Sensory mapping of pelvic dermatomes in women with interstitial cystitis/bladder pain syndrome

Interstitial cystitis-an imbalance of risk and protective factors?

Interstitial cystitis (IC) presents as a chronic pain condition with variable combinations of symptoms depending on the species and individual patient. It is diagnosed by the presence of lower urinary tract signs and symptoms in combination with a variety of comorbid health problems, a history of life adversities, and the absence of other conditions that could cause the lower urinary tract signs. IC occurs naturally in humans and cats as a dimensional condition, with patients presenting with mild, moderate, and severe symptoms. Most patients appear to recover without specific treatment. A number of rodent models of IC have been used to study its causes and treatments. Unfortunately, current therapies generally fail to ameliorate IC symptoms long-term. The recent classification of IC as a chronic primary pain disorder calls for a rethinking of current clinical and research approaches to it. Beginning when a patient encounters a clinician, precipitating, perpetuating, and palliating risk factors can be addressed until a cause or reliably effective therapy is identified, and identifying predisposing and preventive factors can inform epidemiological studies and health promotion interventions. Predisposing, precipitating, and perpetuating risk factors, including environmental, psychological, and biological, increase the activity of the central threat response system (CTRS), which plays a clinically important role in IC symptoms. Studies in cats and rodent models have revealed that environmental enrichment (EE), in the absence of bladder-directed therapies, leads to amelioration of IC symptoms, implying a central role for the CTRS in symptom precipitation and perpetuation. Conceptually moving the source of IC pain to the brain as a motivational state rather than one resulting from peripheral nociceptive input offers both clinicians and researchers novel opportunities to improve care for patients with IC and for researchers to use more ecologically valid rodent models. It may even be that IC results from an excess of risk to protective factors, making this imbalance a targetable cause rather than a consequence of IC.

Evaluation of Central Sensitisation in Bladder Pain Syndrome: A Systematic Review

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS) is a debilitating condition characterised by exaggerated bladder sensations and altered bladder function. It is still unknown whether the condition is a peripheral sensory problem or due to abnormal central sensory processing as seen in central sensitisation. This systematic review, which followed a published and Prospective Register of Systematic Reviews-registered protocol (CRD42021229962), is aimed at establishing the scope of central sensitisation in patients with BPS to aid optimal management and treatment.

METHODS

Four databases were searched, and appraisal of the identified studies was conducted by two independent reviewers based on eligibility criteria: patients with BPS being investigated for central sensitisation with or without comparison of controls, English-language articles, full text and publication in a peer-reviewed journal. The Methodological Index for non-Randomised Studies was used to determine study quality. We identified 763 papers in total, with 15 studies included in the final analysis. All studies were observational and had a low risk of bias. Measures included in the evaluation of CS were questionnaires, urodynamics, and quantitative sensory testing methods.

RESULTS

There was evidence of central sensitisation in patients with BPS in all papers evaluated (15 out of 15). In addition, more significant central sensitisation correlated with severe disease presentation (3 out of 3 papers) and concomitant chronic pain conditions (5 out of 5 papers).

CONCLUSIONS

Central sensitisation plays an integral role in BPS patient pathology. Many secondary measures are used to evaluate this condition. Stratification of patients based on their pathology (peripheral, central or a combination of the two) will aid in implementing an individualised management strategy.

Wet-cupping on calf muscles in polycystic ovary syndrome: a quasi-experimental study

OBJECTIVES

Current modalities for treating polycystic ovary syndrome (PCOS) are not curative and using them for a long period is associated with adverse effects. According to Persian Medicine recommendations, wet cupping on calf muscles can induce menstrual bleeding. In the present study, the effect of wet-cupping (traditional bleeding from capillary vessels) was assessed on menstrual cycles (as primary outcome), hirsutism, and laboratory manifestation of PCOS.

METHODS

A quasi-experimental study was conducted from 2016/5/21 until 2017/5/20 on 66 PCOS women within the age range of 20-40 years and a menstrual interval of at least 60 days during the last year. Participants' calf muscles were cupped on day 26 of their last menstruation cycle following the Persian Medicine recommendations. They were followed for 12 weeks and a menstruation history and physical examination was done twice (4 and 12 weeks after wet cupping). Insulin Resistance (IR) and Free Androgen Index (FAI) were evaluated at baseline and end of the study.

