Sites of Pain From Interstitial Cystitis/Painful Bladder Syndrome

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding and managing pelvic girdle pain from a person-centred biopsychosocial perspective

INTRODUCTION

Clinicians need support to effectively implement a biopsychosocial approach to people with pelvic girdle pain disorders.

PURPOSE

A practical clinical framework aligned with a contemporary biopsychosocial approach is provided to help guide clinician's management of pelvic girdle pain. This approach is consistent with current pain science which helps to explain potential mechanistic links with co/multi-morbid conditions related to pelvic girdle pain. Further, this approach also aligns with the Common-Sense Model of Illness and provides insight into how an individual's illness perceptions can influence their emotional and behavioural response to their pain disorder. Communication is critical to supporting recovery and facilitating behaviour change within the biopsychosocial context and in this context, the patient interview is central to exploring the multidimensional nature of a persons' presentation. Focusing the biopsychosocial framework on targeted cognitive-functional therapy as a key component of care can help an individual with pelvic girdle pain make sense of their pain, build confidence and self-efficacy and facilitate positive behaviour and lifestyle change. There is growing evidence of the efficacy for this broader integrative approach, although large scale effectiveness trials are still needed. An in-depth case study provides guidance for clinicians, showing 'how to' implement these concepts into their own practice within a coherent practical framework.

IMPLICATIONS

This framework can give clinicians more confidence in understanding and managing pelvic girdle pain. The framework provides practical strategies to assist clinicians with implementation; assisting the transition from knowing to doing in an evidence-informed manner that resonates with real world practice.

Chronic scrotal pain: A variable symptom of interstitial cystitis/bladder pain syndrome

Objective:

Treatment of chronic idiopathic scrotal pain is a dilemma and challenge. Many men with this condition undergo multiple therapies and surgeries with no improvement in their symptoms. Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) have a variable clinical presentation and initially complain of only one symptom of urinary urgency, frequency, or pain. We report on patients with chronic idiopathic scrotal pain treated with standard therapy for IC/BPS.

Patients and Methods:

Patients with chronic idiopathic scrotal content pain were evaluated, determined to have chronic idiopathic scrotal content pain, and were treated with either pentosan polysulfate sodium (PPS) or bladder instillations of alkalinized lidocaine and heparin.

Results:

Sixteen males were determined to have chronic idiopathic scrotal pain. Eight males received PPS and eight males received a bladder instillation of alkalinized lidocaine and heparin. All patients had improvement of their scrotal pain to a self-reported acceptable level.

Conclusions:

Chronic idiopathic scrotal pain may be one of the variable presenting symptoms of IC/BPS. This scrotal pain may actually be referred pain from the bladder. Standard therapies for IC/BPS may be a treatment option for chronic idiopathic scrotal pain.

Optogenetic silencing of nociceptive primary afferents reduces evoked and ongoing bladder pain

Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) suffer from chronic pain that severely affects quality of life. Although the underlying pathophysiology is not well understood, inhibition of bladder sensory afferents temporarily relieves pain. Here, we explored the possibility that optogenetic inhibition of nociceptive sensory afferents could be used to modulate bladder pain. The light-activated inhibitory proton pump Archaerhodopsin (Arch) was expressed under control of the sensory neuron-specific sodium channel (sns) gene to selectively silence these neurons. Optically silencing nociceptive sensory afferents significantly blunted the evoked visceromotor response to bladder distension and led to small but significant changes in bladder function. To study of the role of nociceptive sensory afferents in freely behaving mice, we developed a fully implantable, flexible, wirelessly powered optoelectronic system for the long-term manipulation of bladder afferent expressed opsins. We found that optogenetic inhibition of nociceptive sensory afferents reduced both ongoing pain and evoked cutaneous hypersensitivity in the context of cystitis, but had no effect in uninjured, naïve mice. These results suggest that selective optogenetic silencing of nociceptive bladder afferents may represent a potential future therapeutic strategy for the treatment of bladder pain.

