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The effect of intravesical cocktail therapy combined with low-dose amitriptyline on primary bladder pain syndrome. Int Urogynecol J 2022; 33:1225-1230. [PMID: 34977954 DOI: 10.1007/s00192-021-05043-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We compared the effectiveness of intravesical combination treatment and intravesical treatment plus low-dose amitriptyline in patients with primary bladder pain syndrome (PBPS). METHODS A total of 53 patients were included in the study. Demographic data, voiding frequency, nocturia, visual analog scale (VAS) scores, validated O'Leary-Sant IC Symptom Index (ICSI), and IC Problem Index (ICPI) scores and scores on the Short Form-36 (SF-36) questionnaire were collected from the patients at the beginning of the treatment, and at the 6th week and 6th month of the treatment. The patients were divided into two groups. Group 1 received intravesical treatment for 6 weeks. Group 2 received intravesical treatment plus amitriptyline at a dosage of 10 mg/day. RESULTS The frequencies of voiding and VAS scores were significantly improved in groups 1 and 2 at the 6th week compared with pretreatment (in group 1 p < 0.001, p < 0.001, and in group 2 p < 0.001, p < 0.001 respectively). The median ICSI and ICPI scores also significantly decreased in groups 1 and 2 (in group 1 p < 0.001, p < 0.001, and in group 2 p < 0.001, p < 0.001 respectively). Scores on the dimensions of the SF-36 questionnaire were significantly improved in both groups. There was no significant change in terms of VAS, nocturia, ICSI or ICPI scores when comparing the 6th week and 6th month results in groups 1 and 2 (all p > 0.05). Only role functioning/emotional achieved a significant improvement in group 2 (p = 0.007). CONCLUSIONS Intravesical combination therapies are effective in PBPS treatment. Adding low-dose amitriptyline to intravesical therapy in patients with PBPS improves emotional status.
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Piontek K, Apfelbacher C, Ketels G, Brünahl C, Löwe B. Depression Partially Mediates the Association of Adverse Childhood Experiences with Pain Intensity in Patients with Chronic Pelvic Pain Syndrome: Results from a Cross-Sectional Patient Survey. PAIN MEDICINE 2021; 22:1174-1184. [PMID: 33155025 DOI: 10.1093/pm/pnaa325] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Adverse childhood experiences (ACEs), such as emotional and physical maltreatment, are linked to chronic pelvic pain syndrome (CPPS) in adults. Psychological factors are important in understanding CPPS. We aimed to determine the nature and frequency of ACEs in male and female patients with CPPS and to investigate whether somatic symptoms and psychological comorbidities mediate the relationship of ACE severity with pain intensity. DESIGN Cross-sectional study. SETTING Interdisciplinary outpatient clinic for CPPS in Hamburg, Germany. SUBJECTS Individuals with CPPS (n = 234) who were 18 to 84 years of age. METHODS Using a self-administered questionnaire, we assessed the history of ACEs (ACE Scale), pain intensity (McGill Pain Questionnaire), somatic symptoms (Patient Health Questionnaire-15]), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale). Parallel mediation analysis was conducted to examine whether the association of ACE severity with pain intensity is mediated by somatic symptoms, depression, and anxiety. RESULTS Emotional abuse and neglect were reported more than twice as often as physical abuse and neglect (37.2% vs 17.1%). Depression partially mediated the association of ACE severity with pain intensity in the whole study population. In sex-stratified analyses, different patterns of associations were observed, but somatic symptoms predicted pain intensity in both sexes. CONCLUSIONS Emotional maltreatment was highly prevalent, supporting an increased consideration of psychological factors in CPPS and indicating the need to screen for ACEs in patients with CPPS. Findings further suggest that depression and somatic symptoms may be important targets for therapeutic interventions in patients with CPPS who have a history of childhood adversity.
