Symptoms of Interstitial Cystitis, Painful Bladder Syndrome and Similar Diseases in Women: A Systematic Review

Therapeutic Approaches for Urologic Chronic Pelvic Pain Syndrome; Management: Research Advances, Experimental Targets, and Future Directions

Urologic chronic pelvic pain syndrome (UCPPS) is a painful chronic condition with persistent pain originating from the pelvis that often leads to detrimental lifestyle changes in the affected patients. The syndrome develops in both sexes, with an estimated prevalence of 5.7% to 26.6% worldwide. This narrative review summarizes currently recommended therapies for UCPPS, followed by the latest animal model findings and clinical research advances in the field. The diagnosis of UCPPS by clinicians has room for improvement despite the changes in the past decade aiming to decrease the time to treatment. Therapeutic approaches targeting growth factors (i.e., nerve growth factor, vascular endothelial growth factor), amniotic bladder therapy, and stem cell treatments gain more attention as experimental treatment options for UCPPS. The development of novel diagnostic tests based on the latest advances in urinary biomarkers would be beneficial to assist with the clinical diagnosis of UCPPS. Future research directions should address the role of chronic psychologic stress and the mechanisms of pain refractory to conventional management strategies in UCPPS etiology. Testing the applicability of cognitive behavioral therapy in this cohort of UCPPS patients might be promising to increase their quality of life. The search for novel lead compounds and innovative drug delivery systems requires clinically relevant translational animal models. The role of autoimmune responses triggered by environmental factors is another promising research direction to clarify the impact of the immune system in UCPPS pathophysiology. SIGNIFICANCE STATEMENT: This minireview provides an up-to-date summary of the therapeutic approaches for UCPPS with a focus on recent advancements in the clinical diagnosis and treatments of the disease, pathophysiological mechanisms of UCPPS, signaling pathways, and molecular targets involved in pelvic nociception.

Role of cystoscopy as primary initial investigation in interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic painful bladder condition characterized by pelvic pain and urinary symptoms without another identifiable cause. Cystoscopy as primary initial investigation for IC/BPS has not been accepted yet and needs more studies to definitely conclude.

AIMS AND OBJECTIVES

We aimed to assess cystoscopy findings in patients of interstitial cystitis/bladder pain syndrome and to prove role of cystoscopy as primary initial investigation for interstitial cystitis/bladder pain syndrome.

MATERIALS AND METHODS

Our prospective observational study included 35 female patients aged 18-69 years presenting to the Urology OPD at SMS Hospital with suprapubic or pelvic pain for 6 months, bladder pain that worsens with bladder filling and reduced with voiding, dysuria, urinary frequency and urgency, nocturia, dyspareunia. Those with history of bladder capacity more than 350 ml, duration of symptoms less than 6 months, day time frequency less than eight times per day, diagnosis of bacterial cystitis or prostatitis, bladder or ureteral calculi, active genital herpes, any existing urological malignancy, radiation cystitis were excluded from the study. They were then subject to cystoscopy and the findings of the cystoscopy were analyzed.

RESULTS

Out of the 35 patients, 11 (31.43%) had a normal cystoscopy. Of the 24 patients (68.57%) who had a positive cystoscopy, cystoscopy in seven patients (20.0%) revealed an ulcer. All these seven patients underwent fulguration. In the remaining 17 patients the abnormal findings were petechiae, large submucosal bleed. The sensitivity of cystoscopy in detecting the ulcerative type of Interstitial cystitis was found to be 20.0%.

CONCLUSION

Our study found that Cystoscopy, if employed in initial investigation can help early detection of ulcerative variety of IC/BPS and can act as therapeutic modality by using fulguration plus hydrodistension. Larger comparative studies are needed for diagnostic/Therapeutic value of cystoscopy.

Bladder pain syndrome and sexual function: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS)/interstitial cystitis can adversely affect physical, mental, and sexual health. The aim of the systematic review is to compare sexual function between patients with BPS and healthy controls and to examine whether or not treatment of BPS improves sexual function.

METHODS

A literature search was conducted on Embase, Medline, and other databases. Studies comparing sexual function in BPS patients with healthy controls and before/after treatment were included. Where appropriate, data were pooled in a meta-analysis, using a random effects model and the standardised mean difference (SMD) was used for comparison.

RESULTS

Out of 384 studies initially identified, 26 studies met the inclusion criteria for the systematic review and 11 for the meta-analysis. Six studies compared sexual function in BPS cases with healthy controls. All studies found that the Female Sexual Function Index (FSFI) was worse in BPS cases than in controls. Pooled data from 5 studies showed that the SMD was -1.02 (CI -1.64, -0.4) in total FSFI scores between the cases and controls, p=0.001. Further analysis showed better sexual function in all FSFI subdomains in healthy controls. Five studies compared sexual function in BPS patients before treatment with after treatment. Pooled data from 3 studies showed an overall improvement in total FSFI score after intravesical treatment: SMD=0.69 (CI 0.23, 1.14), p=0.003. Further analysis showed improvement in all subdomains.

CONCLUSION

Our review suggests that sexual function might be worse in BPS patients than in the general population, but it seems to improve with intravesical BPS treatment.

Indigenous Peoples' Experience and Understanding of Menstrual and Gynecological Health in Australia, Canada and New Zealand: A Scoping Review

There are a variety of cultural and religious beliefs and customs worldwide related to menstruation, and these often frame discussing periods and any gynecological issues as taboo. While there has been previous research on the impact of these beliefs on menstrual health literacy, this has almost entirely been confined to low- and middle-income countries, with very little information on high-income countries. This project used the Joanna Briggs Institute (JBI) scoping review methodology to systematically map the extent and range of evidence of health literacy of menstruation and gynecological disorders in Indigenous people in the colonized, higher-income countries of Australia, Canada, and New Zealand. PubMed, CINHAL, PsycInfo databases, and the grey literature were searched in March 2022. Five studies from Australia and New Zealand met the inclusion criteria. Only one of the five included studies focused exclusively on menstrual health literacy among the Indigenous population. Despite considerable research on menstrual health globally, studies focusing on understanding the menstrual health practices of the Indigenous populations of Australia, New Zealand, and Canada are severely lacking, and there is little to no information on how Indigenous beliefs of colonized people may differ from the broader society in which they live.

Assessment of bladder pressure and discomfort symptoms: How do overactive bladder differ from interstitial cystitis/bladder pain syndrome patients?

Background

To better understand the sensation of bladder “pressure” and “discomfort”, and how they are similar or distinct from the “pain” and “urgency” symptoms in IC/BPS and OAB.

Methods

IC/BPS and OAB patients rated their bladder pain, pressure, discomfort, and urinary urgency on separate 0–10 numeric rating scales (NRS). Their NRS ratings were compared between IC/BPS and OAB, and Pearson correlations were performed.

Results

Among IC/BPS patients (n = 27), their mean numeric ratings of pain, pressure, discomfort, and urinary urgency were almost identical (6.6 ± 2.1, 6.0 ± 2.5, 6.5 ± 2.2, and 6.0 ± 2.8 respectively). The three-way correlations between pain, pressure, or discomfort were very strong (all > 0.77). Among OAB patients (n = 51), their mean numeric ratings of pain, pressure, and discomfort (2.0 ± 2.6, 3.4 ± 2.9, 3.4 ± 2.9) were significantly lower than urgency (6.1 ± 2.6, p < 0.001). The correlations between urgency and pain, and between urgency and pressure were weak in OAB (0.21 and 0.26). The correlation between urgency and discomfort was moderate in OAB (0.45). The most bothersome symptom of IC/BPS was bladder/pubic pain, while the most bothersome symptom of OAB was urinary urgency and daytime frequency.

Conclusions

IC/BPS patients interpreted bladder pain, pressure, or discomfort as the similar concepts and rated their intensity similarly. It is unclear whether pressure or discomfort provide additional information beyond pain in IC/BPS. Discomfort may also be confused with urgency in OAB. We should re-examine the descriptors pressure or discomfort in the IC/BPS case definition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-01164-8.

Role of circadian rhythms and melatonin in bladder function in heath and diseases

The circadian system modulates all visceral organ physiological processes including urine storage and voiding. The "master clock" of the circadian system lies within suprachiasmatic nucleus of the hypothalamus while "peripheral clocks" are found in most peripheral tissue and organs, including the urinary bladder. Disruptions of circadian rhythms can cause organ malfunction and disorder or exacerbate pre-existing ones. It has been suggested that nocturia, which develops mostly in the elderly, could be a circadian-related disorder of the bladder. In the bladder, many types of gap junctions and ion channels in the detrusor, urothelium and sensory nerves are likely under strict local peripheral circadian control. The pineal hormone, melatonin, is a circadian rhythm synchroniser capable of controlling a variety of physiological processes in the body. Melatonin predominantly acts via the melatonin 1 and melatonin 2 G-protein coupled receptors expressed in the central nervous system, and many peripheral organs and tissues. Melatonin could be beneficial in the treatment of nocturia and other common bladder disorders. The ameliorating action of melatonin on bladder function is likely due to multiple mechanisms which include central effects on voiding and peripheral effects on the detrusor and bladder afferents. More studies are warranted to determine the precise mechanisms of circadian rhythm coordination of the bladder function and melatonin influences on the bladder in health and diseases.

