Pelvic pain and surgeries in women before interstitial cystitis/painful bladder syndrome

Association of endometriosis with interstitial cystitis in chronic pelvic pain syndrome: Short narrative on prevalence, diagnostic limitations, and clinical implications

Introduction: Chronic pelvic pain (CPP) is a diagnostic and therapeutic challenge affecting women of all ages globally. The syndrome is not well understood, but the association of interstitial cystitis (IC) with endometriosis in causing CPP should not be overlooked in managing this cohort. Herein, we present a mini review of this association to evaluate the literature in determining the prevalence of endometriosis and IC concomitantly in patients with CPP, diagnostic limitations, and clinical implications.

Methods: A Medline search of the key words “evil twins’ syndrome,” “interstitial cystitis,” “bladder pain syndrome,” and “endometriosis” was conducted for full-text articles published in English over the past 20 years. The search yielded 40 articles, of which 21 were selected. Cross-referencing bibliographies of each publication yielded an additional 25 references.

Results: Both endometriosis and IC share a similar array of symptoms that are often exacerbated during the perimenstrual period. Multiple authors have reported the frequent coexistence of these two conditions. Over 80% of patients with CPP were found to have both conditions. The prevalence of endometriosis and IC coexistence was greater than that of each condition separately.

Conclusions: It is crucial to look beyond the traditionally diagnosed endometriosis as the cause of CPP. This is true especially in patients whose previous treatment was ineffective. Simultaneous assessment for both conditions is essential to avoid the frequently delayed diagnosis and prevent unsuccessful medical and surgical therapies.

Painful Bladder Symptoms Related to Somatic Syndromes in a Convenience Sample of Community Women with Overactive Bladder Symptoms

PURPOSE

We investigated the relationship of painful bladder filling and urinary urgency to somatic and chronic pain symptoms in women with overactive bladder without an interstitial cystitis/bladder pain syndrome diagnosis.

MATERIALS AND METHODS

Women who met overactive bladder criteria based on symptoms were recruited, including 183 (83.9%) from the community and 35 (16.1%) from the urology clinic to complete validated questionnaires assessing urinary symptoms, somatic symptoms and pain syndromes. Participants were categorized into 1 of 3 groups, including 1) neither symptom, 2) either symptom or 3) both symptoms, based on their reports of painful urinary urgency and/or painful bladder filling. Multivariable regression analyses were performed to determine factors predictive of having painful urgency and/or painful filling.

RESULTS

Of 218 women with overactive bladder 101 (46%) had neither painful bladder filling nor urinary urgency, 94 (43%) had either symptom and 23 (11%) had both symptoms. When controlling for age, women with either or both urological pain symptoms were more likely to have irritable bowel syndrome, chronic pelvic pain and temporomandibular disorder than women in the neither group. Additionally, these women had higher pain intensity and somatic symptoms scores than women with neither symptom.

CONCLUSIONS

The majority of women with overactive bladder who had not been diagnosed with interstitial cystitis/bladder pain syndrome reported painful urgency and/or painful filling. Experiencing painful urgency and/or filling was associated with an increased somatic symptom burden and greater pain intensity. These findings support the hypothesis that overactive bladder and interstitial cystitis/bladder pain syndrome diagnoses may represent a continuum of bladder hypersensitivity.

Prodrome and Non-prodrome Phenotypes of Bladder Pain Syndrome/Interstitial Cystitis

OBJECTIVE

To test the hypothesis that risk factors for bladder pain syndrome/interstitial cystitis (BPS/IC) in women differ between those with and without the BPS/IC prodrome.

MATERIALS AND METHODS

Incident cases of BPS/IC and healthy controls were recruited nationally. More than half the BPS/IC cases reported subsyndromal urinary symptoms for decades before onset of BPS/IC and were identified as having the prodrome. Risk factors for BPS/IC were examined separately for cases with and without the prodrome using a set of matched controls.

RESULTS

Two risk factors distinguished 178 prodrome from 134 non-prodrome cases. One was "UTIs" in the year before BPS/IC onset, possibly a manifestation of the prodrome itself. The other was the presence of the maximal number of nonbladder syndromes (NBSs): prodrome cases were 12 times more likely than non-prodrome cases to have ≥4 NBSs. Additional risk factors for prodrome and/or non-prodrome cases were the direct association of exogenous female hormones, as well as 3 inverse associations: type 2 diabetes mellitus, multiple pregnancies, and current daily smoking.