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Affiliation(s)
- Katharina Piontek
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Apfelbacher
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Gesche Ketels
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Brünahl
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Yi Z, Ou Z, Guo X, Othmane B, Hu J, Ren W, Li H, He T, Qiu D, Cai Z, Chen J, Zu X. Recurrence factors in patients with Keratinizing squamous metaplasia of the bladder after surgical management: a single-center retrospective study. Transl Androl Urol 2021; 10:734-740. [PMID: 33718075 PMCID: PMC7947458 DOI: 10.21037/tau-20-948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Keratinizing squamous metaplasia (KSM) is a clinically heterogeneous disease that lacks research that provide definitive recurrent risk factors. Therefore, we identified the recurrence factors in patients with KSM of the bladder after transurethral resection (TUR). We also attempted to investigate the association between KSM and bladder cancer. Methods Clinical information of 257 patients diagnosed with KSM who underwent TUR in Xiangya Hospital from January 2010 to November 2018 were retrospectively collected. Clinical information was available for follow-up of 223 patients. To determine the risk factors for recurrence, we conducted univariate and multivariate cox regression analysis respectively. To explore the association between KSM and bladder cancer, we used clinical follow-up data. Results The median follow-up time is 49 (IQR, 12–121) months. Five-year recurrence-free rate (RFR) and 1-year RFR were 86.1% and 91.9%, respectively. Thirty-one patients (13.9%) relapsed of KSM after a median follow-up of 49 months (range, 12–121 months), and none of them developed subsequent bladder cancer. Univariate Cox analysis indicated that urinary tract infection [hazard ratio (HR) =2.111; 95% confidence interval (CI): 1.043–4.271; P=0.038], and atypical urothelial hyperplasia of the bladder (HR =4.191; 95% CI: 2.006–8.756; P<0.001) were significant recurrence factors. Multivariate Cox analysis suggested that atypical urothelial hyperplasia of the bladder (HR =3.506; 95% CI: 1.663–7.392; P=0.001) was the independent risk factor for postoperative recurrence of KSM. Conclusions The recurrence rate in patients with KSM was about 13.9%, and atypical urothelial hyperplasia of the bladder was the independent risk factor in patients with KSM recurrence. In cases with bladder atypical urothelial hyperplasia, close follow-ups are necessary. Also, we demonstrated that KSM did not increase the subsequent risk of bladder cancer.
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Affiliation(s)
- Zhenglin Yi
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenyu Ou
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Xi Guo
- Department of Urology, Hunan Provincial People's Hospital, Changsha, China
| | - Belaydi Othmane
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Jiao Hu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Wenbiao Ren
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Huihuang Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Tongchen He
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Dongxu Qiu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhiyong Cai
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Jinbo Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiongbing Zu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
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McAlarnen LA, Ricci Goodman J, Sarwark A, Winder AD, Potkul RK, Liotta MR. Pelvic floor myofascial pain in gynecology oncology patients: A pilot study. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/2284026520984412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Here we present a pilot study investigating the prevalence of pelvic floor myofascial pain in patients presenting to an academic tertiary care gynecologic oncology clinic. We describe patients’ responses to a pain survey including the pain disability index. Methods: An IRB approved prospective survey and chart review was conducted. Patients underwent standard physical exam maneuvers for detection of pelvic floor myofascial pain. Consented patients completed a pain survey and pain disability index on presentation to clinic. Statistical analysis included Chi square test and Mann Whitney test. Results: Twenty-nine percent (45/155) of patients exhibited pelvic floor myofascial pain, while 71% (110/155) did not. Of those with malignancy, 28% (16/57) had pelvic floor myofascial pain and 72% (41/57) did not. Patients with pelvic floor myofascial pain had a significantly higher rating of “pain right now” ( p = 0.001) and “usual level of pain during the past week” ( p = 0.003) than those without such pain. Patients with pelvic floor myofascial pain had significantly greater disability in family/home responsibilities ( p = 0.01), recreation ( p = 0.001), social activity ( p = 0.008), occupation ( p = 0.015), sexual behavior ( p = 0.025), and life support activities ( p = 0.007) compared to those without pelvic floor myofascial pain. Conclusion: Pelvic floor myofascial pain affects 28% of patients with malignancy. Routine incorporation of a myofascial exam can identity those with such pain, which can lead to improved quality of life in gynecologic oncology patients with pelvic floor disorders.
