into two groups according to the route of BTX-A injection; transurethral (group 1, 28 patients) and transrectal ultrasonography-guided (group 2, 35 patients). The chronic prostatitis symptom index (CPSI), maximum urinary flow rate (Q max) and white blood cell (WBC) count in expressed prostatic secretion (EPS) were measured before and at 3, 6 and 12 months after the injection. A significant clinical improvement (SCI, defined as a reduction of 4 points or a 25% decrease in total CPSI score) was correlated with patient age, prostate volume and symptom duration.

RESULTS

In group 1, the pain and quality-of-life domain scores improved, but statistically significantly only at 6 months. The voiding score improved at all follow-up visits. In group 2 there was a significant improvement in all the CPSI domain scores at all follow-up visits, except for pain, which was insignificantly improved by 12 months. The SCI ratings in groups 1 and 2 were 36%, 79% and 57%, and 49%, 89% and 74% in group 2 at the three follow-up visits, respectively. The Q max was significantly improved in both groups during the follow-up (except at 12 months in group 1). There was a significant reduction in the mean WBC count in the EPS in patients with inflammatory prostatitis. Both prostate volume and symptom duration were significantly associated with a lower SCI rating.

CONCLUSION

BTX-A is an available treatment option for patients with refractory CP/CPPS. It is more effective in patients with a small prostate and short symptom duration. The transrectal route provided better results than the transurethral route. More prospective longer term studies are needed.

Inflammation characteristics in bladder pain syndrome ESSIC type 3C/classic interstitial cystitis

OBJECTIVES

Interstitial cystitis is regarded as a heterogenous syndrome with two distinguishable forms: the non-ulcer and the classic form of interstitial cystitis, the latter with Hunner's lesions; or bladder pain syndrome type 3C and non-Hunner bladder pain syndrome, respectively.

METHODS

A cohort of 379 patients diagnosed with interstitial cystitis was studied. Nitric oxide release from the bladder was measured using a chemiluminescence nitric oxide analyzer. Bladder biopsies from the patients and healthy controls were analyzed by routine histopathological examination. Biopsies from a subset of patients and controls were also analyzed by immunohistochemistry and cytokine gene expression by real-time polymerase chain reaction.

RESULTS

Patients with bladder pain syndrome type 3C/classic interstitial cystitis had considerably higher levels of nitric oxide as compared with non-Hunner bladder pain syndrome/non-ulcer interstitial cystitis patients and healthy individuals, and showed histologically a chronic inflammation in the bladder mucosa, with abundant mast cell infiltration in all layers of the bladder wall. No inflammation was noted in non-Hunner bladder pain syndrome/non-ulcer interstitial cystitis patients. The isoenzymes inducible nitric oxide synthase, the catalyst in the nitric oxide production, was strongly expressed in the inflammatory cells in the bladder mucosa of bladder pain syndrome type 3C/classic interstitial cystitis patients. In addition, the expression of the pro-inflammatory cytokines interleukin-6 and interleukin-17A messenger ribonucleic acid, and of anti-inflammatory interleukin-10 messenger ribonucleic acid showed significantly increased levels in bladder pain syndrome type 3C/classic interstitial cystitis compared with healthy controls.

CONCLUSION

Bladder pain syndrome type 3C/classic interstitial cystitis is a distinct inflammatory disease and in many aspects shares features of inflammatory autoimmune diseases. These findings could open up novel research avenues with expectations for new targets for pharmacological treatment.

Development and evaluation of an E-health system to care for patients with bladder pain syndrome/interstitial cystitis

OBJECTIVES

Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease that highly degrades the quality of life for patients. In the present study, Internet intervention was used to care for bladder pain syndrome/interstitial cystitis patients to alleviate their pain and bothering symptoms.

METHODS

Healthcare education was carried out through the Internet by asking the patients, who were randomly divided into study (40 patients) and control (40 patients) groups, to check possible sensitive foods, habits, and behaviors weekly to remind and consolidate important rules for promoting quality of life. The symptom flares consultation through short message service with the Internet used to elevate healthcare efficiency was undertaken. Questionnaires, including Short Form 36 health survey, O'Leary-Sant symptom and problem indices, as well as visual analog scales pain and urgency scales, were used to evaluate quality of life and disease severity improvements before and after information and communication technology intervention. The outcome was evaluated at week 8.

RESULTS

The quality of life of both the control and study groups was significantly improved. The quality of life and visual analog scales for the patients in the study group with information and communication technology intervention showed a much greater improvement compared with the patients in the control group (P < 0.05).

CONCLUSIONS

The E-health system was shown to be effective in improving quality of life of bladder pain syndrome/interstitial cystitis patients through intervention of Internet healthcare education and short message service for the consolidation of healthy behavior and lifestyle in the 8-week follow up.

Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain

Introduction

Evidence suggests that painful intercourse, pain-related psychosocial factors, and altered pain processing magnify the pain experience, but it is not clear how these factors are related to each other.

Aim

The aims were to (i) characterize differences between women with pelvic pain and pain-free women using a battery of pain-related psychosocial measures, clinical pain ratings, and evoked local and remote pain sensitivity; and (ii) examine the relationship between intercourse pain, clinical pain, and local and remote evoked pain sensitivity.

Methods

Women with pelvic pain lasting at least 3 months and pain-free women completed questionnaires and underwent pain sensitivity testing. Self-report measures included clinical pain intensity, pain catastrophizing, pain-related fear, pain anxiety, depression, sexual function, and self-efficacy. Pain sensitivity measures included threshold and tolerance and temporal summation of pain. Separate analyses of variance (anova) were used to test group differences in self-report and pain sensitivity measures. Correlations were calculated among dyspareunia, psychosocial factors, and evoked pain.

Main Outcome Measures

Self-reported pain and pain sensitivity measures.