Vestibular hyaluronic acid injection in provoked vestibulodynia patients and its effect on pain and sexual function: A preliminary report

OBJECTIVE

Provoked vestibulodynia (PVD) is a challenging and distressing problem for women. The aim of this study was to examine the effect of hyaluronic acid (HA) in the management of this condition.

METHOD

This is a retrospective review of 12 women diagnosed with PVD and treated with HA (19 mg/mL) applied, point-by-point, to the vestibular region at 2 mm intervals and at a depth of 0.5 mm. Women completed a pain VAS and a Female Sexual Function Index (FSFI) before and 45 days after treatment.

RESULTS

An improvement was observed both in mean FSFI scores (17.8 to 23.3; p = 0.003) and mean VAS scores (7.2 to 4.1; p = 0.002) after HA application respectively. However, on a telephone interview 3 months post treatment, five women (41.7 %) complained of recurrence of their dyspareunia.

CONCLUSION

HA is a promising management option in provoked vestibulodynia. However, further larger studies with possible alternative regimens and longer follow-up are required.

The Double Insult of Neonatal Cystitis Plus Adult Somatic Inflammation Results in Corticotropin Releasing Factor Type II Receptor-Dependent Bladder Hypersensitivity in Female Rats

The spinal mechanisms of visceral hypersensitivity are poorly understood, particularly when there is an interaction with somatic systems. Recently we demonstrated that rats which were pretreated with neonatal bladder inflammation (NBI) and subsequently pretreated as adults with bladder re-inflammation had augmented reflex and neuronal responses to urinary bladder distension via a corticotropin-releasing factor receptor type II (CRFR2) mechanism. Another insult producing similar augmented responses is somatic inflammation induced by Complete Freund's Adjuvant (CFA) in the hindlimb. Using neurochemical measures and both reflex and neuronal responses to urinary bladder distension as endpoints, the present study probed the role of CRFR2-related mechanisms in bladder hyperalgesia secondary to NBI and CFA-induced hindlimb inflammation. ELISA measures of the lumbosacral spinal cord demonstrated increased CRFR2 protein following pretreatment with NBI+CFA. Intrathecal CRFR2 antagonists blocked the augmentation of visceromotor responses to distension following pretreatment with both NBI+CFA. Lumbosacral dorsal horn neuronal responses to bladder distension in rats pretreated with NBI+CFA were attenuated by the spinal topical administration of a CRFR2 antagonist. These findings are the first demonstration of a somatovisceral interaction working via CRFR2 receptors and support the therapeutic value of these agents in the treatment of painful bladder disorders, particularly when triggered by somatic events. (Word Count 199). PERSPECTIVE: Bladder hypersensitivity occurs following neonatal cystitis and an adult insult such as somatic inflammation. This paper demonstrates that CRFR2-related mechanisms are associated with this hypersensitivity. This supports the therapeutic value of these agents in the treatment of painful bladder disorders, particularly when triggered by somatic events.

Clinical Phenotyping for Pain Mechanisms in Urologic Chronic Pelvic Pain Syndromes: A MAPP Research Network Study

Three categories of pain mechanisms are recognized as contributing to pain perception: nociceptive, neuropathic, and nociplastic (ie, central nervous system augmented pain processing). We use validated questionnaires to identify pain mechanisms in Urologic Chronic Pelvic Pain Syndrome (UCCPS) patients (n = 568, female = 378, male = 190) taking part in the Symptom Patterns Study of the Multidisciplinary Approach to the study of chronic Pelvic Pain Research Network. A cutoff score of 12 on the painDETECT questionnaire (-1 to 38) was used to classify patients into the neuropathic category while the median score of 7 on the fibromyalgia survey criteria (0-31) was used to classify patients into the nociplastic category. Categories were compared on demographic, clinical, psychosocial, psychophysical and medication variables. At baseline, 43% of UCPPS patients were classified as nociceptive-only, 8% as neuropathic only, 27% as nociceptive+nociplastic, and 22% as neuropathic+nociplastic. Across outcomes nociceptive-only patients had the least severe symptoms and neuropathic+nociplastic patients the most severe. Neuropathic pain was associated with genital pain and/or sensitivity on pelvic exam, while nociplastic pain was associated with comorbid pain conditions, psychosocial difficulties, and increased pressure pain sensitivity outside the pelvis. A self-report method classifying individuals on pain mechanisms reveals clinical differences that could inform clinical trials and novel targets for treatment. PERSPECTIVE: This article presents differences in clinical characteristics based on a simple self-report method of classifying pain mechanisms for Urologic Chronic Pelvic Pain Syndrome patients. This method can be easily applied to other chronic pain conditions and may be useful for exploring pathophysiology in pain subtypes.

Comorbidities of bladder pain syndrome in the context of the HITOP distress category: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The aim of this systematic review and meta-analysis is, looking at different care settings, to examine prevalence rates of psychological distress-level comorbidities in female interstitial cystitis/bladder pain syndrome (IC/BPS) patients, their impact on Quality of Life (QoL), and the correlation between such comorbidities and symptom severity.

METHODS

A systematic literature search according to PRISMA guidelines was conducted in PubMed, PsycInfo, Web of Science, Science Direct, and Google Scholar.

RESULTS

Twenty-nine studies were found that met inclusion criteria. Prevalence rates of depression and anxiety are higher in IC/BPS patients compared to the general population; however, due to a wide array of measurements, statistical comparisons between care settings were only possible in two cases showing mixed results. No studies meeting inclusion criteria exist that examine PTSD and borderline personality disorder, though rates of past traumatic experiences seem to be higher in patients than in healthy controls. Psychological comorbidities of the distress category, especially depression, are found in most studies to be related to symptom severity, also yielding statistically significant associations.

CONCLUSIONS

While there is still need for studies focused on some of the comorbidities as well as on different care settings, the data already show that psychological comorbidities of the distress category play an important role in IC/BPS patients regarding suffering, QoL, and symptom severity, thus emphasizing the need for highly specialized interdisciplinary treatment.

Neonatal cystitis leads to alterations in spinal corticotropin releasing factor receptor-type 2 content and function in adult rats following bladder re-inflammation

Spinal mechanisms associated with visceral hypersensitivity are poorly understood. One model of bladder hypersensitivity with phenotypic features similar to the disorder interstitial cystitis/bladder pain syndrome is the neonatal bladder inflammation (NBI) model. In this model, rat pup bladders are infused with zymosan solutions on post-partum days 14-16 and then rats are retested as adults. Studies of other sites of deep tissue hypersensitivity have suggested a role for corticotropin-releasing factor (CRF) receptors type 1 and 2 (CRFR1 and CRFR2). Using neurochemical measures, pharmacological manipulations and both reflex and neuronal responses to urinary bladder distension as endpoints, the present study probed the role of CRFR2s in bladder hyperalgesia secondary to NBI and acute bladder re-inflammation as an adult (ABI). ELISA measures of the lumbosacral spinal cord demonstrated increased CRFR1s and CRFR2s following pretreatment with both NBI + ABI as well as NBI-related increases in the CRFR2 agonist urocortin 2. Intrathecal CRFR2 antagonists, but not a CRFR1 antagonist, blocked the augmentation of visceromotor responses to distension following pretreatment with both NBI + ABI. Lumbosacral dorsal horn neuronal responses to distension in rats pretreated with NBI + ABI were attenuated by the spinal topical administration of a CRFR2 antagonist. These studies suggest therapeutic value of CRFR2 antagonists in the treatment of painful bladder disorders.

Female Sexual Dysfunctions and Urogynecological Complaints: A Narrative Review

Female sexual dysfunctions represent a real widespread problem, usually faced from a psychological point of view; however, millions of women worldwide are impacted by pelvic floor dysfunction, personal shame and social taboos, however, continue to inhibit free conversation on the subject. Women’s quality of life is considerably improved by screening, diagnosing, and controlling urogenital and sexual issues. This review aims to provide a critical perspective of urogenital conditions and common disturbances in female sexual function associated with these issues. It also includes a discussion of postpartum pelvic dysfunction.

Immunomodulation therapy offers new molecular strategies to treat UTI

Innovative solutions are needed for the treatment of bacterial infections, and a range of antibacterial molecules have been explored as alternatives to antibiotics. A different approach is to investigate the immune system of the host for new ways of making the antibacterial defence more efficient. However, the immune system has a dual role as protector and cause of disease: in addition to being protective, increasing evidence shows that innate immune responses can become excessive and cause acute symptoms and tissue pathology during infection. This role of innate immunity in disease suggests that the immune system should be targeted therapeutically, to inhibit over-reactivity. The ultimate goal is to develop therapies that selectively attenuate destructive immune response cascades, while augmenting the protective antimicrobial defence but such treatment options have remained underexplored, owing to the molecular proximity of the protective and destructive effects of the immune response. The concept of innate immunomodulation therapy has been developed successfully in urinary tract infections, based on detailed studies of innate immune activation and disease pathogenesis. Effective, disease-specific, immunomodulatory strategies have been developed by targeting specific immune response regulators including key transcription factors. In acute pyelonephritis, targeting interferon regulatory factor 7 using small interfering RNA or treatment with antimicrobial peptide cathelicidin was protective and, in acute cystitis, targeting overactive effector molecules such as IL-1β, MMP7, COX2, cAMP and the pain-sensing receptor NK1R has been successful in vivo. Furthermore, other UTI treatment strategies, such as inhibiting bacterial adhesion and vaccination, have also shown promise.

