What is the pain of interstitial cystitis like?

Modified Botulinum Toxin Type A Injections Improve Symptoms Associated With Interstitial Cystitis/Bladder Pain Syndrome in Women: A Retrospective Cohort Study

OBJECTIVE

To investigate the efficacy and safety of modified botulinum toxin type A (BoNT-A) injections (with additional periurethral injection [PUI] of BoNT-A) for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

This single-center, retrospective cohort study included 52 adult female patients with IC/BPS, with 24 patients receiving conventional BoNT-A injections and 28 receiving modified BoNT-A injections. The primary outcome measure was patient-reported global response assessment. Secondary outcomes included daytime frequency, nocturia, number of urinary urgency episodes in the voiding diary, pain visual analog score, O'Leary-Sant interstitial cystitis symptom index and interstitial cystitis problem index, pelvic pain and urgency/frequency scores, risk factors for recurrence, and postoperative recurrence-free time.

RESULTS

The median duration of follow-up was 16.0 months (interquartile range 11.75-21 months). Patients who underwent modified BoNT-A injections showed significant improvement in postoperative global response assessment, symptom questionnaires, and pain assessment compared with those who underwent conventional surgery. A statistically significant difference was observed between the 2 groups in terms of recurrence-free time (12.5 vs 18.0 months, P = .02). Subgroup analysis suggested that additional PUI of BoNT-A was more effective in patients with combined severe periurethral pain. No serious complications occurred in both groups, and all minor postoperative complications were temporary.

CONCLUSION

Modified BoNT-A injection is an effective treatment for IC/BPS that significantly reduces pain and improves voiding symptoms. It is particularly effective in patients with combined periurethral pain. In such patients, PUI of BoNT-A should be added to the routine intravesical injection of BoNT-A.

Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study

BACKGROUND

Understanding the relationship between chronic pain conditions and suicidal behavior-suicide attempt, other intentional self-harm, and death by suicide-is imperative for suicide prevention efforts. Although chronic pain conditions are associated with suicidal behaviors, these associations might be attributed to unmeasured confounding or mediated via pain comorbidity.

METHODS

We linked a population-based Swedish twin study (N=17,148 twins) with 10 years of longitudinal, nationwide records of suicidal behavior from health and mortality registers through 2016. To investigate whether pain comorbidity versus specific pain conditions were more important for later suicidal behavior, we modeled a general factor of pain and two independent specific pain factors (measuring pain-related somatic symptoms and neck-shoulder pain, respectively) based on 9 self-reported chronic pain conditions. To examine whether the pain-suicidal behavior associations were attributable to familial confounding, we applied a co-twin control model.

RESULTS

Individuals scoring one standard deviation above the mean on the general pain factor had a 51% higher risk of experiencing suicidal behavior (odds ratio (OR), 1.51; 95% confidence interval (CI), 1.34-1.72). The specific factor of somatic pain was also associated with increased risk for suicidal behavior (OR, 1.80; 95% CI, 1.45-2.22]). However, after adjustment for familial confounding, the associations were greatly attenuated and not statistically significant within monozygotic twin pairs (general pain factor OR, 0.89; 95% CI, 0.59-1.33; somatic pain factor OR, 1.02; 95% CI, 0.49-2.11) CONCLUSION: Clinicians might benefit from measuring not only specific types of pain, but also pain comorbidity; however, treating pain might not necessarily reduce future suicidal behavior, as the associations appeared attributable to familial confounding.

Female Sexual Dysfunctions and Urogynecological Complaints: A Narrative Review

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

Lifestyle and behavioral modifications made by patients with interstitial cystitis

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

New Insights about Chronic Pelvic Pain Syndrome (CPPS)

BACKGROUND

Chronic pelvic pain syndrome (CPPS) is one of the common diseases in urology and gynecology. CPPS is a multifactorial disorder where pain may originate in any of the urogynecological, gastrointestinal, pelvic musculoskeletal, or nervous systems. The symptoms of CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological, and endocrine systems. The aim of this article was to present new insight about CPPS in order to raise awareness of nursing and medical staff in the identification and diagnosis of the syndrome and to promote an appropriate treatment for each woman who suffers from CPPS.