The location of pain and urgency sensations during cystometry

AIMS

The relationship between bladder pain and urinary urgency sensations is poorly understood. We analyzed the relationship between locations and intensities of urgency and pain sensations felt during filling cystometry.

METHODS

Participants completed the King's Health Questionnaire (KHQ) to indicate presence of bladder pain or urgency. During cystometry, participants scored the intensity of urgency and pain, both in the suprapubic and the urethral region, on a VAS scale of 0-10 at a baseline, at first desire, normal desire, strong desire to void, and at maximum cystometric capacity during filling. We allocated the participants to six groups; those reporting urgency or not, pain or not, both symptoms and neither. Friedman's Test was used to ascertain if all scores increased significantly, the Wilcoxon Signed Rank Test was used to demonstrate the difference between scores, and agreement for findings during cystometry was tested with Mann-Whitney U.

RESULTS

A total of 68 women participated; 38 participants reported pain, 57 reported urgency, and 33 reported both symptoms. Pain and urgency scores significantly increased during cystometry (P < 0.0001). For participants reporting pain, suprapubic pain was rated significantly higher than urethral pain. Participants reporting both symptoms, felt more urgency than pain, and again pain more suprapubically than urethrally. Participants reporting only urgency scored suprapubic and urethral urgency similarly at all desires.

CONCLUSIONS

Pain and urgency are well differentiated sensations and are felt at different locations although pain is seemingly easier localized. Neurourol. Urodynam. 36:620-625, 2017. © 2016 Wiley Periodicals, Inc.

Animal Models of Urologic Chronic Pelvic Pain Syndromes: Findings From the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network

OBJECTIVE

To describe the approach taken by the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network investigators to advance the utility of urologic chronic pelvic pain syndromes (UCPPS) animal models.

METHODS

A multidisciplinary team of investigators representing basic science and clinical expertise defined key phenotypic criteria for rodent models of UCPPS. UCPPS symptoms were prioritized based on their clinical significance. Methods for quantifying animal correlates to patient symptoms were developed. The methods were implemented across proposed rodent models for evaluation and comparison of animals for phenotypic characteristics relevant to human symptomatology.

RESULTS

Pelvic pain and urinary frequency were deemed primary features of human UCPPS and were prioritized for assessment in animals. Nociception was quantified using visceromotor response to bladder distention and by applying von Frey filaments to the lower abdomen (referred tactile allodynia). Micturition activity was assessed as free voiding using micturition cages or blotting pad assays and in response to bladder filling by cystometry. Models varied in both depth of characterization and degree of recapitulating pelvic pain and urinary frequency characteristics of UCPPS.

CONCLUSION

Rodent models that reflect multiple key characteristics of human UCPPS may be identified and provide enhanced clinical significance to mechanistic studies. We have developed a strategy for evaluating current and future animal models of UCPPS based on human symptomatology. This approach provides a foundation for improved translation between mechanistic studies in animals and clinical research and serves as a validation strategy for assessing validity of models for symptom-driven disorders of unknown etiology.

Bladder pain syndrome/interstitial cystitis as a functional somatic syndrome

PURPOSE

To determine whether bladder pain syndrome/interstitial cystitis (BPS/IC) has the characteristics of a functional somatic syndrome (FSS).

MATERIALS AND METHODS

There is no accepted definition of an FSS. Consequently, this paper reviewed the literature for common FSS characteristics and for reports that BPS/IC has these characteristics.

RESULTS

Eleven articles met inclusion and exclusion criteria and yielded 18 FSS characteristics. BPS/IC patients manifest all but two: the exceptions were normal light microscopic anatomy (after hydrodistention under anesthesia, some BPS/IC bladders have Hunner's lesions and most have petechial hemorrhages) and normal laboratory tests (many BPS/IC patients have hematuria). Petechial hemorrhages and hematuria are probably related and may appear during naturally-occurring bladder distention. Without such distention, then, the 90% of BPS/IC patients without a Hunner's lesion have all the characteristics of an FSS. Comparisons in the opposite direction were consistent: several additional features of BPS/IC were found in FSSs.