Hyperactivation of innate immunity is a disease determinant in urinary tract infections (UTIs). Modulation of innate immunity has promise as a therapy for UTIs. In this Review, the authors discuss potential mechanisms and immunomodulatory therapeutic strategies in UTIs.

Excessive innate immune responses to infection cause symptoms and pathology in acute pyelonephritis and acute cystitis.

Innate immunomodulation therapy is, therefore, a realistic option for treating these conditions.

Targeting excessive innate immune responses at the level of transcription has been successful in animal models.

Innate immunomodulation therapy reduces excessive inflammation and tissue pathology and accelerates bacterial clearance from infected kidneys and bladders in mice.

Innate immunomodulation therapy also accelerates the clearance of antibiotic-resistant bacterial strains.

The Role of Urinary VEGF in Observational Studies of BPS/IC Patients: A Systematic Review

Background: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic pain condition, often underdiagnosed, with an important impact on patient quality of life. More recently, an association between VEGF and its receptors has been suggested in BPS/IC pathophysiology, due to their role in promoting angiogenesis and inflammation, which can enhance bladder pain. Eventually, VEGF may be used as a biomarker for the diagnosis and prognostication of BPS/IC. To further clarify this issue, this review aims to critically summarize the available information, giving rise to a solid starting point for future studies. Methods: We systematically searched PubMed and Embase, using the queries “urinary VEGF”, “urinary VEGF” AND “pain”, “urinary VEGF” AND “lower urinary tract symptoms” and “urinary VEGF” AND “LUTS” from January 2016 to February 2022. Results: A total of 1026 papers were identified from which 7 articles were included in this study, which assessed 1036 participants. Regarding VEGF levels, overactive bladder (OAB) and healthy patients were used for comparison with BPS/IC patients. VEGF concentration seems to be higher when compared to healthy patients and overactive bladder (OAB) patients. Higher levels of VEGF were associated with pain severity, while a decrease in VEGF concentration was associated with pain and symptom improvement in women. However, these findings were not constant in all studies. Conclusions: There is a trend toward a relevant association between increased VEGF levels and pain or symptom severity in BPS/IC patients. Although there are some discrepancies among the studies and the number of patients included is small, VEGF and its receptors should be considered for future studies regarding its use in BPS/IC pathophysiology, diagnosis and prognostication.

Neonatal cystitis alters mechanisms of stress-induced visceral hypersensitivity in rats

In rodent models, conditioning with acute footshock (AFS) has been demonstrated to produce bladder hypersensitivity which is more robust when rats, tested as adults, had also been pretreated with neonatal bladder inflammation (NBI). The spinal neurochemical mechanisms of pro-nociceptive processes in rats pretreated with NBI are not fully known and so the present study administered intrathecal (IT) opioid (naloxone) and NMDA receptor (MK-801) antagonists to determine whether these receptors' actions had been altered by NBI. Female Sprague-Dawley rat pups were intravesically pretreated on postnatal days P14-P16 with a 1% zymosan solution or with control procedures and then raised to adulthood (12-15 weeks of age). Bladder hypersensitivity was induced through use of an AFS paradigm. Visceromotor responses (VMRs; abdominal muscle contractions) to graded, air pressure-controlled urinary bladder distension were used as nociceptive endpoints. Immediately following AFS pretreatments, rats were anesthetized and surgically prepared. Pharmacological antagonists were administered via an IT catheter onto the lumbosacral spinal cord and VMRs determined 15 min later. Administration of IT naloxone hydrochloride (10 μg) to rats which had been pretreated only with AFS resulted in VMRs that were more robust than VMRs in similarly pretreated rats that received IT normal saline. In contrast, IT naloxone had no significant effect on rats that had been pretreated with both NBI&AFS, although MK-801 was inhibitory. These effects of IT naloxone suggest the presence of inhibitory influences in normal rats that are absent in rats pretreated with NBI. Absence of inhibitory influences produced by AFS was also demonstrated in rats pretreated with NBI&AFS using measures of thermal paw withdrawal latency (PWL): rats pretreated with only AFS had longer PWLs than rats pretreated with both NBI&AFS. Together, a reduction in anti-nociceptive mechanisms coupled with pro-nociceptive NMDA-linked mechanisms results in more robust nociceptive responses to distension in rats which had experienced NBI.

Neonatal Bladder Inflammation Results in Adult Female Mouse Phenotype With Increased Frequency and Nociceptive Responses to Bladder Filling

Bladder pain and hypersensitivity to bladder filling are clinically common, but animal models examining syndromes with these features are limited. A rat model of bladder hypersensitivity produced by neonatal bladder inflammation (NBI) has been reported to have many of the clinical features of bladder pain syndromes. The present study sought to determine whether similar hypersensitivity might be induced by NBI in mice. Female C57BL6/J mice had NBI induced on postnatal days P12-14 by the intravesical administration of zymosan. As adults (12–14 weeks of age), the mice were examined for hypersensitivity of their bladders as: spontaneous voiding and evoked cystometrograms at baseline, and visceromotor responses (VMRs) to urinary bladder distension (UBD) following a secondary insult (either repeated bladder inflammation or acute stress induced by footshock). Mice that experienced NBI demonstrated hypersensitivity, when compared with control mice, manifested as increased spontaneous voiding, increased frequency of evoked voids during intravesical saline infusion, and increased vigor of VMRs to UBD following either acute bladder inflammation or acute stress. This recapitulates the hallmark features of clinical painful bladder disorders and suggest utility of this murine model for the study of these disorders while allowing methodological expansion into well-established genetic and immunological models.

Spinal neurochemical mechanisms of acute stress-induced visceral hypersensitivity in healthy rats

Psychological stress has been demonstrated to increase reports of pain in humans with pelvic pain of urologic origin. In rodent models, conditioning with acute footshock (AFS) has been demonstrated to increase measures of stress/anxiety as well as bladder hypersensitivity. The spinal neurochemical mechanisms of this pro-nociceptive process are unknown and so the present study administered antagonists for multiple receptors that have been associated with facilitatory mechanisms into the spinal intrathecal space. Bladder hypersensitivity was induced through use of an AFS paradigm in which female Sprague-Dawley rats received a 15-min intermittent shock treatment. Visceromotor responses (VMRs; abdominal muscle contractions) to air pressure-controlled urinary bladder distension (UBD) were used as nociceptive endpoints. Immediately following AFS treatments, rats were anesthetized (inhaled isoflurane, IP urethane) and surgically prepared. Pharmacological antagonists were administered via an intrathecal (IT) catheter onto the lumbosacral spinal cord and VMRs to graded UBD determined 15 min later. Administration of IT naloxone hydrochloride (10 μg) and IT phentolamine hydrochloride (10 μg) resulted in VMRs that were more robust than VMRs in rats that received AFS and IT normal saline whereas there was no significant effect of these drugs on VMRs in rats which underwent non-footshock procedures. In contrast, a low dose of the NMDA-receptor antagonist, MK-801 (30 μg), significantly reduced VMRs in rats made hypersensitive to UBD by AFS, but had no significant effect on rats that underwent non-footshock procedures. This study suggests that pro-nociceptive effects of AFS in otherwise healthy rats involve a spinal NMDA-linked mechanism. The effects of IT naloxone and IT phentolamine suggest the presence of inhibitory influences that are opioidergic and/or alpha-adrenergic and that are masked by the pro-nociceptive mechanisms. Other agents with no statistically significant effect on VMRs include methysergide (30 μg), ondansetron (10 μg), mecamylamine (50 μg), antalarmin (24 μg), aSVG30 (12 μg), and SSR149415 (50 μg).

Therapeutic interventions to urologic chronic pelvic pain syndrome and UPOINT system for clinical phenotyping: How far are we?

The assessment and management of urologic chronic pelvic pain syndrome (UCPPS), is controversial. It is classified by voiding symptoms, pelvic pain, and bladder pain, which is weekly treated, weekly understood, and bothersome. In the aspect of clinical efforts and research to help people with this syndrome have been hampered by the deficiency of a widely reliable, accepted, and a valuable tool to evaluate the patient symptoms and quality of life (QoL) impact. However, the etiology comes into sight is multifactorial, and available treatment options have been imprecise considerably in present years. We compiled the published literature on the assessment of the syndrome, a tentative role of pharmacological and non-pharmacological (conservative, alternative, and invasive therapy) interventions in eradicating the disease as well as improving symptoms. The previously published literature on animal models has established the association of immune systems in the etiology, pathogenesis, and progression of the disease. The UPOINT system for clinical phenotyping of UCPPS patients has six predefined domains that direct multimodal therapy, which would lead to significant symptom improvement in the medical field. The narrative review aims to scrutinize the fluctuating scientist's views on the evaluation of patient and multimodal treatment of the UPOINT system.