CONCLUSION

Prodrome cases developed urinary symptoms in their early 20s (ie, the prodrome) and were at very high risk of numerous NBSs. Non-prodrome cases developed urinary symptoms in their early 40s (ie, full-blown BPS/IC) and were no more likely than controls to have the maximal number of NBSs. These findings are consistent with recent suggestions of two BPS/IC phenotypes: one with systemic and psychosocial manifestations and the other more specific to the bladder. Additionally, several risk factors identified here might be hints of related or causal nervous system pathophysiologies.

Will cesarean section increase the risk of interstitial cystitis/painful bladder syndrome?

AIMS

A high number of patients with interstitial cystitis/painful bladder syndrome (IC/PBS) have a history of pelvic surgeries, and cesarean section is one of the most common pelvic surgeries in women. This study aimed to investigate if cesarean section increases the risk of IC/PBS.

METHODS

Women who exclusively gave birth through cesarean section or vaginal delivery were identified from a nationwide database between 2002 and 2013. All were followed up during the study period to detect the event of IC/PBS. The IC/PBS hazard ratio (HR) in the cesarean cohort was compared with the vaginal delivery cohort with and without matching for confounding factors.

RESULTS

The unmatched group included 22 158 cesarean deliveries and 40 214 vaginal deliveries. The IC/PBS HR in the cesarean cohort compared with that in the vaginal delivery cohort was 1.370 (95% confidence interval [CI], 0.903-2.079; P = 0.139). In the matched group, 8368 women were matched in each cesarean and vaginal delivery cohort using propensity scores for age and comorbidities. The IC/PBS HR was 0.725 (95%CI, 0.358-1.471; P = 0.373). Both HRs in these two groups were not significantly different. The incidence density of IC/PBS in delivered women, non-delivery women, and the general female population were not significantly different either (0.310, 0.255, and 0.292 per 1000 person-years, respectively; P = 0.549).

CONCLUSIONS

The risk of IC/PBS was not different between cesarean and vaginal delivery after controlling the confounding factors in this cohort study. Cesarean section has no causal effect on IC/BPS. Furthermore, delivery was not a risk factor for IC/PBS.

Does central sensitization help explain idiopathic overactive bladder?

The pathophysiological mechanisms underlying overactive bladder syndrome (OAB) can include dysfunction of sensory pathways of the peripheral and central nervous systems, resulting in bladder hypersensitivity. Central sensitization describes an induced state of spinal hypersensitivity that is associated with a variety of chronic pain disorders that share many attributes with OAB, albeit without the presence of pain. As such, the concept of central sensitization might be relevant to understanding the mechanisms and clinical manifestations of OAB syndrome. An understanding of the pathophysiology and clinical manifestations of central sensitization, and the evidence that supports a role of central sensitization in OAB, including the potential implications of mechanisms of central sensitization for the treatment of patients with OAB could provide a novel approach to the treatment of patients with this disease. Such an approach would be especially relevant to those patients with central sensitization-related comorbidities, and has the potential to improve the outcomes of these patients in particular.

Somatic syndromes and chronic pain in women with overactive bladder

AIMS

Mechanisms underlying pain perception and afferent hypersensitivity, such as central sensitization, may impact overactive bladder (OAB) symptoms. However, little is known about associations between OAB symptom severity, pain experience, and presence of comorbid chronic pain syndromes. This study examined relationships between OAB symptoms, somatic symptoms, and specific chronic pain conditions in which central sensitization is believed to play a primary role, in a community-based sample of adult women with OAB.

METHODS

We recruited adult women with OAB to complete questionnaires assessing urinary symptoms, pain and somatic symptoms, and preexisting diagnoses of central sensitivity syndromes. We analyzed the effects of overall bodily pain intensity, general somatic symptoms, and diagnoses of central sensitivity syndromes on OAB symptom bother and health-related quality of life.

RESULTS

Of the 116 women in this study, over half (54%) stated their urge to urinate was associated with pain, pressure, or discomfort. Participants reported a wide range of OAB symptoms and health-related quality of life. There was a significant, positive correlation between OAB symptoms and somatic symptoms as well as overall pain intensity. Only 7% of women met diagnostic criteria for fibromyalgia; yet these women demonstrated significantly increased OAB symptom burden and decreased OAB quality of life compared to those without fibromyalgia.

CONCLUSION

Women with more severe OAB symptoms reported increased general somatic symptom burden and increased overall body pain intensity, especially women with fibromyalgia. These findings suggest that attributes of pain and co-morbidity with chronic pain conditions may impact the experience of OAB symptoms for many women. Neurourol. Urodynam. 36:1113-1118, 2017. © 2016 Wiley Periodicals, Inc.