CONCLUSIONS

This systematic but untested method is consistent with but does not test the hypothesis that BPS/IC in some patients might best be understood as an FSS. Like most conditions, BPS/IC is probably heterogeneous; hence only a proportion of BPS/IC cases are likely to be manifestations of an FSS. This hypothesis has several implications. Explorations of processes that connect the FSSs might contribute to understanding the pathogenesis of BPS/IC. Patients with FSSs are at risk for BPS/IC and may benefit from future preventive strategies. Therapies that are useful in FSSs also may be useful in some cases of BPS/IC.

Pelvic organ cross-sensitization to enhance bladder and urethral pain behaviors in rats with experimental colitis

Neural cross-sensitization has been postulated as a mechanism underlying overlaps of chronic pelvic pain disorders such as bladder pain syndrome/interstitial cystitis (BPS/IC) and irritable bowel syndrome (IBS). Animals with experimental colitis have been used to study the underlying mechanisms for overlapped pelvic pain symptoms, and shown to exhibit bladder overactivity evidenced by frequent voiding; however, it has not directly been evaluated whether pain sensation derived from the lower urinary tract is enhanced in colitis models. Also, the cross-sensitization between the colon and urethra has not been studied previously. In the present study, we therefore investigated pain behaviors induced by nociceptive stimuli in the lower urinary tract and the involvement of C-fiber afferent pathways using rats with colitis induced by intracolonic application of 2,4,6-trinitrobenzenesulfonic acid (TNBS). In TNBS-induced colitis rats at 10 days, intravesical application of resiniferatoxin (RTx) induced a significantly greater number of episodes of both licking and freezing behaviors, which were reduced by capsaicin-sensitive C-fiber afferent desensitization. Histochemical studies using fluorescent dye tracers injected into the colon, bladder or urethra showed that dichotomized afferent neurons comprised 6.9-14.5% of L1, L6 and S1 dorsal root ganglion (DRG) neurons innervating the colon or the lower urinary tract. Transient receptor potential vanilloid 1 (TRPV1) mRNA expression was significantly increased in, the bladder, urethra and S1 DRG in colitis rats. An increase in myeloperoxidase (MPO) activity was found in the colon, but not in the bladder or urethra after intracolonic TNBS treatment. These results indicate that TNBS-induced colitis increased pain sensitivity in the bladder and urethra via activation of C-fiber afferent pathways due to colon-to-bladder and colon-to-urethral cross-sensitization, suggesting the contribution of pelvic organ cross-sensitization mechanisms to overlapped pain symptoms in BPS/IC and IBS.

The overlap and distinction of self-reported symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder: a questionnaire based analysis

PURPOSE

We compared symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder based on patient self-reported symptoms on validated questionnaires.

MATERIALS AND METHODS

We prospectively recruited 26 patients diagnosed with interstitial cystitis/bladder pain syndrome, 53 diagnosed with overactive bladder and 30 healthy controls to participate in a questionnaire based study that inquired about lower urinary tract symptoms. The questionnaires used were GUPI, ICSI, ICPI, ICIQ-OAB, ICIQ-UI, IUSS, numerical rating scales of the severity of bladder pain, pressure or discomfort, and numerical rating scale of the severity of urgency and frequency symptoms.

RESULTS

On univariate analysis patients with interstitial cystitis/bladder pain syndrome reported significantly more severe pain symptoms than those with overactive bladder. Patients with overactive bladder reported significantly more severe urinary incontinence symptoms than those with interstitial cystitis/bladder pain syndrome. There was no difference in frequency and urgency severity between the groups. Surprisingly, 33% of patients with overactive bladder reported pain or discomfort when the bladder filled and 46% with interstitial cystitis/bladder pain syndrome reported urgency incontinence. On multivariate analysis ICIQ-UI total scores (p = 0.01) and bladder pain severity on the numerical rating scale (p <0.01) distinguished the 2 conditions with 90.6% sensitivity and 96.1% specificity. Overactive bladder had higher ICIQ-UI and lower numerical rating scale pain scores.

