Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness

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.

A randomized-controlled pilot trial of telemedicine-delivered cognitive-behavioral therapy tailored for interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating urologic pain condition with few treatment advances in the past 25 years. Individuals with IC/BPS often experience significant psychological distress, which worsens symptoms and functioning. To date, there have been no large-scale, randomized controlled trials (RCTs) of comprehensive psychological interventions for IC/BPS. We conducted a 2:1 RCT of an 8-session patient-informed cognitive-behavioral therapy (CBT) intervention designed for IC/BPS for reducing pain-related symptoms and improving quality of life, delivered through telemedicine. Individuals with IC/BPS (N = 78) were randomized to receive either 8 weeks of CBT specifically designed for IC/BPS (n = 52) or an attention control condition (n = 26). Urologic symptoms (Genitourinary Pain Index, GUPI), pain-related symptoms, affective distress, and quality of life were evaluated before, immediately after, and 3 months posttreatment. Both conditions reported significant but similar reductions (P = 0.922) in the a priori primary outcome of genitourinary symptoms at posttreatment (GUPI reduction = 6.6 vs 4.8, for CBT and control, respectively) and long-term follow-up (8.1 vs 6.6, for CBT and control). However, the CBT group had significantly greater improvement in Patient Global Impression of Change (PGIC) scores and was significantly more likely to be treatment responders (PGIC ≥ 6) (37% vs 8%, P = 0.019 for CBT and control), with a large relative effect size (OR = 6.68). A subgroup analysis of CBT recipients showed that responders (PGIC 6) displayed significant reductions in genitourinary symptoms (P = 0.023), pain intensity (P = 0.027), and pain interference (P = 0.013) posttreatment. Telemedicine-delivered pain CBT for IC/BPS shows promise for improving outcomes, and this trial demonstrates the need for larger RCTs of CBT for IC/BPS.

Myofascial urinary frequency syndrome is a novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction

This study describes a novel, distinct phenotype of urinary symptoms named "myofascial urinary frequency syndrome" (MUFS) present in one-third of individuals presenting with urinary frequency. In addition to a characteristic symptom constellation suggestive of myofascial dysfunction, MUFS subjects exhibit "persistency": a persistent feeling of needing to urinate regardless of urine volume. On examination, 97% of MUFS patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. To confirm this symptom pattern was attributable to the pelvic floor musculature, we confirmed the presence of "persistency" in 68 patients with pelvic floor myofascial dysfunction established through comprehensive examination and electromyography and corroborated by improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming MUFS is a distinct LUTS symptom complex.

Bladder pain syndrome and sexual function: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome (BPS)/interstitial cystitis can adversely affect physical, mental, and sexual health. The aim of the systematic review is to compare sexual function between patients with BPS and healthy controls and to examine whether or not treatment of BPS improves sexual function.

METHODS

A literature search was conducted on Embase, Medline, and other databases. Studies comparing sexual function in BPS patients with healthy controls and before/after treatment were included. Where appropriate, data were pooled in a meta-analysis, using a random effects model and the standardised mean difference (SMD) was used for comparison.

RESULTS

Out of 384 studies initially identified, 26 studies met the inclusion criteria for the systematic review and 11 for the meta-analysis. Six studies compared sexual function in BPS cases with healthy controls. All studies found that the Female Sexual Function Index (FSFI) was worse in BPS cases than in controls. Pooled data from 5 studies showed that the SMD was -1.02 (CI -1.64, -0.4) in total FSFI scores between the cases and controls, p=0.001. Further analysis showed better sexual function in all FSFI subdomains in healthy controls. Five studies compared sexual function in BPS patients before treatment with after treatment. Pooled data from 3 studies showed an overall improvement in total FSFI score after intravesical treatment: SMD=0.69 (CI 0.23, 1.14), p=0.003. Further analysis showed improvement in all subdomains.

CONCLUSION

Our review suggests that sexual function might be worse in BPS patients than in the general population, but it seems to improve with intravesical BPS treatment.

Are pelvic pain and increased pelvic floor muscle tone associated in women with persistent noncancer pelvic pain? A systematic review and meta-analysis

BACKGROUND

The association between pelvic pain and pelvic floor muscle (PFM) tone in women with persistent noncancer pelvic pain (PNCPP) is unclear.

AIM

To synthesize the evidence of the association between pelvic pain and PFM tone in women with PNCPP.

METHODS

A systematic review was conducted via MEDLINE, Emcare, Embase, CINAHL, PsycINFO, and Scopus to identify relevant studies. Studies were eligible if pelvic pain and PFM tone outcome measures were reported among women aged >18 years. The National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess study quality. Studies were pooled by assessment of PFM tone via a random effects model. Associations between the presence of pelvic pain and PFM tone were assessed with odds ratio (OR), while linear associations were assessed with Pearson or Spearman correlation.

OUTCOMES

Pelvic pain measures (intensity, threshold, and frequency) and resting PFM tone in women with PNCPP, as evaluated by any clinical assessment method or tool.

RESULTS

Twenty-four studies were included in this review. The presence of pelvic pain was significantly associated with increased PFM tone as assessed by digital palpation (OR, 2.85; 95% CI, 1.66-4.89). Pelvic pain intensity was inversely but weakly associated with PFM flexibility when evaluated through dynamometry (r = -0.29; 95% CI, -0.42 to -0.17). However, no significant associations were found between pelvic pain and PFM tone when measured with other objective assessment methods.

CLINICAL IMPLICATIONS

Pelvic pain and increased PFM tone may not be directly associated; alternatively, a nonlinear association may exist. A range of biopsychosocial factors may mediate or moderate the association, and clinicians may need to consider these factors when assessing women with PNCPP.