Results

Twenty-eight pain-free women and 14 women with pelvic pain participated in this study. Women with pelvic pain reported greater pain intensity and greater psychosocial involvement compared with pain-free women. No differences existed between groups for thermal or pressure measures, but women with pelvic pain rated their pain with pain testing significantly higher than pain-free women. Intercourse pain was significantly associated with affective and sensory pain and pressure pain ratings at the puborectalis, vulvar vestibule, adductor longus tendons, and tibialis anterior muscle.

Conclusions

Differences in local pain ratings suggest that women with pelvic pain perceive stimuli in this region as more painful than pain-free women although the magnitude of stimuli does not differ. Alappattu MJ, George SZ, Robinson ME, Fillingim RB, Moawad N, LeBrun EW, and Bishop MD. Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain. Sex Med 2015;3:14–23.

Prevalence and use of complementary health approaches among women with chronic pelvic pain in a prospective cohort study

OBJECTIVE

The aim of this study was to examine the prevalence of and factors associated with use of complementary health approaches among women with chronic pelvic pain (CPP).

DESIGN

We analyzed data from the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives, a prospective cohort study of women seeking care for noncancerous pelvic problems with intact uteri at enrollment. Among a subset of 699 participants who reported having CPP, we analyzed the prevalence of complementary health approaches used and associated patient sociodemographic and clinical characteristics, health-related quality of life, attitudes and beliefs, and conventional health care practices.

RESULTS

At baseline, slightly over one-half (51%) of women with CPP used at least one complementary health approach in the past year, including acupuncture (8%), special foods or diets (22%), herbs (27%), and vitamins and minerals (29%). During follow-up surveys conducted annually for 4 years, a substantial proportion of women (44.8%) used complementary health approaches at more than half of the assessments. Users of complementary health approaches were more likely to undergo a hysterectomy or oophorectomy or to use gonadotropin-releasing hormone agonists or opioids during the study compared with nonusers. Women with CPP who used complementary health approaches also had more optimal health-related quality of life measured by the Pelvic Problem Impact Questionnaire (31.6 vs 25.6, P < 0.001).

CONCLUSION(S)

Many women with CPP consistently use complementary health approaches. The substantial interest in and high prevalence of complementary health approaches used alongside conventional medical approaches highlight the need for better understanding of multimodal approaches to address the complex condition of CPP.

Sono-electro-magnetic therapy for treating chronic pelvic pain syndrome in men: a randomized, placebo-controlled, double-blind trial

Objective

To assess the efficacy and safety of sono-electro-magnetic therapy compared to placebo in men with refractory CPPS.

Patients and Methods

In a randomized, placebo-controlled, double-blind single center trial, we assessed the effect of sono-electro-magnetic therapy in men with treatment refractory CPPS. Sixty male patients were randomly assigned to treatment with either sono-electro-magnetic (n = 30) or placebo therapy (n = 30) for 12 weeks. The primary outcome was a change in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) from baseline to 12 weeks.

Results

The 12-week difference between sono-electro-magnetic and placebo therapy in changes of the NIH-CPSI total score was −3.1 points (95% CI −6.8 to 0.6, p = 0.11). In secondary comparisons of NIH-CPSI sub-scores, we found differences between groups most pronounced for the quality-of-life sub-score (difference at 12 weeks −1.6, 95% CI −2.8 to −0.4, p = 0.015). In stratified analyses, the benefit of sono-electro-magnetic therapy appeared more pronounced among patients who had a symptom duration of 12 months or less (difference in NIH-CPSI total score −8.3, 95% CI −14.5 to 2.6) than in patients with a longer symptom duration (−0.8, 95% CI −4.6 to 3.1; p for interaction = 0.023).

Conclusions

Sono-electro-magnetic therapy did not result in a significant improvement of symptoms in the overall cohort of treatment refractory CPPS patients compared to placebo treatment. Subgroup analysis indicates, however, that patients with a symptom-duration of 12 months or less may benefit from sono-electro-magnetic therapy, warranting larger randomized controlled trials in this subpopulation.

Trial Registration

ClinicalTrials.gov NCT00688506

A new paradigm in chronic bladder pain

The concept of visceral pain has moved from organ-centered disease to a conceptualization based on pathophysiological mechanisms, integrating psychosocial and sexual dimensions. The terms painful bladder syndrome and bladder pain syndrome have been coined to include all patients with bladder pain. There is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes IC/BPS is likely to be underdiagnosed and undertreated in both men and women IC/BPS requires a multidisciplinary team approach toward management. This report is adapted from paineurope 2014; Issue 2, ©Haymarket Medical Publications Ltd, and is presented with permission. Paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication.

Clinical comparision of intravesical hyaluronic acid and hyaluronic acid-chondroitin sulphate therapy for patients with bladder pain syndrome/interstitital cystitis

INTRODUCTION

Patients with a history of bladder pain syndrome/interstitial cystitis (BPS/IC) and who responded poorly or unsatisfactorily with previous treatment were compared taking intravesical hyaluronic acid (HA) or hyaluronic acid-chondroitin sulphate (HA-CS).

METHODS

Patients were treated with intravesical instillation with 50 mL sterile sodium hyalurinic acid (Hyacyst, Syner-Med, Surrey, UK) (n = 32) and sodium hyaluronate 1.6% sodium chondroitin sulphate 2% (Ialuril, Aspire Pharma, UK) (n = 33). Intravesical instillations were performed weekly in first month, every 15 days in the second month and monthly in third and fourth months, for a total of 8 doses. Patients were evaluated using a visual analog pain scale (VAS), interstitial cystitis symptom index (ICSI), interstitial cystitis problem index (ICPI), voiding diary for frequency/nocturia, cystometric bladder capacity and voided volume at the beginning and at 6 months. All patients had a potassium sensitivity test (PST) initially. Wilcoxon and Mann-Whitney U tests were used for statistical analysis.