CONCLUSIONS

There is considerable overlap of self-reported symptoms between interstitial cystitis/bladder pain syndrome and overactive bladder. This overlap raises the possibility that the 2 conditions represent a continuum of a bladder hypersensitivity syndrome.

Segmental hyperalgesia to mechanical stimulus in interstitial cystitis/bladder pain syndrome: evidence of central sensitization

PURPOSE

We investigate if subjects with interstitial cystitis/bladder pain syndrome demonstrate mechanical or thermal hyperalgesia, and whether the hyperalgesia is segmental or generalized (global).

MATERIALS AND METHODS

Ten female subjects with interstitial cystitis/bladder pain syndrome and 10 age matched female controls without comorbid fibromyalgia or narcotic use were recruited for quantitative sensory testing. Using the method of limits, pressure pain and heat pain thresholds were measured. Using the method of fixed stimulus, the visual analog scale pain experienced was recorded when a fixed pressure/temperature was applied.

RESULTS

The visual analog scale pain rated by female subjects with interstitial cystitis/bladder pain syndrome was significantly higher than that rated by female control subjects when a fixed mechanical pressure (2 or 4 kg) was applied to the suprapubic (T11) area (p = 0.028). There was an up shift of the stimulus-response curve, which corresponded to the presence of mechanical hyperalgesia in the suprapubic area in interstitial cystitis/bladder pain syndrome. However, the visual analog scale pain rated by subjects with interstitial cystitis/bladder pain syndrome was not different from that rated by controls when a fixed pressure was applied at the other body sites (T1 arm, L4 leg, S2-3 sacral). No difference in visual analog scale pain rating was noted when a fixed heat stimulus (35C or 37C) was applied to any of the body sites tested (T1, T11, L4, S2). There was no difference in pressure pain thresholds or thermal pain thresholds between subjects with interstitial cystitis/bladder pain syndrome and controls.

CONCLUSIONS

Female subjects with interstitial cystitis/bladder pain syndrome showed segmental hyperalgesia to mechanical pressure stimulation in the suprapubic area (T10-T12). This segmental hyperalgesia may be explained in part by spinal central sensitization.

Interstitial cystitis/bladder pain syndrome: diagnosis and management

INTRODUCTION AND HYPOTHESIS

The bladder pain syndrome (BPS) is a spectrum of urological symptoms characterised by bladder pain with typical cystoscopic features. Diagnosis and management of this syndrome may be difficult. There is no evidence-based management approach for the diagnosis or treatment of BPS. The objective of this study was to critically review and summarise the evidence relating to the diagnosis and treatment of the bladder pain syndrome.

METHODS

A review of published data on the diagnosis and treatment of the BPS was performed. Our search was limited to English-language articles, on the "diagnosis", and "management" or "treatment" of "interstitial cystitis" and the "bladder pain syndrome" in "humans."

RESULTS

Frequency, urgency and pain on bladder filling are the most common symptoms of BPS. All urodynamic volumes are reduced in patients with BPS. Associated conditions include psychological distress, depression, history of sexual assault, irritable bowel syndrome and fibromyalgia. Cystoscopy remains the test for definitive diagnosis, with visualisation of haemorrhage on cystoreduction. A multidisciplinary treatment approach is essential in the management of this condition. Orally administered amitriptyline is an efficacious medical treatment for BPS. Intravesical hyaluronic acid and local anaesthetic, with/without hydrodistension are among new treatment strategies. Sacral or pudendal neuromodulation is effective, minimally invasive and safe. Surgery is reserved for refractory cases.