METHODS

A literature review about the factors associated with CPPS and therapeutic interventions for CPPS was conducted.

RESULTS

CPPS represents a chronic pain syndrome that combines anatomic malfunction of the pelvic floor muscles with malfunction of pain perception linked with psychological and cognitive factors.

CONCLUSIONS

The therapeutic interventions in CPPS cases should, consequently, follow a multidisciplinary approach.

Characterization of Whole Body Pain in Urological Chronic Pelvic Pain Syndrome at Baseline: A MAPP Research Network Study

PURPOSE

We characterized the location and spatial distribution of whole body pain in patients with urological chronic pelvic pain syndrome using a body map. We also compared the severity of urinary symptoms, pelvic pain, nonpelvic pain and psychosocial health among patients with different pain patterns.

MATERIALS AND METHODS

A total of 233 women and 191 men with urological chronic pelvic pain syndrome enrolled in a multicenter, 1-year observational study completed a battery of baseline measures, including a body map describing the location of pain during the last week. Participants were categorized with pelvic pain if they reported pain in the abdomen and pelvis only. Participants who reported pain beyond the pelvis were further divided into 2 subgroups based on the number of broader body regions affected by pain, including an intermediate group with 1 or 2 additional regions outside the pelvis and a widespread pain group with 3 to 7 additional regions.

RESULTS

Of the 424 enrolled patients 25% reported pelvic pain only and 75% reported pain beyond the pelvis, of whom 38% reported widespread pain. Participants with a greater number of pain locations had greater nonpelvic pain severity (p <0.0001), sleep disturbance (p = 0.035), depression (p = 0.005), anxiety (p = 0.011), psychological stress (p = 0.005) and negative affect scores (p = 0.0004), and worse quality of life (p ≤0.021). No difference in pelvic pain and urinary symptom severity was observed according to increasing pain distribution.

CONCLUSIONS

Three-quarters of the men and women with urological chronic pelvic pain syndrome reported pain outside the pelvis. Widespread pain was associated with greater severity of nonpelvic pain symptoms, poorer psychosocial health and worse quality of life but not with worse pelvic pain or urinary symptoms.

Comparison of baseline urological symptoms in men and women in the MAPP research cohort

PURPOSE

The clinical features of the interstitial cystitis/bladder pain syndrome are similar to those of the chronic prostatitis/chronic pelvic pain syndrome. However, to our knowledge no studies have directly compared the characteristics of these syndromes in men and women.

MATERIALS AND METHODS

The MAPP Research Network recruited 191 men and 233 women with IC/BPS or CP/CPPS. Baseline data included demographics, Interstitial Cystitis Symptom Index and Problem Index scores; Genitourinary Pain Index score; American Urological Association Symptom Index score; Likert scales to assess urinary urgency, frequency, pain and overall symptom severity; and a single question about the most bothersome pelvic symptom.

RESULTS

After adjustment for age, income and symptom duration, measures of pain severity were similar across genders. Mean scores for the ICSI, ICPI and AUASI were significantly higher in women than in men, reflecting more bladder focused symptoms in women. The most bothersome single symptom in men as well as in women was pain in the pubic/bladder area (men 34%, women 58%). The characteristics of the men and women in the MAPP cohort were similar to those reported in other research cohorts for IC/BPS and CP/CPPS.

CONCLUSIONS

Our findings indicate that pain severity is similar for both genders and that bladder focused symptoms (urgency, suprapubic pain, frequency) are more common in women. However, a substantial proportion of men also reported these types of bladder symptoms.

Interstitial Cystitis - Elucidation of Psychophysiologic and Autonomic Characteristics (the ICEPAC Study): design and methods

BACKGROUND AND PURPOSE

Interstitial cystitis/bladder pain syndrome (IC/BPS) is relatively common and associated with severe pain, yet effective treatment remains elusive. Research typically emphasized the bladder's role, but given the high presence of systemic comorbidities, the authors hypothesized a pathophysiologic nervous system role. This paper reports the methodology and approach to study the nervous system in women with IC/BPS. The study compares neurologic, urologic, gynecologic, autonomic, gastrointestinal, and psychological features of women with IC/BPS, their female relatives, women with myofascial pelvic pain (MPP), and healthy controls to elucidate the role of central and peripheral processing.