STRENGTHS AND LIMITATIONS

This review was reported according to the PRISMA guidelines. All possible findings from relevant theses and conference abstracts were considered in our search. However, nonlinear associations between pelvic pain and increased PFM tone were not assessed as part of this review.

CONCLUSION

Pelvic pain may be linearly associated with increased PFM tone and decreased PFM flexibility when measured with digital palpation or dynamometry; however, this association was not observed when other aspects of PFM tone were assessed through objective methods. Future studies are required using robust assessment methods to measure PFM tone and analyses that account for other biopsychosocial factors that may influence the association.

Myofascial Frequency Syndrome: A novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction

Background

Patients presenting with lower urinary tract symptoms (LUTS) are historically classified to several symptom clusters, primarily overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). Accurate diagnosis, however, is challenging due to overlapping symptomatic features, and many patients do not readily fit into these categories. To enhance diagnostic accuracy, we previously described an algorithm differentiating OAB from IC/BPS. Herein, we sought to validate the utility of this algorithm for identifying and classifying a real-world population of individuals presenting with OAB and IC/BPS and characterize patient subgroups outside the traditional LUTS diagnostic paradigm.

Methods

An Exploratory cohort of 551 consecutive female subjects with LUTS evaluated in 2017 were administered 5 validated genitourinary symptom questionnaires. Application of the LUTS diagnostic algorithm classified subjects into controls, IC/BPS, and OAB, with identification of a novel group of highly bothered subjects lacking pain or incontinence. Symptomatic features of this group were characterized by statistically significant differences from the OAB, IC/BPS and control groups on questionnaires, comprehensive review of discriminate pelvic exam, and thematic analysis of patient histories. In a Reassessment cohort of 215 subjects with known etiologies of their symptoms (OAB, IC/BPS, asymptomatic microscopic hematuria, or myofascial dysfunction confirmed with electromyography), significant associations with myofascial dysfunction were identified in a multivariable regression model. Pre-referral and specialist diagnoses for subjects with myofascial dysfunction were catalogued.

Findings

Application of a diagnostic algorithm to an unselected group of 551subjects presenting for urologic care identified OAB and IC/BPS in 137 and 96 subjects, respectively. An additional 110 patients (20%) with bothersome urinary symptoms lacked either bladder pain or urgency characteristic of IC/BPS and OAB, respectively. In addition to urinary frequency, this population exhibited a distinctive symptom constellation suggestive of myofascial dysfunction characterized as "persistency": bothersome urinary frequency resulting from bladder discomfort/pelvic pressure conveying a sensation of bladder fullness and a desire to urinate. On examination, 97% of persistency patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. We therefore classified this symptom complex "myofascial frequency syndrome". To confirm this symptom pattern was attributable to the pelvic floor, we confirmed the presence of "persistency" in 68 patients established to have pelvic floor myofascial dysfunction through comprehensive evaluation corroborated by symptom improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming that myofascial frequency syndrome is a distinct LUTS symptom complex.

Interpretation

This study describes a novel, distinct phenotype of LUTS we classified as myofascial frequency syndrome in approximately one-third of individuals with urinary frequency. Common symptomatic features encompass elements in other urinary syndromes, such as bladder discomfort, urinary frequency and urge, pelvic pressure, and a sensation of incomplete emptying, causing significant diagnostic confusion for providers. Inadequate recognition of myofascial frequency syndrome may partially explain suboptimal overall treatment outcomes for women with LUTS. Recognition of the distinct symptom features of MFS (persistency) should prompt referral to pelvic floor physical therapy. To improve our understanding and management of this as-yet understudied condition, future studies will need to develop consensus diagnostic criteria and objective tools to assess pelvic floor muscle fitness, ultimately leading to corresponding diagnostic codes.

Funding

This work was supported by the AUGS/Duke UrogynCREST Program (R25HD094667 (NICHD)) and by NIDDK K08 DK118176 and Department of Defense PRMRP PR200027, and NIA R03 AG067993.

Objective Changes in Pelvic Floor Muscle Strength and Length in Women With High-Tone Pelvic Floor Dysfunction After Pelvic Floor Physical Therapy (RELAX Trial)

IMPORTANCE

Although pelvic floor physical therapy (PFPT) is effective in treating high-tone pelvic floor dysfunction (HTPFD), data on the mechanism of improvement are limited.

OBJECTIVES

This study aimed to compare squeeze intravaginal closure force after 6 weeks of PFPT in women affected by HTPFD and, secondarily, to describe changes in levator dimensions and short-term effects of PFPT on bladder, bowel, and pain symptoms.

METHODS

We conducted a prospective cohort study of patients undergoing 6 sessions of PFPT for the diagnosis of HTPFD. At baseline, we measured intravaginal closure force using an instrumented speculum, levator hiatal dimension using a 3-dimensional endovaginal ultrasonography, and symptom severity using 3 validated questionnaires. Intravaginal closure force and symptoms were reevaluated after the second, fourth, and sixth PFPT sessions, and levator hiatus was reevaluated at the sixth session.

RESULTS

Twenty-six women were enrolled and 22 completed 6 sessions and are included in the analysis. Contrary to our hypothesis, mean ± SD vaginal closure force (N) did not demonstrate a significant change (3.27 ± 2.34 vs 3.67 ± 2.02 N, P = 0.18). However, mean levator hiatal area (cm2) increased between visit 1 (13.71 ± 1.77 cm2) and visit 6 (14.43 ± 2.17 cm2, P = 0.05), as did the transverse diameter (3.83 ± 0.03 vs 3.95 ± 0.03 cm, P = 0.04). Survey responses demonstrated significant improvements across all measures of genitourinary symptoms, pain, lower gastrointestinal symptoms and quality-of-life measures after 6 sessions of PFPT.

CONCLUSION

Although the levator hiatal area increased after 6 sessions of PFPT (suggesting muscle lengthening), we were unable to demonstrate that this changed the force generated by pelvic floor muscles as measured by a speculum.