RESULTS

In total, 53 patients met the study criteria. There were 30 patients in the HA-CS group (mean age: 48.47) and 23 patients in the HA group (mean age: 49.61) (p > 0.05). The initial PST was positive in 71.7% patients (38/53) overall with no difference between groups (p > 0.05). Responses for VAS, ICCS, ICPS, 24-hour frequency/nocturia statistically improved in both groups at 6 months. There was no significant difference in symptomatic improvement (p > 0.05). Eight patients had mild adverse events.

CONCLUSION

HA and HA/CS instillation can be effective in BPS/IC patients who do not respond to conservative treatment. An important limitation of our study is that the HA dosage of the 2 treatment arms were different. It would be more appropriate with same HA dosage in both groups; however, there was no commercially available glycosaminoglycan (GAG) substance with same HA dosage for single and combination therapy. Large, long-term randomized studies are required to determine if there is a difference between these treatments.

OnabotulinumtoxinA (Botox) nerve blocks provide durable pain relief for men with chronic scrotal pain: a pilot open-label trial

INTRODUCTION

Chronic scrotal pain (CSP) is a common, often debilitating, condition affecting approximately 4.75% of men. While nerve blocks using local anesthetics usually provide temporary pain relief, there are no publications on the use of longer acting nerve blocks to provide more durable pain relief for men with CSP.

AIM

The aim of this study was to determine if onabotulinumtoxinA (Botox) cord blocks provide durable pain relief for men with CSP.

METHODS

In this pilot open-label study, men with CSP who had failed medical management but experienced temporary pain relief from a standard cord block underwent a cord block with 100U Botox.

MAIN OUTCOME MEASURES

The outcomes measured were changes 1, 3, and 6 months post-Botox injection in (i) a 10-point visual analog scale (VAS) pain score; (ii) scrotal tenderness on a three-point scale as rated by physical examination; and (iii) the Chronic Epididymitis Symptom Index (CESI) to measure the severity and impact of scrotal pain on men. Paired t-tests were used to compare groups.

RESULTS

Eighteen patients with CSP seen between April and September 2013 had Botox injected as a cord block. At the 1-month follow-up, pain reduction was reported by 72% of patients (mean VAS score: 7.36 vs. 5.61, P < 0.003), while by physical examination 44 and 34% of the men had either complete or partial resolution of scrotal tenderness. In addition, there was also a significant reduction in CESI scores (22.19 vs. 19.25, P < 0.04). At 3 months, 56% had both sustained pain reduction and reduced tenderness based on the VAS score (mean: 7.36 vs. 6.02, P < 0.05) and physical exam. The CESI score continued to be significantly lower. Unfortunately, by 6 months, most men had a return to their baseline levels of pain and tenderness.

CONCLUSIONS

Our pilot study found that Botox cord blocks provide pain reduction for 3 months or more for most men with CSP.

Pentosan polysulfate sodium for treatment of interstitial cystitis/bladder pain syndrome: insights from a randomized, double-blind, placebo controlled study

PURPOSE

We compared the efficacy and safety of the currently recommended dose of pentosan polysulfate sodium with a third of the daily dose and with placebo.

MATERIALS AND METHODS

In this multicenter, double-blind, randomized, placebo controlled study 368 adults with interstitial cystitis/bladder pain syndrome, defined as an ICSI total score of 8 or greater and a score of greater than 0 on the 4 ICSI component items, received pentosan polysulfate sodium 100 mg once daily or 3 times daily, or matching placebo for 24 weeks. Study eligibility was not based on cystoscopy findings. ICSI was administered at baseline, and at weeks 4, 8, 12, 18 and 24. Unblinded interim analysis performed at 6 years with 54% of the target number of 645 patients enrolled resulted in early study termination.

RESULTS

There was no statistically significant difference between the pentosan polysulfate sodium group and the placebo group or between the 2 pentosan polysulfate sodium groups for the primary end point, defined as responder achieving a 30% or greater reduction from the baseline ICSI total score at study end. This primary end point was achieved by 48 of 118 patients (40.7%) in the placebo group, and by 51 of 128 (39.8%) and 52 of 122 (42.6%) in the pentosan polysulfate sodium 100 mg once daily and 3 times daily groups, respectively. Pentosan polysulfate sodium was well tolerated with a similar percent of patients (range 10.2% to 13.3%) across the groups discontinuing due to an adverse event.

CONCLUSIONS

Results of this study in a broad population of patients with symptoms consistent with interstitial cystitis revealed no treatment effect vs placebo for pentosan polysulfate sodium at the currently established dose or at a third of the daily dose.

Novel treatment of chronic perineal pain in a woman by extracorporeal shock wave therapy: a case report and published work review

In published work review, extracorporeal shock wave therapy (ESWT) has been showed to be effective in treating chronic perineal/pelvic pain in men, but there was no published report on its use in women. We report a case of female chronic perineal pain successfully treated by ESWT. A 51-year-old woman presented with persistent perineal scar pain after excision of a vulval-vaginal nodule despite oral analgesics and gabapentin. After 11 cycles of ESWT, she reported termination of analgesics consumption and decreased perineal pain score from 8 to 2. The Short Form 36 Questionnaire demonstrated improvement in physical and mental health conditions. There was no complication encountered. We postulate that the effect of ESWT in this patient was based on reduction of muscle tone and alternating the threshold of pain memory, similar to the mechanisms in male patients. Further study is required to determine the use of ESWT in treating female chronic perineal pain.