RESULTS

Wet-cupping on calf muscles significantly improved menstrual cycles' frequency 0.37(95% CI: 0.13, 0.51), p-value=0.001 and hirsutism after 4 and 12 weeks of intervention were -1.9 (95% CI: -2.5, -0.5), p-value<0.001 and -1.4(95% CI: -2.1, -0.8), p-value<0.001, respectively. While it was not significant in changing the IR and FAI. About 33% of participants suffered from mild temporary discomforts (which were resolved within a few minutes of rest) and 9% reported mild long-term side effects.

CONCLUSIONS

It is considered that wet-cupping on calf muscles can be propounded as an optional treatment of PCOS for those not willing to use chemical medication.

Characterization and Prevalence of Female Pelvic Pain in a General Outpatient Urology Population

OBJECTIVE

To assess the character and prevalence of female pelvic pain in a general urology population presenting for evaluation of unrelated non-painful complaints.

METHODS

This is an IRB-approved, prospective, cross-sectional survey-based assessment of pelvic pain in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints (eg, kidney stones) were excluded. Participating patients completed an original 22-item survey with questions pertaining to pelvic pain. Specific focus was placed on pain characteristics, including location, quality, frequency, exacerbating factors, and severity. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns.

RESULTS

A total of 181 women (mean age 56 years) completed the survey. Overall, 75 (41%) women reported pelvic pain. Two-thirds reported experiencing pain "often" to "always" over the preceding month. Patients described a significant variety of pain locations and qualities. The most common sites of pain were lower back (73%) and bladder (72%), while "dull/aching" was the most common pain quality. A majority (84%) of patients had multiple concurrent pain locations, with 40 unique pain location combinations being reported. Similarly, 13 and 10 unique combinations were seen with pain quality and eliciting activity, respectively.

CONCLUSION

A significant percentage of women presenting to a general urology clinic experience pelvic pain. There was wide variety of pain characteristics and unique patterns. Further research is needed to comprehensively assess pain characteristics and develop related diagnostic pathways.

Ceftriaxone inhibits stress-induced bladder hyperalgesia and alters cerebral micturition and nociceptive circuits in the rat: A multidisciplinary approach to the study of urologic chronic pelvic pain syndrome research network study

AIMS

Emotional stress plays a role in the exacerbation and development of interstitial cystitis/bladder pain syndrome (IC/BPS). Given the significant overlap of brain circuits involved in stress, anxiety, and micturition, and the documented role of glutamate in their regulation, we examined the effects of an increase in glutamate transport on central amplification of stress-induced bladder hyperalgesia, a core feature of IC/BPS.

METHODS

Wistar-Kyoto rats were exposed to water avoidance stress (WAS, 1 hour/day x 10 days) or sham stress, with subgroups receiving daily administration of ceftriaxone (CTX), an activator of glutamate transport. Thereafter, cystometrograms were obtained during bladder infusion with visceromotor responses (VMR) recorded simultaneously. Cerebral blood flow (CBF) mapping was performed by intravenous injection of [¹⁴ C]-iodoantipyrine during passive bladder distension. Regional CBF was quantified in autoradiographs of brain slices and analyzed in three dimensional reconstructed brains with statistical parametric mapping.

RESULTS

WAS elicited visceral hypersensitivity during bladder filling as demonstrated by a decreased pressure threshold and VMR threshold triggering the voiding phase. Brain maps revealed stress effects in regions noted to be responsive to bladder filling. CTX diminished visceral hypersensitivity and attenuated many stress-related cerebral activations within the supraspinal micturition circuit and in overlapping limbic and nociceptive regions, including the posterior midline cortex (posterior cingulate/anterior retrosplenium), somatosensory cortex, and anterior thalamus.

CONCLUSIONS

CTX diminished bladder hyspersensitivity and attenuated regions of the brain that contribute to nociceptive and micturition circuits, show stress effects, and have been reported to demonstrated altered functionality in patients with IC/BPS. Glutamatergic pharmacologic strategies modulating stress-related bladder dysfunction may be a novel approach to the treatment of IC/BPS.