Localization of the urge to void in patients with painful bladder syndrome

The location of pain and urgency sensations during cystometry

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Overactive bladder

Overactive bladder syndrome is highly prevalent, and increasingly so with aging. It is characterized by the presence of urinary urgency, and can be associated with incontinence, increased voiding frequency, and nocturia. Assessment needs to exclude serious medical disorders that might present with similar symptoms, and a bladder diary is an invaluable part of understanding the presentation. Initial management is conservative, comprising education, bladder training, and advice on fluid intake. Drug therapy options include antimuscarinic medications and beta-3 adrenergic receptor agonists. Persistent overactive bladder syndrome, despite initial therapy, requires a review of the patient’s understanding of conservative management and compliance, and adjustment of medications. For refractory cases, specialist review and urodynamic testing should be considered; this may identify detrusor overactivity or increased filling sensation, and needs to exclude additional factors, such as stress incontinence and voiding dysfunction. Botulinum neurotoxin-A bladder injections can be used in severe overactivity, provided the patient is able and willing to do intermittent self-catheterisation, which is necessary in about 5% of treated patients. Sacral nerve stimulation and tibial nerve stimulation are other approaches. Major reconstructive surgery, such as augmentation cystoplasty, is rarely undertaken in modern practice but remains a possibility in extreme cases.

The multidimensional sensation of desire to void differs between people with and without overactive bladder

AIM

To determine whether the multidimensional sensation of desire to void can be reliability assessed and whether differences exist between people with and without overactive bladder (OAB). Assessing reliability and convergent validity of OAB screening tools comprised a secondary aim.

METHODS

This observational, repeated-measures study involved 64 volunteers (47 female), aged ≥50 years, with and without OAB symptoms. Six sensory dimensions (intensity, unpleasantness, suddenness, perceived difficulty "holding on," bladder fullness and location of sensation) were assessed by structured interview on two occasions. Overactive bladder status was determined using the OAB Symptom Score and OAB Awareness Tool. Reliability of sensory dimensions was assessed via random effects mixed modeling. The ability of each sensory dimension to predict OAB status was determined by partial least squares regression.

RESULTS

With the exception of sensory intensity, perceived bladder fullness, and one location of sensation, sensory dimensions were reliably reported. Sensory intensity, unpleasantness, suddenness, and perceived difficulty "holding on" predicted OAB, whereas perceived bladder fullness and sensory location did not. The OAB screening questionnaires demonstrated comparable test-retest reliability and convergent validity.

CONCLUSIONS

People with and without OAB can reliably describe the multidimensional sensation of desire to void. The sensation of desire to void is more intense, unpleasant, sudden, and perceived as more difficult to hold on in people with OAB.

Urgency and pain in patients with overactive bladder and bladder pain syndrome. What are the differences?

BACKGROUND

The Overactive Bladder Syndrome (OAB) and the Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) are different urological conditions sharing 'urgency' as a common symptom. The aim of this review is to address our existing knowledge and establish how these symptoms are interrelated and to determine whether or not there is a common link between both symptoms complexes that help to distinguish one from the other.

METHODS

Pubmed was used to obtain references for this non-systematic review aiming to discuss differences between OAB and BPS/IC. Guidelines of several professional associations and discussions based on expert opinion from the authors were implemented.

RESULTS

Whilst in BPS the hallmark symptom is pain on bladder filling, urgency is the defining symptom of OAB. Whilst it is likely that the pain in BPS/IC arises from local inflammation in the bladder wall, the nature of urgency as a symptom, its origin, and the relationship between urgency and pain, as well as the different afferent mechanisms associated with the genesis of these sensory symptoms, remains unknown. Although the aetiology of both OAB and PBS/IC is unclear, the influence of environmental factors has been suggested. Both are chronic conditions with very variable symptom resolution and response to therapy. The relationship with voiding dysfunction, gynaecological causes of chronic pelvic pain or the possible alteration of the hypothalamic-pituitary-adrenal axis and psychological disorders has not been established. Inflammation has been suggested as the common link between OAB and BPS/IC.

CONCLUSIONS

OAB and BPS/IC are different symptoms complexes that share urgency as a common symptom. None of them have a specific symptom although pain on bladder filling is the hallmark symptom in BPS/IC. Bladder pain with urgency should be a trigger for referral to the provider with appropriate knowledge and expertise in this disease state, whereas the management of OAB should be part of normal routine care in the community.

Descriptors of sensation confirm the multidimensional nature of desire to void

AIMS

To collect and categorize descriptors of "desire to void" sensation, determine the reliability of descriptor categories and assess whether descriptor categories discriminate between people with and without symptoms of overactive bladder.

METHODS

This observational, repeated measures study involved 64 Australian volunteers (47 female), aged 50 years or more, with and without symptoms of overactive bladder. Descriptors of desire to void sensation were derived from a structured interview (conducted on two occasions, 1 week apart). Descriptors were recorded verbatim and categorized in a three-stage process. Overactive bladder status was determined by the Overactive Bladder Awareness Tool and the Overactive Bladder Symptom Score. McNemar's test assessed the reliability of descriptors volunteered between two occasions and Partial Least Squares Regression determined whether language categories discriminated according to overactive bladder status. Post hoc Chi squared analysis and relative risk calculation determined the size and direction of overactive bladder prediction.

RESULTS

Thirteen language categories (Urgency, Fullness, Pressure, Tickle/tingle, Pain/ache, Heavy, Normal, Intense, Sudden, Annoying, Uncomfortable, Anxiety, and Unique somatic) encapsulated 344 descriptors of sensation. Descriptor categories were stable between two interviews. The categories "Urgency" and "Fullness" predicted overactive bladder status. Participants who volunteered "Urgency" descriptors were twice as likely to have overactive bladder and participants who volunteered "Fullness" descriptors were almost three times as likely not to have overactive bladder.