METHODS AND RESULTS

In total, 228 women (76 IC/BPS, 76 MPP, 38 family members, and 38 healthy controls) will be recruited. Subjects undergo detailed screening, structured neurologic examination of limbs and pelvis, tender point examination, autonomic testing, electrogastrography, and assessment of comorbid functional dysautonomias. Interpreters are blinded to subject classification. Psychological and stress response characteristics are examined with assessments of stress, trauma history, general psychological function, and stress response quantification. As of December 2012, data collection is completed for 25 healthy controls, 33 IC/BPS ± MPP, eight MPP, and three family members. Recruitment rate is accelerating and strategies emphasize maintaining and encouraging investigator participation in study science, internet advertising, and presentations to pelvic pain support groups.

CONCLUSION

The study represents a comprehensive, interdisciplinary approach to sampling autonomic and psychophysiologic characteristics of women with IC/BPS. Despite divergent opinions on study methodologies based on specialty experiences, the study has proven feasible to date and different perspectives have proved to be one of the greatest study strengths.

Evidence for overlap between urological and nonurological unexplained clinical conditions

PURPOSE

Unexplained clinical conditions share common features such as pain, fatigue, disability out of proportion to physical examination findings, inconsistent laboratory abnormalities, and an association with stress and psychosocial factors. We examined the extent of the overlap among urological and nonurological unexplained clinical conditions characterized by pain. We describe the limitations of previous research and suggest several possible explanatory models.

MATERIALS AND METHODS

Using hallmark symptoms and syndromes as search terms a search of 12 databases identified a total of 1,037 full-length published articles in 8 languages from 1966 to April 2008. The search focused on the overlap of chronic pelvic pain, interstitial cystitis, painful bladder syndrome, chronic prostatitis/chronic pelvic pain syndrome or vulvodynia with fibromyalgia, chronic fatigue syndrome, temporomandibular joint and muscle disorders or irritable bowel syndrome. We abstracted information on authorship, type of case and control groups, eligibility criteria, case definitions, study methods and major findings.

RESULTS

The literature suggests considerable comorbidity between urological and nonurological unexplained clinical conditions. The most robust evidence for overlap was for irritable bowel syndrome and urological unexplained syndromes with some estimates of up to 79% comorbidity between chronic pelvic pain and symptoms of irritable bowel syndrome. However, most studies were limited by methodological problems, such as varying case definitions and selection of controls.

CONCLUSIONS

The overlap between urological and selected nonurological unexplained clinical conditions is substantial. Future research should focus on using standardized definitions, and rigorously designed, well controlled studies to further assess comorbidity, clarify the magnitude of the association and examine common pathophysiological mechanisms.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Methods and incentives for the early diagnosis of bladder pain syndrome/interstitial cystitis

INTRODUCTION

The concept of interstitial cystitis (IC) has changed dramatically during the last decades, eventually representing a symptom complex with varying contents. To include all patients with bladder pain, the umbrella term 'bladder pain syndrome' (BPS) has been suggested, incorporating the classic presentation of IC as a separate phenotype. This change of concepts has not been uncontroversial. Bladder pain syndrome often has a profound effect on the patients' quality of life. Generally, recognition of this problem complex is hampered by insufficient familiarity in the medical community. The correct diagnosis is often delayed by several years and may be preceded by multiple medical consultations and treatment attempts. There is no doubt that an early and correct diagnosis is of great significance for the patient.

AREAS COVERED

In this article, a critical review of methods and means to approach the diagnosis is presented including some notes of current controversies.