The Effectiveness Of Trigger Point Treatment In Chronic Pelvic Pain; A Pilot Randomised Controlled Trial

Objective To investigate the effectiveness of ischemic compression and low-level laser therapy methods combined with exercise on the myofascial trigger points in women with Chronic Pelvic Pain and to determine which method is more effective.

Methods It was a parallel designed, single-blind pilot randomized clinical trial. Patients were recruited at physiotherapy laboratory of the Istanbul University from September 2017 to June 2019. Twenty-eight women patients with Chronic Pelvic Pain were included into the trial. Patients were randomized into two groups. Group 1 received ischemic compression and Group 2 received low-level laser therapy twice a week for 6 weeks. Both groups received the same standard exercise program. Pain, range of motion, pelvic floor symptom severity, quality of life, satisfaction, anxiety, and depression were assessed after 6 weeks, and 1-year follow up.

Results Following the treatment, significant differences were observed within both group subjects in pain, range of motion, symptom severity, quality of life, and anxiety-depression (p<0.05). This significant improvement in pain, symptom severity, symptoms related quality of life and pain subgroup of Short Form 36, continued after 1-year follow up (p<0.05). In comparison between group, Group 1 have more significant improvement than Group 2 in terms of symptoms related quality of life (p<0.05).

Conclusion Both methods have shown efficacy and can be used safely in chronic pelvic pain patients. Because it is more effective on symptoms related quality of life, the ıschemic compression method may be preferred for primary use.

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 difference in pelvic floor muscle tone between women with and without pelvic pain? A systematic review and meta-analysis

BACKGROUND

Alterations in pelvic floor muscle (PFM) function have been observed in women with persistent noncancer pelvic pain (PNCPP) as compared with women without PNCPP; however, the literature presents conflicting findings regarding differences in PFM tone between women with and without PNCPP.

AIM

To systematically review the literature comparing PFM tone in women with and without PNCPP.

METHODS

MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Scopus were searched from inception to June 2021 for relevant studies. Studies were included that reported PFM tone data in women aged ≥18 years with and without PNCPP. The risk of bias was assessed with the National Heart, Lung, and Blood Institute Quality Assessment Tool. Standardized mean differences (SMDs) for PFM tone measures were calculated via random effects models.

OUTCOMES

Resting PFM tone parameters, including myoelectrical activity, resistance, morphometry, stiffness, flexibility, relaxation, and intravaginal pressure, measured by any clinical examination method or tool.

RESULTS

Twenty-one studies met the inclusion criteria. Seven PFM tone parameters were measured. Meta-analyses were conducted for myoelectrical activity, resistance, and anterior-posterior diameter of the levator hiatus. Myoelectrical activity and resistance were higher in women with PNCPP than in women without (SMD = 1.32 [95% CI, 0.36-2.29] and SMD = 2.05 [95% CI, 1.03-3.06], respectively). Women with PNCPP also had a smaller anterior-posterior diameter of the levator hiatus as compared with women without (SMD = -0.34 [95% CI, -0.51 to -0.16]). Meta-analyses were not performed for the remaining PFM tone parameters due to an insufficient number of studies; however, results of these studies suggested greater PFM stiffness and reduced PFM flexibility in women with PNCPP than in women without.

CLINICAL IMPLICATIONS

Available evidence suggests that women with PNCPP have increased PFM tone, which could be targeted by treatments.

STRENGTHS AND LIMITATIONS

A comprehensive search strategy was used with no restriction on language or date to review studies evaluating PFM tone parameters between women with and without PNCPP. However, meta-analyses were not undertaken for all parameters because few included studies measured the same PFM tone properties. There was variability in the methods used to assess PFM tone, all of which have some limitations.

CONCLUSION

Women with PNCPP have higher PFM tone than women without PNCPP; therefore, future research is required to understand the strength of the relationship between pelvic pain and PFM tone and to investigate the effect of treatment modalities to reduce PFM tone on pelvic pain in this population.

Myofascial Pelvic Pain: Best Orientation and Clinical Practice. Position of the European Association of Urology Guidelines Panel on Chronic Pelvic Pain

CONTEXT

Despite the high prevalence of a myofascial pain component in chronic pelvic pain (CPP) syndromes, awareness and management of this component are lacking among health care providers.

OBJECTIVE

To summarize the current state of the art for the management of myofascial pain in chronic primary pelvic pain syndromes (CPPPS) according to scientific research and input from experts from the European Association of Urology (EAU) guidelines panel on CPP.

EVIDENCE ACQUISITION

A narrative review was undertaken using three sources: (1) information in the EAU guidelines on CPP; (2) information retrieved from the literature on research published in the past 3 yr on myofascial pelvic pain; and (3) expert opinion from panel members.

EVIDENCE SYNTHESIS

Studies confirm a high prevalence of a myofascial pain component in CPPPS. Examination of the pelvic floor muscles should follow published recommendations to standardize findings and disseminate the procedure. Treatment of pelvic floor muscle dysfunction and pain in the context of CPP was found to contribute to CPP control and is feasible via different physiotherapy techniques. A multidisciplinary approach is the most effective.

CONCLUSIONS

Despite its high prevalence, the myofascial component of CPP has been underevaluated and undertreated to date. Myofascial pain must be assessed in all patients with CPPPS. Treatment of the myofascial pain component is relevant for global treatment success. Further studies are imperative to reinforce and better define the role of each physiotherapy technique in CPPPS.

PATIENT SUMMARY

Pain and inflammation of the body's muscle and soft tissues (myofascial pain) frequently occurs in pelvic pain syndromes. Its presence must be evaluated to optimize management for each patient. If diagnosed, myofascial pain should be treated.