CONCLUSIONS

There remains a paucity of evidence for the diagnosis and treatment of BPS. We encountered significant heterogeneity in the assessment of symptoms, duration of treatment and follow up of patients in our literature review.

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.

Pain in interstitial cystitis/bladder pain syndrome: do characteristics differ in ulcerative and non-ulcerative subtypes?

INTRODUCTION AND HYPOTHESIS

Key differences between interstitial cystitis/bladder pain syndrome (IC/BPS) subtypes (with and without Hunner's ulcer) have been noted. We hypothesized that pain characteristics in women grouped by IC/BPS subtype would differ.

METHODS

A survey was mailed to 749 women to assess IC/BPS pain and other characteristics. Cystoscopy/hydrodistention reports were reviewed for presence/absence of Hunner's ulcer. The McGill Pain Questionnaire Short Form© (MPQ-SF), Brief Pain Inventory (BPI), and Interstitial Cystitis Symptom and Problem Indices (ICSI-PI) assessed symptoms. Data were analyzed with Pearson's chi-square, Fisher's exact, t tests, and Wilcoxon rank tests.

RESULTS

Of the 214 women that returned a survey (36 ulcerative and 178 non-ulcerative IC/BPS), similar proportions in each group reported that certain foods, exercise, and/or stress triggered symptoms. Fewer ulcerative patients reported pain with vaginal penetration than non-ulcerative (5/33, 15.2 % vs 76/160, 47.5 %; p = 0.0006). On the BPI, the ulcerative and non-ulcerative groups reported similar numbers of painful areas (mean 4.1 ± 6.1 and 4.1 ± 3.8; p = 0.33), and lower abdominal/pelvic pain was reported most (13/35, 37 % vs 79/172, 46 %; p = 0.34) followed by lower back pain (12/35, 34 % vs 69/172, 40 %; p = 0.52). Even though ICSI-PI, MPQ-SF, and BPI scores/responses did not differ, on the MPQ-SF the three words most frequently used by ulcerative patients to describe their pain were sharp, stabbing, and hot burning, and in non-ulcerative were aching, cramping, and tender.

CONCLUSIONS

These measures did not reveal any significant differences in pain between subtypes. More research is needed in larger samples to determine whether differences exist.

Construct validity of an instrument to measure neuropathic pain in women with bladder pain syndrome

AIMS

To determine the construct validity of an instrument to measure neuropathic pain in women with bladder pain syndrome (BPS). Our hypothesis is that neuropathic, bladder, and bowel pain represent different constructs in women with BPS.

METHODS

Secondary planned analysis of a prospective cross-sectional study of 150 women with BPS. The relationship between neuropathic pain, urinary, and bowel symptoms was assessed.

RESULTS

The correlation of the total neuropathic pain score with total urinary and bowel symptom scores was low to moderate (r = 0.28-0.49). The correlation of specific neuropathic pain items with bladder and bowel pain was also low to moderate (r = 0.12-0.36). Women with neuropathic pain had significantly higher scores for urinary urgency, bladder pain, abdominal pain, diarrhea, and constipation than women with non-neuropathic pain (all P < 0.0001).

CONCLUSION

Somatosensory neuropathic pain and "visceral" bladder and bowel pain represent separate but related constructs in women with BPS.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

Association of neuropathic pain with bladder, bowel and catastrophizing symptoms in women with bladder pain syndrome

PURPOSE

In this study we determined if there is an association of neuropathic pain with urinary, bowel and catastrophizing symptoms in women with bladder pain syndrome.

MATERIALS AND METHODS

Female patients with a diagnosis of bladder pain syndrome completed validated questionnaires to assess neuropathic pain, urinary and bowel symptoms, quality of life and pain catastrophizing. Women were dichotomized into neuropathic pain and nonneuropathic pain groups. Urinary and bowel symptoms, pain catastrophizing and quality of life scores were compared between the 2 groups using parametric and nonparametric tests.