Altered detrusor gap junction communications induce storage symptoms in bladder inflammation: a mouse cyclophosphamide-induced model of cystitis

Lower urinary tract symptoms (LUTS) include storage, voiding and post-micturition symptoms, featuring many urological diseases. Storage symptoms are the most frequent among these and associated with overactive bladder and non-bacterial bladder inflammation such as interstitial cystitis/bladder pain syndrome (IC/BPS). Gap junction, a key regulator of hyperactive conditions in the bladder, has been reported to be involved in pathological bladder inflammation. Here we report involvement of gap junction in the etiology of storage symptoms in bladder inflammation. In this study, cyclophosphamide-induced cystitis was adapted as a model of bladder inflammation. Cyclophosphamide-treated mice showed typical storage symptoms including increased urinary frequency and reduced bladder capacity, with concurrent up-regulation of connexin 43 (GJA1), one of the major gap junction proteins in the bladder. In isometric tension study, bladder smooth muscle strips taken from the treated mice showed more pronounced spontaneous contraction than controls, which was attenuated by carbenoxolone, a gap junction inhibitor. In voiding behavior studies, the storage symptoms in the treated mice characterized by frequent voiding were alleviated by 18α-glycyrrhetinic acid, another gap junction inhibitor. These results demonstrate that cyclophosphamide-induced mouse model of cystitis shows clinical storage symptoms related with bladder inflammation and that gap junction in the bladder may be a key molecule of these storage symptoms. Therefore, gap junction in the bladder might be an alternative therapeutic target for storage symptoms in bladder inflammation.

Alternative treatment in prostate pain syndrome based on Iranian traditional medicine

Introduction:

Unknown etiology and pathophysiology of prostate pain syndrome (PPS) has led to a lack of proper and competent treatment in modern medicine. According to the guidelines of European Association of Urology (EAU), use of complementary treatments is recommended for PPS. In this preliminary study, analyzing the signs and symptoms of PPS from the viewpoint of Iranian traditional medicine (ITM) was helpful in selecting the appropriate alternative treatment.

Case Presentation:

Two male patients diagnosed with PPS were evaluated and treated according to the ITM. Each patient took 15 mL oxymel 45 minutes after lunch and dinner. For each patient, four clinical visits were made with one week intervals and the validated Farsi version of international prostate symptom score (IPSS) and numeric pain rating score (NPRS) were completed for them.

Conclusions:

Considering the fact that other major pathological causes are ruled out, many of the symptoms and signs observed in these patients were similar to those associated with flatulency-related diseases in ITM. Selecting treatment with oxymel was based on this view and led to improvements in the digestive and urinary symptoms according to Farsi version of the IPSS and NPRS.

Nonspecific genitourinary pain improves after prostatectomy using holmium laser enucleation of prostate in patients with benign prostatic hyperplasia: a prospective study

OBJECTIVE

To investigate changes in nonspecific genitourinary discomfort or pain (GUDP) before and after holmium laser enucleation of prostate (HoLEP). GUDP associated with lower urinary tract symptoms (LUTS) is a common complaint among benign prostatic hyperplasia (BPH) patients, but very little is known about this clinical entity.

METHODS

From February 2010 to August 2011, 100 HoLEP patients with complete clinical data at a single institution were enrolled in the study to analyze the degree of GUDP with a visual analog scale (VAS) from 0 to 10 points at baseline and at 3 and 6 months postoperatively, and to investigate any relationships between GUDP and urodynamics, uroflowmetry, and scores from the International Prostate Symptom Score (IPSS) questionnaire.

RESULTS

Fifty-six patients had LUTS only, while the remaining 44 had both LUTS and GUDP. Pain was located in the suprapubic (42.0%), perineal/penile (33.0%), back (17.0%), and perianal (8.0%) regions. During the post-operative period, at six months, the VAS, IPSS, peak flow rate and post-void residual volume had improved significantly in 44 GUDP patients (p<0.010). GUDP had completely resolved in 40 (90.9%) patients and had decreased in four (9.1%) patients, while seven (12.5%) patients developed GUDP with voiding in the urethral and perineal areas by the third month postoperatively. When compared to patients with complete resolution, those with persistent GUDP were found to have a significantly higher preoperative presence of bladder outlet obstruction (BOO) as an independent risk factor (OR 6.173, 95% CI 1.132-1.323).

CONCLUSION

Both GUDP and LUTS improved significantly after HoLEP. Patients with significant preoperative BOO tended to have persistent GUDP after surgery.

Prevalence and risk factors of pelvic pain

OBJECTIVES

To determine the prevalence of Chronic Pelvic Pain (CPP) symptoms in Malaga and its province and to identify risk factors associated.

METHOD

a cross-sectional study was carried out in Malaga and its province, 18-65 years-old throughout a non-probability sampling by quotas (n = 887), stratified by sex, age and counties. All participants completed the QCPP-M, a self-administered questionnaire, validated tool due to its ability to discriminate patients with and without CPP.

RESULTS

prevalence of symptoms of CPP in subjects between 18-65 years-old was 22.8% in general population (30.9% women and 15.6% men) (RR = 1.974 for women versus men, 95% CI 1.53-2.55, P < .001). After correction by sex and age individuals who practice physical activity had a lower score in QCPP-M that others who do not not (mean difference -0.65 ± 0.27). They were significantly associated with higher scores in the following factors: lifting and/or moving weights in activities of daily life (1.34 ± 0.33), laxatives intake and/or high-fiber diet (2.09 ± 0.48), having suffered from urogenital infectious disease in the past: vulvovaginitis, cystitis and prostatitis (1.77 ± 0.55), hemorrhoids/anal fissure (1.31 ± 0.40) or pelvic trauma (1.21 ± 0, 61) respectively. Individuals who spend more time standing had a tendency to have higher scores on QCPP-M (coefficient of regression adjusted for sex and age of 0.078 points/hour, SE = 0.04, P < .068).

CONCLUSIONS

High prevalence of CPP symptoms in Málaga (22.8%), this is related with significantly several risk factors.

