Cognitive Behavioral Therapy for Chronic Pelvic Pain: What Is It and Does It Work?

PURPOSE

Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome in women and men and chronic prostatitis/chronic pelvic pain syndrome in men, is a common, often disabling urological disorder that is neither well understood nor satisfactorily treated with medical treatments. The past 25 years have seen the development and validation of a number of behavioral pain treatments, of which cognitive behavioral therapy (CBT) is arguably the most effective. CBT combines strategies of behavior therapy, which teaches patients more effective ways of behaving, and cognitive therapy, which focuses on correcting faulty thinking patterns. As a skills-based treatment, CBT emphasizes "unlearning" maladaptive behaviors and thoughts, and replacing them with more adaptive ones that support symptom self-management.

MATERIALS AND METHODS

This review describes the rationale, technical procedures, and empirical basis of CBT.

RESULTS

While evidence supports CBT for treatment-refractory chronic pain disorders, there is limited understanding of why or how CBT might work, for whom it is most beneficial, or the specific UCPPS symptoms (eg, pain, urinary symptoms) it effectively targets. This is the focus of EPPIC (Easing Pelvic Pain Interventions Clinical Research Program), a landmark NIH trial examining the efficacy of low-intensity, home-based CBT for UCPPS relative to a nonspecific comparator featuring self-care recommendations of AUA guidelines.

CONCLUSIONS

Systematic efforts to increase both the efficiency of CBT and the way it is delivered (eg, home-based treatments) are critical to scaling up CBT, optimizing its therapeutic potential, and reducing the public health burden of UCPPS.

Combination of urinary biomarkers and machine-learning models provided a higher predictive accuracy to predict long-term treatment outcomes of patients with interstitial cystitis/bladder pain syndrome

PURPOSE

To identify predictive factors for satisfactory treatment outcome of the patients with IC/BPS using urine biomarkers and machine-learning models.

METHODS

The IC/BPS patients were prospectively enrolled and provide urine samples. The targeted analytes included inflammatory cytokines, neurotrophins, and oxidative stress biomarkers. The patients with overall subjective symptom improvement of ≥ 50% were considered to have satisfactory results. Binary logistic regression, receiver-operating characteristic (ROC) curve, machine-learning decision tree, and random forest models were used to analyze urinary biomarkers to predict satisfactory results.

RESULTS

Altogether, 57.4% of the 291 IC/BPS patients obtained satisfactory results. The patients with satisfactory results had lower levels of baseline urinary inflammatory cytokines and oxidative biomarkers than patients without satisfying results, including interleukin-6, monocyte chemoattractant protein-1 (MCP-1), C-X-C motif chemokine 10 (CXCL10), oxidative stress biomarkers 8-hydroxy-2'-deoxyguanosine (8-OHDG), 8-isoprostane, and total antioxidant capacity (TAC). Logistic regression and multivariable analysis revealed that lower levels of urinary CXCL10, MCP-1, 8-OHDG, and 8-isoprostane were independent factors. The ROC curve revealed that MCP-1 level had best area under curve (AUC: 0.797). In machine-learning decision tree model, combination of urinary C-C motif chemokine 5, 8-isoprostane, TAC, MCP-1, and 8-OHDG could predict satisfactory results (accuracy: 0.81). The random forest model revealed that urinary 8-isoprostance, MCP-1, and 8-OHDG levels had the most important influence on accuracy.

CONCLUSION

Machine learning decision tree model provided a higher accuracy for predicting treatment outcome of patients with IC/BPS than logistic regression, and levels of 8-isoprostance, MCP-1, and 8-OHDG had the most important influence on accuracy.

Urologic Chronic Pelvic Pain Syndrome Flares: A Comprehensive, Systematic Review and Meta-Analysis of the Peer-Reviewed Flare Literature

PURPOSE

We sought to systematically review and summarize the peer-reviewed literature on urologic chronic pelvic pain syndrome flares, including their terminology, manifestation, perceived triggers, management and prevention strategies, impact on quality of life, and insights into pathophysiologic mechanisms, as a foundation for future empirical research.

MATERIALS AND METHODS

We searched 6 medical databases for articles related to any aspect of symptom exacerbations for interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome. A total of 1486 abstracts and 398 full-text articles were reviewed, and data were extracted by at least 2 individuals.

RESULTS

Overall, we identified 59 articles, including 36 qualitative, cross-sectional, or case-control; 15 cohort-based; and 8 experimental articles. The majority of studies described North American patients with confirmed diagnoses. "Flare" was a commonly used term, but additional terminology (eg, exacerbation) was also used. Most flares involved significant increases in pain intensity, but less data were available on flare frequency and duration. Painful, frequent, long-lasting, and unpredictable flares were highly impactful, even over and above participants' nonflare symptoms. A large number of perceived triggers (eg, diet, stress) and management/prevention strategies (eg, analgesics, thermal therapy, rest) were proposed by participants, but few had empirical support. In addition, few studies explored underlying biologic mechanisms.

CONCLUSIONS

Overall, we found that flares are painful and impactful, but otherwise poorly understood in terms of manifestation (frequency and duration), triggers, treatment, prevention, and pathophysiology. These summary findings provide a foundation for future flare-related research and highlight gaps that warrant additional empirical studies.

Multi-omics analyses uncover metabolic signatures and gene expression profiles of interstitial cystitis/bladder pain syndrome

BACKGROUND AND OBJECTIVE

We explore molecular and metabolic pathways involved in interstitial cystitis (IC) with integrating multi-omics analysis for identifying potential diagnostic and therapeutic targets.

METHODS

Mouse models of IC/bladder pain syndrome (BPS) were established by intraperitoneal injection of cyclophosphamide and bladder tissue samples were collected for metabolomics and transcriptome analysis.

RESULTS

We found a total of 82 and 145 differential metabolites in positive ion modes and negative ion modes, respectively. Glycerophospholipid metabolism, choline metabolism in cancer, and nucleotide metabolism pathways were significantly enriched in the IC/BPS group. Transcriptome analysis demonstrated that 1069 upregulated genes and 1087 downregulated genes were detected. Importantly, the stronger enrichment for cell cycle pathway was observed in IC/BPS than that in normal bladder tissue, which may be involved in the process of bladder remodeling. Moreover, the inflammatory response and inflammatory factors related pathways were enriched in the IC/BPS group.

CONCLUSIONS

Our findings provide critical directions for further exploration of the molecular pathology underlying IC/BPS.

Validation of Distinct Bladder Pain Phenotypes Utilizing the MAPP Research Network Cohort

INTRODUCTION AND HYPOTHESIS

As interstitial cystitis/bladder pain syndrome (IC/BPS) likely represents multiple pathophysiologies, we sought to validate three clinical phenotypes of IC/BPS patients in a large, multi-center cohort using unsupervised machine learning (ML) analysis.

METHODS

Using the female Genitourinary Pain Index and O'Leary-Sant Indices, k-means unsupervised clustering was utilized to define symptomatic phenotypes in 130 premenopausal IC/BPS participants recruited through the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) research network. Patient-reported symptoms were directly compared between MAPP ML-derived phenotypic clusters to previously defined phenotypes from a single center (SC) cohort.

RESULTS

Unsupervised ML categorized IC/BPS participants into three phenotypes with distinct pain and urinary symptom patterns: myofascial pain, non-urologic pelvic pain, and bladder-specific pain. Defining characteristics included presence of myofascial pain or trigger points on examination for myofascial pain patients (p = 0.003) and bladder pain/burning for bladder-specific pain patients (p < 0.001). The three phenotypes were derived using only 11 features (fGUPI subscales and ICSI/ICPI items), in contrast to 49 items required previously. Despite substantial reduction in classification features, unsupervised ML independently generated similar symptomatic clusters in the MAPP cohort with equivalent symptomatic patterns and physical examination findings as the SC cohort.

CONCLUSIONS

The reproducible identification of IC/BPS phenotypes, distinguishing bladder-specific pain from myofascial and genital pain, using independent ML analysis of a multicenter database suggests these phenotypes reflect true pathophysiologic differences in IC/BPS patients.

Validation of a simple body map to measure widespread pain in urologic chronic pelvic pain syndrome: A MAPP Research Network study

PURPOSE

In patients with urologic chronic pelvic pain syndrome (UCPPS), the presence of widespread pain appears to identify a distinct phenotype, with a different symptom trajectory and potentially different response to treatment than patients with pelvic pain only.

MATERIALS AND METHODS

A 76-site body map was administered four times, at weekly intervals, to 568 male and female UCPPS participants in the MAPP Network protocol. The 76 sites were classified into 13 regions (1 pelvic region and 12 nonpelvic regions). The degree of widespread pain was scored from 0 to 12 based on the number of reported nonpelvic pain regions. This continuous body map score was regressed over other measures of widespread pain, with UCPPS symptom severity, and with psychosocial variables to measure level of association. These models were repeated using an updated body map score (0-12) that incorporated a threshold of pain ≥ 4 at each site.

RESULTS

Body map scores showed limited variability over the 4 weekly assessments, indicating that a single baseline assessment was sufficient. The widespread pain score correlated highly with other measures of widespread pain and correlated with worsened UCPPS symptom severity and psychosocial functioning. Incorporating a pain severity threshold ≥4 resulted in only marginal increases in these correlations.

CONCLUSIONS

These results support the use of this 13-region body map in the baseline clinical assessment of UCPPS patients. It provides reliable data about the presence of widespread pain and does not require measurement of pain severity, making it relatively simple to use for clinical purposes.

Urinary Sphingosine-1-Phosphate as a Biomarker for Bladder Pain Syndrome

IMPORTANCE

Sphingosine-1-phosphate (S1P) is a signaling molecule involved in inflammation and bladder contraction.