EXPERT OPINION

The key to an early diagnosis is symptom recognition. We are dealing with a heterogeneous concept including various phenotypes. The successful treatment requires understanding and expedient use of objective means, such as cystoscopy, biopsy and input from the multidisciplinary team. In the literature, limited evidence exists for the management of BPS/IC, due to heterogeneity in methodology and description of the syndrome(s). A more consequent use of available methods is desirable. For the immediate future, better understanding of the aetiology, pathogenesis and presentation of various BPS/IC phenotypes is indispensable.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Are ulcerative and nonulcerative interstitial cystitis/painful bladder syndrome 2 distinct diseases? A study of coexisting conditions

OBJECTIVES

Coexisting conditions associated with interstitial cystitis/painful bladder syndrome (IC/PBS) have not been fully explored by IC/PBS subtypes. We compared comorbid diagnoses/symptoms in women with ulcerative (ULC) and nonulcerative (N-ULC) IC/PBS and controls.

METHODS

Adult women with IC/PBS and controls without IC/PBS completed a mailed survey assessing for 21 diagnoses. IC/PBS subtype was determined by hydrodistention reports. Standardized questionnaires assessed IC/PBS symptoms (Interstitial Cystitis Symptom/Problem Indexes [ICSI-PI]) and for undiagnosed fibromyalgia, irritable bowel syndrome, and depression (Symptom Intensity Score [SIS]; Rome III Functional Bowel Questionnaire; Center for Epidemiologic Studies Depression Scale [CES-D]). Data were analyzed using the Pearson chi-square, Fisher exact, Wilcoxon rank test, or Spearman rank correlation coefficient.

RESULTS

Of 178 N-ULC IC/PBS patients, 36 ULC IC/PBS patients, and 425 controls, ULC IC/PBS subjects were older (median 63 years; P < .01) and less employed (P < .01), but groups were similar on other demographic characteristics. N-ULC reported more chronic diagnoses (mean 3.5 ± 2.3) than ULC (2.3 ± 2.0) and controls (1.2 ± 1.5) (P < .01). When N-ULC and ULC IC/PBS patients were compared, more N-ULC IC/PBS patients had fibromyalgia (P = .03), migraines (P = .03), temporomandibular joint disorder (P < .01), and higher CES-D (P = .02) and SIS scores (P = .01). The ULC IC/PBS group voided more frequently during the daytime (P = .03) and nighttime (P < .01) and had smaller mean bladder capacity than N-ULC (P < .01). No significant differences were seen between N-ULC and ULC IC/PBS patients on the ICSI-PI and Rome III.

CONCLUSIONS

Notable differences in the number of comorbid diagnoses and symptoms were seen between IC/PBS subtypes and controls. Subtypes should continue to be evaluated individually to ascertain other similarities and differences.

Urologic chronic pelvic pain syndrome

Painful bladder syndrome or urologic chronic pelvic pain syndrome is a chronic condition that presents with lower urinary tract symptoms that include dysuria, urgency, frequent urination, and chronic pelvic pain. Diagnoses included in the painful bladder syndrome are interstitial cystitis and prostatodynia. The history, physical examination, and laboratory evaluation of patients with lower urinary tract symptoms are important in ruling out other diagnoses. Treatment options that are US Food and Drug Administration approved and evidence based are limited; however, many symptom-based treatment options can reduce symptoms and improve quality of life.

The genetic and environmental contribution to the occurrence of bladder pain syndrome: an empirical approach in a nationwide population sample

BACKGROUND

The aetiology of bladder pain syndrome (BPS) remains poorly understood, and a number of pathogenic mechanisms have been proposed. The importance of genetic factors for BPS is receiving growing attention, but data so far are of a preliminary nature.

OBJECTIVE

To empirically assess the genetic and environmental contribution to BPS in a population-based sample of twins.

DESIGN, SETTING, AND PARTICIPANTS

The study included >25,000 twins born between 1959 and 1985. Individuals with BPS were identified using latent class cluster analysis (LCCA) based on self-reported symptoms from a nationwide screening for complex diseases in the Swedish Twin Registry. By comparing monozygotic and dizygotic twins, we estimated twin similarity and the relative proportions of phenotypic variance resulting from genetic and environmental factors.