Effectiveness of diet, sexual habits and lifestyle modifications on treatment of chronic pelvic pain syndrome

BACKGROUND

The potential benefits of a therapeutic regimen for chronic pelvic pain syndrome (CPPS) based on the adherence to some specific rules concerning diet, sexual habits and lifestyle have never been investigated.

METHODS

A review of literature was executed to prepare a vademecum of 13 rules relating to diet, sexual habits and lifestyle that patients had to adhere to in order to treat CPPS. Patients affected by CPPS were enrolled and assigned to two equal groups that were both treated with 100 mg of nimesulide for 1 week. Group two patients were instructed to adhere to the vademecum rules, whereas patients in Group one received instructions to make no changes in their lifestyles. The NIH-Chronic Prostatitis Symptom Index was administered at baseline and after 3 months. The main outcome measure was the change in the mean total NIH-Chronic Prostatitis Symptom Index scores between the two groups from baseline to after treatment. Statistical methods for two-group comparisons were used.

RESULTS

Overall,100 patients were recruited. Thirty-nine out of fifty patients (78%) belonging to Group two adhered to the vademecum rules. In Group one, the total NIH-Chronic Prostatitis Symptom Index score was 21.9 at baseline and 17.6 post-treatment, whereas in Group two these scores were 22.1 and 8.1, respectively (P<0.0001).

CONCLUSIONS

We detected 13 potentially eliminable risk factors for CPPS on the basis of which we prepared a vademecum of 13 rules to treat this disease that were well tolerated and highly effective in significantly reducing all types of symptoms caused by CPPS.

Clinical significance of national institutes of health classification in patients with chronic prostatitis/chronic pelvic pain syndrome

Purpose

We determined the effects of alpha-blockers and quinolone in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) classified by National Institute of Health (NIH) consensus group.

Materials and Methods

Data from a total of 111 patients who were diagnosed with CP/CPPS between June 2010 and June 2012 were analyzed retrospectively. The patients were classified into group 1 (category IIIA, n=40) and group 2 (category IIIB, n=71). Treatment using alfuzosin and levofloxacin was given to both groups for 6 weeks. International Prostate Symptom Score (IPSS) and NIH Chronic Prostatitis Symptom Index were measured before and after therapy.

Results

Group 1 had a significant decrease in total IPSS score, CPSI pain score, CPSI quality of life (QoL) score, and total CPSI score (p=0.043, p=0.006, p=0.015, and p=0.006, respectively). Group 2 had a significant decrease in IPSS voiding symptom score, IPSS storage symptom score, total IPSS, CPSI pain score, CPSI voiding score, CPSI QoL score, and total CPSI score (p=0.002, p=0.004, p=0.001, p=0.001, p=0.006, p=0.001, and p=0.001, respectively). The CPSI score was reduced by 6 points or more in 50.0% of patients (n=18) in group 1 and in 51.6% of patients (n=32) in group 2. However, there was no statistically significant difference between the changes in IPSS and CPSI scores across the 2 groups.

Conclusions

Although combination treatment reduced the CPSI score in both groups, there was no significant difference between the groups after combination treatment. We suggest that factors other than inflammation also contribute to symptoms associated with CP/CPPS.

Diagnostic value of pelvic floor surface electromyography in functional anorectal pain

AIM: To assess the diagnostic value of pelvic floor surface electromyography (sEMG) in functional anorectal pain (FARP) using receiver operating characteristic (ROC) curve analysis.

METHODS: The parameters of pelvic floor sEMG in 118 patients with FARP and 103 normal controls were measured according to the Glazer protocol. Parameters included amplitude (AVG), coefficient of variance (CV), onset time and median frequency (MF). The ROC curve was plotted to assess the diagnostic value of pelvic floor sEMG.

RESULTS: Compared with the control group, the FARP group had a lower AVG (23.81 ± 13.75 vs 30.55 ± 16.14, P < 0.05) and a higher CV (0.43 ± 0.12 vs 0.30 ± 0.07, P < 0.05) during the tonic phase and a higher CV during the endurance phase (0.40 ± 0.15 vs 0.28 ± 0.09, P < 0.05). The critical value of CV during the tonic and endurance phases were 0.35 and 0.31, respectively, and the areas under ROC curve were 0.813 and 0.761.

CONCLUSION: CV during the tonic and endurance phases has better diagnostic value in FARP.

Complementary treatment in chronic pelvic pain syndrome: a case report study

INTRODUCTION

The use of traditional medicine has been emerged in the treatment of BPS (bladder pain syndrome) due to its high prevalence and expenses and its insufficient treatment by conventional therapies. Iranian traditional medicine has discussed such diseases. Considering the signs and symptoms of BPS and "reeh", the proposed mechanism of flatulency as casualty of recurrent circulating pains seems to be a proper diagnose. So, as a preliminary study the authors administered Horse Mint as one of effective traditional herbs on flatulent pain in a patient with BPS.

CASE PRESENTATION

A 60-year-old female was referred with the diagnosis of BPS. Six clinical visits with 2-week intervals were performed for patient, and the NIH-ICSI (National Institutes of Health Interstitial Cystitis Symptom Index) was completed, which was used as a pretreatment symptom quantifier and post-treatment outcome tool. Horse mint (Mentha longifolia) was prescribed twice a day for 12 weeks.

DISCUSSION

Clinical visits showed alleviation of signs, symptoms, and changes in the patient's NIH-ICSI score, suggesting further studies on this field.

Pharmacokinetic considerations for therapies used to treat interstitial cystitis

INTRODUCTION

Interstitial cystitis (IC) or bladder pain syndrome (BPS) is defined as supra-pubic pain related to bladder filling. IC is characterized by a particular symptom complex with no identifiable causes; as with bladder hypersensitivity it is usually associated with urinary frequency and urgency with bladder pain. No current treatments have a significant impact on symptoms over time.