OBJECTIVES

The aims of this case-control pilot study were to compare urinary S1P concentrations in bladder pain syndrome (BPS) participants to controls and determine whether these concentrations correlate with disease severity and duration.

STUDY DESIGN

Adult females with BPS and controls were enrolled. Bladder pain syndrome participants completed an O'Leary-Sant questionnaire. Information on duration of symptoms and treatment history was obtained. Urinary S1P and creatinine concentrations were determined. Mann-Whitney U tests were used to compare groups, and Spearman correlation was used to test for associations between concentrations and duration and severity of symptoms.

RESULTS

Twenty-five participants were in each group. Median S1P concentration was 1,225 ng/dL in the BPS group and 2,183 ng/dL in the control group, which was significantly different (P < 0.0001). This difference did not persist when normalized to urinary creatinine (P = 0.58). No differences were noted in urinary S1P concentrations between treated and untreated participants (P = 0.53) or with symptom scores of 13 or greater and less than 13 (P = 0.69). Sphingosine-1-phosphate levels did not correlate with O'Leary-Sant scores (P = 0.08) or duration of symptoms (P = 0.67). Results did not change when using S1P concentrations normalized to creatinine.

CONCLUSIONS

This study demonstrated successful quantification of human urinary S1P concentrations. A difference in urinary S1P was found between BPS participants and controls but not when normalized to creatinine. While this is the first study to investigate urinary S1P as a biomarker for BPS, results suggest that it may have a potential role as a biomarker requiring further research.

Current position of neuromodulation for bladder pain syndrome/interstitial cystitis

PURPOSE OF REVIEW

Despite established effectiveness in overactive bladder and nonobstructive retention, neuromodulation's application in interstitial cystitis/bladder pain syndrome (IC/BPS) remains a topic of ongoing research. The purpose of this article is to review recent developments in neuromodulation as treatment of IC/BPS offering guidance for healthcare practitioners dealing with IC/BPS cases.

RECENT FINDINGS

Recent research underlines the promising role of sacral, tibial and pudendal neuromodulation in management of IC/BPS symptoms. Studies reveal encouraging outcomes, particularly in alleviating urgency and frequency symptoms. However, while urgency and frequency symptoms tend to improve, comprehensive pain relief remains a challenge. Percutaneous tibial nerve stimulation (PTNS) and transcutaneous tibial nerve stimulation (TTNS) stand out due to their minimal invasive nature. Existing literature points to the need for larger prospective studies with extended follow-up periods to validate the efficacy and sustainability of neuromodulation.

SUMMARY

Neuromodulation is a promising treatment modality for refractory IC/BPS. Due to the minimal invasive nature, they should be tried before rigorous surgery. However, the limited quantity of available data and the variability in pain relief outcomes necessitate cautious interpretation. The review emphasizes the need for further research.

Efficacy and safety of intravesical dimethyl sulfoxide treatment for patients with refractory Hunner-type interstitial cystitis: Real-world data postofficial approval in Japan

OBJECTIVES

To examine real-world data regarding intravesical dimethyl sulfoxide (DMSO) therapy after official approval as a treatment for Hunner-type interstitial cystitis (HIC) in Japan.

METHODS

This single institution, retrospective observational study was conducted between 2021 and 2022 to evaluate the outcomes of 30 patients with refractory HIC who received intravesical DMSO therapy according to the approved standardized regimen: administration of DMSO every 2 weeks for a total of 12 weeks. Treatment outcomes were evaluated using a 7-graded global response assessment scale, O'Leary and Sant's symptom and problem indices (OSSI/OSPI), the overactive bladder symptom score (OABSS), an 11-point pain intensity numerical rating scale, quality of life (QOL) score, and frequency volume chart variables. Related complications were also documented.

RESULTS

The response rates at 2, 4, 6, 8, 10, and 12 weeks were 36.7%, 43.3%, 53.3%, 60.0%, 70.0%, and 70.0%, respectively. Compared with baseline, OSSI/OSPI, pain intensity, urinary frequency, and the QOL score improved significantly from 4 weeks of treatment. The OABSS score and functional bladder capacity also showed a tendency toward moderate improvement, but the difference was not significant. The mean duration of symptom relapse after termination of treatment was 6.4 ± 3.9 months. No patients discontinued treatment due to adverse events, although acute bladder irritation during infusion was noted in 21 patients (70%), which disappeared within 3 days.

CONCLUSIONS

This study verifies the safety, moderately durable efficacy, and tolerability of the standard intravesical treatment with DMSO for HIC in Japan.

Research on symptoms composition, time series evolution, and network visualisation of interstitial cystitis based on complex network community discovery algorithm

We analyzed the symptoms composition of Interstitial Cystitis (IC), the regularity of the evolution of symptoms before and after treatment, and the visualization of the community network, to provide a reference for clinical diagnosis and treatment of Interstitial Cystitis. Based on the outpatient electronic case data of 552 patients with Interstitial Cystitis, we used a complex network community discovery algorithm, directed weighted complex network, and Sankey map to mine the data of the symptoms composition of Interstitial Cystitis, the evolution of symptoms before and after treatment and the visualization of the community network, to analyze the epidemiological characteristics of interstitial cystitis symptoms in the real world. By the community division of the complex network of interstitial cystitis symptoms, We finally obtained three core symptom communities. Among them, symptom community A (bladder-related symptoms) is the symptom community with the highest proportion of nodes (60.00%) in the complex network of Interstitial Cystitis, symptom community B (non-bladder-related symptoms 1) ranks second (32.00%) in a complex network of Interstitial Cystitis, and symptom community C (non-bladder-related symptoms 2) has the lowest proportion (8.00%). There is a complex evolutionary relationship between the symptoms of Interstitial Cystitis before and after treatment. Among the single symptoms before and after treatment, the decreased rate of Day frequency is 93.22%, and the reduced urgency rate is 93.07%. The decline rate of Nocturia was 82.33%. From the perspective of different communities, the overall symptoms of symptom community A decreased by 34.39% after treatment, the general symptoms of symptom community B decreased by 35.37%, and the prevalent symptoms of symptom community C decreased by 71.43%. In the case of using diet regulation treatment to treat bladder pain, the cure rate of bladder pain can reach 22.67%. The cure rate of burning in bladders can get 15.38% with Percutaneous Sacral neuromodulation, 96.95% with diet regulation treatment, and 100% with Percutaneous Sacral neuromodulation. When using behavioral physiotherapy to treat bladder pain, 3.57% of the patient's symptoms change to bladder discomfort; 4% of the patient's symptoms change to bladder discomfort when using oral medicine to treat bladder pain.Symptom research methods based on community findings can effectively explore the rule of symptom outcome of Interstitial Cystitis before and after treatment, and the results are highly interpretable by professionals. The cover image is based on the Original Article Research on symptoms composition, time series evolution, and network visualisation of interstitial cystitis based on complex network community discovery algorithm by Lei Pang et al., https://doi.org/10.1049/syb2.12083.

[The interpretation of the updated American Urological Association guideline of interstitial cystitis/bladder pain syndrome in 2022]

In 2022, American Urological Association updated the guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS). A significant change has been made in treatment recommendations. The updated guideline no longer divided treatments into first-line through sixth-line tiers. Instead, treatment is categorized into behavioral/non-pharmacologic, oral medicines, bladder instillations, procedures, and major surgery. This change emphasizes the heterogeneity of IC/BPS patients and the importance of individualized treatment, overturns traditional unreasonable ideas about hierarchical and progressive treatment, and encourages patients and physicians to make treatment decisions together. At the same time, the panel emphasized the importance of early implementation of cystoscopy in patients suspected of Hunner lesions and warned against the possibility of pentosan polysulfate causing a unique retinal pigmentary maculopathy. Urinary reconstruction surgery was considered to only be used as a last resort for the treatment of IC/BPS, and there is uncertainty about the overall balance between benefits and risks/burdens. The updated guideline provides a new understanding and decision-making basis for the diagnosis and treatment of IC/BPS. However, it should be noted that the clinical characteristics of Chinese patients should be considered in practice and the application of the guideline should be localized.

Hypertension and urologic chronic pelvic pain syndrome: An analysis of MAPP-I data

BACKGROUND

Urologic chronic pelvic pain syndrome (UCPPS), which includes interstitial cystitis/bladder pain syndrome (IC/BPS) and chronic prostatitis (CP/CPPS), is associated with increased voiding frequency, nocturia, and chronic pelvic pain. The cause of these diseases is unknown and likely involves many different mechanisms. Dysregulated renin-angiotensin-aldosterone-system (RAAS) signaling is a potential pathologic mechanism for IC/BPS and CP/CPPS. Many angiotensin receptor downstream signaling factors, including oxidative stress, fibrosis, mast cell recruitment, and increased inflammatory mediators, are present in the bladders of IC/BPS patients and prostates of CP/CPPS patients. Therefore, we aimed to test the hypothesis that UCPPS patients have dysregulated angiotensin signaling, resulting in increased hypertension compared to controls. Secondly, we evaluated symptom severity in patients with and without hypertension and antihypertensive medication use.

METHODS

Data from UCPPS patients (n = 424), fibromyalgia or irritable bowel syndrome (positive controls, n = 200), and healthy controls (n = 415) were obtained from the NIDDK Multidisciplinary Approach to the Study of Chronic Pelvic Pain I (MAPP-I). Diagnosis of hypertension, current antihypertensive medications, pain severity, and urinary symptom severity were analyzed using chi-square test and t-test.

RESULTS

The combination of diagnosis and antihypertensive medications use was highest in the UCPPS group (n = 74, 18%), followed by positive (n = 34, 17%) and healthy controls (n = 48, 12%, p = 0.04). There were no differences in symptom severity based on hypertension in UCPPS and CP/CPPS; however, IC/BPS had worse ICSI (p = 0.031), AUA-SI (p = 0.04), and BPI pain severity (0.02). Patients (n = 7) with a hypertension diagnosis not on antihypertensive medications reported the greatest severity of pain and urinary symptoms.