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Affiliation(s)
- Lindsey A. McAlarnen
- Department of Obstetrics and Gynecology, Division of Gynecology Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jean Ricci Goodman
- Department of Obstetrics and Gynecology, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Anne Sarwark
- Department of Anesthesia, New York Medical College at Metropolitan Hospital, New York, NY, USA
| | - Abigail D. Winder
- Department of Obstetrics and Gynecology, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Ronald K. Potkul
- Department of Obstetrics and Gynecology, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Margaret R. Liotta
- Department of Obstetrics and Gynecology, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
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Wang H, Chong T, Tang XY, Zheng WB. Transurethral resection in women with symptomatic keratinizing squamous metaplasia of urinary bladder: A retrospective study of 92 cases. Low Urin Tract Symptoms 2019; 12:137-142. [PMID: 31762198 PMCID: PMC7217002 DOI: 10.1111/luts.12294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022]
Abstract
Objectives To investigate the efficacy of transurethral resection (TUR) on relieving urinary symptoms in patients with keratinizing squamous metaplasia (KSM) of the urinary bladder. Methods Data were analyzed from a retrospective study of patients receiving transurethral bipolar plasma resection (bi‐TUR) treatment for symptomatic KSM. Urinary symptoms were assessed by the International Prostate Symptom Score (IPSS) and a numeric rating scale pain score. Efficacy was assessed using the IPSS to determine changes from baseline in lower urinary tract symptoms (LUTS). Self‐reported quality of life (QoL) was assessed by the last question of the IPSS questionnaire. Results A total of 92 female patients were included in the analysis. The median age was 42 years. LUTS, pain, and hematuria were the most common symptoms that affected patients. The median follow‐up duration was 51 months. There were significant improvements in LUTS from baseline IPSS after TUR (P < .001). The percentage of the patients with moderate to severe LUTS went down from 52.2% to 18.5%. The median Numeric Rating Scale (NRS)‐11 pain score reduced from 3 at baseline to 0 at the last visit. Twenty‐one out of 40 patients reported that the pain symptoms disappeared completely. No patients reported hematuria symptoms at the final follow‐up. Improvement of self‐reported QoL was significant (P < .001). A total of 57.6% of patients reported an improvement, 26.1% of patients reported no improvement, and 16.3% reported deterioration. Conclusions Bi‐TUR therapy significantly relieved urinary symptoms in women with KSM. Improvement of QoL was acceptable with a success rate of 57.6%. Considering the very low complication rate, our study supported bi‐TUR as an alternative treatment for patients who are resistant to medical therapy.