MEASUREMENTS

Twin similarity was measured.

RESULTS AND LIMITATIONS

The LCCA yielded an overall BPS prevalence of 1.1% and 2.4% for males and females, respectively. In males, the contribution of genetic effects to BPS could not be assessed because of the small number of concordant twin pairs. In women, twin similarity estimates indicated a genetic component for the aetiology of BPS, but genetic factors contributed less than one-third of the total variation in susceptibility to BPS. Nonshared environmental factors accounted for more than two-thirds of the variance, whereas early nongenetic factors shared within the family were of little or no consequence to the risk of developing BPS later in life. Use of self-reported symptoms to define the disease phenotype is a limitation of the study.

CONCLUSIONS

The influence of environmental factors in the development of BPS in women is substantial, whereas genetic influences are of only modest importance for the possibility of developing the disease.

Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis

INTRODUCTION AND HYPOTHESIS

The objectives of this study are to investigate myofascial pain in patients with interstitial cystitis (IC) and to correlate myofascial exam findings with validated questionnaires.

METHODS

A retrospective chart review was performed on 186 patients with a diagnosis of IC from April 2007 to December 2008. Demographics, history and physical examination, and validated pelvic floor dysfunction questionnaire scores were extracted. The data was evaluated with SPSS for Windows using Spearman's rho, Mann-Whitney, and Kruskal-Wallis statistical analyses.

RESULTS

Myofascial pain was demonstrated in 78.3% of IC patients with at least one myofascial trigger point, and 67.9% of patients had numerous areas of trigger points. Mild correlations were seen with trigger points and scores from the PUF, PFDI-20, and PFIQ-7 questionnaires.

CONCLUSIONS

Myofascial pain is prevalent among IC patients and positively correlated with pelvic floor dysfunction scores. These findings support evaluation of pelvic floor myofascial pain in IC patients and suggest a possible benefit from pelvic floor therapy.

Evidence for overlap between urological and nonurological unexplained clinical conditions

PURPOSE

Unexplained clinical conditions share common features such as pain, fatigue, disability out of proportion to physical examination findings, inconsistent laboratory abnormalities, and an association with stress and psychosocial factors. We examined the extent of the overlap among urological and nonurological unexplained clinical conditions characterized by pain. We describe the limitations of previous research and suggest several possible explanatory models.

MATERIALS AND METHODS

Using hallmark symptoms and syndromes as search terms a search of 12 databases identified a total of 1,037 full-length published articles in 8 languages from 1966 to April 2008. The search focused on the overlap of chronic pelvic pain, interstitial cystitis, painful bladder syndrome, chronic prostatitis/chronic pelvic pain syndrome or vulvodynia with fibromyalgia, chronic fatigue syndrome, temporomandibular joint and muscle disorders or irritable bowel syndrome. We abstracted information on authorship, type of case and control groups, eligibility criteria, case definitions, study methods and major findings.

RESULTS

The literature suggests considerable comorbidity between urological and nonurological unexplained clinical conditions. The most robust evidence for overlap was for irritable bowel syndrome and urological unexplained syndromes with some estimates of up to 79% comorbidity between chronic pelvic pain and symptoms of irritable bowel syndrome. However, most studies were limited by methodological problems, such as varying case definitions and selection of controls.

CONCLUSIONS

The overlap between urological and selected nonurological unexplained clinical conditions is substantial. Future research should focus on using standardized definitions, and rigorously designed, well controlled studies to further assess comorbidity, clarify the magnitude of the association and examine common pathophysiological mechanisms.

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

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

Interstitial cystitis: bladder pain and beyond

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evidence-based criteria for pain of interstitial cystitis/painful bladder syndrome in women

OBJECTIVES

No diagnostic physical signs, urologic findings, or laboratory tests are available for interstitial cystitis/painful bladder syndrome (IC/PBS). Its diagnosis is determined by symptoms and the exclusion of mimicking diseases. We hypothesized that certain pain characteristics are sensitive criteria for diagnosing IC/PBS.