CONCLUSION

This pattern of findings suggests that there may be a relationship between hypertension and UCPPS. Treating hypertension among these patients may result in reduced pain and symptom severity. Further investigation on the relationship between hypertension, antihypertensive medication use, and UCPPS and the role of angiotensin signaling in UCPPS conditions is needed.

Urinary ATP may be a biomarker of interstitial cystitis/bladder pain syndrome and its severity

Urinary tract cells respond to bladder distension by releasing adenosine triphosphate (ATP). Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) exhibit elevated urinary ATP levels compared to asymptomatic controls. This study aimed to evaluate the potential of urinary ATP as a non-invasive biomarker for IC/BPS and its correlation with symptom severity. We included 56 patients diagnosed with IC/BPS and 50 asymptomatic controls. Urine samples were collected from both groups. Urinary ATP levels were quantified using the luciferin-luciferase bioluminescence method. The severity of IC/BPS symptoms was assessed using the visual analogue score (VAS), Interstitial Cystitis Symptom Index (ICSI), and Interstitial Cystitis Problem Index (ICPI) from the O'Leary-Sant score. We specifically examined the correlation between symptom scores and urinary ATP levels in IC/BPS patients. Urinary ATP levels were significantly higher in IC/BPS patients compared to the control group (P < 0.0001). There was a significant positive correlation between urinary ATP concentrations and VAS, ICPI, and ICSI scores among IC/BPS patients (P < 0.0001). The threshold value for ATP concentration was set at 56.6 nM, with an area under the receiver operating characteristic (ROC) curve of 0.811 (95% CI 0.730 - 0.892). Our findings indicate that IC/BPS patients excrete elevated amounts of ATP in their urine. This suggests that urinary ATP might serve as a non-invasive biomarker for IC/BPS, with a predictive potential in terms of symptom severity.

Multimodal therapies and strategies for the treatment of interstitial cystitis/bladder pain syndrome in Taiwan

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by bladder pain, frequency, and nocturia. The most common pathologies include chronic inflammation and bladder urothelium dysfunction. According to the bladder condition with or without Hunner's lesions, IC/BPS can be divided into "IC" in patients with Hunner's lesion (HIC) and "BPS" in those without Hunner's lesion (NHIC). Previous studies have reported greater central sensitization and interorgan cross-talk in patients with NHIC. Multimodal treatments have been recommended in clinical guidelines under the biopsychosocial model. The bladder-gut-brain axis has also been speculated, and multimodal therapies are necessary. Unfortunately, currently, no treatment has been reported durable for IC/BPS. Patients with IC/BPS usually experience anxiety, depression, holistic physical responses, and even threats to social support systems. The lack of durable treatment outcomes might result from inadequate diagnostic accuracy and differentiation of clinical phenotypes based on the underlying pathophysiology. Precision assessment and treatment are essential for optimal therapy under definite IC/BPS phenotype. This article reviewed currently available literature and proposed a diagnosis and treatment algorithm. Based on bladder therapy combined with suitable physical and psychological therapies, a well-grounded multimodal therapy and treatment algorithm for IC/BPS following a diagnostic protocol are indispensable.

The life experiences of women with interstitial cystitis/bladder pain syndrome: A qualitative phenomenological study

AIM

To explore the life experiences of women with interstitial cystitis.

DESIGN

A qualitative phenomenological study.

METHODS

Fifteen women with interstitial cystitis were recruited from a regional hospital in Taiwan using purposive sampling. Data were collected via one-on-one semistructured interviews and analysed using the Colaizzi's method. Rigorous testing was conducted to identify the themes and subthemes.

RESULTS

Four major themes were identified: torment, restriction, acceptance and empowerment. These themes reflect the life experiences of women with interstitial cystitis. They endured unrelenting physical and psychological distress and loneliness, experienced obstacles and limitations in daily living because of their symptoms, accepted reality and considered their symptoms as a part of everyday life and developed coping skills for the disease.

CONCLUSION

Medical care, psychological support and emotional venting are crucial for women with interstitial cystitis. Despite living a life full of frustrations and suffering caused by the unpredictable and unrelenting nature of interstitial cystitis, through external support and intrinsic positive cognitive reconstruction, women with interstitial cystitis gradually accepted that they were ill. They adapted to their situation, developed a suitable lifestyle and pace and ultimately achieved stable coexistence with the disease.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Although women with interstitial cystitis are affected by an incurable disease, through adequate assistance and reconstruction of perception, they can develop coping skills and stably coexist with their disease. There is a delicate dynamic balance between their lives and disease.

IMPACT

This study may help clinicians to understand patients' life experiences and provide suitable care. This may improve the quality of care provided to women with interstitial cystitis and help them adapt to their disease, thereby improving their life satisfaction.

REPORTING METHOD

This study was reported according to the COREQ checklist.

PATIENT OR PUBLIC CONTRIBUTION

Women with interstitial cystitis contributed to the study data.

The Persistency Index: a novel screening tool for identifying myofascial pelvic floor dysfunction in patients seeking care for lower urinary tract symptoms

BACKGROUND

Patients with myofascial pelvic floor dysfunction often present with lower urinary tract symptoms, such as urinary frequency, urgency, and bladder pressure. Often confused with other lower urinary tract disorders, this constellation of symptoms, recently termed myofascial urinary frequency syndrome, is distinct from other lower urinary tract symptoms and optimally responds to pelvic floor physical therapy. A detailed pelvic floor myofascial examination performed by a skilled provider is currently the only method to identify myofascial urinary frequency syndrome. Despite a high influence on quality of life, low awareness of this condition combined with no objective diagnostic testing leads to the frequent misdiagnosis or underdiagnosis of myofascial urinary frequency syndrome.

OBJECTIVE

This study aimed to develop a screening measure to identify patients with myofascial urinary frequency syndrome (bothersome lower urinary tract symptoms secondary to myofascial pelvic floor dysfunction) from patient-reported symptoms.

STUDY DESIGN

A population of patients with isolated myofascial urinary frequency syndrome was identified by provider diagnosis from a tertiary urology practice and verified by standardized pelvic floor myofascial examination and perineal surface pelvic floor electromyography. Least Angle Shrinkage and Selection Operator was used to identify candidate features from the Overactive Bladder Questionnaire, Female Genitourinary Pain Index, and Pelvic Floor Distress Index predictive of myofascial urinary frequency syndrome in a pooled population also containing subjects with overactive bladder (n=42), interstitial cystitis/bladder pain syndrome (n=51), and asymptomatic controls (n=54) (derivation cohort). A simple, summated score of the most discriminatory questions using the original scaling of the Pelvic Floor Distress Index 5 (0-4) and Genitourinary Pain Index 5 (0-5) and modified scaling of Female Genitourinary Pain Index 2b (0-3) had an area under the curve of 0.75. As myofascial urinary frequency syndrome was more prevalent in younger subjects, the inclusion of an age penalty (3 points added if under the age of 50 years) improved the area under the curve to 0.8. This score was defined as the Persistency Index (possible score of 0-15). The Youden Index was used to identify the optimal cut point Persistency Index score for maximizing sensitivity and specificity.

RESULTS

Using a development cohort of 215 subjects, the severity (Pelvic Floor Distress Index 5) and persistent nature (Female Genitourinary Pain Index 5) of the sensation of incomplete bladder emptying and dyspareunia (Female Genitourinary Pain Index 2b) were the most discriminatory characteristics of the myofascial urinary frequency syndrome group, which were combined with age to create the Persistency Index. The Persistency Index performed well in a validation cohort of 719 patients with various lower urinary tract symptoms, including overactive bladder (n=285), interstitial cystitis/bladder pain syndrome (n=53), myofascial urinary frequency syndrome (n=111), controls (n=209), and unknown diagnoses (n=61), exhibiting an area under the curve of 0.74. A Persistency Index score ≥7 accurately identified patients with myofascial urinary frequency syndrome from an unselected population of individuals with lower urinary tract symptoms with 80% sensitivity and 61% specificity. A combination of the Persistency Index with the previously defined Bladder Pain Composite Index and Urge Incontinence Composite Index separated a population of women seeking care for lower urinary tract symptoms into groups consistent with overactive bladder, interstitial cystitis/bladder pain syndrome, and myofascial urinary frequency syndrome phenotypes with an overall diagnostic accuracy of 82%.

CONCLUSION

Our study recommends a novel screening method for patients presenting with lower urinary tract symptoms to identify patients with myofascial urinary frequency syndrome. As telemedicine becomes more common, this index provides a way of screening for myofascial urinary frequency syndrome and initiating pelvic floor physical therapy even before a confirmatory pelvic examination.

Neutrophil-to-lymphocyte ratio as a promising non-invasive biomarker for symptom assessment and diagnosis of interstitial cystitis/bladder pain syndrome

BACKGROUND

Our study aims to investigate the association between the serum neutrophil-to-lymphocyte ratio (NLR) and interstitial cystitis (IC), as well as to explore whether NLR can serve as a diagnostic marker to distinguish IC from overactive bladder (OAB). We postulate that elevated NLR levels are intricately linked to the onset and clinical presentation of IC, and that the NLR profiles in OAB patients exhibit discernible disparities from those of IC patients.

METHODS

In a retrospective analysis, we scrutinized the medical records of 70 women diagnosed with IC/BPS, 20 women diagnosed with OAB, and a randomly selected cohort of 150 healthy women who underwent physical examinations during the same temporal frame. A comprehensive panel of blood tests was administered to all participants, and NLR was determined through the calculation of the neutrophil-to-lymphocyte proportion. Additionally, symptom assessment questionnaires and urination diaries were collected from IC/BPS patients.