AREAS COVERED

This systematic review examines the pharmacokinetic aspects and adverse event of present IC therapy to highlight appropriate treatment to improve the symptoms of IC. This article reviews material obtained via Medline, PubMed, and EMBASE literature searches up to October 2013.

EXPERT OPINION

The correct approach to IC should consider a multidisciplinary team of specialists and a multimodal treatment package that include psychotherapy, behavior change, physical activation, and analgesic treatment. Unfortunately, a single therapeutic target for IC is not yet known. With regard to pathophysiology and therapy, there is more to discover. The first insult damages the bladder urothelium, hence vehicles that lead the drug to penetrate the wall of the bladder might be a novel strategic approach.

Urgency and pain in patients with overactive bladder and bladder pain syndrome. What are the differences?

BACKGROUND

The Overactive Bladder Syndrome (OAB) and the Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) are different urological conditions sharing 'urgency' as a common symptom. The aim of this review is to address our existing knowledge and establish how these symptoms are interrelated and to determine whether or not there is a common link between both symptoms complexes that help to distinguish one from the other.

METHODS

Pubmed was used to obtain references for this non-systematic review aiming to discuss differences between OAB and BPS/IC. Guidelines of several professional associations and discussions based on expert opinion from the authors were implemented.

RESULTS

Whilst in BPS the hallmark symptom is pain on bladder filling, urgency is the defining symptom of OAB. Whilst it is likely that the pain in BPS/IC arises from local inflammation in the bladder wall, the nature of urgency as a symptom, its origin, and the relationship between urgency and pain, as well as the different afferent mechanisms associated with the genesis of these sensory symptoms, remains unknown. Although the aetiology of both OAB and PBS/IC is unclear, the influence of environmental factors has been suggested. Both are chronic conditions with very variable symptom resolution and response to therapy. The relationship with voiding dysfunction, gynaecological causes of chronic pelvic pain or the possible alteration of the hypothalamic-pituitary-adrenal axis and psychological disorders has not been established. Inflammation has been suggested as the common link between OAB and BPS/IC.

CONCLUSIONS

OAB and BPS/IC are different symptoms complexes that share urgency as a common symptom. None of them have a specific symptom although pain on bladder filling is the hallmark symptom in BPS/IC. Bladder pain with urgency should be a trigger for referral to the provider with appropriate knowledge and expertise in this disease state, whereas the management of OAB should be part of normal routine care in the community.

Pelvic pain: a pathway for care developed for both men and women by the British Pain Society

This paper aims to explain the key points and highlight some of the controversies in the development of the British Pain Society's pelvic pain patient pathway map. Many clinicians lack experience and confidence with this group of patients, and this issue is highlighted. Additionally, the difficulties of classification and definitions in this area are discussed in detail. These are historical causes of disagreement among specialists which can lead to confused clinical care. This group of patients have multiple issues that cross many professional boundaries; they are best managed by the co-ordinated involvement of multiple teams. Patients suffer from significant distress and disability that often needs specialist assessment and intervention (interdisciplinary). This suggests that an integrated approach is required across the historic boundaries of primary and secondary care. A variety of interventions, including opioids and neuromodulation are recommended in the pathway and the controversies surrounding these inclusions are aired in detail.

Chronic unexplained orchialgia: a concept analysis

AIMS

To conduct an analysis of the concept of chronic unexplained orchialgia.

BACKGROUND

Chronic unexplained orchialgia is a concept unique to men's health; however, clarity is lacking regarding the precise meaning of the key attributes of this important concept.

DESIGN

Walker and Avant's framework was used to guide this concept analysis.

DATA SOURCES

Literature sources included bibliographic databases.

REVIEW METHODS

Literature published in English from January 1970 to December 31, 2012 was reviewed. Thematic analysis identified critical attributes, antecedents and consequences of the concept.

RESULTS

Based on the analysis, a contemporary definition for chronic unexplained orchialgia is proposed, rooted in the concept of chronic pain. This definition is based on the concept analysis and the defining attributes that were identified in the literature. Chronic unexplained orchialgia is a subjective negative experience of adult men, perceived as intermittent or continuous pain of variable intensity, present at least three months, localizing to the testis(es) in the absence of objective organic findings and that interferes with quality of life.

CONCLUSION

This analysis provides a precise definition for chronic unexplained orchialgia and distinguishes it from other similar terms. This concept analysis provides conceptual clarity that can guide understanding and development of a conceptual framework, middle range theory, or situation-specific theory. Further exploration of this concept is recommended to uncover the influence of social, sexual and cultural factors.

Elimination of Hunner's Ulcers by Fulguration in Patients With Interstitial Cystitis: Is It Effective and Long Lasting?

PURPOSE

To evaluate the outcome of fulguration of Hunner's ulcers (HUs) in painful bladder syndrome/interstitial cystitis (PBS/IC) that is refractory to conservative treatment.

MATERIALS AND METHODS

Patients diagnosed with refractory PBS/IC and treated with fulguration between 2011 and 2013 were identified through screening of medical records. To evaluate treatment outcomes, voiding diaries, the visual analogue scale (VAS) for pain, and two IC symptom questionnaires (pelvic pain and urgency/frequency scale [PUF] and O'Leary-Sant IC symptom index and IC problem index [OS]) were used. Fulguration was deemed to be successful if the VAS score was <2 or less than half of the preoperative VAS score.

RESULTS

In total, 27 patients with PBS/IC in whom conservative treatments had failed were enrolled. Two months after fulguration, decreases were observed in the mean 24-hour urinary frequency (from 16.0 to 10.2), 24-hour urgency episodes (8.0 to 1.8), and the VAS (5.8 to 1.2), PUF symptom (15.1 to 7.0), PUF bother (8.4 to 2.7), OS symptom (15.1 to 7.2), and OS problem (13.8 to 6.0) scores. At 5 and 10 months, all variables had worsened. At 2, 5, and 10 months, the success rates were 94.1%, 70.0%, and 33.3%, respectively. Four patients underwent one repeat fulguration on average 11.3 months after the first fulguration. Repeat fulguration was not significantly associated with any clinical characteristics.