Novel research approaches for interstitial cystitis/bladder pain syndrome: thinking beyond the bladder

Despite years of basic and clinical research focused on interstitial cystitis/bladder pain syndrome (IC/BPS), including clinical trials of candidate therapies, there remains an insufficient understanding of underlying cause(s), important clinical features and a lack of effective treatments for this syndrome. Progress has been limited and is likely due to many factors, including a primary focus on the bladder and lower urinary tract as origin of symptoms without adequately considering the potential influence of other local (pelvic) or systemic factors. Traditionally, there has been a lack of sufficiently diverse expertise and application of novel, integrated methods to study this syndrome. However, some important insights have been gained. For example, epidemiological studies have revealed that IC/BPS is commonly associated with other chronic pain conditions, including fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome. These observations suggest that IC/BPS may involve systemic pathophysiology, including alterations of the central nervous system in some patients. Furthermore, there may be multiple causes and contributing factors that manifest in the symptoms of IC/BPS leading to multiple patient sub-groups or phenotypes. Innovative research is necessary to allow for a more complete description of the relationship between this syndrome and other disorders with overlapping symptoms. This report provides examples of such innovative research studies and their findings which have the potential to provide fresh insights into IC/BPS and disorders associated with chronic pain through characterization of broad physiologic systems, as well as assessment of the contribution of the bladder and lower urinary tract. They may also serve as models for future investigation of symptom-based urologic and non-urologic disorders that may remain incompletely characterized by previous, more traditional research approaches. Furthermore, it is anticipated a more holistic understanding of chronic urologic pain and dysfunction will ensue from productive interactions between IC/BPS studies like those described here and broader cutting-edge research endeavors focused on potentially related chronic pain disorders. A more comprehensive vision for IC/BPS inquiry is anticipated to yield new insights into basic disease mechanisms and clinical characteristics that will inform future research studies that will lead to more effective therapies and improved clinical care for these patients.

Functional somatic syndromes as risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis

OBJECTIVE

We tested the hypothesis that functional somatic syndromes (FSSs) are risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis (BPS/IC).

METHODS

In 312 women with incident BPS/IC, we diagnosed seven pre-BPS/IC syndromes: chronic pelvic pain (CPP), fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome (IBS), sicca syndrome, migraine, and panic disorder. Each was defined as present before 12 months (existing syndrome) or onset within 12 months (new syndrome) prior to BPS/IC onset. Retrospectively, we sought associations between prior hysterectomy and existing FSSs. Prospectively, we studied associations of existing and new syndromes with subsequent hysterectomy. Logistic regression analyses adjusted for age, race, menopause and education.

RESULTS

The retrospective study showed prior hysterectomy (N=63) to be associated with existing CPP and the presence of multiple existing FSSs. The prospective study revealed that 30/249 women with a uterus at baseline (12%) underwent hysterectomy in early BPS/IC. This procedure was associated with new CPP (OR 6.0; CI 2.0, 18.2), new IBS (OR 5.4; CI 1.3, 22.3), and ≥3 existing FSSs (OR 3.9; CI 1.1, 13.9).

CONCLUSION

Accounting for CPP and IBS, the presence of multiple FSSs (most without pelvic pain) was a separate, independent risk factor for hysterectomy in early BPS/IC. This suggests that patient features in addition to abdominopelvic abnormalities led to this procedure. Until other populations are assessed, a prudent approach to patients who are contemplating hysterectomy (and possibly other surgeries) for pain and who have IBS or numerous FSSs is first to try alternative therapies including treatment of the FSSs.

Before the onset of interstitial cystitis/bladder pain syndrome, the presence of multiple non-bladder syndromes is strongly associated with a history of multiple surgeries

OBJECTIVE

Certain functional somatic syndromes (FSSs) such as fibromyalgia and irritable bowel syndrome are accompanied by diffuse pain amplification. Women with interstitial cystitis/bladder pain syndrome (IC/BPS) have numerous FSSs, as well as other non-bladder syndromes (NBSs) that are linked to the FSSs. They also report multiple surgeries. Since pain is a common indication for surgery, we tested the hypothesis that NBSs were associated with surgeries.

METHODS

We interviewed 312 incident IC/BPS cases and controls on NBSs and number of surgeries before the index date (for cases, IC/BPS onset date). Poisson and logistic regression analyses adjusted for age, race, educational level, and menopause.