RESULTS

NLR levels exhibited significant distinctions among the IC/BPS, Normal, and OAB groups (P < 0.001). Within the IC/BPS group, Hunner type interstitial cystitis (HIC) demonstrated notably divergent NLR levels in comparison to non-Hunner type interstitial cystitis (NHIC) (p = 0.001). Additionally, we observed positive correlations between NLR and Nighttime voids (r = 0.268, p = 0.029), ICPI (r = 0.327, p = 0.007), ICSI (r = 0.369, p = 0.002), PUF Symptom Scale (r = 0.263, p = 0.032), and PUF (r = 0.297, p = 0.015). The receiver operating characteristic (ROC) analysis yielded an area under the curve (AUC) of 0.765 for NLR in distinguishing IC/BPS from the Normal group, and an AUC of 0.707 in discerning IC from OAB. Furthermore, the AUC of NLR was 0.723 for identifying HIC and NHIC patients.

CONCLUSIONS

Our study unveils the prospective utility of serum NLR as a promising biomarker for both diagnostic and symptom evaluation purposes in IC/BPS patients. It effectively demarcates this condition from OAB, which presents with similar clinical features. Consequently, NLR demonstrates potential as a non-invasive diagnostic instrument to distinguish between the subtypes of IC, particularly HIC and NHIC, which manifest similar symptoms within the IC/BPS spectrum.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

Number of patients with interstitial cystitis/bladder pain syndrome seen before versus during the COVID-19 pandemic at an academic, urban, multisite urogynecology practice

OBJECTIVES

Little is known about the impact of the COVID-19 pandemic on interstitial cystitis/bladder pain syndrome (IC/BPS). We aim to compare the number of newly diagnosed IC/BPS cases and number of patients with flares prior to and during the pandemic.

METHODS

We conducted a retrospective cohort study of women ≥18 years who were diagnosed with or treated for IC/BPS between March 2019 and March 2021 at an academic, urban, multisite urogynecology practice. The primary outcome was the number of IC/BPS cases from March 1, 2019 to February 29, 2020 (pre-pandemic) compared with March 1, 2020 to February 28, 2021 (during pandemic). The secondary outcome was the number of patients with flares during those same two time periods. Demographic and clinical characteristics were compared using nonparametric tests and interrupted time series (ITS) was used to evaluate our outcomes of interest. p-Value <.05 was considered significant.

RESULTS

Fifty-four women (4.87% of new patients) were diagnosed with IC/BPS during the pandemic compared with 40 women pre-pandemic (4.05% of new patients). The median age was 35.0. Seventy-two percent were premenopausal, 75% sexually active, and 31% had anxiety, and there were no significant differences between groups. Although the number of patients newly diagnosed with IC/BPS was higher during the pandemic, the diagnosis rates between time periods were not statistically different. Thirty-five patients experienced flares during the pandemic compared with 49 patients the year prior (p = .43). This difference was also not statistically significant on ITS analysis.

CONCLUSIONS

Although more patients were diagnosed with IC/BPS during versus before the pandemic, the difference in diagnosis rates was not different between these periods.

Recurrence after postoperative intravesical instillation therapy in Hunner type interstitial cystitis

We performed a prospective, single-arm study comparing outcomes between transurethral ablation plus postoperative instillation of hyaluronic acid and chondroitin sulfate (HACS group) and transurethral ablation only in patients with Hunner type interstitial cystitis (historical control group). A total of 78 patients were enrolled, and 51 were included in the per-protocol analysis set. The 2-year recurrence rate was 47.1% (95% CI, 32.9-61.5) in the HACS group, which was significantly lower than that in the control group (86.2%; 95% CI, 74.6-93.9, P < 0.001). After instillation therapy, the hazard ratio for recurrence was 0.38 (95% CI, 0.23-0.65, P < 0.001). The HACS group had an increased recurrence-free survival with the median interval not being reached, while it was 11.4 months in the control group (95% CI, 8.8-13.8, P < 0.001). Regardless of the instillation treatment, there were significant improvements in all symptom questionnaire scores and pain compared to the baseline. However, in the instillation group, improvement was stable even after 12 months. In patients with Hunner type interstitial cystitis, intravesical instillation of hyaluronic acid and chondroitin sulfate after transurethral ablation significantly reduced the recurrence rate and maintained symptom improvement for more than 1 year.

Quality of life analysis in bladder pain syndrome/interstitial cystitis: implications for a multimodal integrated treatment

BACKGROUND

The aim of this study was to evaluate whether there is a higher prevalence of anxiety-depressive disorders in women with BPS/IC (bladder pain syndrome/interstitial cystitis) than in women with chronic non-neoplastic pain with or without fibromyalgia, to examine possible correlations between urological and psychiatric symptoms.

METHODS

The patients included in the study were divided into two groups: 1) group 0: patients with an existing diagnosis of BPS/IC. BPS/IC was confirmed by reviewing medical record; group 1+2: patients with chronic non-neoplastic pain, suffering from fibromyalgia or other types of chronic pain (chronic arthralgia or lower back pain). Three questionnaires were administered: PHQ-9 to investigate psychological symptoms, O'Leary Saint (ICSI-ICPI) to investigate urological symptoms in women with BPS/IC and BPI to investigate specifically pain.

RESULTS

The survey included 69 patients, 42 patients had a diagnosis of BPS/IC while 27 of them had chronic non-neoplastic pain. The average PHQ-9 Score was 10.3 in BPS/IC group, considered as major depression (score between 10 and 14); the average score of PHQ-9 was 6.9 in group 1+2, as in sub-threshold depression (between 5-9).

CONCLUSIONS

The chronic pain of BPS/IC can affect mood more than in other painful conditions, as more than half of this population has a score that identifies depression with the PHQ-9 questionnaire, confirming the hypothesis that the syndrome is associated with a higher prevalence of an anxious-depressive condition.

Bladder pain syndrome and pregnancy

Bladder pain syndrome (BPS) is a poorly understood condition. In pregnancy, lower urinary tract symptoms and pain are common, but the possibility of BPS is rarely considered and almost never explored. The consequences of BPS on pregnancy and vice versa are poorly understood, and management options appear to be limited. This article reviews the current evidence to allow us to better counsel, investigate, diagnose and manage patients with suspected or known BPS who fall pregnant or who are considering pregnancy. MEDLINE, EMBASE and PubMed were searched for a combination of mesh terms of keywords: 'cystitis', 'interstitial', 'bladder', 'pain' and 'pregnancy'. Relevant articles were identified, reviewed and further relevant articles identified from the references. CONCLUSION: BPS symptoms are very common in pregnancy, with limited data suggesting significant negative effects on the woman and pregnancy. There are safe options for investigation, diagnosis and management in pregnancy. There is a need to raise awareness of the impact of BPS symptoms in pregnancy and the available options for diagnoses and management, improving patient experience and outcomes. PATIENT SUMMARY: Patients with BPS or symptoms akin to BPS need not be abandoned in pregnancy. There is data to support them in making decisions around investigation and management in pregnancy.

Cystoscopy, an indispensable tool for the diagnosis and prognosis of bladder pain syndrome, takes nomograms for predicting recurrence

PURPOSE

We aimed to illustrate the importance of cystoscopy for the diagnosis and prognosis of bladder pain syndrome (BPS) or interstitial cystitis (IC).

METHODS AND MATERIALS

We designed a 4-year prospective follow-up study. Patients who underwent cystoscopy between May 2011 and July 2021 with a diagnosis of BPS/IC before surgery or positive cystoscopic findings during initial surgery at Peking University People's Hospital were enrolled. Data related to symptom recurrence were obtained through clinic visits and telephone follow-up. We compared the differences in clinical features of BPS/IC subtypes differentiated by cystoscopy and first created clinical predictive nomograms for BPS/IC.

RESULTS

A total of 141 patients were included. There was an 8.51% chance of BPS/IC being misdiagnosed as other diseases or other diseases being misdiagnosed as BPS/IC without cystoscopy. Patients with HIC had higher pain scores and ICPI, higher residual urine volume, lower first-sense-to-void, and maximum cystometric bladder capacities than NHIC. Nomogram Models showed that patients who with higher ICPI, ICSI and lower AMBC have a greater recurrence probability, and lesions in the trigone may indicate a greater likelihood of recurrence than lesions in other bladder walls.

CONCLUSIONS

Timely detection of bladder cancer and other diseases using cystoscopy can avoid poor treatment effects. BPS/IC subtypes can be classified according to mucosal changes under cystoscopy. Lesions in the bladder triangle can indicate a higher recurrence risk, which is important in follow-up treatment. We strongly recommend that cystoscopy should be included in the international BPS/IC diagnostic criteria.

Image Segmentation for High-Density Surface Electromyography Mappings of Pelvic Floor Muscle Activity of Women with Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) can result in pelvic floor muscle (PFM) overactivity. Current clinical assessment protocols include basic electromyographic assessment of PFM activation; however, they do not provide a comprehensive assessment localized to each region of the PFM. We examined the ability of high-definition features from intravaginal high-density surface electromyography (HD-sEMG) to assess the severity of PFM overactivity in female IC/BPS patients. HD-sEMG was collected from fifteen female IC/BPS patients and fifteen urologically healthy female controls. The 2D mappings of root mean squared amplitude (RMS) at rest normalized by maximal voluntary contraction (resting RMS ratios) were segmented via k-means to identify areas of peak activity and surrounding activity. Female IC/BPS patients exhibited significantly greater resting RMS ratios for peak activity (p=0.0096), surrounding activity (p=0.0003), and average activity (p=0.0016) compared to healthy female controls. Furthermore, the area of peak activity was significantly larger for female IC/BPS patients than for healthy female controls (p=0.0063). Image segmentation of intravaginal HD-sEMG provides a more robust biomarker of PFM as compared to current methods.