RESULTS

Of 150 women with bladder pain syndrome 40 (27%) had features of neuropathic pain while 110 (73%) did not. Women with features of neuropathic pain had significantly worse urinary urgency (mean ± SD 3.1 ± 3.1 vs 2.1 ± 1.7, p <0.001), bladder pain (3.0 ± 1.1 vs 2.0 ± 1.3, p <0.001), bowel pain (8.8 ± 4.0 vs 5.3 ± 3.6, p <0.001), diarrhea (7.8 ± 6.1 vs 4.1 ± 4.3, p <0.001), quality of life (12.2 ± 5.5 vs 9.8 ± 3.8, p <0.001) and higher pain catastrophizing (32.2 ± 12.4 vs 23.1 ± 14.3, p <0.001) scores than those without neuropathic pain.

CONCLUSIONS

In women with bladder pain syndrome the presence of neuropathic pain is significantly associated with the severity of bladder and bowel pain, urinary urgency and diarrhea. Women with features of neuropathic pain also have worse pain catastrophizing and quality of life than those without features of neuropathic pain.

Nocturia in interstitial cystitis/painful bladder syndrome

OBJECTIVES

To explore the roles of pain and urgency in the nocturia of patients with interstitial cystitis/painful bladder syndrome (IC/PBS).

METHODS

In a longitudinal study of incident IC/PBS cases, we assessed the associations of the presence and severity of nocturia with the presence and severity of pain and urgency, using multivariate analyses when necessary. Additionally, we simply asked patients with IC/PBS what awakens them at night.

RESULTS

The multivariate analyses revealed associations of urgency with the presence and severity of nocturia and of bladder pain with the severity of nocturia. Direct queries of patients with IC/PBS about urgency and the reasons for awakening demonstrated that bladder pain might have played a twofold role: directly in awakening a large minority of patients and possibly indirectly in the majority by generating the sensation of urgency.

CONCLUSIONS

These findings are consistent with urinary urgency and bladder pain each being in the causal pathway leading to nocturia in patients with IC/PBS.

Efficacy of sacral neuromodulation in treatment of bladder pain syndrome: long-term follow-up

AIMS

This study was sought to evaluate the efficacy and durability of sacral neuromodulation in the treatment of bladder pain syndrome (BPS) patients.

METHODS

A retrospective chart review was performed of patients who had unilateral sacral nerve stimulator (InterStim®) for refractory BPS between June 2002 and December 2004. Patients were qualified for permanent implantation by showing ≥ 50% improvement in their bladder pain and voiding symptoms 1-week post-percutaneous nerve evaluation (PNE). Voiding diary was completed at pre-implantation, 1 year, and on the last visit. Urinary distress inventory short form was completed pre-implantation and on the last visit. Bladder pain was evaluated by visual analogue scale. Primary outcome was improvement in bladder pain. Differences among groups were compared by one-way ANOVA and t-test. Statistical significance was set at P ≤ 0.05.

RESULTS

Twenty-one female patients diagnosed with BPS had PNE; 11 patients (52%) showed ≥ 50% improvement in their bladder pain and voiding symptoms and they consider candidates for permanent implantation (Table I), while 10 patients (48%) failed to show 50% improvement in their voiding symptoms or bladder pain (Table II). In those 11 patients who underwent permanent implantation, the average patient's age was 44.3 ± 8.9 years; average time since diagnosis was 3 ± 0.8 years; the average follow- up was 71.5 ± 9.3 months (Table III). There was significant improvement in the bladder pain and voiding parameters at 1-year follow-up, which was maintained at 5-year follow-up. There was continuous improvement in urgency (1.2 ± 0.68) at 1-year follow-up, and (0.98 ± 0.72) at the last visit. Average voided volume was also continuously improved from 242 ± 62.7 ml at 1-year follow-up to 276 ± 64.7 ml on the last visit.

CONCLUSION

Sacral neuromodulation as part of multimodal treatment provides an effective long-term treatment option for sub-group of refractory BPS.