Components of the Endogenous Cannabinoid System as Potential Biomarkers for Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition causing bladder pressure and pain. The condition is of unknown etiology and is often accompanied by other symptoms, including chronic pelvic pain, increased urinary urgency, and frequency. There is no definitive diagnosis for IC/BPS, and treatment options are currently limited to physical therapy and medications to help alleviate symptoms. The endogenous cannabinoid system (ECS) is an important regulator of numerous physiological systems, including the urinary system. Modulations of the ECS have been shown to be beneficial for IC/BPS-associated pain and inflammation in rodents. As an attempt to identify potential biomarkers for IC/BPS, we reviewed experimental studies where the components of the ECS have been quantified in experimental models of IC/BPS. Further investigations using well-defined animal models and patients’ data are required to obtain stronger evidence regarding the potential for ECS components to be definitive biomarkers for IC/BPS.

A Model in Female Rats With Phenotypic Features Similar to Interstitial Cystitis/Bladder Pain Syndrome

This report describes methodological and exploratory investigations of the zymosan-induced neonatal bladder inflammation (NBI) model of interstitial cystitis/bladder pain syndrome (IC/BPS) in female rats. These results validate and extend the currently employed model by evaluating critical timepoints for obtaining treatment effects and identified that a second insult as an adult including repeat intravesical zymosan, intravesical lipopolysaccharide, acute footshock stress, neuropathic nociception (facial) or somatic inflammation (hindpaw) all resulted in magnified visceromotor responses to urinary bladder distension (UBD) in rats which had experienced NBI when compared with their controls. NBI also resulted in increased tone and reactivity of pelvic floor musculature to UBD, as well as increased responsiveness to intravesical potassium chloride solutions, abnormal anxiety measures (elevated plus maze) and an increased number of submucosal petechial hemorrhages following 30 min of hydrodistension of the bladder. These phenotypic findings have correlates to the clinical features of IC/BPS in humans and so support use of this model system to examine mechanisms of and treatments for IC/BPS.

Prevalence of Bladder Pain Syndrome-like Symptoms: a Population-based Study in Korea

OBJECTIVES

To investigate the prevalence of bladder pain syndrome (BPS)-like symptoms in the general population of South Korea.

METHODS

Between April 16, 2016 and April 29, 2016, we conducted an online survey and computer-assisted personal interviews with adults aged 40-79 years in Korea using structured questionnaires. The sample size was 3,000 (95% confidence level standard error ± 1.79%), and the sampling method was simple randomization according to sex, age, and residential area in proportion to the resident registration demographics of the Korean Ministry of Interior and Safety as of March 2016. All participants were surveyed using the Korean version of the Pelvic Pain and Urgency/Frequency (PUF) Patient Symptom Scale and Geriatric Depression Scale (GDS). The primary outcome was the prevalence of BPS-like symptoms, defined as a total PUF score of ≥ 12.

RESULTS

Overall, the prevalence of BPS-like symptoms was 16.4% (483 of 3,000 participants). Women (21.4%) had a significantly higher prevalence of BPS-like symptoms than men (10.7%) (P < 0.01). The prevalence by age was significantly higher in the 70s group than in the other age groups (P < 0.01), and increased significantly with the increasing severity of depression on the GDS (P < 0.01). The prevalence of BPS-like symptoms according to the marital status was significantly different, that is, the prevalence among divorced/bereaved individuals was higher than those of married or unmarried individuals (P < 0.01).

CONCLUSION

Our large, representative population-based study showed that BPS-like symptoms are widespread among the general population of South Korea. BPS is considered a disease that deserves greater attention as it is far more common than previously thought and can negatively affect many people's quality of life.

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.

Systemic and intrathecal baclofen produce bladder antinociception in rats

BACKGROUND

Baclofen, a clinically available GABAB receptor agonist, produces non-opioid analgesia in multiple models of pain but has not been tested for effects on bladder nociception.

METHODS

A series of experiments examined the effects of systemic and spinally administered baclofen on bladder nociception in female anesthetized rats. Models of bladder nociception included those which employed neonatal and adult bladder inflammation to produce bladder hypersensitivity.

RESULTS

Cumulative intraperitoneal dosing (1-8 mg/kg IP) and cumulative intrathecal dosing (10-160 ng IT) of baclofen led to dose-dependent inhibition of visceromotor responses (VMRs) to urinary bladder distension (UBD) in all tested models. There were no differences in the magnitude of the analgesic effects of baclofen as a function of inflammation versus no inflammation treatments. Hemodynamic (pressor) responses to UBD were similarly inhibited by IT baclofen as well as UBD-evoked excitatory responses of spinal dorsal horn neurons. The GABAB receptor antagonist, CGP 35,348, antagonized the antinociceptive effects of IT baclofen on VMRs in all tested models but did not affect the magnitude of the VMRs by itself suggesting no tonic GABAB activity was present in this preparation. Tolerance to a seven day continuous IT infusion of baclofen was not observed.

CONCLUSIONS

These data provide support for a clinical trial of baclofen as a non-opioid treatment of human bladder pain.

The diagnostic and therapeutic efficacy of cystoscopy with hydrodistension and random biopsies in clinically suspected interstitial cystitis/bladder pain syndrome

OBJECTIVE

We aimed to explore the diagnostic and therapeutic efficacy of cystoscopy with hydrodistension and random biopsies for clinically suspected interstitial cystitis/bladder pain syndrome (IC/BPS).

STUDY DESIGN

We reviewed the data of fifty-five clinically suspected IC/BPS patients underwent cystoscopy with hydrodistension and random biopsies. Global Response Assessment was used to evaluate the efficacy. Disease severity was assessed by thorough history, physical examination, 3-day frequency volume chart, visual analog scale of pain, Interstitial Cystitis Symptom Index (ICSI) and clinical phenotype system (UPOINT).

RESULTS

According to the pathologic outcomes from random biopsies, three out of the 55 clinically suspected IC/BPS were diagnosed as bladder carcinoma. Among the 52 IC/BPS patients, thirty-six patients (69.2%) had initial chief complaints of urinary frequency and urgency. Under cystoscopy, twenty-nine patients and 23 patients were classified as Hunner ulcer type and diffuse global mucosal bleeding (grade III glomerulation). The median functional bladder capacity of the 52 IC/BPS patients was 100 ml. Hydrodistension was effective in 28 patients (53.8%) at postoperative 3 months, which decreased to 25% at post-hydrodistension 6 months and to 13.5% at 12 months. For the 28 hydrodistension-effective patients, the remission degrees of daytime frequency, nocturia, VAS bladder pain and ICSI score were 50.3%, 49.4%, 68.1% and 48%, which were significantly higher than the 16.9% (daytime frequency, P < 0.001), 20.5% (nocturia, P = 0.021), 7.4% (VAS pain score, P < 0.001) and 6.1% (ICSI, P < 0.001) in the hydrodistension-negative group. According to the UPOINT system, the hydrodistension-effective cases had significantly higher rates of symptom remission in U (P = 0.002), P (P = 0.026), O (P < 0.001), and T (P < 0.001) domains than the corresponding negative cases. In effective group, the O domain had the most remission rate (26 out of 28, 92.9%, P < 0.001), followed by the U domain (12 out of 28, 42.9%, P < 0.001) and T domain (12 out of 28, 42.9%, P < 0.001).

CONCLUSION

Histopathological analysis from random biopsies could distinguish bladder carcinoma from clinically suspected IC/BPS. Hydrodistension is more likely to be effective when chronic pelvic pain is obviously alleviated. The efficacy of hydrodistension could act in a certain period of time.

Immunomodulation-A Molecular Solution to Treating Patients with Severe Bladder Pain Syndrome?

Background

Patients with bladder pain syndrome experience debilitating pain and extreme frequency of urination. Numerous therapeutic approaches have been tested, but as the molecular basis of disease has remained unclear, specific therapies are not available.

Objective

Recently, a systematic gene deletion strategy identified interleukin-1 (IL-1) hyperactivation as a cause of severe cystitis in a murine model. Treatment with an IL-1 receptor antagonist (IL-1RA) restored health in genetically susceptible mice, linking IL-1–dependent inflammation to pain and pathology in the bladder mucosa. The study objective was to investigate whether IL-1RA treatment might be beneficial in patients with bladder pain syndrome.

Design, setting, and participants

Patients diagnosed with bladder pain syndrome were invited to participate and subjected to daily IL-1RA injections for 1 wk, followed by a treatment break. Patients with other urological disorders accompanied by pain were included as controls.

Outcome measurements and statistical analysis

When symptoms returned, treatment was resumed and responding patients were maintained on treatment long term, with individualized dosing regimens. Symptom scores were recorded and molecular effects were quantified by neuropeptide and gene expression analysis. DNA samples were subjected to exome genotyping.

Results and limitations

IL-1RA treatment reduced bladder pain and the frequency of urination in 13/17 patients (p < 0.001). Substance P levels in urine were lowered, and responders returned to a more normal lifestyle. Neuroinflammatory-dependent and IL-1–dependent gene networks were inhibited, as well as regulators of innate immunity. Genotyping revealed disease-associated IL1R1, NLRP3, and IL1RN DNA sequence variants in the responders. Controls did not benefit from IL-1RA treatment, except for one patent with cystitis cystica.

Conclusions

In this clinical study, IL-1RA treatment is proposed to reduce chronic bladder pain, immediately and in the long term. Despite the limited number of study patients, the potent acute effect and lasting symptom relief indicate that this therapeutic approach may be worth exploring in controlled clinical trials.