Early and recent exposure to adversity, TLR-4 stimulated inflammation, and diurnal cortisol in women with interstitial cystitis/bladder pain syndrome: A MAPP research network study

Both early (ELA) and recent life adversity (RLA) have been linked with chronic pain conditions and persistent alterations of neuroendocrine and inflammatory responses. Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a chronic urologic disorder characterized by bladder and/or pelvic pain, and excessive urinary frequency and/or urgency. IC/BPS has been associated with high levels of ELA as well as a distinct inflammatory signature. However, associations between ELA and RLA with inflammatory mechanisms in IC/BPS that might underlie the link between adversity and symptoms have not been examined. Here we investigated ELA and RLA in women with IC/BPS as potential risk factors for inflammatory processes and hypothalamic-pituitaryadrenal (HPA) abnormalities using data from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. Women with IC/BPS and healthy controls (n = 154 and 32, respectively) completed surveys, collected salivary cortisol at awakening and bedtime for 3 days, and gave a blood sample which was analyzed for 7 LPS-stimulated cytokines and chemokines (IL-6, TNFα, IL-1β, MIP1α, MCP1, IL-8, and IL-10). Two cytokine/chemokine composites were identified using principal components analysis. Patients with greater exposure to RLA or cumulative ELA and RLA of at least moderate severity showed elevated levels of a composite of all cytokines, adjusting for age, body mass index, and study site. Furthermore, there was a trending relationship between ELA and the pro-inflammatory composite score. Nocturnal cortisol and cortisol slope were not associated with ELA, RLA, or inflammation. The present findings support the importance of adverse events in IC/BPS via a biological mechanism and suggest that ELA and RLA should be assessed as risk factors for inflammation as part of a clinical workup for IC/BPS.

Clinically Important Differences for Pain and Urinary Symptoms in Urological Chronic Pelvic Pain Syndrome: A MAPP Network Study

PURPOSE

Symptom heterogeneity in interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome, collectively termed urological chronic pelvic pain syndrome, has resulted in difficulty in defining appropriate clinical trial endpoints. We determine clinically important differences for 2 primary symptom measures, pelvic pain severity and urinary symptom severity, and evaluate subgroup differences.

MATERIALS AND METHODS

The Multidisciplinary Approach to the Study of Chronic Pelvic Pain Symptom Patterns Study enrolled individuals with urological chronic pelvic pain syndrome. We defined clinically important differences by associating changes in pelvic pain severity and urinary symptom severity over 3 to 6 months with marked improvement on a global response assessment using regression and receiver operating characteristic curves. We evaluated clinically important differences for absolute and percent change and examined differences in clinically important differences by sex-diagnosis, presence of Hunner lesions, pain type, pain widespreadness, and baseline symptom severity.

RESULTS

An absolute change of -4 was clinically important in pelvic pain severity among all patients, but clinically important difference estimates differed by pain type, presence of Hunner lesions, and baseline severity. Pelvic pain severity clinically important difference estimates for percent change were more consistent across subgroups and ranged from 30% to 57%. The absolute change urinary symptom severity clinically important difference was -3 for female participants and -2 for male participants with chronic prostatitis/chronic pelvic pain syndrome only. Patients with greater baseline severity required larger decreases in symptoms to feel improved. Estimated clinically important differences had lower accuracy among participants with low baseline symptoms.

CONCLUSIONS

A reduction of 30%-50% in pelvic pain severity is a clinically meaningful endpoint for future therapeutic trials in urological chronic pelvic pain syndrome. Urinary symptom severity clinically important differences are more appropriately defined separately for male and female participants.

Centering Group Treatment for Women With Interstitial Cystitis/Bladder Pain Syndrome: A Prospective, Parallel-Group Cohort Study

IMPORTANCE

Women with interstitial cystitis/bladder pain syndrome (ICBPS) face isolation and treatment challenges. Group medical visits using Centering models have successfully treated other conditions but have not been explored in ICBPS.

OBJECTIVE

This study aimed to describe ICBPS pain and symptom control comparing standard treatment alone versus standard treatment augmented with Centering visits.

STUDY DESIGN

This prospective cohort study recruited women with ICBPS receiving standard care (control) or standard care augmented with group Centering. We administered validated questionnaires at baseline and monthly for 12 months. The primary outcome was change in the pain numerical rating scale, with Patient-Reported Outcomes Measurement Information System Pain Interference Scale and Bladder Pain/Interstitial Cystitis Symptom Score change as secondary measures.

RESULTS

We enrolled 45 women (20 Centering, 25 controls). Centering had significantly better numerical rating scale pain scores at 1 month (mean difference [diff], -3.45) and 2 months (mean diff, -3.58), better Patient-Reported Outcomes Measurement Information System Pain Interference Scale scores at 1 month (mean diff, -10.62) and 2 months (mean diff, -9.63), and better Bladder Pain/Interstitial Cystitis Symptom Score scores at 2 months (mean diff, -13.19), and 3 months (mean diff, -12.3) compared with controls. In modeling, treatment group (Centering or control) and educational levels were both associated with all the outcomes of interest. Beyond 6 months, there were too few participants for meaningful analyses.

CONCLUSIONS

Women with ICBPS participating in a Centering group have, in the short term, less pain, pain interference, and ICBPS-specific symptoms than patients with usual care alone. Larger studies with more follow-up are needed to determine if this treatment effect extends over time.

Overactive bladder with urodynamic study-induced bladder pain: An overactive bladder subtype with symptoms similar to those of interstitial cystitis/painful bladder syndrome

Overactive bladder (OAB) and interstitial cystitis/painful bladder syndrome (IC/PBS) are 2 lower urinary tract disorders with urgency and bladder pain for diagnosis and with several other shared symptoms. Because of their overlapping symptoms, precise differential diagnosis of OAB and IC/PBS remains difficult. Thus, we characterize a subgroup of OAB with bladder pain (OAB-BP) that can be differentiated from OAB alone by urodynamic study (UDS) findings. We also further examined the clinical presentations and urodynamic parameters of OAB alone, OAB-BP, and IC/PBS. Data were collected between September 2018 and April 2019. Patients were categorized into 3 groups, OAB-alone (no bladder pain during UDS, n = 39), OAB-BP (with bladder pain during UDS, n = 35), and IC/PBS (the comparator, n = 39). Chi-square tests were used to compare OAB alone, OAB-BP, and IC/PBS with respect to their clinical presentations and urodynamic parameters. Factors with P < .05 were further analyzed through post hoc comparisons with Bonferroni adjustment. An unique subgroup of OAB patients was identified (i.e., OAB-BP), bladder pain can only be induced at maximal cytometric capacity during UDS. We also identified that the case histories and UDS parameters (e.g., low first desire, normal desire, and maximum cytometric capacity) of the OAB-BP group were more similar to those of the IC/PBS group than to those of the OAB-alone group. The OAB-BP group and the IC/PBS group reported more intrusive, longer-lasting symptoms before their final diagnoses, more extensive family history of urinary tract disorder, and more associated comorbidities (e.g., irritable bowel syndrome, and myofascial pain) than the OAB-alone group. The UDS assessment induced bladder pain in the OAB-BP group to reveal their hidden symptoms. Careful attention to patient history and sophisticated UDS evaluation may help to identify this unique OAB group.

Development of a patient-centered text message-based platform for the self-management of interstitial cystitis/bladder pain syndrome symptoms

OBJECTIVE

To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks.

RESULTS

Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother).

CONCLUSION

A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

Is There a Role for Bladder Biopsy in the Diagnosis of Non-Hunner Lesions Interstitial Cystitis?

INTRODUCTION

Bladder pain syndrome/interstitial cystitis (BPS/IC) is either Hunner lesion interstitial cystitis (HL IC) or non-Hunner lesion interstitial cystitis (N-HL IC), differing in the presence of HLs on cystoscopy. Cystoscopy is essential in diagnosing HL but are bladder biopsies useful in N-HL IC patients? Our objective was to assess bladder biopsy in patients with N-HL IC, evaluating whether the count of mast cells (MCs) and percentage of activated MCs could measure severity.

MATERIALS AND METHODS

This is a single-centre retrospective study.

INCLUSION CRITERIA

diagnosis of BPS/IC by ESSIC definition; absence of HLs. Each patient had three bladder biopsies.

STATISTICAL ANALYSIS

χ2/Fischer's exact test; Wilcoxon signed-ranks test/Mann-Whitney U test. Statistical significance: p < 0.05.

RESULTS

We separated 48 women into Group 1 with <50% of MCs activated and Group 2 with >50%. We compared the results of the O'Leary-Sant questionnaire between the two groups and did not find any correlation between the severity of the pathology and either the MC count in the detrusor or the percentage of activated MCs in the lamina propria or detrusor.

DISCUSSION/CONCLUSION

These findings cast doubt on the usefulness of bladder biopsy for the evaluation of severity in N-HL IC.

Food Sensitivities in a Diverse Nationwide Cohort of Veterans With Interstitial Cystitis/Bladder Pain Syndrome

PURPOSE

Prior studies suggest that certain foods exacerbate interstitial cystitis/bladder pain syndrome symptoms. However, these studies were limited in size and demographics. We assessed the presence of diet sensitivities among patients with interstitial cystitis/bladder pain syndrome and compared them with patients with other pelvic pain conditions and healthy controls.

MATERIALS AND METHODS

We identified Veterans Affairs patients nationwide by querying ICD-9/10 codes for interstitial cystitis/bladder pain syndrome. Patients were assigned to interstitial cystitis, other pelvic pain, or healthy control cohorts after chart review. We mailed all patients the Shorter-Moldwin Food Sensitivity Questionnaire to evaluate the self-perceived effects of specific foods/beverages on urinary symptoms and/or bladder pain.