RESULTS

Number of surgeries increased with number of NBSs in both cases and controls whether chronic pelvic pain (CPP), the only NBS generally accepted as an indication for surgery, was present or not. Logistic regression analysis showed that among cases CPP was the only individual NBS associated with a history of multiple surgeries, and then only modestly [odds ratio (OR) 1.9, confidence intervals (CI) 1.06, 3.2]. By far the strongest association was the number of NBSs. The OR for multiple surgeries increased with number of NBSs: for cases with 4-5 NBSs the OR was 14.1 (1.8, 113) and with 6-9 NBSs, 33.1 (3.9, 279). Controls had fewer syndromes and fewer surgeries and this linkage was less prominent.

CONCLUSION

Among IC/BPS cases, the number of NBSs was strongly correlated with the number of surgeries. Understanding temporal relationships will be necessary to explore causal linkages and may modify surgical practice.

Prevalence of pain syndromes, mood conditions, and asthma in adolescents and young women with endometriosis

STUDY OBJECTIVE

Adult women with endometriosis are often diagnosed with comorbid pain, mood, and autoimmune conditions. This study aims to describe the occurrence of pain syndromes, mood conditions, and asthma in adolescents and young women with endometriosis evaluated at our medical center.

DESIGN

Retrospective review of medical records.

SETTING

Department of Obstetrics and Gynecology at a tertiary referral center.

PARTICIPANTS

138 adolescents/young women who were less than age 24 years at the time of their initial visit at our medical center, and whose surgical diagnosis of endometriosis was made at our institution or by outside institutions by the age of 21.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Prevalence of comorbid pain syndromes (defined as interstitial cystitis, irritable bowel syndrome, chronic headaches, chronic low back pain, vulvodynia, fibromyalgia, temporomandibular joint disease, and chronic fatigue syndrome), mood conditions (defined as depression and anxiety), and asthma.

RESULTS

Comorbid pain syndromes were found in 77 (56%) women, mood conditions in 66 (48%) women, and asthma in 31 (26%) women. Comparing endometriosis patients with and without comorbid pain syndromes, no differences were found in age at time of diagnosis, endometriosis symptoms, and endometriosis stage. Patients with comorbid pain syndromes were more likely to report mood conditions (62% vs 30% respectively, P < .001) and smoking (31% vs 10% respectively, P = .003), underwent more surgeries for endometriosis (median of 2 [range, 1-7] vs 1 [range, 1-5], P < .005), and were more likely to undergo appendectomy or cholecystectomy (30% vs 13%, P = .02).

CONCLUSIONS

Comorbid pain syndromes, mood conditions and asthma are common in adolescents and young women with endometriosis.

Is there a high incidence of hysterectomy and other nonbladder surgeries before and after onset of interstitial cystitis/bladder pain syndrome?

OBJECTIVE

The objective of the study was to compare with controls the incidence of nonbladder pelvic surgeries in the months before and after the onset of interstitial cystitis/bladder pain syndrome (IC/BPS).

STUDY DESIGN

The design of the study used an existing database from a retrospective case-control study of 312 incident IC/BPS cases and matched controls plus a longitudinal study of the cases that examined lifetime approximated annual incidence of surgeries with that in the months before and after the onset of IC/BPS.

RESULTS

In cases, in the month before the onset of IC/BPS, the approximated annual incidence of nonbladder pelvic surgeries was 15 times higher and of hysterectomy 25 times higher than the incidences of previous years and similarly higher than controls. This rate declined to preindex levels over the first 2 years of IC/BPS.

CONCLUSION

There may be a very high incidence of nonbladder surgeries just before IC/BPS onset that decreases to historical levels over the first years of the syndrome.

The number of existing functional somatic syndromes (FSSs) is an important risk factor for new, different FSSs

OBJECTIVE

The objective of this study is to test the hypothesis that the number of functional somatic syndromes (FSSs) predicts new, additional FSSs.

METHODS

In a recent case-control study of interstitial cystitis/painful bladder syndrome (IC/PBS), we used symptom-based consensus definitions to identify these FSSs: fibromyalgia (FM), chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), chronic pelvic pain, migraine, sicca syndrome and panic disorder. Those present before the incidence year were called antecedent FSSs; those with onset during the incidence year were called incident FSSs. In each of two groups, 312 IC/PBS cases and 313 controls, rates of incident FSSs were compared among those with 0, 1, 2, or ≥3 antecedent FSSs. Confounding was assessed using logistic regression analyses that included the individual antecedent FSSs, published correlates of these FSSs, and demographic variables.