Patient summary

Treatment with an interleukin-1 (IL-1) receptor antagonist is proposed for treating bladder pain syndrome, as it can result in symptom relief and increase quality of life. Reduced neuroinflammation and IL-1 signaling provided molecular evidence of the treatment effects.

Optimising the management of bladder pain syndrome

Objective:

Clinicians have shown variable practice in the diagnosis and management of bladder pain syndrome (BPS). This study assessed pain localisation sites, common co-morbidities, investigations and treatment patterns in clinical practice.

Patients and methods:

We performed a retrospective analysis of 412 patients attending our pelvic pain clinic between 2004 and 2016. Frequency counts were used to summarise findings.

Results:

Pain in women ( N=388) was localised to the lower abdomen (92.0%), lower back (71.1%) and vagina (60.8%). Men ( N=24) typically presented with testicular pain with painful ejaculation (70.8%). Nearly all (95.4%) patients reported sexual dysfunction. Visceral neuropathic pain and autoimmune co-morbidities, such as irritable bowel syndrome, chronic headaches or migraines and skin lesions, were more prevalent in our cohort than in the general population. All patients had urine culture and sensitivities and flexible cystoscopy. Laparoscopy, urodynamic studies and bladder biopsies were mostly normal, but were essential in excluding other pathologies. Good pain control was achieved on amitriptyline (83.0%). Hydro-distension and benign bladder ulcer cauterisation provided temporary symptomatic relief.

Conclusion:

This study demonstrates that patient expectation management and education is essential in BPS, with most achieving good pain control with conservative measures and amitriptyline. Those receiving intravesical treatments will most likely require subsequent revisions.

Level of evidence:

Not applicable for this single-centre audit.

Cystoscopic findings in women with minimal and maximal lower urinary tract symptoms

Background

Glomerulations are not specific for interstitial cystitis/bladder pain syndrome (IC/BPS). Controversy exists about whether cystoscopic findings differ between patients with and without lower urinary tract symptoms. We sought to compare the prevalence of cystoscopic findings in women with “no or minimal” urinary symptoms to those with a “high” symptom burden.

Methods

This is a secondary analysis of a prospective cohort study performed at a University Educational Facility. Participants in this study were part of a larger prospective study, in which female patients scheduled to undergo routine gynecologic procedures were all consented for cystoscopy with hydrodistension (CWHD). We defined the “minimally symptomatic group” as those with ≤1 on each of the O’Leary/Sant Interstitial Cystitis Symptom Index (ICSI) subscores and without history of IC/BPS. The “highly symptomatic” cohort of women had composite ICSI score ≥12 and a Burning/Pain subscore of 4 or 5. All were non-smokers.

Results

A total of 84 women underwent CWHD, with 33 having minimal symptoms and 51 being highly symptomatic. The two groups were not statistically different when assessing for ‘any glomerulations’ compared to ‘no glomerulations.’ However, minimally symptomatic women had an eight-fold lower prevalence of significant glomerulations than highly symptomatic women (3.0% minimally symptomatic vs. 23.5% highly symptomatic, P<0.05.)

Conclusions

Extensive glomerulations (≥10 in 3 or 4 quadrants) are rare in women with minimal urinary symptoms. These findings contrast with prior limited prospective data which quoted similar incidence of glomerulations in IC/BPS patients and asymptomatic patients. This study highlights the importance of evaluating objective evidence on CWHD and merits further investigation as part of the ongoing conversation regarding the definition of bladder health and pathology

Painful Bladder Syndrome/Interstitial Cystitis and High Tone Pelvic Floor Dysfunction

This article provides an overview of 2 conditions that defy straightforward characterization and treatment: interstitial cystitis/painful bladder syndrome often coexists with high tone pelvic floor dysfunction. These conditions are common in gynecologic patients who present with chronic pelvic pain and are often misdiagnosed due to their syndromic nature and amorphous definitions. Clinicians should maintain a high level of suspicion for these processes in patients with chronic pelvic pain or recurrent urinary tract infection symptoms. Optimal treatment uses a multimodal approach to alleviate symptoms.

Hidrox® and Chronic Cystitis: Biochemical Evaluation of Inflammation, Oxidative Stress, and Pain

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic bladder condition characterized by frequent urination, inflammation, oxidative stress, and pain. The aim of the study was to evaluate the anti-inflammatory and antioxidant effects of an oral administration of Hidrox^® (10 mg/kg) in the bladder and spinal cord in a rodent model of IC/BPS. The chronic animal model of cystitis was induced by repeated intraperitoneal injections of cyclophosphamide (CYP) for five consecutive days. Treatment with Hidrox^® began on the third day of the CYP injection and continued until the 10th day. CYP administration caused macroscopic and histological bladder changes, inflammatory infiltrates, increased mast cell numbers, oxidative stress, decreased expression of the tight endothelial junction (e.g., zonula occludens-1 (ZO-1) and occludin), and bladder pain. Treatment with Hidrox^® was able to improve CYP-induced inflammation and oxidative stress via the nuclear factor erythroid 2-related factor 2 (Nrf2)/heme oxygenase 1 (HO-1) pathway. It was also able to reduce bladder pain which was aggravated by the activation of neuroinflammation in the central nervous system. In particular, Hidrox^® reduced the brain-derived neurotrophic factor (BDNF), as well as the activation of astrocytes and microglia, consequently reducing mechanical allodynia. These results indicate that nutritional consumption of Hidrox^® can be considered as a new therapeutic approach for human cystitis, increasing the conceivable potential of a significant improvement in the quality of life associated with a lowering of symptom intensity in patients with IC/BPS.

The Effect of a Diagnosis on Patients With Interstitial Cystitis/Bladder Pain Syndrome: A Qualitative Approach

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain condition that significantly affects patient quality of life. We investigated whether receiving a formal medical diagnosis of IC/BPS was perceived by patients to improve symptoms and disease-specific quality of life.

METHODS

Participants with self-reported IC/BPS completed publicly available online surveys. Surveys included demographic information, validated questionnaires, and a free-text response. Participants were asked to comment on the utility of obtaining a diagnosis. Investigators coded the responses and analyzed the results using grounded theory methodology.

RESULTS

Six hundred seventy-three participants who responded to the free-text were analyzed. The mean age of respondents was 52 years, with an average of 10 years since IC/BPS diagnosis. The IC/BPS pain syndrome diagnosis had wide ranging effects on both symptoms and coping. These effects were often mediated by improvements in perceived control and empowerment after diagnosis. Although most participants noted benefit after diagnosis of IC/BPS, some reported harmful effects ranging from stigmatization by providers to desperation when told that there was not a cure.

CONCLUSIONS

A formal medical diagnosis of IC/BPS has a significant effect on patients who experience the condition. Although diagnosis usually improves symptoms and coping, a universal experience was not described by all IC/BPS patients. Given that most patients report improvement, more work is needed to expedite diagnosis. In addition, we must better understand factors associated with lack of symptom and quality of life improvement after an IC/BPS diagnosis has been made by medical providers.

Does Obtaining a Diagnosis of Interstitial Cystitis/Bladder Pain Syndrome Improve Symptoms or Quality of Life? A Cross-sectional Questionnaire-Based Study

OBJECTIVES

The aim of this study was to investigate whether receiving a clinical diagnosis of interstitial cystitis (IC) or bladder pain syndrome (BPS) improves patients' symptoms, health-related quality of life (HRQOL), or ability to cope with their symptoms.

METHODS

In this cross-sectional study, participants with self-reported IC/BPS completed an online questionnaire recalling their perceived change in symptoms after diagnosis and treatment. The questionnaire included demographic information, overall HRQOL measured on a visual analog scale (VAS), O'Leary-Sant Interstitial Cystitis Problem Index, the Urinary Impact Questionnaire, and questions regarding patient beliefs about diagnosis. HRQOL and symptom impact scales were compared before and after diagnosis and treatment. Demographic data, symptom data, and beliefs were examined for correlation with improvement in quality of life after diagnosis.

RESULTS

A total of 1052 participants initiated the survey and were included in the analysis; most of them identified as female, non-Hispanic, and white (90%). Before symptom onset, median VAS HRQOL score was 87 (interquartile range [IQR], 77-95). Median scores nadired at 34 (IQR, 20-59) after symptom onset before diagnosis, but improved to 61 after diagnosis and treatment (IQR, 38-74; all P < 0.001). Scores remained stable after diagnosis and initiation of treatment with a median score of 65 at the time of survey (IQR, 37-80; P > 0.05). Age, insurance type, and improvement in scores on the symptom impact scale predicted improvement in HRQOL after diagnosis and treatment in the multivariable model.

CONCLUSIONS

Participants reported improvements on global and symptom-specific quality of life measures after diagnosis and treatment for IC/BPS.

The Roles of T cells in Bladder Pathologies

T lymphocytes play important roles in the skin and mucosal surfaces such as the gut and lung. Until recently the contributions of T cells to mammalian bladder immunity were largely unknown. With newer techniques, including single-cell RNA sequencing and reporter mice, an understanding is emerging of T cell roles in bladder diseases (bacterial infections, bladder cancer, chronic inflammation). In these pathologies, many bladder T cell responses can be harmful to the host through suboptimal clearance of bacteria or cancer cells, or by modulating autoinflammation. Recent findings suggest that T cell behavior might be influenced by resident T cell interactions with the bladder microbiota and other immunostimulants. Thus, regulating bladder T cell functions could emerge as a putative immunotherapy to treat some bladder diseases.