RESULTS

In the interstitial cystitis/bladder pain syndrome cohort, 70% had ≥1 food sensitivity vs 37% of the other pelvic pain cohort and 32% of healthy controls (P < .001). The average number of sensitivities were similar between other pelvic pain conditions and healthy control cohorts, which were significantly less than in interstitial cystitis/bladder pain syndrome patients. Interstitial cystitis/bladder pain syndrome patients were more sensitive to acidic, spicy foods, and certain beverages vs other cohorts (all P < .001). Within the interstitial cystitis/bladder pain syndrome cohort, Black patients had significantly higher sensitivity to alcoholic and noncaffeinated beverages than Whites. Black patients did report significantly worsened urinary urgency than Whites (P < .05).

CONCLUSIONS

In a diverse population of veterans, interstitial cystitis/bladder pain syndrome patients had significantly more food sensitivities than those without interstitial cystitis/bladder pain syndrome. This suggests that food sensitivities could be suggestive of interstitial cystitis/bladder pain syndrome, which could make the Shorter-Moldwin Food Sensitivity Questionnaire a helpful diagnostic tool and aid in distinguishing interstitial cystitis/bladder pain syndrome from conditions often confused with interstitial cystitis/bladder pain syndrome.

Compensatory coping and depression in women with interstitial cystitis/bladder pain syndrome

INTRODUCTION

Women with genitourinary pain, a hallmark symptom of interstitial cystitis/bladder pain syndrome (IC/BPS), are at a two- to four-fold risk for depression as compared to women without genitourinary pain. Despite the pervasive impact of IC/BPS on psychological health, there is a paucity of empirical research on understanding the relation between IC/BPS and psychological distress. It has been previously reported that women with overactive bladder use increased compensatory coping and these behaviors are associated with heightened anxiety and stress. However, it is unknown whether a similar pattern emerges in IC/BPS populations, as ICBPS and OAB share many similar urinary symptoms. The current study examined the relationship between compensatory coping behaviors and symptoms of psychological distress in a sample of women with IC/BPS to inform understanding of risk and potential mechanisms for intervention.

METHOD

This was a secondary analysis of an observational cohort of women with bladder symptoms. Fifty-five adult women with IC/BPS completed validated assessments of genitourinary symptoms, emotional distress, and bladder coping behaviors. Five compensatory coping behaviors were summed to create a total Bladder Coping Score. Linear regression examined associations between individual coping behaviors, total compensatory coping scores, and other risk variables.

RESULTS

Most (93%) participants reported use of at least one compensatory coping behavior. Age, education level, history of vaginal birth, and symptom severity were all associated with greater compensatory coping scores, and anxiety was not. Beyond the influence of symptom severity, higher levels of depression were significantly associated with higher compensatory coping scores.

DISCUSSION

Greater compensatory coping was associated with increased depression but not anxiety, suggesting different profiles of coping and psychological distress may exist among different types of bladder dysfunction.

Broaden Horizons: The Advancement of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating disease that induces mental stress, lower urinary symptoms, and pelvic pain, therefore resulting in a decline in quality of life. The present diagnoses and treatments still lead to unsatisfactory outcomes, and novel diagnostic and therapeutic modalities are needed. Although our understanding of the etiology and pathophysiology of IC/BPS is growing, the altered permeability of the impaired urothelium, the sensitized nerves on the bladder wall, and the chronic or intermittent sensory pain with inaccurate location, as well as pathologic angiogenesis, fibrosis, and Hunner lesions, all act as barriers to better diagnoses and treatments. This study aimed to summarize the comprehensive information on IC/BPS research, thereby promoting the progress of IC/BPS in the aspects of diagnosis, treatment, and prognosis. According to diverse international guidelines, the etiology of IC/BPS is associated with multiple factors, while the presence of Hunner lesions could largely distinguish the pathology, diagnosis, and treatment of non-Hunner lesions in IC/BPS patients. On the basis of the diagnosis of exclusion, the diverse present diagnostic and therapeutic procedures are undergoing a transition from a single approach to multimodal strategies targeting different potential phenotypes recommended by different guidelines. Investigations into the mechanisms involved in urinary symptoms, pain sensation, and bladder fibrosis indicate the pathophysiology of IC/BPS for further potential strategies, both in diagnosis and treatment. An overview of IC/BPS in terms of epidemiology, etiology, pathology, diagnosis, treatment, and fundamental research is provided with the latest evidence. On the basis of shared decision-making, a multimodal strategy of diagnosis and treatment targeting potential phenotypes for individual patients with IC/BPS would be of great benefit for the entire process of management. The complexity and emerging evidence on IC/BPS elicit more relevant studies and research and could optimize the management of IC/BPS patients.

Pelvic Floor Myofascial Pain Might Influence Treatment Outcome of Interstitial Cystitis/Bladder Pain Syndrome: A Prospective Study

BACKGROUND

In patients with interstitial cystitis or bladder pain syndrome (IC/BPS), 85% were found to have pelvic floor myofascial pain (PFMP) and hypertonicity (PFH). However, they physicians are not typically trained to consider or assess PFMP as a contributing factor to patients' IC/BPS symptoms.

OBJECTIVE

This study aimed to explore the relationship between PFMP and treatment outcomes in women with IC/BPS.

STUDY DESIGN

A prospective study.

SETTING

Department of Urology, Medical Center, Hualien, Taiwan.

METHODS

Patients with IC/BPS who received any type of treatment were prospectively enrolled. They underwent vaginal digital examination at baseline. PFMP severity was quantified on the visual analog scale (VAS). Subject assessment items included O'Leary-Sant symptom score (OSS), Global Response Assessment (GRA), and Beck's anxiety inventory. Object assessment items included bladder computed tomography (CT), urodynamic parameters, maximum bladder capacity, and grade of glomerulation.

RESULTS

A total of 65 women with IC/BPS (mean age, 57.1 ± 11.3 years) were enrolled in the study. Patients with more severe PFMP had significantly higher rate of dyspareunia (P = 0.031); more comorbidities (P = 0.010); higher number of PFMP sites (P < 0.001); and higher OSS (P = 0.012). PFMP severity was not significantly correlated with bladder conditions, whether subjective or objective. Moreover, PFMP severity (VAS) was significantly negatively associated with the GRA score.

LIMITATIONS

There was a small sample size and short follow-up duration, the patients in this study are all women, and the applicability to other populations is uncertain.

CONCLUSION

PFMP might affect the subjective results of IC/BPS treatment but not the bladder condition. Therefore, in the future treatment of patients with IC/BPS, digital vaginal examinations of pelvic floor muscles should be performed and focused more on the PFM-related conditions, and necessary PFM treatments, such as the vaginal pelvic floor muscle message, should be scheduled.

Long-Term Symptom Trajectories in Urologic Chronic Pelvic Pain Syndrome: A MAPP Research Network Study

OBJECTIVE

To characterize Urologic Chronic Pelvic Pain Syndrome (UCPPS) pain and urinary symptom trajectories with up to 9 years of follow-up and evaluate whether initial 1-year trajectories are associated with longer-term changes.

MATERIALS AND METHODS

Data were analyzed from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Network's prospective observational protocols including the Epidemiology and Phenotyping Study (EPS; baseline to Year 1), EPS Extension (EXT; Years 1-5), and Symptom Patterns Study (SPS: 3-year study; Years 3-9). Adults with Interstitial Cystitis/Bladder Pain Syndrome or Chronic Prostatitis/Chronic Pelvic Pain Syndrome provided patient-reported assessments biweekly (EPS), every 4 months (EXT), or quarterly (SPS). Primary outcomes were composite pain (0-28) and urinary (0-25) severity scores. Multi-phase mixed effects models estimated outcomes over time, adjusted for baseline severity and stratified by EPS symptom trajectory.

RESULTS

163 participants (52% women; mean ± SD age 46.4 ± 16.1 years) completed EPS and enrolled in EXT; 67 also enrolled in SPS. Median follow-up was 4.6 years (range 1.3-9.0). After 1 year: 27.6%, 44.8% and 27.6% and 27.0%, 38.0% and 35.0% were improved, stable or worse in pain and urinary symptom severity, respectively. On average, pain and urinary symptom scores did not change further during EXT and SPS periods.

CONCLUSIONS

Women and men with UCPPS showed remarkable stability in pain and urinary symptom severity for up to 9 years, irrespective of their initial symptom trajectory, suggesting UCPPS is a chronic condition with stable symptoms over multiple years of follow-up.

The cumulative effect of unmet social needs on noncancerous genitourinary conditions and severity of lower urinary tract symptoms

PURPOSE

There is growing awareness on how social determinants of health may significantly influence health outcomes. The purpose of this study was to investigate the relationship between unmet social needs and the incidence and severity of multiple noncancerous genitourinary conditions.

MATERIALS AND METHODS

A community-based sample of United States adults was recruited electronically to complete questionnaires on clinical and demographic information, urinary symptoms, and social needs. Logistic regression was used to assess the effect between the number of unmet social needs and various noncancerous genitourinary conditions and severity of lower urinary tract symptoms. Model was adjusted for age, gender, race, insurance, and type of living community.

RESULTS

A total of 4,224 participants were included for final analysis. The incidence of all genitourinary conditions assessed was associated with an increasing number of unmet social needs. Additionally, having three or more unmet social needs, as compared to no needs, was associated with an increased risk of all conditions and worse symptoms-including a 23.7% increased risk of interstitial cystitis (95% confidence interval [CI] 18.8%-28.7%, p < 0.001), 21.9% risk of urge urinary incontinence (95% CI 16.8%-27.0%, p < 0.001), and 20.6% risk of overactive bladder (95% CI 15.6-25.7, p < 0.001).