Interstitial cystitis/painful bladder syndrome: what do patients mean by "perceived" bladder pain?

OBJECTIVES

To report the reasons patients with interstitial cystitis/painful bladder syndrome (IC/PBS) give for the perception that the bladder is the source of their pain. The perception that the bladder is the source of pain is a necessary criterion for many definitions of IC/PBS.

METHODS

Events Preceding Interstitial Cystitis was a case-control study seeking risk factors for IC/PBS. The inclusion criteria for incident cases included "lower abdominal pain" or "bladder pain" and ≥2 of the following symptoms: urinary frequency, urgency, and/or nocturia. The patients were systematically followed and at 18 months after the baseline interview were asked an open-ended question about their reasons for perceiving the bladder to be the source of their pain.

RESULTS

Of the 179 patients with current pain, 164 (92%) claimed ≥1 bladder or lower urinary tract symptoms caused them to perceive that their pain involved the bladder. Of these, 41% noted a "bladder" location for their pain; 34% noted pain increasing with bladder filling and/or decreasing with bladder emptying; 31% claimed the presence of urgency and/or frequency; 23% described worsened pain during and/or after urination; and 17% mentioned other urinary symptoms. Finally, 8% noted only nonurinary symptoms (4 patients) or "do not know" (11 patients).

CONCLUSIONS

No predominant reason was found that patients with IC/PBS gave for suspecting the bladder to be the source of pain. The common reasons included pain location, changes with the urinary cycle, and an association with other urinary symptoms. To clarify the relationship of IC/PBS to other chronic pain syndromes, which often are comorbidities, these features of IC/PBS should be queried.

Pelvic pain in urogynaecology. Part I: evaluation, definitions and diagnoses

Aim of this review is to summarise the available literature on the definitions and assessment of pelvic pain in the urogynaecological patient. A MEDLINE search and a hand search of conference proceedings of the International Continence Society and International Urogynecological Association were performed. Sixty-nine articles were reviewed. The site of pain was specified in 45% of the articles, 20% used the digital examination of pelvic myofascial trigger points for the diagnosis; 20%, the Pelvic Pain and Urgency/Frequency Symptom Scale; 26%, the Interstitial Cystitis Symptom and Problem Index and 39%, a simple visual analogue scale. The diagnosis was interstitial cystitis in 67% and chronic pelvic pain in 19% of the articles. Consensus on the diagnostic procedures and definition of pelvic pain in the urogynaecological patient should be achieved in order to provide exact diagnostic information which will lead to more satisfying treatment options.

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

OBJECTIVE

The objective of the study was to compare subjects with interstitial cystitis/painful bladder syndrome (IC/PBS) with controls on prior surgeries.

STUDY DESIGN

IC/PBS subjects were compared with matched controls on surgeries and possible surgical indications prior to their index dates.

RESULTS

Adjusted for demographic variables, logistic regression showed subjects exceeded controls in surgeries longer than 12 months and less than 1 month before the index date. However, addition of possible surgical indications showed chronic pelvic pain (CPP) to have a strong association with IC/PBS, whereas associations with surgeries were reduced to nonsignificance.

CONCLUSION

Although women with IC/PBS were more likely to have experienced prior surgeries than controls, the apparent indications for surgeries, not the surgeries themselves, were stronger risk factors for IC/PBS. In particular, a prior history of CPP had a strong association with IC/PBS. Several features of study design, including extensive medical record review, suggest that prior CPP was not undiagnosed IC/PBS. Further investigation of CPP may yield insight into the pathogenesis of IC/PBS.

Visceral organ cross-sensitization - an integrated perspective

Viscero-somatic referral and sensitization has been well documented clinically and widely investigated, whereas viscero-visceral referral and sensitization (termed cross-organ sensitization) has only recently received attention as important to visceral disease states. Because second order neurons in the CNS have been extensively shown to receive convergent input from different visceral organs, it has been assumed that cross-organ sensitization arises by the same convergence-projection mechanism as advanced for viscero-somatic referral and sensitization. However, increasing evidence also suggests participation of peripheral mechanisms to explain referral and sensitization. We briefly summarize behavioral, morphological and physiological support of and focus on potential mechanisms underlying cross-organ sensitization.

Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome

PURPOSE

A combination of manual physiotherapy and specific relaxation training effectively treats patients with chronic prostatitis/chronic pelvic pain syndrome. However, little information exists on myofascial trigger points and specific chronic pelvic pain symptoms. We documented relationships between trigger point sites and pain symptoms in men with chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS

We randomly selected a cohort of 72 men who underwent treatment with physiotherapy and relaxation training from 2005 to 2008. Patients self-reported up to 7 pelvic pain sites before treatment and whether palpation of internal and external muscle trigger points reproduced the pain. Fisher's exact test was used to compare palpation responses, ie referral pain, stratified by reported pain site.

RESULTS

Pain sensation at each anatomical site was reproduced by palpating at least 2 of 10 designated trigger points. Furthermore, 5 of 7 painful sites could be reproduced at least 50% of the time (p <0.05). The most prevalent pain sites were the penis in 90.3% of men, the perineum in 77.8% and the rectum in 70.8%. Puborectalis/pubococcygeus and rectus abdominis trigger points reproduced penile pain more than 75% of the time (p <0.01). External oblique muscle palpation elicited suprapubic, testicular and groin pain in at least 80% of the patients at the respective pain sites (p <0.01).

CONCLUSIONS

This report shows relationships between myofascial trigger points and reported painful sites in men with chronic prostatitis/chronic pelvic pain syndrome. Identifying the site of clusters of trigger points inside and outside the pelvic floor may assist in understanding the role of muscles in this disorder and provide focused therapeutic approaches.

Differential diagnosis of chronic pelvic pain in women: the urologist's approach

Chronic pelvic pain in women can be caused by a host of gynecological, gastrointestinal, musculoskeletal, neurologic, as well as urologic disorders. An initial broad differential diagnosis is essential. At times, overlapping symptoms and vague physical findings necessitate a multidisciplinary diagnostic approach. A thorough history, which is careful to characterize all aspects of the patient's symptoms, can usually direct the differential toward the bladder when this organ is the source of the pain. Interstitial cystitis/painful bladder syndrome (IC/PBS) should be included in the differential diagnosis, but it should not be used as an expeditious diagnosis when pain coexists with frequency and urgency. Multiple other urologic conditions such as overactive bladder, urinary tract infection, urethral diverticulum, periurethral masses (Skene gland cyst or abscess), and even urethral stricture disease, have overlapping symptom complexes with IC/PBS, and they must not be overlooked as they are much more easily diagnosed and treated. By using a stepwise approach and an evidence-based thought process, the obscurity of chronic bladder and urethral pain can evolve into a progressively narrowing differential.

Paediatric painful bladder syndrome/interstitial cystitis: diagnosis and treatment

To describe the pathophysiology, diagnosis and controversies surrounding the diagnosis and pharmacological treatments of painful bladder syndrome/interstitial cystitis (PBS/IC) in children, we reviewed adult and paediatric literature pertaining to PBS/IC. Paediatric PBS/IC presents similarly to adult PBS/IC. The diagnosis is made by exclusion. Paediatric PBS/IC patients complain most commonly of urinary frequency, and abdominal pain occurs in up to 88% of affected children. Enuresis may also be a presenting complaint. Urinalysis and urine cultures are unremarkable. Management of paediatric PBS/IC is similar to that of adult PBS/IC, and non-surgical management includes dietary, lifestyle and pharmacological therapy. Pharmacological options include pentosan polysulfate, amitriptyline, hydroxyzine, cimetidine or intravesical therapies (dimethyl sulfoxide or 'therapeutic solution').

Interstitial cystitis: bladder pain and beyond

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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