METHODS

In women with recent-onset IC/PBS recruited in 2004 to 2006 for the case-control study, "Events Preceding Interstitial Cystitis," we identified the locations of each patient's pain and in a nonleading way asked about the effects of 17 different experiences (criteria) on the pain. We identified a set of criteria that described the largest number of patients in the Events Preceding Interstitial Cystitis study. In a secondary analysis of another cohort recruited by others in 1993 to 1997, the Interstitial Cystitis Database, we determined the proportion of patients captured by these same criteria.

RESULTS

In the Events Preceding Interstitial Cystitis study, pain that worsened with a certain food or drink and/or worsened with bladder filling and/or improved with urination was reported by 151 (97%) of 156 patients. These were the only three criteria that applied directly to the bladder. The same three criteria described the pain of 262 (97%) of 270 women in the Interstitial Cystitis Database who "definitely" had IC/PBS.

CONCLUSIONS

An hypothesis generated in one IC/PBS patient group and tested in another--pain that worsened with certain food or drink and/or worsened with bladder filling and/or improved with urination--was described by 97% of the patients with IC/PBS in each cohort. This triad might describe the pain of IC/PBS and contribute to a sensitive case definition. Estimating specificity awaits comparison with other diseases with similar symptoms.

[Urethral and scrotal pain syndromes]

Painful diseases of the pelvis are not rare. Urethral and scrotal pains are part of the chronic pelvic pain syndromes along with chronic prostatitis and painful bladder syndrome/interstitial cystitis. The objective of this review is to update the current knowledge about epidimiology, etiology, diagnosis and best treatment for patients with urethral and scrotal pain syndromes. Epidemiological data for both syndromes are scant. We lack of uniform definition or readily available diagnostic marker and aetiology remains unclear. The pain could be a neuropathic without a specific stimulus or disproportionate to the stimulus intensity. Regarding diagnosis, there is no evidence to qualify or quantify the symptoms to include or exclude patients. Nevertheless, it is very important to know functional neuroanatomy in the evaluation of these patients. Treatment always should be primary conservatively. Surgery should be avoided if possible. As no specific treatment is available, decrease the pain is the main objective, therefore urologist should know how to manage analgesics, antidepressant and anticonvulsants.

Treatment approaches for painful bladder syndrome/interstitial cystitis

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a disease of unknown aetiology, characterised by severe pressure and pain in the bladder area or lower pelvis that is frequently or typically relieved by voiding, along with urgency or frequency of urination in the absence of urinary tract infections. PBS/IC occurs primarily in women, is increasingly recognised in young adults, and may affect as many as 0.1-1% of adult women. PBS/IC is often comorbid with allergies, endometriosis, fibromyalgia, irritable bowel syndrome and panic syndrome, all of which are worsened by stress. As a result, patients may visit as many as five physicians, including family practitioners, internists, gynaecologists, urologists and pain specialists, leading to confusion and frustration. There is no curative treatment; intravesical dimethyl sulfoxide, as well as oral amitriptyline, pentosan polysulfate and hydroxyzine have variable results, with success more likely when these drugs are given together. Pilot clinical trials suggest that the flavonoid quercetin may be helpful. Lack of early diagnosis and treatment can affect outcomes and leads to the development of hyperalgesia/allodynia.

Levator ani trigger point injections: An underutilized treatment for chronic pelvic pain

AIMS

We conducted this study to examine the role of trigger point injections in females with chronic pelvic pain (CPP) of at least 6 months duration and specific levator ani trigger points.

METHODS

This prospective study included 18 consecutive female patients with CPP and specific palpable levator ani trigger points. Pain was evaluated before and after trigger point injection on a Visual Analog Scale (VAS). Patient global satisfaction (PGS) and cure rates (PGC) were also measured by a VAS on a scale of 0-100%. The trigger points were identified manually by intravaginal palpation of the levator ani bilaterally. A mixture of 10 cc of 0.25% bupivacaine, 10 cc of 2% lidocaine and 1 cc (40 mg) of triamcinolone was used for injection of 5 cc per trigger point. A 5.5'' Iowa trumpet pudendal needle guide was used for injection. All but one injection were performed in the office setting without sedation. Pelvic floor muscle exercises were taught for use after injection. Success was defined as a decrease in pain as measured by a VAS of 50% or more, as well as PGS and PGC scores of 60% or greater. There was a mean follow up of 3 months after trigger point injection.