Use of low-intensity extracorporeal shock wave therapy in the management of interstitial cystitis/bladder pain syndrome patients: A thirty case study in a tertiary medical center

INTRODUCTION

Low-energy extracorporeal shock wave therapy (LiESWT) is a new potential treatment for intractable interstitial cystitis/bladder pain syndrome (IC/BPS), and this paper will evaluate its therapeutic effects on IC/BPS.

MATERIALS AND METHODS

This prospective clinical trial enrolled 30 women who have been diagnosed with IC/PBS to receive LiESWT treatment at an intensity of 0.25 mJ/mm² and a frequency of 3 pulses/second, for a total of 3000 pulses within 8 weeks. And we assessed questionnaires (including O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI)), 3-day voiding diary, and urodynamic study at the following intervals: 4 weeks of LiESWT (W4), 8 weeks of LiESWT (W8), 1-month follow-up (F1), 3-month follow-up (F3) after LiESWT, and 1 year follow-up (F12).

RESULTS

The primary outcome of questionnaires showed significant improvement of symptoms compared to baseline (W0), especially on ICSI(12.87 ± 3.44 before treatment and 7.87 ± 5.27 at F12, p < 0.05). 3-day voiding diary also revealed significant decrease in daytime voiding frequency (15.57 ± 5.22 times before treatment and 10.70 ± 4.21 times at F1, p < 0.05) and significant increase on average voiding volume (95.85 ± 35.30 mL before treatment and 161.27 ± 74.21 mL at F1, p < 0.05). However, there were no significant differences in all parameters of the urodynamic study.

CONCLUSION

LiESWT can mitigate pain and lower urinary tract symptoms and improve the quality of life in IC/PBS patients, but does not increase the maximal cystometric capacity.

Non-pharmacological therapies for treating chronic pelvic pain in women: A review

Chronic pelvic pain (CPP) is an intricate condition with multiple etiologies that lead to indefinite pain mechanisms. Physicians and researchers are challenged in its treatment, and the combined therapy of pharmacologic and non-pharmacologic treatment has been recognized as a multidisciplinary approach cited by guidelines and adopted in clinical practice. As an alternative therapy for CPP, non-pharmacologic therapies benefit patients and deserve further study. This study reviews the literature published from January 1991 to April 2022 on non-pharmacologic therapies for CPP in adult women. Based on a survey, this review found that the most commonly used non-pharmacological therapies for CPP include pelvic floor physical therapy, psychotherapy, acupuncture, neuromodulation, and dietary therapy. By evaluating the efficacy and safety of each therapy, this study concluded that non-pharmacological therapies should be included in the initial treatment plan because of their high degree of safety and low rate of side effects. To fill the lack of data on non-pharmacologic therapies for CPP, this study provides evidence that may guide treatment and pain management.

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.

Chronic Pelvic Pain: A Comprehensive Review

Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse.

Transvaginal Photobiomodulation Improves Pain in Women with Pelvic Muscle Tenderness and Interstitial Cystitis/Bladder Pain Syndrome: A Preliminary Observational Study

PURPOSE

Interstitial Cystitis/ Bladder Pain Syndrome (IC/BPS) is characterized by pelvic/bladder pain, associated with pelvic muscle tenderness, urgency, frequency, and dysuria. Prior studies show that transvaginal photobiomodulation (TV-PBM) reduces pain in women with chronic pelvic pain (CPP). Our objective was to obtain preliminary data on treatment effect and adherence, in women with IC/BPS who selected TV-PBM therapy for management of pelvic pain.

MATERIALS AND METHODS

Before-and-after observational cohort study of women with IC/BPS who received TV-PBM in 17 US practices. Pain was measured using a 0-10 numeric rating scale (NRS). The primary outcome was a minimal clinical important difference (MCID); reduction of overall pelvic pain severity by ≥2 NRS points from baseline compared to after 8 treatments. Cohen d coefficient measured effect size (low effect size d<0.2, medium 0.2<d<0.8, and high d>0.8).

RESULTS

Of 140 patients with IC/BPS who self-selected to start TV-PBM therapy, 89.3% (n=125) completed 4 treatments and 59.3% (n=83) completed 8. Improvement ≥1 NRS point was reported by 73.5% (n=61) and meaningful improvement (≥2 points) was reported by 63.9% (n=53) after 8 treatments. In this group, patients with severe / moderate pain decreased from 83.1% (n=44) to 38.5% (n=20); p<0.001. Pain levels decreased as follows: overall pelvic pain MCID=-2.7, d=1.07, pain with urination MCID=-2.6, d=1.0; pain with exercise MCID=-2.6, d=0.91, pain with intercourse MCID=-2.5, d=0.82.

CONCLUSION

In real-world clinical settings, 2/3 women with IC/BPS who opted to undergo TV-PBM therapy reported significant decrease in pelvic pain and dysuria. These findings are promising; however, controlled studies are needed.

Association of physical therapy techniques can improve pain and urinary symptoms outcomes in women with bladder pain syndrome. A randomized controlled trial

Purpose:

to verify the effects of biofeedback (BF) and manual therapy (MT) associated with transcutaneous electrical nerve stimulation (TENS) or postural exercises (PE) in the treatment of bladder pain syndrome (BPS) in women regarding pain and urinary symptoms.

Materials and Methods:

a parallel-randomized controlled trial was conducted in BPS patients diagnosed according to NIH clinical criteria. Two specialized physiotherapists applied demographic and validated questionnaires of perineal and suprapubic pain (VAS), urinary symptoms and problems (ICSI and ICPI) and sexual function (FSFI) and a physical assessment was made to identify myofascial trigger points. Thirty-one women, mean age 51.8 ± 10.9 were randomized in three groups of treatment consisting of ten weekly sessions of BF and MT (Conventional group); BF, MT, and TENS (TENS group); and BF, MT, and PE (Postural group).