Lifestyle and behavioral modifications made by patients with interstitial cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) negatively affects the quality of life. In this study, we investigated the lifestyle behavioral changes patients with IC/BPS make to cope with their symptoms. This prospective study was conducted between August 2018 and June 2019. All patients had a primary symptom of suprapubic pain with a full bladder and other lower urinary tract symptoms for more than 6 weeks as well as cystoscopic findings. All participants completed our self-developed questionnaire, which included informations about their living and work environment, occupational garments, dietary habits, and personal habits. Continuous variables were compared using an independent sample t test, and categorical variables were compared using a chi-square test. We recruited 86 patients with IC/BPS and age-matched 86 controls without IC/BPS. In our study, patients with IC/BPS had more cranberry intake (45.34% vs. 5.81%, P < 0.05) than non-IC/BPS controls; the IC/BPS group had decreased consumption of coffee and spicy food; and wore less makeup or special work garments. In conclusion, patients with IC/BPS tend to make several lifestyle behavioral changes to cope with their symptoms.

Small Fiber Polyneuropathy in Hunner Lesion and Non-Hunner Lesion Interstitial Cystitis/Bladder Pain Syndrome

OBJECTIVE

This study aimed to determine whether small fiber polyneuropathy (SFPN) diagnosis differs between Hunner lesion interstitial cystitis/bladder pain syndrome (HL IC/BPS) and non-Hunner lesion IC/BPS (NHL IC/BPS).

METHODS

This was a pilot study of 20 women with IC/BPS. Results from baseline questionnaires, such as Genitourinary Pain Index, Interstitial Cystitis Symptom Index/Interstitial Cystitis Problem Index (ICSI/ICPI), Patient Health Questionnaire-2, were collected.Two punch biopsies were performed on each patient: distal leg and thigh. The samples were evaluated for intraepidermal nerve fiber density. One intraepidermal nerve fiber density less than the fifth percentile, regardless of site, indicated a positive SPFN diagnosis.

RESULTS

Twenty patients were enrolled; 10 HL IC/BPS and 10 NHL IC/BPS. The HL IC/BPS group was found to be significantly older than the NHL IC/BPS group (63 vs 48 years, P = 0.007). No significant differences were found in employment or relationship statuses, or in levels of education or comorbidities between the 2 groups.Sixty percent (6/10) of patients had SFPN in the NHL IC/BPS group compared with 40% (4/10) in the HL IC/BPS group. No significant differences were seen in SFPN positivity (P = 0.3) or Genitourinary Pain Index, Patient Health Questionnaire-2, or Interstitial Cystitis Symptom Index/Interstitial Cystitis Problem Index scores between the NHL and HL IC/BPS groups.

CONCLUSIONS

Similar to previously published studies, 60% of NHL IC/BPS patients in this cohort were positive for SFPN compared with only 40% of the HL IC/BPS patients. Larger studies may be needed to realize the full impact of SFPN in IC/BPS.

Association of Longitudinal Changes in Symptoms and Urinary Biomarkers in Patients with Urological Chronic Pelvic Pain Syndrome: A MAPP Research Network Study

PURPOSE

We analyzed a series of novel noninvasive urinary biomarkers for their ability to objectively monitor the longitudinal clinical status of patients with urological chronic pelvic pain syndrome.

MATERIALS AND METHODS

Baseline, 6 and 12-month urine samples were collected (216) and used to quantify vascular endothelial growth factor, vascular endothelial growth factor (VEGF) receptor 1 (R1), neutrophil gelatinase associated lipocalin (NGAL), matrix metalloproteinase-2, matrix metalloproteinase (MMP)-9, and MMP-9/NGAL complex by enzyme-linked immunosorbent assays. Patient symptom changes were classified as improved, stable or worse using a functional clustering algorithm. Proportional odds models were used to evaluate the association between symptom change and urinary biomarkers.

RESULTS

Across all sampled participants, longitudinal decreases in normalized VEGF concentration (pg/μg) were associated with pain severity improvement, and decreases in MMP-9, NGAL and VEGF-R1 concentration (pg/ml) as well as NGAL normalized concentration were associated with improved urinary symptoms. Longitudinal decreases in normalized VEGF-R1 were associated with pain improvement in patients with moderate widespreadness, no bladder symptoms and no painful filling. Lower baseline normalized VEGF-R1 concentration was associated with pain improvement in patients with pelvic pain only. Higher baseline MMP-9/NGAL levels were associated with pain and urinary improvement across all participants. Moreover, longitudinal increases in MMP-2 concentration was associated with improved pain in men and patients with painful filling.

CONCLUSIONS

Our results suggest these urinary biomarkers may be useful in monitoring urological chronic pelvic pain syndrome symptom changes with respect to both urinary severity and pain severity. With further testing, they may represent objective biological measures of urological chronic pelvic pain syndrome progression and/or resolution while also providing insight into the pathophysiology of urological chronic pelvic pain syndrome.

Microbiology testing and antibiotic treatment for urinary tract infections in general practice: a nationwide observational study

PURPOSE

Routine urine testing is recommended prior to antibiotic treatment for urinary tract infections (UTIs) among high-risk groups for complicated UTIs. This study aims to examine whether the proportion of UTI encounters where antibiotics are prescribed that have accompanying urine testing differs by patient groups.

METHODS

A retrospective analysis was conducted using records of general practice encounters for UTIs occurring between January 2013 and July 2018 in an Australian national database. We calculated the proportion of UTI encounters with antibiotics prescribed that had accompanying urine microbiology testing and the odds ratios for the likelihood of testing by patient groups using generalised estimating equations.

RESULTS

Of 132,688 UTI encounters with antibiotics prescribed, 95,800 (72.2%) were accompanied by urine testing. Among high-risk groups for complicated UTIs and expected to have a high likelihood of testing, we found pregnant women [82.6% vs. non-pregnant 72.3%, adjusted odds ratio (aOR) 1.82, 95% confidence intervals (CI) 1.55-2.12] and children aged 5-9 years (77.6% vs. 20-44 years 72.0%, aOR 1.33, 95% CI 1.22-1.45) had relatively high odds of testing. However, children aged < 5 years (68.7% vs. 20-44 years 72.0%, aOR 0.83, 95% CI 0.76-0.90), patients with recurrent UTIs (69.0% compared to first-onset UTIs 73.6%, aOR 0.81, 95% CI 0.79-0.83), and patients in residential aged care facilities (67.3% vs. not 72.3%, aOR 0.80, 95% CI 0.72-0.90) had relatively low odds of testing.

CONCLUSION

Our results suggest inconsistencies and potential underuse of urine testing when antibiotics were prescribed for high-risk groups in UTI management. Further antibiotic stewardship is needed to improve guideline-based antibiotic prescribing for UTIs.

The Multidisciplinary Approach to The Study of Chronic Pelvic Pain (MAPP) Research Network*: Design and implementation of the Symptom Patterns Study (SPS)

AIMS

The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network initiated a second observational cohort study-the Symptom Patterns Study (SPS)-to further investigate the underlying pathophysiology of Urologic Chronic Pelvic Pain Syndrome (UCPPS) and to discover factors associated with longitudinal symptom changes and responses to treatments.

METHODS

This multisite cohort study of males and females with UCPPS features a run-in period of four weekly web-based symptom assessments before a baseline visit, followed by quarterly assessments up to 36 months. Controls were also recruited and assessed at baseline and 6 months. Extensive clinical data assessing urological symptoms, nonurological pain, chronic overlapping pain syndromes, and psychosocial factors were collected. Diverse biospecimens for biomarker and microbiome studies, quantitative sensory testing (QST) data under multiple stimuli, and structural and functional neuroimaging scans were obtained under a standardized protocol.

RESULTS

Recruitment was initiated (July 2015) and completed (February 2019) at six discovery sites. A total of 620 males and females with UCPPS and 73 Controls were enrolled, including 83 UCPPS participants who re-enrolled from the first MAPP Network cohort study (2009-2012). Baseline neuroimaging scans, QST measures, and biospecimens were obtained on 578 UCPPS participants. The longitudinal follow-up of the cohort is ongoing.

CONCLUSIONS

This comprehensive characterization of a large UCPPS cohort with extended follow-up greatly expands upon earlier MAPP Network studies and provides unprecedented opportunities to increase our understanding of UCPPS pathophysiology, factors associated with symptom change, clinically relevant patient phenotypes, and novel targets for future interventions.

