Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS)

Resilience among adults with chronic urologic pelvic pain syndrome: A flexible self-regulation perspective

While coping with the heavy patient demands of chronic pain requires psychological resilience, its core mechanisms have not been systematically studied in high-impact pain disorders like Urologic Chronic Pelvic Pain Syndrome (UCPPS). Applying a flexible self-regulation (FSR) model of resilience, we sought to characterize how flexibility deficits in the abilities to read, decode, and respond appropriately to contextual cues (context sensitivity) and coping flexibility relative to known protective (e.g., pain-specific resilience, social support) and vulnerability factors (e.g., catastrophizing), correspond with symptom severity and quality of life (QoL) impairment in patients with refractory UCPPS symptoms. Participants included 113 (Mean age = 43.56, SD = 14.79, 81.4% female) formally diagnosed UCPPS (Interstitial Cystitis/Bladder Pain Syndrome or Chronic Prostatitis/Chronic Pelvic Pain Syndrome) patients with refractory pelvic pain. Baseline data, completed as part of an NIH clinical trial, included FSR components, Pain Resilience Scale, social support, Positive and Negative Affect Schedule, Coping Strategies Questionnaire - Catastrophizing, pelvic pain, and urinary severity indices, and QoL (CDC Healthy Days, PROMIS physical and mental health). Regression analyses, using a Bayesian variable selection method, examined how protective and vulnerability factors were associated with symptom and QoL outcomes. As predicted, context sensitivity and coping flexibility corresponded with higher QoL. The pattern of results was more consistent for components of FSR than for dispositional psychological factors including pain resilience, negative affectivity, and pain catastrophizing. Data demonstrates the importance of resilience rooted in a theory-informed, empirically grounded flexible self-regulation conceptual model. PERSPECTIVE: Flexible self-regulation, a cognitive-affective construct critical to the development of resilience, is important for understanding adaptation to nociplastic pain disorders like UCPPS. Contextual-based coping based on situational flexibility corresponds with quality of life, which may may be a novel therapeutic target for optimizing behavioral pain treatments for high-impact pain disorders.

Augmentation of Interstitial Cystitis-Bladder Pain Syndrome Treatment With Meditation and Yoga: A Randomized Controlled Trial

OBJECTIVE

To investigate whether yoga and meditation added to usual care improves treatment response in women with interstitial cystitis-bladder pain syndrome.

METHODS

This randomized trial compared women with interstitial cystitis-bladder pain syndrome receiving standard care alone (control group) with those receiving standard care plus meditation and yoga (mind-body group). Standard care was defined as behavioral changes or medications recommended by the American Urological Association. Individuals in the control group received standard care, and those in the mind-body group received standard care augmented with a commercially available meditation application and standardized yoga tutorial video. Both groups continued their current interstitial cystitis-bladder pain syndrome standard care treatments. The primary outcome was the modified GRA (Global Response Assessment), comparing responders (moderately, markedly improved) with nonresponders at 12 weeks. On power analysis assuming α=5% and β=80%, a sample size of 82 participants was required to find 30% difference on the GRA between groups. Weekly GRA scores over 12 weeks were also compared. Secondary outcomes included ICPI (Interstitial Cystitis Problem Index)/ICSI (Interstitial Cystitis Symptom Index), pain, pain interference, anxiety/depression, and self-efficacy scores and treatment escalation over 12 weeks.

RESULTS

Among 97 randomized participants (49 mind-body group, 48 control group), groups did not differ in characteristics or symptoms at baseline. The mind-body group had more GRA responders compared with the control group at 12 weeks (31/43 [72.1%] vs 10/39 [25.6%], relative risk [RR] 2.8, 95% CI, 1.6-4.6), corroborated by superior weekly GRA results over 12 weeks. The mind-body group had superior beneficial change on the ICPI (RR 1.8, 95% CI, 0.5-3.1), ICSI (RR 1.9, 95% CI, 0.2-3.6), and pain (RR 1.4, 95% CI, 0.4-2.5) scores than the control group at 12 weeks. The mind-body group required less treatment escalation than the control group (2/45 [4.4%] vs 14/42 [33.3%], RR 0.13, 95% CI, 0.03-0.55).

CONCLUSION

The addition of meditation and yoga to standard interstitial cystitis-bladder pain syndrome care was associated with improved treatment response and required fewer additional interventions compared with standard care alone.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04820855.

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

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

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.