CONCLUSIONS

Unmet social needs are associated with an increased incidence of noncancerous genitourinary conditions as well as worse symptom severity, with multiple unmet social needs displaying a cumulative effect. These findings suggest that there is utility in screening patients for unmet social needs, and that the healthcare system should develop a more integrated approach to manage  patients with urinary conditions.

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.

Clinical presentation, videourodynamic characteristics, and treatment outcome in men with interstitial cystitis-like lower urinary tract symptoms

PURPOSE

In men, lower urinary tract symptoms (LUTS) similar to interstitial cystitis/bladder pain syndrome (IC/BPS) are difficult to diagnose, and treatment outcomes are poor. This study investigated clinical characteristics and videourodynamic study (VUDS) parameters, pathophysiology, and treatment outcomes in men with IC-like LUTS.

METHODS

Men with frequency, urgency, dysuria, and bladder pain initially diagnosed as IC/BPS by ESSIC criteria were assessed to rule out other lower urinary tract diseases (LUTD) by voiding diary, digitorectal examination, urinalysis, VUDS, and cystoscopic hydrodistention. Subsequent treatments for LUTD and specific treatment for IC/BPS were based on VUDS and cystoscopic findings. Clinical VUDS characteristics and treatment outcomes were compared with those of women with IC/BPS.

RESULTS

Seventy consecutive men (median age 54.5 years) were enrolled. The median maximum bladder capacity under cystoscopic hydrodistention was 650 mL (IQR 495-763) and glomerulation grade was 2 (1.0-2.0). The patients had moderate anxiety and depression severity; 49% had improved treatment outcomes. On VUDS, 42 (60%) patients had variable LUTD, including detrusor overactivity (n = 14), bladder neck dysfunction (n = 15), dysfunctional voiding (n = 3), and poor relaxation of the external sphincter (n = 24); also, 22 (31.4%) had a previous bladder outlet procedure. The self-reported treatment outcome was significantly better for patients with vs. without LUTD (p = 0.014).

CONCLUSIONS

Men with IC-like LUTS diagnosed as IC/BPS may have bladder outlet dysfunction as well as bladder dysfunction, causing a hypersensitive and painful bladder. The IC-like symptoms in the patients with LUTD might, in part, originated from bladder outlet dysfunction rather than the bladder alone.

Corneal Sensation and Nerve Fiber Changes in Patients With Interstitial Cystitis

PURPOSE

Central sensitization syndromes are associated with ocular surface discomfort and certain changes in corneal sensation. The aim of this study was to evaluate corneal changes in patients with interstitial cystitis (IC).

METHODS

Thirty patients with IC and 32 healthy control subjects were included in this study. All patients had a detailed ophthalmological examination including measurement of corneal sensation with Cochet-Bonnet esthesiometer, tear breakup time, Schirmer I test, and Ocular Surface Disease Index questionnaire. After these examinations, corneal subbasal nerve plexus of the patients was evaluated with in vivo corneal confocal microscopy (IVCM) and the images were analyzed using fully automated software (ACC Metrics Corneal Nerve Fiber Analyzer V.2).

RESULTS

There was no significant difference between the groups regarding age and gender distribution. Corneal sensation was significantly higher in patients with IC (P = 0.03), whereas tear breakup time, Schirmer I test, and Ocular Surface Disease Index scores were similar between the patients and controls. IVCM demonstrated nerve fiber loss in patients with IC. Corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length were significantly reduced in patients with IC compared with healthy controls (P < 0.001, P = 0.04, and P < 0.001, respectively).

CONCLUSIONS

Patients with IC had increased corneal sensation and decreased nerve fiber density in IVCM analysis. Corneal nerve fiber loss might decrease the induction threshold of the remaining fibers to induce peripheral sensitization, which may also trigger central sensitization in long term.

Do medication prescription patterns follow guidelines in a cohort of women with interstitial cystitis/bladder pain syndrome?

OBJECTIVE

To describe prescription prevalence of oral bladder pain medications among women with interstitial cystitis/bladder pain syndrome (IC/BPS) and to compare with current treatment guidelines.

METHODS

We sampled female patients with an ICD-9/10 diagnosis of IC/BPS (595.1/N30.10) by querying active users of the Veterans Health Administration. Medical records were reviewed to determine whether patients met IC/BPS diagnostic criteria. A cohort of women with other pelvic pain disorders was identified. Prescription prevalence of typical non-narcotic oral bladder pain medications was compared between the two groups and healthy controls. Prescription prevalence was also compared before and after the diagnosis of IC/BPS was made using Poisson regression.

RESULTS

There were 641 women who met criteria for IC/BPS and 197 women with "Other pelvic pain" disorders. Women with IC/BPS were prescribed a pain medication more often than those with "Other pelvic pain" (77% vs. 59%, p < 0.0001). Of the women with IC/BPS, 44% tried three or more pain medications. Of women with a diagnosis of IC/BPS, only 67% were prescribed an American Urological Association-recommended medication. Prescription prevalence increased after diagnosis for both pentosan polysulfate (10%-29%, p < 0.0001) and hydroxyzine (17%-40%, p < 0.0001), but not for amitriptyline or cimetidine. Amitriptyline was prescribed to 223 women with IC/BPS, only 125 of which (56%) had a documented history of depression.

CONCLUSIONS

Many women with IC/BPS required multiple bladder prescriptions, highlighting the difficulty in finding an effective treatment for IC/BPS. Pentosan polysulfate and hydroxyzine were preferred IC/BPS medications. Our next step will be to analyze treatment patterns in those patients who did not receive medications.

Multimodal Single-Cell Analyses Outline the Immune Microenvironment and Therapeutic Effectors of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) has a significant impact on quality of life, but the etiopathogenesis remains largely unknown. The bladder microenvironment of patients with IC/BPS to obtain biological evidence supporting diagnosis and novel therapy is systematically characterized. Single-cell RNA sequencing (scRNA-seq) and image mass cytometry (IMC) are applied to bladder biopsies of the IC/BPS cohort. A total of 42 distinct cell clusters are identified from different groups. The increased hyperactivated Th1-biased response, but not Th2-biased response, and decreased immunosuppressive Treg are elucidated in the bladder microenvironment of non-Hunner-type IC (NHIC)/Hunner-type IC (HIC). M2/M2-like macrophage extends in the HIC and M1-like macrophage extends in NHIC, all of which secrete a range of chemokines with different pattern. The pro-inflammatory mediators, TNF-α, produced by tissue-resident macrophages and IL6, by the inflammatory fibroblasts are identified as key mediators of IC/BPS pathogenesis. Additionally, a regulatory network between different cell types is observed as a shift from structural cell communication in unaffected normal bladder to a Macrophage-Endothelial-dominated interactome in NHIC/HIC. The results demonstrate the high heterogeneity in NHIC/HIC, and provide an essential resource for diagnosis, and treatment of IC/BPS in the future by highlighting the importance of the microenvironment of bladder mucosa.

Reliability and Validity of Pain and Urinary Symptom Severity Assessment in Urological Chronic Pelvic Pain: A MAPP Network Analysis

PURPOSE

We assessed the reliability and validity of an efficient severity assessment for pelvic pain and urinary symptoms in urological chronic pelvic pain syndrome, which consists of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS

A total of 578 patients were assessed using brief, empirically derived self-report scales for pelvic pain severity (PPS) and urinary symptom severity (USS) 4 times during a 1-month period and baseline clinic visit that included urological, pain and illness-impact measures. Mild, moderate and severe categories on each dimension were examined for measurement stability and construct validity.

RESULTS

PPS and USS severity categories had adequate reliability and both discriminant validity (differential relationships with specific clinical and self-report measures) and convergent validity (common association with nonurological somatic symptoms). For example, increasing PPS was associated with pelvic tenderness and widespread pelvic pain, whereas USS was associated with urgency during a bladder filling test and increased sensory sensitivity. PPS and USS categories were independently associated with nonurological pain and emotional distress. A descriptive analysis identified higher likelihood characteristics associated with having moderate to severe PPS or USS or both. Lack of sex interactions indicated that the measures are comparable in interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome.

CONCLUSIONS

Women and men with urological chronic pelvic pain syndrome can be reliably subgrouped using brief self-report measures of mild, moderate or severe pelvic pain and urinary symptoms. Comparisons with a broad range of clinical variables demonstrate the validity and potential clinical utility of these classifications, including use in clinical trials, health services and biological research.

Demographic Differences and Disparities in the Misdiagnosis of Interstitial Cystitis/Bladder Pain Syndrome in a National Cohort of VA Patients

OBJECTIVE

To explore association between misdiagnosis of IC/BPS and demographics. Interstitial cystitis/bladder pain syndrome (IC/BPS) is associated with significant diagnostic uncertainty, resulting in frequent misdiagnosis as there is little known about the potential impact of key demographic factors.

METHODS

All patients in the VA system between 1999-2016 were identified by ICD-9/10 codes for IC/BPS (595.1/N30.10) (n = 9,503). ICD code accuracy for true IC/BPS (by strict criteria) was assessed by in-depth chart abstraction (n = 2,400). Associations were explored between rates of misdiagnosis and demographics.

RESULTS

IC/BPS criteria were met in only 651 (48.8%) of the 1,334 charts with an ICD code for IC/BPS reviewed in depth. There were no differences in the misdiagnosis rate by race (P=.27) or by ethnicity (P=.97), after adjusting for differences in age and gender. In IC/BPS-confirmed cases, female patients were diagnosed at a younger age than males (41.9 vs. 58.2 years, P<.001). Black and Hispanic patients were diagnosed at a younger age compared to White (41.9 vs. 50.2 years, P<.001) and non-Hispanic patients, respectively (41.1 vs. 49.1 years, P=.002).