RESULTS

Thirteen of 18 women improved with the first trigger point injection resulting in a comprehensive success rate of 72%. Six (33%) of 18 women were completely pain free.

CONCLUSION

In the management of CPP, a non-surgical office-based therapy such as trigger point injections can be effective in selected patients.

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

PURPOSE

In women symptoms of interstitial cystitis are difficult to distinguish from those of painful bladder syndrome and they appear to overlap with those of urinary tract infection, chronic urethral syndrome, overactive bladder, vulvodynia and endometriosis. This has led to difficulties in formulating a case definition for interstitial cystitis, and complications in the treatment and evaluation of its impact on the lives of women. We performed a systematic literature review to determine how best to distinguish interstitial cystitis from related conditions.

MATERIALS AND METHODS

We performed comprehensive literature searches using the terms diagnosis, and each of interstitial cystitis, painful bladder syndrome, urinary tract infection, overactive bladder, chronic urethral syndrome, vulvodynia and endometriosis.

RESULTS

Of 2,680 screened titles 604 articles were read in full. The most commonly reported interstitial cystitis symptoms were bladder/pelvic pain, urgency, frequency and nocturia. Interstitial cystitis and painful bladder syndrome share the same cluster of symptoms. Chronic urethral syndrome is an outdated term. Self-reports regarding symptoms and effective antibiotic use can distinguish recurrent urinary tract infections from interstitial cystitis in some but not all women. Urine cultures may also be necessary. Pain distinguishes interstitial cystitis from overactive bladder and vulvar pain may distinguish vulvodynia from interstitial cystitis. Dysmenorrhea distinguishes endometriosis from interstitial cystitis, although many women have endometriosis plus interstitial cystitis.

CONCLUSIONS

In terms of symptoms interstitial cystitis and painful bladder syndrome may be the same entity. Recurrent urinary tract infections may be distinguished from interstitial cystitis and painful bladder syndrome via a combination of self-report and urine culture information. Interstitial cystitis and painful bladder syndrome may be distinguished from overactive bladder, vulvodynia and endometriosis, although identifying interstitial cystitis and painful bladder syndrome in women with more than 1 of these diseases may be difficult.

Assessing urgency in interstitial cystitis/painful bladder syndrome

OBJECTIVES

Interstitial cystitis/painful bladder syndrome (IC/PBS) at present is a symptom-based diagnosis. The Interstitial Cystitis Symptom Index (ICSI), also known as the O'Leary-Sant Symptom Index, is a widely used scale that assesses the four cardinal symptoms of IC/PBS (ie, bladder pain, urgency, frequency, and nocturia), by asking how often each is experienced. In an ongoing case-control study of recent-onset IC/PBS, we compared the ICSI with a series of questions that addressed the severity of these symptoms.

METHODS

Recruiting nationally, we enrolled women with IC/PBS symptoms of 12 months' duration or less. We assessed the severity of pain, frequency, and urgency using Likert and categorical scales, and how often these symptoms were experienced using the ICSI. We compared these scales by frequency distributions and interscale correlations.

RESULTS

In 138 women with recent-onset IC/PBS, the scores for frequency were correlated and, for pain, appeared to be complementary. However, for urgency, the ICSI question of "the strong need to urinate with little or no warning" consistently yielded lower scores than the severity question of "the compelling urge to urinate that is difficult to postpone." Some patients denied urgency to the ICSI question yet reported intense urgency to the severity question.

CONCLUSIONS

Compared with the severity question, the ICSI underestimated the prevalence and degree of urgency. This observation is consistent with the views of others that sudden urgency does not define the sensation experienced by many patients with IC/PBS. Clarifying this symptom description may assist in developing a usable case definition for IC/PBS.