CONCLUSIONS

In PBS/IC that was refractory to medication or other conservative treatments, HU elimination by fulguration effectively improved symptoms. However, this effect decreased gradually over time.

Successful management of chronic pelvic pain

Chronic pelvic pain is a common, multifactorial complaint that affects both women and men, causing disability and frustration for patients. The exact aetiology remains unknown, although several theories have been proposed. Assessment should be undertaken with care and compassion, while considering the sensitive nature of the area. Management involves ruling out treatable pathology concomitant with strategies to control pain. Novel treatment approaches have been investigated for specific clinical scenarios. The more severe CPP cases are best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and including musculoskeletal, neurologic and psychological mechanisms.

Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome

Magnetic resonance (MR) neurography - guided nerve blocks and injections describe a techniques for selective percutaneous drug delivery, in which limited MR neurography and interventional MR imaging are used jointly to map and target specific pelvic nerves or muscles, navigate needles to the target, visualize the injected drug and detect spread to confounding structures. The procedures described, specifically include nerve blocks of the obturator nerve, lateral femoral cutaneous nerve, pudendal nerve, posterior femoral cutaneous nerve, sciatic nerve, ganglion impar, sacral spinal nerve, and injection into the piriformis muscle.

Combined intravesical sodium hyaluronate/chondroitin sulfate therapy for interstitial cystitis/bladder pain syndrome: a prospective study

OBJECTIVES

The aim of this study was to verify the efficacy and safety of intravesical treatment combining sodium hyaluronate (HA) and chondroitin sulfate (CS) in patients with interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

Between February 2010 and May 2011, 20 consecutive women with IC/BPS were treated with intravesical instillations containing sodium HA (1.6%; 800 mg/50 ml) and sodium CS (2%; 1 g/50 ml) weekly for the first month, biweekly for the second month, and then monthly for at least 3 months. Before and after treatment, all patients filled in the Interstitial Cystitis Symptom Index and Problem Index (ICSI/ICPI), the Patient Health Questionnaire 9 and the Pelvic Pain and Urgency/Frequency Patient Symptom Scale (PUF). Treatment efficacy was assessed by comparing the pre- and post-treatment mean scores of the three questionnaires using Student's t test (p value <0.05 was considered significant).

RESULTS

Statistically significant mean decreases in ICSI (from 13.0 to 9.3; p = 0.0003), ICPI (from 11.35 to 8.85; p = 0.0078) and PUF (from 20.0 to 15.75; p = 0.0007) questionnaire scores were seen. No cases of side effects or complications were observed. The mean follow up was 5 months.

CONCLUSIONS

Despite the limitations of this study, the outcomes confirmed the role of combination therapy with HA and CS as a safe and effective option for the treatment of IC/BPS. Further randomized controlled studies with a higher number of patients and a longer follow-up period are needed to confirm these results.

Complementary and alternative treatments for chronic pelvic pain

Chronic pelvic pain (CPP) is a significant clinical entity that affects both men and women alike. The etiologies of CPP are multifactorial, and treatments are myriad. Complementary and Alternative Medicine (CAM) refers to non-allopathic health systems, and its use is popular in the United States. In particular, several recent studies have investigated the efficacy of various CAM practices in the treatment of CPP. The authors systematically evaluated recent literature in this area by searching the PubMed database for English-language studies published between January 2007 and August 2012.

Expressed prostate secretions in the study of human papillomavirus epidemiology in the male

Introduction

Exploring different sampling sites and methods is of interest for studies of the epidemiology of HPV infections in the male. Expressed prostate secretions (EPS) are obtained during digital rectal examination (DRE), a daily routine urological diagnostic procedure, following massage of the prostate.

Materials and Methods

Urethral swabs and EPS samples were obtained from a consecutive sample of 752 men (mean age 32.4 years; median life-time sex partners 34) visiting urology outpatient clinics in St. Petersburg, Russia and tested for HPV DNA by general primer PCR, followed by genotyping using Luminex.

Results

Overall, 47.9% (360/752) of men were HPV-positive, with 42.0% (316/752) being positive for high-risk (HR-) HPV and 12.6% (95/752) for multiple HPV types. HPV-positivity in the EPS samples was 32.6% (27.7% HR-HPV) and in the urethral samples 25.9% (24.5% HR-HPV). 10.6% were HPV positive in both EPS and urethral samples. 6.4% had the same HPV-type in both EPS and urethral samples. 10.6% were HPV positive in both EPS and urethral samples. 6.4% had the same HPV-type in both EPS and urethral samples. The concordance between the urethral samples and EPS was 62.5% (470/752), with 80 cases double positive and 390 cases double negative in both sites. The sensitivity of urethral samples for overall HPV detection was 54.2% (195/360). Compared to analysis of urethral samples only, the analysis of EPS increased the HPV prevalence in this population with 26.2%.

Conclusion

EPS represent informative sampling material for the study of HPV epidemiology in the male.

The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development

CONTEXT

Progress in the science of pain has led pain specialists to move away from an organ-centred understanding of pain located in the pelvis to an understanding based on the mechanism of pain and integrating, as far as possible, psychological, social, and sexual dimensions of the problem. This change is reflected in all areas, from taxonomy through treatment. However, deciding what is adequate investigation to rule out treatable disease before moving to this way of engaging with the patient experiencing pain is a complex process, informed by pain expertise as much as by organ-based medical knowledge.

OBJECTIVE

To summarise the evolving changes in the management of patients with chronic pelvic pain by referring to the 2012 version of the European Association of Urology (EAU) guidelines on chronic pelvic pain.