CONCLUSIONS

The sensation of desire to void is reliably described over sessions separated by a week, the language used reflects multiple dimensions of sensation, and can predict overactive bladder status.

Dimensions of sensation assessed in urinary urgency: a systematic review

PURPOSE

Urinary urgency is an adverse sensory experience. Confirmation of the multidimensional nature of other adverse sensory experiences such as pain and dyspnea has improved the understanding of neurophysiological and perceptual mechanisms leading to innovations in assessment and treatment. It has been suggested that the sensation of urgency may include multiple dimensions such as intensity, suddenness and unpleasantness. In this systematic review we determine which dimensions of sensation have been assessed by instruments used to measure urinary urgency.

MATERIALS AND METHODS

A systematic search was undertaken of MEDLINE, Embase, AMED, CINAHL, Ageline, Web of Science, InformIT Health and Scopus databases to identify studies that included assessments of urinary urge or urgency. Articles were included in the analysis if they were primary studies that described the method used to measure urge/urgency in adults and published in English in peer reviewed publications since January 1, 2000. Articles were excluded from study if urgency was measured only in conjunction with other symptoms (eg frequency or incontinence) or if there was no English version of the instrument. Secondary analyses and systematic reviews were retained to hand search references for additional primary studies. Data were extracted for the instruments used to measure urge/urgency. For each instrument the items specific to urinary urgency were reviewed using a prospectively developed categorization process for the sensory dimension and the measurement metric. Items used to assess urinary urgency were collated in a matrix (sensory dimensions vs assessment metric). The most frequently used dimensions, metrics and combinations were descriptively analyzed.

RESULTS

After removal of duplicate articles 1,048 full text articles were screened and 411 were excluded, leaving 637 eligible articles from which data were extracted. A total of 216 instruments were identified which were 1 of 6 types, namely 1) wider symptom questionnaires, 2) urgency specific questionnaires, 3) ordinal scales, 4) visual analog scales, 5) event records or 6) body maps. These 216 instruments contained a total of 309 urgency specific items. Of the instruments 51% did not define a dimension of sensation and 26% did not define the metric used. From the remaining instruments 8 dimensions of sensation and 5 types of metrics were identified. From most common to least common, the sensory dimensions assessed were behavioral response, intensity, suddenness, bother, affective response, unpleasantness, quality (descriptors) and problems associated with sensation. Metrics were magnitude, frequency, presence, time frame or location. The most common sensory dimension/metric combinations were frequency of a behavioral response (14% of items) and magnitude of bother caused by the sensation (8% of items).

CONCLUSIONS

The hypothesis that urinary urgency is multidimensional is supported by the range of dimensions assessed with available instruments. To clarify the nature of urinary urgency compared with the normal desire to void, prospective studies are required to determine whether sensory dimensions are distinct, and which may delineate between normal and pathological sensation.

Nocturia in interstitial cystitis/painful bladder syndrome

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Basic mechanisms of urgency: roles and benefits of pharmacotherapy

INTRODUCTION

Since urgency is key to the overactive bladder syndrome, we have reviewed the mechanisms underlying how bladder filling and urgency are sensed, what causes urgency and how this relates to medical therapy.

MATERIALS AND METHODS

Review of published literature.

RESULTS

As urgency can only be assessed in cognitively intact humans, mechanistic studies of urgency often rely on proxy or surrogate parameters, such as detrusor overactivity, but these may not necessarily be reliable. There is an increasing evidence base to suggest that the sensation of ‘urgency’ differs from the normal physiological urge to void upon bladder filling. While the relative roles of alterations in afferent processes, central nervous processing, efferent mechanisms and in intrinsic bladder smooth muscle function remain unclear, and not necessarily mutually exclusive, several lines of evidence support an important role for the latter.

CONCLUSIONS

A better understanding of urgency and its causes may help to develop more effective treatments for voiding dysfunction.

Validation of a modified National Institutes of Health chronic prostatitis symptom index to assess genitourinary pain in both men and women

OBJECTIVES

To date, separate condition-specific instruments have been used to assess severity of symptoms, in men and women with urological pain conditions. We developed a single instrument that can be used to assess treatment response in clinical trials and cohort studies that involve both genders.

METHODS

We developed the Genitourinary Pain Index (GUPI) by modifying and adding questions to the National Institutes of Health-Chronic Prostatitis Symptom Index. To assess discriminant validity, concurrent validity, and reliability, we administered the GUPI to 1653 men and 1403 women in a large managed care population. To assess responsiveness, we administered the GUPI to 47 men and women who completed a National Institutes of Health-sponsored trial of pelvic floor physical therapy.

RESULTS

The GUPI discriminated between men with chronic prostatitis or interstitial cystitis, those with other symptomatic conditions (dysuria, frequency, chronic cystitis), and those with none of these diagnoses (P <.05). It also discriminated between women with interstitial cystitis, those with incontinence, and those with none of these diagnoses (P <.05). The GUPI demonstrated good internal consistency within subscale domains, and GUPI scores correlated highly with scores on the Interstitial Cystitis Symptom Index and Problem Index. The GUPI was highly responsive to change, and the change in score was similar in both male and female responders. A reduction of 7 points robustly predicted being a treatment responder (sensitivity 100%, specificity 76%).

CONCLUSIONS

The GUPI is a valid, reliable, and responsive instrument that can be used to assess the degree of symptoms in both men and women with genitourinary pain complaints.

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.