Results:

Postural group improved perineal and suprapubic pain after treatment (p<0.001 and p=0.001, respectively), and the suprapubic pain improvement remained persistent at 3 months of follow up (p=0.001). Postural group improved urinary symptoms and problems after treatment (p<0.001 and p=0.005, respectively) and during follow up (p<0.001 and p=0.001).

Conclusions:

Biofeedback and manual therapy associated with postural exercises showed a significant improvement in perineal and suprapubic pain and urinary symptoms after treatment and during follow-up. Both results suggest a possible role for the use of this physiotherapy technique to treat BPS patients. Longer follow-up and a larger number of patients are necessary to confirm these conclusions.

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.

Pathophysiology, assessment, and treatment of overactive bladder symptoms in patients with interstitial cystitis/bladder pain syndrome

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is prevalent, difficult to treat, and has close symptom overlap with overactive bladder (OAB). A review of the pathophysiology, assessment, and treatment of IC/BPS patients with overlapping OAB symptoms has not been summarized recently in the published literature.

METHODS

A review of the published literature on the overlap of IC/BPS and OAB was conducted using MeSH terminology (1992-2022).

RESULTS

The pathophysiology of IC/BPS is not fully understood. Animal research has found the bladder trigone and base are richly populated by afferent fibers, including many small unmyelinated C-fibers that may be upregulated in IC/BPS. Successful therapies with multimodal effects on OAB symptoms in patients with IC/BPS are likely to exert beneficial effects on both pain and lower urinary tract symptoms. Potentially efficacious therapies for the treatment of OAB in IC/BPS include pelvic floor physical therapy, oral pharmacotherapy (antimuscarinics and beta-3 agonists), sacral neuromodulation, percutaneous tibial nerve stimulation, and botulinum toxin A (BTA). Antimuscarinics and beta-3 agonists have yielded partial efficacy in IC/BPS, although may help differentiate symptoms of OAB from those associated with IC/BPS. The transvaginal trigone treatment (T3) intradetrusor injection approach allows for delivery of therapeutics to the bladder without the need for a cystoscope and appears to be feasible.

CONCLUSIONS

Further research is needed to understand the pathophysiology of IC/BPS and symptom overlap with OAB, which in turn should enable the development of more personalized therapeutics.

Effectiveness of Myofascial Manual Therapies in Chronic Pelvic Pain Syndrome: A Systematic Review and Meta-Analysis

INTRODUCTION AND HYPOTHESIS

Chronic pelvic pain syndrome (CPPS) is defined as the occurrence of chronic pelvic pain (CPP) in the absence of a specific cause. People typically refer to pain associated with urological, gynaecological, and sexual dysfunction, affecting the quality of life. Therefore, we assessed the effectiveness of myofascial manual therapies (MMT) for pain and symptom impact.

METHODS

A systematic review and meta-analysis were conducted. Findings were reported following the 2020 PRISMA statement. Five databases were searched for RCTs. Studies were independently assessed through a standardized form, and their internal validity was evaluated using the Cochrane risk of bias (RoB) tool. Effect sizes (ES) were calculated post-treatment, and the quality of evidence was assessed through GRADE criteria.

RESULTS

Seven articles were included in the review, five of these in the meta-analysis. None of these studies were completely judged at low RoB. MMT was revealed to be not significantly superior for pain reduction [ES: -0.54 (-1.16; 0.08); p = 0.09], for symptom impact [ES: -0.37 (-0.87; 0.13); p = 0.15], and for quality of life [ES: -0.44 (-1.22, 0.33), p = 0.26] compared to standard care. The quality of evidence was "very low". Other results were presented in a qualitative synthesis.

CONCLUSIONS

In patients with CPP/CPPS, MMT is not considered superior to other interventions for pain reduction and symptom impact improvements. However, a positive trend was detected, and we should find confirmation in the future. Further high-quality, double-blinded, sham-controlled RCTs are first necessary to confirm these positive effects and to improve the quality of evidence.

Recommendations on the use of intravesical hyaluronic acid instillations in bladder pain syndrome

INTRODUCTION

Bladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet.

OBJECTIVE

To synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA. The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations.

RESULTS

There is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment).

CONCLUSIONS

Intravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles). Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up).

Vaginal stretching therapy and class IIIB vaginal laser treatment for pelvic floor myofascial pain: a randomized clinical trial

PURPOSE

Several treatment options are proposed for the management of pelvic floor myofascial pain (PFMP). Manual therapy, such as vaginal stretching (VS), is one of these options. Photobiomodulation therapy (PBMT) with a laser device is a treatment option for PFMP that has been tested on other muscles. The aim of this study was to evaluate the effect of VS combined or not with PBMT for PFMP treatment.

METHODS

One hundred three women with PFMP were enrolled in a double-blind randomized trial and assigned to VS+PBMT (10 treatments over 2 weeks with 100 mw delivering 12 joules to surface intravaginally, using near-infrared light 808 nm) and VS+shamPBMT treatment groups. Pain severity was assessed by Visual Analog Scale (VAS). Pelvic floor muscle function was assessed by Oxford Scale and surface electromyography. Urinary symptoms were evaluated by ICIQ-OAB and ICIQ-SF questionnaires, and intestinal constipation was assessed by ROMA criteria.

RESULTS

There was a significant improvement in pain intensity (VAS) after treatment in both groups, with no difference between groups (p = 0.46). More than 50% of the women complained of severe pain before treatment, and after treatments, it was reported by less than 20% of women (p < 0.001), with no difference between groups (p = 0.08). Urinary symptoms improved in both groups (p < 0.001) with no difference between groups (p = 0.37). Intestinal constipation improved in the VS+PBMT group only (p = 0.01).

CONCLUSION

VS and VS with near-infrared vaginal laser therapy were equally effective at decreasing myofascial pelvic pain and reducing urinary symptoms TRIAL REGISTRATION: REBEC (Registro Brasileiro de Ensaios Clínicos; Brazilian Registry of Clinical Trials) under no.RBR-2TDCQ4 (November 11, 2018).