RESULTS

The incidence of a new FSS increased with the number of antecedent FSSs, as did that of incident FM, CFS and IBS studied separately. These findings were not confounded by other variables. The presence of multiple antecedent FSSs generally had the highest odds ratio for new, different, incident FSSs.

CONCLUSIONS

This study revealed that the number of antecedent FSSs was among the strongest risk factors for other FSSs, especially incident FM, CFS and IBS. This suggests that the FSSs are linked through a polysyndromic phenotype. If each FSS is heterogeneous, to seek a pathogenesis common to all FSSs, individuals with multiple FSSs should be sought; to seek a pathogenesis unique to a specific FSS, mature persons who have only that FSS should be studied.

Functional somatic syndromes: sensitivities and specificities of self-reports of physician diagnosis

OBJECTIVE

Functional somatic syndromes have no laboratory or pathologic abnormalities and so are diagnosed by symptom-based case definitions. However, many studies, including recent ones, have used self-reports of physician diagnosis rather than the case definitions. Our objective was to determine the sensitivities and specificities of self-report of physician diagnosis for chronic fatigue syndrome (CFS), fibromyalgia (FM), irritable bowel syndrome (IBS), panic disorder, and migraine.

METHODS

Each of 312 female patients with incident interstitial cystitis/bladder pain syndrome and matched population-based controls were queried on self-report of physician diagnosis and separately on established case definitions for each of these syndromes.

RESULTS

Using the symptom-based case definitions as standards, we found that self-report of physician diagnosis did not identify 90% of the controls who had CFS, 77% who had FM, 69% who had IBS, 43% who had panic disorder, and 23% who had migraine. In addition, it missed most individuals with multiple syndromes. Findings in one cohort (controls) were confirmed in another (patients with interstitial cystitis/bladder pain syndrome).

CONCLUSIONS

Self-report of physician diagnosis did not identify most of the three most venerable functional somatic syndromes, IBS, FM, and, especially, CFS; nor did it identify substantial minorities of individuals with panic disorder and migraine. Self-report of physician diagnosis was particularly poor in recognizing persons with multiple syndromes. The insensitivity of this diagnostic test has effects on not only prevalence and incidence estimates but also correlates, comorbidities, and case recruitment. To reveal individuals with these syndromes, singly or together, queries of symptoms, not diagnoses, are necessary.

Association of bladder pain syndrome/interstitial cystitis with urinary calculus: a nationwide population-based study

INTRODUCTION AND HYPOTHESIS

Although one prior study reported an association between bladder pain syndrome/interstitial cystitis (BPS/IC) and urinary calculi (UC), no population-based study to date has been conducted to explore this relationship. Therefore, using a population-based data set in Taiwan, this study set out to investigate the association between BPS/IC and a prior diagnosis of UC.

METHODS

This study included 9,269 cases who had received their first-time diagnosis of BPS/IC between 2006 and 2007 and 46,345 randomly selected controls. We used conditional logistic regression analysis to compute the odds ratio (OR) and its corresponding 95 % confidence interval (CI) for having been previously diagnosed with UC between cases and controls.

RESULTS

There was a significant difference in the prevalence of prior UC between cases and controls (8.1 vs 4.3 %, p < 0.001). Conditional logistic regression analysis revealed that cases were more likely to have been previously diagnosed with UC than controls (OR = 1.70; 95 % CI = 1.56-1.84) after adjusting for chronic pelvic pain, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, panic disorder, migraine, sicca syndrome, allergy, endometriosis, and asthma. BPS/IC was found to be significantly associated with prior UC regardless of stone location; the adjusted ORs of kidney calculus, ureter calculus, bladder calculus, and unspecified calculus when compared to controls were 1.58 (95 % CI = 1.38-1.81), 1.73 (95 % CI = 1.45-2.05), 3.80 (95 % CI = 2.18-6.62), and 1.83 (95 % CI = 1.59-2.11), respectively.

CONCLUSIONS

This work generates the hypothesis that UC may be associated with BPS/IC.

Interstitial cystitis: diagnosis and management

Interstitial cystitis/painful bladder syndrome is a chronic condition that causes debilitating bladder pain which can be associated with urgency, frequency and nocturia. Its cause is not clear and it is still a disease diagnosed by exclusion. Oral or intravesical therapies are the main stay of treatment whilst surgical procedures are reserved for refractory cases. This condition usually warrants a multidisciplinary approach for optimum outcome. This article gives an overview of the changes in definition, aetiopathogenesis and available treatments.