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Affiliation(s)
- Huan Wang
- Department of Urology, Second Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China.,Department of Urology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Tie Chong
- Department of Urology, Second Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Xiu-Ying Tang
- Department of Female Urology, The First People's Hospital of Yueyang, Yueyang City, China
| | - Wen-Bo Zheng
- Department of Clinical Medicine, Medical School, Xiangnan College, Chenzhou, China
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Piontek K, Ketels G, Albrecht R, Schnurr U, Dybowski C, Brünahl CA, Riegel B, Löwe B. Somatic and psychosocial determinants of symptom severity and quality of life in male and female patients with chronic pelvic pain syndrome. J Psychosom Res 2019; 120:1-7. [PMID: 30929698 DOI: 10.1016/j.jpsychores.2019.02.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 02/08/2023]
Abstract
AIMS To investigate the combined impact of somatic and psychosocial factors on symptom severity and physical and mental quality of life (QoL) in male and female patients with chronic pelvic pain syndrome (CPPS). METHODS We examined 234 patients aged 18 to 84 years attending an interdisciplinary outpatient clinic for patients with CPPS in Hamburg, Germany. Using self-reports, we assessed CPPS symptom severity (NIH-CPSI), with the female counterpart of each male anatomical site used in the questionnaire for women; physical and mental QoL (SF-12) as well as symptoms of depression (PHQ-9) and anxiety (GAD-7); pain catastrophizing cognitions (PCS); social support (F-SozU) and medication intake. The presence of trigger and tender points was assessed in a physiotherapy examination. Hierarchical multiple regression analysis was calculated to analyze the contribution of somatic and psychosocial variables on CPPS symptom severity. Analyses were repeated with physical and mental QoL as outcomes. RESULTS In the overall model, the intake of pain medication (B = 3.78, SE = 1.25, p = .006), the presence of depressive symptoms (B = 0.40, SE = 0.15, p = .01) and pain catastrophizing (B = 0.18, SE = 0.05, p = .001) significantly predicted CPPS symptom severity. Corresponding analyses revealed a differential pattern of factors predicting physical and mental QoL, whereas higher levels of depressive symptoms were consistently associated with diminished mental (B = -0.63; p < .001) and physical QoL (B = -0.85; p < .001). CONCLUSION Present results emphasize the importance of psychosocial factors, in particular of depression, in CPPS symptom severity and both physical and mental QoL and give support to an integrated treatment concept encompassing both psychological support and somatic aspects of the disease.
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Affiliation(s)
- Katharina Piontek
- Institute for Medical Psychology, University Medicine Greifswald, Greifswald, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Gesche Ketels
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rebecca Albrecht
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike Schnurr
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Dybowski
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian A Brünahl
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Riegel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Quaghebeur J, Wyndaele JJ, De Wachter S. Pain areas and mechanosensitivity in patients with chronic pelvic pain syndrome: a controlled clinical investigation. Scand J Urol 2017; 51:414-419. [PMID: 28678646 DOI: 10.1080/21681805.2017.1339291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE A thorough clinical assessment including physical examination is crucial in a diagnostic work-up, including in patients with chronic pelvic pain syndrome (CPPS). This study investigated the prevalence of pain areas and the mechanosensitivity of peripheral nerves in patients with CPPS and compared the findings with a healthy control group. MATERIALS AND METHODS Healthy volunteers and patients diagnosed with CPPS were assessed with physical examinations and neurodynamic testing. RESULTS The CPPS group (n = 26) and the control group (n = 28) showed no statistical differences between males and females for age and body mass index (Mann-Whitney U test). The patients in the CPPS group were significantly older and had a significantly higher weight compared to controls. Healthy volunteers did not show any pain area or mechanosensitivity of the examined peripheral nerves of the lumbosacral plexus. Patients with CPPS showed a variety of pain from different musculoskeletal origins. Neurodynamic testing demonstrated significant mechanosensitivity in at least one nerve of the lumbosacral plexus in 88% of the patients with CPPS, suggesting minor nerve injuries. Pudendal nerve mechanosensitivity was found in 85% of patients, while 42% had multiple nerves involved. Unilateral or bilateral pudendal channel palpatory pain was present in 62% of the CPPS group and not in controls. CONCLUSIONS This study shows musculoskeletal pain and a high prevalence of minor nerve injuries in CPPS patients, indicating the presence of abnormal impulse generation sites that can help in understanding the clinical picture in CPPS patients and guiding their treatment.
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Affiliation(s)
- Jörgen Quaghebeur
- a Department of Urology , University Hospital Antwerp , Edegem , Belgium.,b Department of Urology , University of Antwerp , Antwerp , Belgium
| | | | - Stefan De Wachter
- a Department of Urology , University Hospital Antwerp , Edegem , Belgium.,b Department of Urology , University of Antwerp , Antwerp , Belgium
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Abstract
Although the cause of chronic pelvic pain (CPP) is multifactorial, a substantial number of cases have musculoskeletal and neuromuscular causes. Multiple stakeholders, including physicians with varying degrees of pain training ranging from primary care physicians, obstetricians, gynecologists, urologists, neurologists, gastroenterologists, psychologists, physical therapists, and physiatrists, are involved in the care of these patients. Physiatrists play a pivotal role in the treatment of patients with CPP because their training focuses on improving quality of life through a holistic approach to patient management and on the musculoskeletal and neuromuscular systems.