Clinical Management of Chronic Pelvic Pain in Endometriosis Unresponsive to Conventional Therapy

Background: Although several treatments are currently available for chronic pelvic pain, 30–60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. Methods: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. Results: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Conclusion: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.

Therapeutic interventions to urologic chronic pelvic pain syndrome and UPOINT system for clinical phenotyping: How far are we?

The assessment and management of urologic chronic pelvic pain syndrome (UCPPS), is controversial. It is classified by voiding symptoms, pelvic pain, and bladder pain, which is weekly treated, weekly understood, and bothersome. In the aspect of clinical efforts and research to help people with this syndrome have been hampered by the deficiency of a widely reliable, accepted, and a valuable tool to evaluate the patient symptoms and quality of life (QoL) impact. However, the etiology comes into sight is multifactorial, and available treatment options have been imprecise considerably in present years. We compiled the published literature on the assessment of the syndrome, a tentative role of pharmacological and non-pharmacological (conservative, alternative, and invasive therapy) interventions in eradicating the disease as well as improving symptoms. The previously published literature on animal models has established the association of immune systems in the etiology, pathogenesis, and progression of the disease. The UPOINT system for clinical phenotyping of UCPPS patients has six predefined domains that direct multimodal therapy, which would lead to significant symptom improvement in the medical field. The narrative review aims to scrutinize the fluctuating scientist's views on the evaluation of patient and multimodal treatment of the UPOINT system.

Roles of mesenchymal stem cells and exosomes in interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by several symptoms of higher sensitivity of the lower urinary tract, such as bladder pain/discomfort, urgency, urinary frequency, pelvic pain and nocturia. Although the pathophysiology of IC/BPS is not fully understood, the hypothesis suggests that mast cell activation, glycosaminoglycan (GAG) layer defects, urothelium permeability disruption, inflammation, autoimmune disorder and infection are potential mechanisms. Mesenchymal stem cells (MSCs) have been proven to protect against tissue injury in IC/BPS by migrating into bladders, differentiating into key bladder cells, inhibiting mast cell accumulation and cellular apoptosis, inhibiting inflammation and oxidative stress, alleviating collagen fibre accumulation and enhancing tissue regeneration in bladder tissues. In addition, MSCs can protect against tissue injury in IC/BPS by secreting various soluble factors, including exosomes and other soluble factors, with antiapoptotic, anti-inflammatory, angiogenic and immunomodulatory properties in a cell-to-cell independent manner. In this review, we comprehensively summarized the current potential pathophysiological mechanisms and standard treatments of IC/BPS, and we discussed the potential mechanisms and therapeutic effects of MSCs and MSC-derived exosomes in alleviating tissue injury in IC/BPS models.

Effectiveness of self-myofascial release combined with biofeedback and electrical stimulation for the management of myofascial pelvic pain: A randomized controlled trial

BACKGROUND

Myofascial pelvic pain (MFPP) caused by myofascial trigger points (MTrPs) is a major contributor to chronic pelvic pain in women. However, the effect of the patient's self-myofascial release (SMFR) is unclear. This study aimed to investigate the effect of SMFR combined with biofeedback and electrical stimulation (BES) therapy in comparison with BES alone in patients with MFPP.

METHODS

A prospective randomized controlled study was conducted. Sixty-eight patients were randomly allocated into BES-SMFR group (n = 34) and BES group (n = 34). Every patient received 4 weeks of treatment, evaluated at baseline (T0), 4 weeks post-intervention (T4) and 12-week follow-up (T12). The primary outcome was pain intensity. The secondary outcomes were degree of activation of MTrPs, surface electromyography (sEMG) levels and Patient Global Impression of Improvement (PGI-I).

RESULTS

Compared with the effect of BES, BES-SMFR treatment significantly decreased pain intensity and the degree of activation of MTrPs in the levator ani (p = 0.02) and obturator internus (p = 0.03), as well as the sEMG levels of the pre-test resting baseline and post-test resting baseline (all p < 0.01). The degree of activation of MTrPs in the piriformis and coccygeus (all p > 0.05) and the sEMG levels of the quick flicks and endurance contraction were not significantly different. The BES-SMFR treatment improved the PGI-I scale at T4 (p = 0.02) but not at T12 (p = 0.40).

CONCLUSIONS

This study confirmed that the addition of SMFR to BES treatment resulted in superior outcomes compared with those with BES alone in patients with MFPP.

SIGNIFICANCE STATEMENT

Myofascial pelvic pain (MFPP) is a major contributor of female chronic pelvic pain. Myofascial release has been used commonly for better pain release; however, poor therapeutic effect due to poor patient compliance is common in clinical practice. Therefore, in future research, there is a need to investigate the effect of patient's self-myofascial release (SMFR) technique, which can eliminate the need for frequent office visits and improve patient compliance to some extent, in patients with MFPP.

Pelvic-floor function, dysfunction, and treatment

The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system's multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training. The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory's explanations of function and dysfunction.

An observational cohort study of pelvic floor photobiomodulation for treatment of chronic pelvic pain

Aim: This research is the first to evaluate the effectiveness of trans-vaginal photobiomodulation therapy (TV-PBMT) for chronic pelvic pain. Materials & methods: Observational analysis of 128 women, undergoing TV-PBMT for chronic pelvic pain. Minimal clinically important difference, defined as ≥2-point drop on a 0-10 numeric pain rating scale (NPRS), and effect size Cohen d coefficient, was calculated over nine treatments for overall pain, and pain with activities. Results: Compared with baseline, 64.5% of women showed improvement in overall pain, pain with bowel movement, intercourse, exercise, urination, sitting and vulvar pain (minimal clinically important difference = -2.4, -2.0, -2.4, -2.1, -2.1, -2.0, -3.1; d = 0.9, 0.7, 0.9, 0.7, 0.7, 0.7, 0.9) by treatment 9. Conclusion: In this cohort, TV-PBMT resulted in improvement of pelvic pain without serious adverse events.