CONCLUSION

There was a high rate of misdiagnosis of IC/BPS overall, with only 48.8% of patients with an ICD code for IC/BPS meeting diagnostic criteria. There were no significant associations between diagnostic accuracy and race/ethnicity. Black and Hispanic patients were more likely to receive a diagnosis of IC/BPS at a younger age, suggesting there may be differing natural histories or presentation patterns of IC/BPS between racial/ethnic groups.

New therapeutic approach with extracellular vesicles from stem cells for interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating chronic disorder characterized by suprapubic pain and urinary symptoms such as urgency, nocturia, and frequency. The prevalence of IC/BPS is increasing as diagnostic criteria become more comprehensive. Conventional pharmacotherapy against IC/BPS has shown suboptimal effects, and consequently, patients with end-stage IC/BPS are subjected to surgery. The novel treatment strategies should have two main functions, anti-inflammatory action and the regeneration of glycosaminoglycan and urothelium layers. Stem cell therapy has been shown to have dual functions. Mesenchymal stem cells (MSCs) are a promising therapeutic option for IC/BPS, but they come with several shortcomings, such as immune activation and tumorigenicity. MSC-derived extracellular vesicles (MSC-EVs) hold numerous therapeutic cargos and are thus a viable cell-free therapeutic option. In this review, we provide a brief overview of IC/BPS pathophysiology and limitations of the MSC-based therapies. Then we provide a detailed explanation and discussion of therapeutic applications of EVs in IC/BPS as well as the possible mechanisms. We believe our review will give an insight into the strengths and drawbacks of EV-mediated IC/BPS therapy and will provide a basis for further development. [BMB Reports 2022; 55(5): 205-212].

Female Pelvic Conditions: Chronic Pelvic Pain

Chronic pelvic pain (CPP) is defined as at least 6 months of pain originating from the lower abdomen or pelvis that is not associated with pregnancy. Symptoms include abdominal bloating, low back pain, and dyspareunia. CPP is considered a symptom and not a diagnosis. The etiology may involve a specific organ or condition (eg, endometriosis, adhesions). The most common associated conditions are endometriosis, interstitial cystitis, irritable bowel syndrome, and depression. The history and physical examination are essential in the evaluation. A comprehensive history that encompasses the gynecologic, obstetric, surgical, and psychosocial histories is key. The psychosocial history should include screening for depression, anxiety, posttraumatic stress disorder, and physical and sexual abuse because of their association with CPP. The physical examination should include musculoskeletal, abdominal, and gynecologic examinations. The choice of laboratory tests and imaging studies should be guided by the history and physical examination findings. Management is multimodal and involves management of associated conditions, pharmacotherapy, surgeries and procedures, physical therapy, and behavior and lifestyle therapies. The multidisciplinary care team typically consists of the primary care physician, subspecialty physicians (eg, gynecology, pain management, psychiatry, gastroenterology, urology), a physical therapist, and a behavioral health subspecialist.

Age-Related Macular Degeneration Masquerade: A Review of Pentosan Polysulfate Maculopathy and Implications for Clinical Practice

ABSTRACT

Pentosan polysulfate (PPS) sodium (Elmiron) is the only Food and Drug Administration (FDA)-approved oral medication to treat interstitial cystitis, also known as bladder pain syndrome. A symptomatic pigmentary maculopathy associated with PPS was reported in 2018. Since then, recognition of this unique drug toxicity has increased rapidly. This potentially sight-threatening side effect prompted the FDA in June 2020 to update the label for PPS to warn about "retinal pigmentary changes." A challenging feature of pentosan maculopathy is its ability to mimic many other retinal conditions, including inherited retinal dystrophies such as pattern dystrophy, mitochondrially inherited diabetes and deafness, and Stargardt disease, and age-related macular degeneration. In this review, we discuss the history of PPS maculopathy and its implications for thousands of at-risk interstitial cystitis patients. We use published literature and an illustrative case from our institution to highlight the importance of diagnosing PPS maculopathy. We also compare PPS maculopathy to age-related macular degeneration, explain why differentiating between the 2 is clinically important, and highlight avenues for further research. Finally, we highlight the paucity of data on patients of color and why this lack of understanding may impact patient care.

Diagnostic Utility of Serum and Urinary Metabolite Analysis in Patients with Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVE

To identify the potential biomarkers of interstitial cystitis/painful bladder syndrome (IC), a chronic syndrome of bladder-centric pain with unknown etiology that has an adverse impact on quality of life, we analyzed the urine and serum metabolomes of a cohort of IC patients and non-disease controls (NC).

METHODS

Home collection of serum and urine samples was obtained from 19 IC and 20 NC females in the Veterans Affairs (VA) Health Care System. IC was diagnosed independently by thorough review of medical records using established criteria. Biostatistics and bioinformatics analyses, including univariate analysis, unsupervised clustering, random forest analysis, and metabolite set enrichment analysis (MSEA), were then utilized to identify potential IC biomarkers.

RESULTS

Metabolomics profiling revealed distinct expression patterns between NC and IC. Random forest analysis of urine samples suggested discriminators specific to IC; these include phenylalanine, purine, 5-oxoproline, and 5-hydroxyindoleacetic acid. When these urinary metabolomics-based analytes were combined into a single model, the AUC was 0.92, suggesting strong potential clinical value as a diagnostic signature. Serum-based metabolomics did not provide potential IC discriminators.

CONCLUSION

Analysis of serum and urine revealed that women with IC have distinct metabolomes, highlighting key metabolic pathways that may provide insight into the pathophysiology of IC. The findings from this pilot study suggest that integrated analyses of urinary metabolites, purine, phenylalanine, 5-oxoproline, and 5-HIAA, can lead to promising IC biomarkers for pathophysiology of IC. Validation of these results using a larger dataset is currently underway.

Interstitial cystitis/bladder pain syndrome patient is associated with subsequent increased risks of outpatient visits and hospitalizations: A population-based study

Interstitial cystitis/bladder pain syndrome (IC/BPS) is not only a chronic urinary bladder pain syndrome but is also associated with multifactorial etiology. Our study aimed to test the hypothesis that IC/BPS is associated with subsequent increased risks of outpatient visits and hospitalizations. Using nationwide database, the diagnoses were based on the International Classification Codes (ICD-9-CM) (595.1) of at least three outpatient services during 2002-2008, (n = 27,990) and cystoscopic finding Hunner type and/or glomerulation with pre-audit criteria. All recruited cases monitored for subsequent outpatient visits and hospitalizations for 2 years, including all-cause and specialty-specific departments, were classified according to medical specialty and age group (<40, 40-60, ≥60 years of age). IC/BPS patients have more overall outpatient department (OPD) visits and an overall adjusted incidence rate ratio (IRR) of 1.64. As for specialty, IRRs were higher in psychiatry (2.75), Chinese medicine (2.01), and emergency medicine (2.00), besides urology and gynecology. The IRRs decreased as age advanced (2.01, 1.71, and 1.44, respectively), except for gynecology (2.42, 2.52, and 2.81). A similar phenomenon happens in hospitalization with IRR of 1.69. Due to claim data characteristics, whether ulcer type IC/BPS findings can be deductive to non-ulcer type remains inclusive. Current results indicate the impacts of healthcare burden in broad spectrum about IC/PBS patients. IC/BPS has been suggested to be associated with lower threshold of healthcare visits and some coexisting disease and is comprised of systemic dysregulation, and is beyond the scope of local bladder-urethra disease. Adequate recognition of associated or comorbid factors and possible recommendation or referral for IC/BPS patients can help provide better healthcare quality.

[BLADDER PAIN SYNDROME - DOES DETRUSOR MASTOCYTOSIS PREDICT SYMPTOMATIC IMPROVEMENT FOLLOWING BLADDER HYDRODISTENTION UNDER ANESTHESIA?]

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic, debilitating syndrome involving bladder pain and lower urinary tract symptoms (LUTS), with a substantial effect on patients' quality of life. IC/BPS poses a diagnostic challenge, and its available treatment options remain only moderately effective. Bladder-wall biopsies from IC/BPS patients commonly uncover mastocytosis. While mast-cells are suspected as pivotal in disease pathogenesis, the clinical significance of their presence remains unclear. Clinical guidelines differ on whether or not bladder biopsies should be a part of routine IC/BPS workup.

AIMS

To determine whether detrusor mastocytosis can serve as a prognostic marker for treatment response and improvement duration.

METHODS

We retrospectively collected patient data for IC/BPS patients who underwent bladder hydrodistension under anesthesia. We used statistical modelling to determine the effect of mastocystosis and other possible predictive factors - age, comorbidity, Hunner lesions - on the presence and duration of symptom improvement.

RESULTS

A total of 35 patients (89% female, median age 63.5 [IQR 48.8-73.6] years) underwent hydrodistension, of whom 28 (89% female, median age 63.0 [44.8-73.1] years) had bladder biopsies; 11 (39%) of them had mastocystosis. Within a median follow-up of 8.8 [1.7-24.2] months, 11 (100%) of the patients with mastocytosis and 9 (53%) of the patients without it, experienced symptomatic improvement (p=0.007). Improvement duration was 8 months longer (p=0.006) in those with mastocystosis. Univariate logistic regression models were used to estimate odds ratios (OR). Mastocytosis (p=0.004) and Charlson Comorbidity score were the only variables with a statistically significant OR. Univariate survival models were fitted, and improvement duration was estimated to be longer in patients with mastocystosis (p=0.01). A multivariate Cox regression model found no variable to be statistically significant, though mastocystosis was borderline significant (p=0.055).

CONCLUSIONS

Mastocystosis defines a discernible phenotype of IC/BPS, which exhibits higher rates and longer duration of hydrodistention treatment response.

DISCUSSION

Notwithstanding limitations of sample size and retrospective study design, we were able to demonstrate that mastocystosis can serve as a prognostic factor for symptom improvement after hydrodistension in IC/BPS patients. Prospective studies are required to validate this finding and to investigate the mechanisms involved.