Histamine induces peripheral and central hypersensitivity to bladder distension via the histamine H1 receptor and TRPV1

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common chronic pelvic disorder with sensory symptoms of urinary urgency, frequency, and pain, indicating a key role for hypersensitivity of bladder-innervating sensory neurons. The inflammatory mast cell mediator histamine has long been implicated in IC/BPS, yet the direct interactions between histamine and bladder afferents remain unclear. In the present study, we show, using a mouse ex vivo bladder afferent preparation, that intravesical histamine enhanced the mechanosensitivity of subpopulations of afferents to bladder distension. Histamine also recruited “silent afferents” that were previously unresponsive to bladder distension. Furthermore, in vivo intravesical histamine enhanced activation of dorsal horn neurons within the lumbosacral spinal cord, indicating increased afferent signaling in the central nervous system. Quantitative RT-PCR revealed significant expression of histamine receptor subtypes ( Hrh1– Hrh3) in mouse lumbosacral dorsal root ganglia (DRG), bladder detrusor smooth muscle, mucosa, and isolated urothelial cells. In DRG, Hrh1 was the most abundantly expressed. Acute histamine exposure evoked Ca2+ influx in select populations of DRG neurons but did not elicit calcium transients in isolated primary urothelial cells. Histamine-induced mechanical hypersensitivity ex vivo was abolished in the presence of the histamine H1 receptor antagonist pyrilamine and was not present in preparations from mice lacking transient receptor potential vanilloid 1 (TRPV1). Together, these results indicate that histamine enhances the sensitivity of bladder afferents to distension via interactions with histamine H1 receptor and TRPV1. This hypersensitivity translates to increased sensory input and activation in the spinal cord, which may underlie the symptoms of bladder hypersensitivity and pain experienced in IC/BPS.

Urologic chronic pelvic pain syndrome: insights from the MAPP Research Network

Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome, is characterized by chronic pain in the pelvic region or genitalia that is often accompanied by urinary frequency and urgency. Despite considerable research, no definite aetiological risk factors or effective treatments have been identified. The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network uses a novel integrated strategy to characterize UCPPS as a systemic disorder that potentially involves multiple aetiologies. The first phase, MAPP I, included >1,000 participants who completed an intensive baseline assessment followed by a 12-month observational follow-up period. MAPP I studies showed that UCPPS pain and urinary symptoms co-vary, with only moderate correlation, and should be evaluated separately and that symptom flares are common and can differ considerably in intensity, duration and influence on quality of life. Longitudinal clinical changes in UCPPS correlated with structural and functional brain changes, and many patients experienced global multisensory hypersensitivity. Additionally, UCPPS symptom profiles were distinguishable by biological correlates, such as immune factors. These findings indicate that patients with UCPPS have objective phenotypic abnormalities and distinct biological characteristics, providing a new foundation for the study and clinical management of UCPPS.

A MAPP Network Case-control Study of Urological Chronic Pelvic Pain Compared With Nonurological Pain Conditions

OBJECTIVES

Limited research suggests commonalities between urological chronic pelvic pain syndromes (UCPPS) and other nonurological chronic overlapping pain conditions (COPCs) including fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome. The goal of this case-control study was to examine similarities and differences between UCPPS and these other COPCs.

MATERIALS AND METHODS

As part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research (MAPP) Network, we examined 1039 individuals with UCPPS (n=424), nonurological COPCs (n=200), and healthy controls (HCs; n=415). Validated standardized measures were used to assess urological symptoms, nonurological pain symptoms, and psychosocial symptoms and traits.

RESULTS

Participants with UCPPS had more urological symptoms than nonurological COPCs or HCs (P<0.001); nonurological COPC group also had significantly worse urological symptoms than HCs (P<0.001). Participants with nonurological COPCs reported more widespread pain than those with UCPPS (P<0.001), yet both groups had similarly increased symptoms of anxiety, depression, negative affect, perceived stress, neuroticism, and lower levels of extraversion than HCs (P<0.001). Participants with UCPPS with and without COPCs reported more catastrophizing than those with nonurological COPCs (P<0.001).

DISCUSSION

Findings are consistent with the hypothesis of common underlying biopsychosocial mechanisms and can guide the comprehensive assessment and treatment of these conditions regardless of the primary site of pain or diagnosis. Heightened catastrophizing in UCPPS should be examined to inform psychosocial interventions and improve patient care.

Verification of mesenchymal stem cell injection therapy for interstitial cystitis in a rat model

Objective

Interstitial cystitis (IC) is a chronic intractable disease. Recently, the potential application of stem cell (SC) therapy was suggested for IC management. This study aimed to establish an optimal SC source and verify the efficacy and safety of SC injection therapy in an IC rat model.

Design

After IC animal model induction, urine-derived stem cells (USCs), adipose tissue-derived stem cells (ADSCs), bone marrow-derived stem cells (BMSCs) and amniotic fluid-derived stem cells (AFSCs) were injected into the bladder submucosa. The following parameters were analysed: 1) functional improvement of bladder via cystometry, 2) histological changes and 3) inflammatory gene expression and regenerative potential of damaged bladder tissues. Additionally, an optimal method for SC introduction in terms of effective bladder regeneration was analysed.

Results

Intercontraction interval was significantly increased and inflammatory reactions and fibrotic changes were decreased in all of the SC-injected groups than in the control group. PCR analysis revealed that inflammatory gene expression significantly decreased in the USC-treated group than in the other groups. To confirm the optimal SC injection route in the IC rat model, group was divided according to the following criteria: 1) direction of SC injection into the bladder submucosa, 2) injection via tail vein, 3) transurethral instillation. In each analysis, the groups in which SCs were injected into the bladder submucosa showed significantly longer intercontraction interval, better morphologic regeneration and inhibition of bladder inflammatory reaction compared with the other groups.

Conclusion

Regardless of the cell source, human tissue-derived mesenchymal SCs regenerated damaged bladder tissue, promoted functional recovery and inhibited inflammatory cell accumulation in an IC rat model; particularly, USC had the highest inhibitory effect on inflammation. Additionally, direct USC injection into the bladder submucosa was expected to have the best therapeutic effect, which will be an important factor for clinical applications in the future.

Monoacylglycerol lipase inhibition as potential treatment for interstitial cystitis

Interstitial cystitis is a chronic inflammatory condition of the urinary bladder with an unclear etiology. Currently, there are no widely accepted long-term treatment options available for patients with IC, with the European Association of Urology (EAU, 2017 guidelines), American Urology Association (AUA, 2014 guidelines), and the Royal College of Obstetricians and Gynaecologists (RCOG, 2016 guidelines) all suggesting various different conservative, pharmacological, intravesical, and surgical interventions. The endocannabinoid system represents a potential target for IC treatment and management. Activation of cannabinoid receptor 2 (CBR2) with various agonists has previously been shown to reduce leukocyte differentiation and migration, in addition to inhibiting the release of pro-inflammatory cytokines at the site of inflammation. These receptors have been identified in the detrusor and sensory nerves of the urothelium in various mammalian species, including humans. We hypothesize that by inhibiting the enzymes responsible for the catabolism of endogenous cannabinoids locally, bladder concentrations of CBR2 agonists will increase, particularly 2-arachidonyl glycerol, resulting in a diminished inflammatory response.

The misdiagnosis of interstitial cystitis/bladder pain syndrome in a VA population

AIMS

The complexity of Interstitial Cystitis/bladder Pain Syndrome (IC/BPS) has led to a great deal of uncertainty around the diagnosis and prevalence of the condition. Under the hypothesis that IC/BPS is frequently misdiagnosed, we sought to assess the accuracy of the ICD-9/ICD-10 code for IC/BPS using a national data set.

METHODS

Using the Veterans Affairs Informatics and Computing Infrastructure, we identified a random sample of 100 patients with an ICD-9/ICD-10 diagnosis of IC/BPS (595.1/N30.10) by querying all living patients in the Veterans Affairs (VA) system. We purposely sampled men and women equally to better understand gender-specific practice patterns. Patients were considered a correct IC/BPS diagnosis if they had two visits complaining of bladder-centric pain in the absence of positive urine culture at least 6 weeks apart. Patients were considered not to have IC/BPS if they had a history of pelvic radiation, systemic chemotherapy, metastatic cancer, or bladder cancer.

RESULTS

Of the 100 patients, 48 were female and 52 were male. Five had prior radiation, one had active cancer, and 10 had bladder cancer (all male), and an additional fifteen had insufficient records. Of the remaining 69 patients, 43% did not have IC/BPS. Of these patients who did not have IC/BPS, 43% complained only of overactive bladder (OAB) symptoms, which was more common in women (63%) than men (21%), P = .003.

CONCLUSIONS

In our small sample from a nationwide VA system, results indicate that IC/BPS has a high misdiagnosis rate. These findings shed light on the gender-specific diagnostic complexity of IC/BPS.

Outcomes of intravesical chondroitin-sulfate and combined hyaluronic-acid/chondroitin-sulfate therapy on female sexual function in bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

Our aim was to determine the efficacy of intravesical chondroitin sulfate (CS) and combined hyaluronic acid/chondroitin sufate (HA/CS) treatment and their effects on sexual function of females with interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

A total of 68 female patients with IC/BPS between 2012 and 2018 were reviewed. Thirty-three patients were treated with combined HA/CS and 28 patients were treated with CS. Instillations were performed weekly for the first month, biweekly for the second month, and monthly in the third and fourth months. Before and after the sixth month of the treatment, all patients were evaluated with the Female Sexual Function Index (FSFI), visual analog pain scale (VAS), interstitial cystitis symptom index (ICSI), interstitial cystitis problem index (ICPI), and voiding diary, and changes were recorded.