Painful Bladder Syndrome/Interstitial Cystitis and High Tone Pelvic Floor Dysfunction

This article provides an overview of 2 conditions that defy straightforward characterization and treatment: interstitial cystitis/painful bladder syndrome often coexists with high tone pelvic floor dysfunction. These conditions are common in gynecologic patients who present with chronic pelvic pain and are often misdiagnosed due to their syndromic nature and amorphous definitions. Clinicians should maintain a high level of suspicion for these processes in patients with chronic pelvic pain or recurrent urinary tract infection symptoms. Optimal treatment uses a multimodal approach to alleviate symptoms.

The innervation of the bladder, the pelvic floor, and emotion: A review

The innervation of the pelvic region is complex and includes extensive neurologic pathways. The higher centres' organisation determining the pelvic floor and organs' function remains a challenge understanding the physiological and pain mechanisms. Psychological and emotional factors have a profound influence on the pelvic floor and organ dysfunction such as LUTS. LUTS are associated with stress, depression, and anxiety. Neuroception is a subconscious neuronal system for detecting threats and safety and might explain the permanent disturbance of higher brain centres maintaining functional urological and gastrointestinal disorders and sphincter dysfunction.

Bladder Instillations With Triamcinolone Acetonide for Interstitial Cystitis-Bladder Pain Syndrome: A Randomized Controlled Trial

OBJECTIVE

To evaluate the utility of adding triamcinolone acetonide to a standard bladder instillation solution for treatment of interstitial cystitis-bladder pain syndrome.

METHODS

This was a single-center, randomized, double-blind trial that compared symptom response in women with interstitial cystitis-bladder pain syndrome who underwent six bladder instillations with triamcinolone acetonide or six instillations without. All instillation solutions contained heparin, viscous lidocaine, sodium bicarbonate, and bupivacaine. The primary outcome was the change in interstitial cystitis-bladder pain syndrome symptoms from the first to sixth bladder instillation between groups based on the total OLS (O'Leary-Sant Questionnaire) score. Assuming a 4.03-point or larger difference in the mean total OLS score from the first to sixth bladder instillation as compared between the groups, 64 participants were needed to show a significant difference with 80% power at the 0.05 significance level.

RESULTS

From January 2019 to October 2020, 90 women were enrolled-45 per group; 71 (79%) completed all six bladder instillations. Randomization resulted in groups with similar characteristics. There was no difference between groups in the primary outcome (bladder instillation with triamcinolone acetonide: mean OLS change -6.7 points, 95% CI 4.6-8.8 and bladder instillation without triamcinolone acetonide: mean OLS change -5.8 points, 95% CI 3.4-8.1; P=.31). Women in both groups had improvement in their interstitial cystitis-bladder pain syndrome symptoms as indicated by a decrease in the total OLS score from the first to sixth bladder instillation.

CONCLUSION

The addition of triamcinolone acetonide to a standard bladder instillation solution does not improve symptoms associated with interstitial cystitis-bladder pain syndrome.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03463915.

Interstitial Cystitis/Bladder Pain Syndrome Treatment: A Systematic Review of Sexual Health Outcomes

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition with highly prevalent negative consequences on sexual health and quality of life. However, there is a lack of consensus regarding treatment options that improve sexual function in this population. This study aims to review the current literature on sexual health outcomes in patients treated for IC/BPS.

METHODS

We conducted a systematic review of the literature on sexual health outcomes after treatment of IC/BPS. PubMed, MEDLINE, EMBASE, CINHAL, and Google Scholar were queried, and results were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria for this review were: IC/BPS was clearly defined in the cohort, sexual health outcomes were measured as the primary or a secondary outcome, manuscript was written in English from January 2000 to April 2020. Studies on cystectomy were excluded as radical surgery is a confounding factor for sexual dysfunction.

RESULTS

We identified 1611 items with our search algorithm and determined that 10 studies ultimately met inclusion criteria. 4 of 10 studies reported improved sexual function after treatment. 4 of 10 studies were randomized control trials and reported no improvement in sexual function in each of the therapies that were investigated. Data were conflicting regarding the effect of intravesical hyaluronic acid.

CONCLUSION

This systematic review demonstrates the lack of focus on sexual health outcomes in studies of the IC/BPS. There was no strong evidence that any modality used to treat IC/BPS also improves sexual function despite the higher prevalence in this population. Chen A, Shahiyan RH, Anger J. Interstitial Cystitis/Bladder Pain Syndrome Treatment: A Systematic Review of Sexual Health Outcomes. Sex Med Rev 2021;xx:xx-xx.

Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy

INTRODUCTION

Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.

OBJECTIVES

To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.

METHODS

PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included. Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients' perceived effect.

RESULTS

The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.

CONCLUSION

The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2021;XX:1-22.

Evaluation of a novel deep tissue transvaginal near-infrared laser and applicator in an ovine model

Photobiomodulation therapy (PBMT) is an effective means of treating muscle spasm and pain. A novel near-infrared laser system has been commercialized for the treatment of myofascial pelvic pain in women (SoLá Therapy, UroShape, LLC). This study was undertaken to determine if this device is capable of delivering therapeutic levels of irradiance to the pelvic muscles and to identify the surface irradiance required to achieve this goal. This novel class IV near-infrared laser and transvaginal applicator were used to deliver near-infrared light energy through the vaginal mucosa of an adult Suffolk/Dorset Ewe. Irradiance was measured on the surface of the levator ani muscle, inside the levator ani muscle, and inside the bladder. Measurements were taken at powers of 5 W and 0.5 W. 3.0% of vaginal surface irradiance was measured inside of the levator ani muscle. 4.4% of vaginal surface irradiance was measured inside the bladder. At 5 W, the novel laser system provided a surface irradiance of 738 mW/cm². At 0.5 W, the system provided a surface irradiance of 74 mW/cm². A novel class IV near-infrared laser and transvaginal applicator delivered therapeutic irradiance to the levator ani muscle and bladder of an anesthetized ewe at a power setting of 5 W. A power setting of 0.5 W failed to deliver therapeutic energy into either the levator ani muscle or bladder. Clinical applications targeting deeper tissues such as the pelvic muscles and or bladder should consider power settings that exceed 0.5 W and or irradiance of ≥ 75 mW/cm².