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Vasudevan V, Moldwin R. Addressing quality of life in the patient with interstitial cystitis/bladder pain syndrome. Asian J Urol 2017; 4:50-54. [PMID: 29264207 PMCID: PMC5730899 DOI: 10.1016/j.ajur.2016.08.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 08/09/2016] [Indexed: 01/22/2023] Open
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating, chronic condition characterized by chronic pelvic pain, urinary urgency, and frequency and is well-known to be associated with a decrease in work productivity, emotional changes, sleep, sexual dysfunction, and mobility. Many metrics of quality of life (QoL) in this patient population have been developed; however, a unified, standardized approach to QoL in these patients has not been determined. The effects of IC/BPS and co-morbid conditions on QoL are described using current validated metrics. Next, data regarding successful treatment of IC/BPS in terms of QoL improvement are reviewed. While QoL is the single most important clinical measure of success in the treatment of patients suffering from IC/BPS, addressing QoL in this patient population remains a significant challenge, as its effects on QoL are highly variable and unable to be differentiated from the effects of comorbid conditions on QoL, including depression, poor sleep, and inability to work. Future studies will need to address treatment efficacy on the basis of IC/BPS specific QoL metrics, and multi-modal assessment and therapy to address comorbid disease will also play an important role in the future to ensure comprehensive management of these patients.
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Affiliation(s)
- Vinaya Vasudevan
- Department of Urology, The Smith Institute for Urology, Northwell Health, New Hyde Park, NY, USA
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Equal Improvement in Men and Women in the Treatment of Urologic Chronic Pelvic Pain Syndrome Using a Multi-modal Protocol with an Internal Myofascial Trigger Point Wand. Appl Psychophysiol Biofeedback 2015; 41:215-24. [DOI: 10.1007/s10484-015-9325-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Dinis S, de Oliveira JT, Pinto R, Cruz F, Buffington CT, Dinis P. From bladder to systemic syndrome: concept and treatment evolution of interstitial cystitis. Int J Womens Health 2015; 7:735-44. [PMID: 26229509 PMCID: PMC4516339 DOI: 10.2147/ijwh.s60798] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Interstitial cystitis, presently known as bladder pain syndrome, has been recognized for over a century but is still far from being understood. Its etiology is unknown and the syndrome probably harbors different diseases. Autoimmune dysfunction, urothelial leakage, infection, central and peripheral nervous system dysfunction, genetic disease, childhood trauma/abuse, and subsequent stress response system dysregulation might be implicated. Management is slowly evolving from a solo act by the end-organ specialist to a team approach based on new typing and phenotyping of the disease. However, oral and invasive treatments are still largely aimed at the bladder and are based on currently proposed pathophysiologic mechanisms. Future research will better define the disease, permitting individualization of treatment.
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Affiliation(s)
- Sara Dinis
- Faculty of Medicine, University of Porto, Porto, Portugal ; Department of Obstetrics and Gynecology, Hospital de São João, Porto, Portugal
| | - Joana Tavares de Oliveira
- Faculty of Veterinary Medicine, ULHT, Lisbon, Portugal ; Institute of Molecular Pathology and Immunology (IPATIMUP), University of Porto, Porto, Portugal
| | - Rui Pinto
- Faculty of Medicine, University of Porto, Porto, Portugal ; Department of Urology, Hospital de São João, Porto, Portugal
| | - Francisco Cruz
- Faculty of Medicine, University of Porto, Porto, Portugal ; Department of Urology, Hospital de São João, Porto, Portugal
| | - Ca Tony Buffington
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, OH, USA
| | - Paulo Dinis
- Faculty of Medicine, University of Porto, Porto, Portugal ; Department of Urology, Hospital de São João, Porto, Portugal
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