EVIDENCE ACQUISITION

The working panel highlights some of the most important aspects of the management of patients with chronic pelvic pain emerging in recent years in the context of the EAU guidelines on chronic pelvic pain. The guidelines were completely updated in 2012 based on a systematic review of the literature from online databases from 1995 to 2011. According to this review, levels of evidence and grades of recommendation were added to the text. A full version of the guidelines is available at the EAU office or Web site (www.uroweb.org).

EVIDENCE SYNTHESIS

The previously mentioned issues are explored in this paper, which refers throughout to dilemmas for the physician and treatment team as well as to the need to inform and engage the patient in a collaborative empirical approach to pain relief and rehabilitation. These issues are exemplified in two case histories.

CONCLUSIONS

Chronic pelvic pain persisting after appropriate treatment requires a different approach focussing on pain. This approach integrates the medical, psychosocial, and sexual elements of care to engage the patient in a collaborative journey towards self-management.

Evidence-Based Guidelines on the Use of Opioids in Chronic Non-Cancer Pain—A Consensus Statement by the Pain Association of Singapore Task Force

Introduction: While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed. Materials and Methods: A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions. Results: Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour. Conclusion: Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as second- or third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required. Key words: Chronic pain, Consensus statement, Guidelines, Non-cancer pain, Opioids

[The care situation of patients with interstitial cystitis in Germany: results of a survey of 270 patients]

BACKGROUND

Using a comprehensive questionnaire the care situation of 270 patients with interstitial cystitis (IC) and bladder pain syndrome in Germany was recorded. Despite comprehensive literature on IC (62,000 citations in PubMed) almost nothing is known of the everyday care and quality of patient care in Germany.

RESULTS

In total 94% of the patients were women and 6% men, the average age of women was 53.5 years and that of men 67 years and 47.77% of the patients felt that they were well or very well informed about the disease whereby the internet was the source of information in many cases. The exchange of information among patients will increase further through social networks. The diagnosis of IC was made most frequently (62.22%) by biopsy and histological examination followed by urodynamics, potassium test, hydrodistension and cystoscopy. The average duration of the diagnosis was 9 years, 46.67% of the patients consulted a doctor more than 20 times before the diagnosis was made and 51.84% had to pass water more than 14 times per day. Frequency, nocturia and pain were the leading symptoms and 25% of the patients complained of urge incontinence. Among oral medications, analgesics were taken most frequently (61.7%) followed by pentosan polysulphate, antidepressants, antiepileptic drugs, antispasmodics and remedies for urinary urgency. In the self-assessment of the success of treatment with oral medications (helped very well and well), pentosan polysulphate, analgesics, antidepressants and antiepileptic drugs were considered to be the best. Medications that restore the glucosamine lining of the bladder were used predominantly for instillation into the bladder included hyaluronic acid, chondroitin sulphate and a combination of both and pentosan polysulphate. In the self-assessment of the success of treatment with instillation therapy (helped very well or well) the order was: chondroitin sulphate (62.69%), hyaluronic acid (55.77%), a combination of both (53.66%) and pentosan polysulphate (46.30%). The electromotive drug administration (EMDA) procedure with the use of direct current to introduce medications into the bladder wall was mentioned surprisingly often, namely, in 119 patients. In the self-assessment success (helped very well or well) was considered the best for intravesical procedures with 61.34%.

CONCLUSIONS

Compared with all drug procedures instillation of medications into the bladder was mentioned 368 times and was assessed by the patients as having helped very well and noticeably by 53.53%, followed by special invasive procedures at 50.56%/271 mentions, alternative therapies at 41.11%/287 mentions and oral medication at 39.75%/1,024 mentions. Hyaluronic acid and chondroitin sulphate products, the combination of both and pentosan polysulphate (oral and intravesical) are not reimbursed by the statutory health insurance. Over 40% of patients treated with these therefore discontinued the treatment for reasons of cost.

Effects of a Short Course of Oral Prednisolone in Patients with Bladder Pain Syndrome with Fluctuating, Worsening Pain despite Low-Dose Triple Therapy

PURPOSE

Triple therapy with gabapentin, amitriptyline, and nonsteroidal antiinflammatory drugs is efficacious for chronic bladder pain syndrome/interstitial cystitis (BPS/IC). However, transient, fluctuating, worsening pain or flare-up symptoms may develop during treatment for a variety of reasons. Here, we assessed the validity of our observational experience regarding a short course of oral prednisolone therapy, which might be of value in the management of flare-up symptoms of BPS/IC.

METHODS

Between May 2007 and May 2012, 7 women (mean age, 61.5 years; range, 44.8 to 75.4 years) with BPS/IC presenting with transient, fluctuating, worsening pain as a flare-up symptom despite low-dose triple therapy received a 1- to 3-month course of oral prednisolone 10 mg. The outcome measures used were the IC symptom scale (ICSS, O'Leary-Sant Interstitial Cystitis Symptom Index) and a visual analogue scale (VAS), which were completed at baseline and after treatment.

RESULTS

There were statistically significant differences in the ICSS and VAS score before and after prednisolone treatment (P<0.05 by Wilcoxon singed-rank test). The pretreatment IC symptom index (ICSI), IC problem index (ICPI), and VAS score were 16.7± 2.2, 13.7±2.3, and 8.3±1.5 (mean±standard deviation [SD]), and the posttreatment scores were 4.9±2.3, 4.3±1.1, and 2.5±0.9 (mean±SD), respectively. The ICSI, ICPI, and VAS scores were improved after prednisolone treatment by 70.7%, 68.6%, and 69.9%, respectively. Low-dose triple therapy with prednisolone caused no significant adverse effects.

CONCLUSIONS

In patients with BPS/IC who show transient, fluctuating, worsening pain as flare-up symptoms despite undergoing low-dose triple therapy, a short course of oral prednisolone therapy was sufficiently effective. However, large-scale studies should be performed to verify our findings.