RESULTS

A statistically significant improvement was determined for FSFI, VAS, ICSI, and ICPI scores after treatment in both groups. Among baseline characteristics, a weak but significant negative correlation was determined only between the ICSI score improvement and age (rho: -0.38; p = 0.03) on statistical analysis. Compared with CS, combined HA/CS treatment was superior in terms of ICSI, ICPI, and daytime and nighttime frequency improvement (0.042, 0.038, 0.039, and 0.045; respectively). All domains of the sexual function index were significantly improved at the sixth month of intravesical therapy in both groups. A statistical difference was not found between the two groups.

CONCLUSIONS

Although it seems that intravesical HA/CS combination is superior to CS alone in terms of symptom reduction, both of them have beneficial effects on sexual function.

Impact of early adverse life events and sex on functional brain networks in patients with urological chronic pelvic pain syndrome (UCPPS): A MAPP Research Network study

Pain is a highly complex and individualized experience with biopsychosocial components. Neuroimaging research has shown evidence of the involvement of the central nervous system in the development and maintenance of chronic pain conditions, including urological chronic pelvic pain syndrome (UCPPS). Furthermore, a history of early adverse life events (EALs) has been shown to adversely impact symptoms throughout childhood and into adulthood. However, to date, the role of EAL's in the central processes of chronic pain have not been adequately investigated. We studied 85 patients (56 females) with UCPPS along with 86 healthy controls (HCs) who had resting-state magnetic resonance imaging scans (59 females), and data on EALs as a part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network Study. We used graph theory methods in order to investigate the impact of EALs on measures of centrality, which characterize information flow, communication, influence, and integration in a priori selected regions of interest. Patients with UCPPS exhibited lower centrality in the right anterior insula compared to HCs, a key node in the salience network. Males with UCPPS exhibited lower centrality in the right anterior insula compared the HC males. Females with UCPPS exhibited greater centrality in the right caudate nucleus and left angular gyrus compared to HC females. Males with UCPPS exhibited lower centrality in the left posterior cingulate, angular gyrus, middle temporal gyrus, and superior temporal sulcus, but greater centrality in the precuneus and anterior mid-cingulate cortex (aMCC) compared to females with UCPPS. Higher reports of EALs was associated with greater centrality in the left precuneus and left aMCC in females with UCPPS. This study provides evidence for disease and sex-related alterations in the default mode, salience, and basal ganglia networks in patients with UCPPS, which are moderated by EALs, and associated with clinical symptoms and quality of life (QoL).

Purinergic P2X7 receptors as therapeutic targets in interstitial cystitis/bladder pain syndrome; key role of ATP signaling in inflammation

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic lower urinary tract condition. Patients with IC/BPS suffer from debilitating pain and urinary urgency. The underlying etiology of IC/BPS is unknown and as such current treatments are mostly symptomatic with no real cure. Many theories have been proposed to describe the etiology of IC/BPS, but this review focuses on the role of inflammation. In IC/BPS patients, the permeability of the urothelium barrier is compromised and inflammatory cells infiltrate the bladder wall. There are increased levels of many inflammatory mediators in patients with IC/BPS and symptoms such as pain and urgency that have been associated with the degree of inflammation. Recent evidence has highlighted the role of purinergic receptors, specifically the P2X7 receptor, in the process of inflammation. The results from studies in animals including cyclophosphamide-induced hemorrhagic cystitis strongly support the role of P2X7 receptors in inflammation. Furthermore, the deletion of the P2X7 receptor or antagonism of this receptor significantly reduces inflammatory mediator release from the bladder and improves symptoms. Research results from IC/BPS patients and animal models of IC/BPS strongly support the crucial role of inflammation in the pathophysiology of this painful disease. Purinergic signaling and purinergic receptors, especially the P2X7 receptor, play an undisputed role in inflammation. Purinergic receptor antagonists show positive results in treating different symptoms of IC/BPS.

Analysis of key genes and micro-RNA-mRNA regulatory networks in women with ulcerative interstitial cystitis/pain bladder syndrome

INTRODUCTION AND HYPOTHESIS

This aim of this study was to better understand ulcerative interstitial cystitis/painful bladder syndrome (IC/PBS) at the molecular level and provide new clues related to diagnosis and treatment.

METHODS

The microarray data set GSE11783, including the mRNA and miRNA profiles of bladder tissue obtained at cystoscopic biopsy from patients with ulcerative IC/PBS (presence of at least one Hunner's ulcer) and normal controls, was downloaded from the GEO (Gene Expression Omnibus) database (National Center for Biotechnology Information). These were evaluated using Greenspring GX and Ingenuity Pathway Analysis (IPA) software. The differentially expressed genes (DEGs) and miRNAs (DEMs) in these two groups were identified. Subsequently, the DEGs were subjected to functional analysis, and a protein-protein interaction (PPI) network was constructed. Finally, the miRNA-mRNA regulatory network was visualized using Cystoscope software.

RESULTS

Four DEMs and 1521 DEGs were identified between the ulcerative IC/PBS and control groups. The PPI network of the DEGs was constructed by STRING, which was composed of 393 nodes and 1039 edges, including 221 upregulated genes and 172 downregulated genes. Moreover, 27 genes in the PPI network were identified as hub genes in the IC/PBS group, e.g., PNOC, SSTR1, FPR3, GPR18 and APLNR. Subsequently, 27 clusters were selected from the PPI network using MCODE. It was shown that the most significant cluster consisted of 22 nodes and 231 edges. Moreover, miR-21 was the most significantly upregulated miRNA and was predicted to target one upregulated gene (RASGRP1) and two downregulated genes (KLF5 and SC5D).

CONCLUSIONS

The results of this data mining and integration provide further information on the possible molecular basis of IC/PBS pathogenesis as well as potential biomarkers and therapeutic targets for ulcerative IC/PBS diagnosis and treatment.

Neonatal bladder inflammation alters the role of the central amygdala in hypersensitivity produced by Acute Footshock stress in adult female rats

There is increasing evidence that chronic pain may be associated with events that occur during critical periods of development. Recent studies have identified behavioral, spinal neurophysiological and spinal/peripheral neurochemical differences in rats that have experienced neonatal bladder inflammation (NBI): a putative model of the chronically painful bladder disorder, interstitial cystitis. Stress has been shown to exacerbate symptoms of interstitial cystitis and produces bladder hypersensitivity in animal models. We recently reported that Acute Footshock-induced bladder hypersensitivity was eliminated in otherwise normal rats by prior bilateral lesions of the central nucleus of the amygdala. Since the spinal and peripheral nervous systems of NBI-treated rats are known to differ from normal rats, the present experiments sought to determine whether a supraspinal nervous system structure, the central amygdala, is still necessary for the induction of Acute Footshock-induced hypersensitivity. The effect of bilateral amygdala electrolytic lesions on Acute Footshock-induced bladder hypersensitivity in adult female rats was tested in Control rats which underwent a control protocol as neonates and in experimental rats which experienced NBI. Consistent with our previous report, in Control rats, Acute Footshock-induced bladder hypersensitivity was eliminated by bilateral Amygdala Lesions. In contrast, Acute Footshock-induced bladder hypersensitivity in NBI-treated rats was unaffected by bilateral Amygdala Lesions. These findings provide evidence that NBI results in the recruitment of substrates of bladder hypersensitivity that may differ from those of normal rats. This, in turn, suggests that unique therapeutics may be needed for painful bladder disorders like interstitial cystitis.

Symptomatic overlap in overactive bladder and interstitial cystitis/bladder pain syndrome: development of a new algorithm

OBJECTIVES

To address challenges in the diagnosis and classification of storage lower urinary tract symptoms (LUTS), we sought to define the fundamental features of overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), two conditions with considerable symptomatic overlap. Through retrospective comparison of self-reported symptoms in women with a range of clinical presentations and symptom severities, we have attempted to refine the diagnostic features of OAB and IC/BPS and to develop a novel clinical nomogram to improve patient screening and classification.

MATERIALS AND METHODS

We performed a univariate analysis comparing responses to the female Genitourinary Pain Index (fGUPI), the OAB Questionnaire and O'Leary-Sant Indices (the Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index) in an initial cohort of 50 patients with OAB, patients with IC/BPS and control subjects. Only eight questions differed significantly between the IC/BPS and OAB groups; we used five unique questions and three measuring bother to generate a novel composite scoring system and nomogram that included urgency incontinence, bladder pain and symptomatic bother domains to differentiate these populations, which was validated in a second cohort of 150 patients. The addition of a self-reported bother index resulted in the creation of a diagnostic algorithm to identify and classify LUTS clusters across the total population.

RESULTS

While all validated questionnaires could distinguish between controls and patients with storage LUTS, no combined symptom scores differed significantly between the IC/BPS and OAB groups. These results are reflective of the prevalence of significant bladder pain (35%) in patients with OAB and the presence of urge incontinence (25%) in patients with IC/BPS. Only the fGUPI pain domain scores differed between patients in the OAB and IC/BPS groups, but it was not accurate enough for diagnostic evaluation (68% accuracy). Our composite scores and nomogram gave a much-improved diagnostic accuracy (94%) and demonstrated utility as a screening tool to identify storage LUTS in patients presenting for unrelated complaints, e.g. microhaematuria.

CONCLUSIONS

There is significant overlap of urinary tract symptoms between OAB and IC/BPS. We present a novel algorithm that provides a binary output capable of guiding clinical diagnosis. Future studies aimed at assessing the diagnostic value of novel classification schemes that address symptoms rather than specific diagnoses may improve patient prognosis.