Clinical Outcomes of a Multidisciplinary Female Chronic Pelvic Pain Program

OBJECTIVE

The aim of this study was to describe patient-reported longitudinal outcomes in a multidisciplinary female chronic pelvic pain (CPP) program.

METHODS

We conducted a retrospective cohort study for women cared for in a tertiary, multidisciplinary, female (CPP) program between 2012 and 2017. Patient demographics were collected from electronic medical records. Patients completed the numerical rating scale for pain, Pain Disability Index (PDI), and Patient Global Impression of Improvement scale at each visit. Mixed-effects models were used to assess change in patient responses over time.

RESULTS

Patients (N = 317) with a mean age of 44.3 years (SD, 14.6) and median duration of symptoms of 3 years (interquartile range, 1.0-7.0) were assessed in this analysis. The primary diagnosis was pelvic floor myofascial pain (67%). On multivariable analysis, numerical rating scale scores decreased by -0.11 point [95% confidence interval (CI), -0.20 to -0.01] every 3 months (P = 0.03). On multivariable analysis, total PDI score decreased by -0.88 point (95% CI, -1.43 to -0.33) (P = 0.003), and PDI sexual subscores decreased by -0.29 point (95% CI, -0.44 to -0.14) (P < 0.001) every 3 months. A higher (worse) Patient Global Impression of Improvement score was associated with a higher (worse) PDI score at follow-up (odds ratio, 1.04; 95% CI, 1.01-1.07; P = 0.01).

CONCLUSIONS

Patients in a multidisciplinary CPP program demonstrated improvement over time in pain disability that was associated with an overall global impression of improvement.

Interventional treatment for myofascial pelvic floor pain in women: systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

Female myofascial pain (MFP) of the pelvic floor muscles (PFM) is a subtype of chronic pelvic pain associated with urinary, anorectal, and sexual symptoms, such as dyspareunia. Treatment remains poorly discussed, and we hypothesized that different treatments could improve outcomes versus placebo or no treatment.

METHODS

A systematic review (CRD 42020201419) was performed in June 2020 using the following databases: PubMed, Cochrane Library, Web of Science, Embase, Scopus, BVSalud, Clinicaltrials.gov , and PEDro, including randomized clinical trials related to MPF of PFM. Primary outcome was pain after treatment, and secondary outcomes were quality of life and sexual function. Risk of bias and quality of evidence (GRADE criteria) were evaluated. Meta-analysis for continuous variables was performed (mean difference between baseline and treatment and post-treatment mean between groups).

RESULTS

Five studies were included (n = 218). Final mean VAS score (GRADE: very low) after 4 weeks of treatment (p = 0.14) and the mean difference from baseline and 4 weeks (p = 0.66) between groups were not different between the intervention and control groups. Quality of life according to the SF-12 questionnaire (GRADE: very low) followed the same pattern. However, sexual function (GRADE: low) according to the total FSFI score (MD = -5.07 [-8.31, -1.84], p < 0.01, i² = 0%) and the arousal, orgasm, and pain domains improved in the intervention groups when the mean difference from baseline and 4 weeks was compared with controls.

CONCLUSION

Pain and quality of life after 4 weeks of heterogeneous intervention differed between the intervention and control groups in sexual function: FSFI in studies improved in almost all domains. VAS (in three studies) and SF-12 (in two studies) failed to demonstrate differences.

Improvement in Quality of Life with Pelvic Floor Muscle Training and Biofeedback in Patients with Painful Bladder Syndrome/Interstitial Cystitis

Objective: To prove the benefits of pelvic floor muscle training with biofeedback (BFB) as a complementary treatment in women with bladder pain syndrome/interstitial cystitis (BPS/IC). Methods: Prospective, randomized study in 123 women with BPS/IC. Groups: BFB+ (n = 48): women with oral drug treatment (perphenazine and amitriptyline) plus intravesical instillations (sodium hyaluronate) plus pelvic floor muscle training with BFB; BFB−: (n = 75): women with oral drug treatment plus intravesical instillations. Variables: age, body mass index (BMI), time of follow-up, length of disease, time free of disease, diseases and health conditions concomitant, and responses to the SF-36 health-related quality of life questionnaire at the first consultation (SF-36 pre-treatment), and at the end of the study (SF-36 post-treatment). The treatment was considered successful when the SF-36 score reached values equal to or greater than 80 points or when the initial value increased by 30 or more points. Results: Mean age was 51.62 years old (23–82). BMI was higher in BFB−. The mean length of BPS/IC condition was 4.92 years (1–20), shorter in BFB+ than in BFB−. Mean SF-36 score pre-treatment was 45.92 points (40–58), lower in BFB+ than in BFB−. Post-treatment SF-36 score was higher than pre-treatment SF-36 score both in BFB+ and BFB−. SF-36 values were higher in BFB+ compared to BFB− over the follow-up. Conclusions: BFB improves quality of life in women with BPS/IC as adjunct therapy to combined oral and intravesical treatment.

Complementary and Alternative (CAM) Treatment Options for Women with Pelvic pain

Purpose of review

I.To provide an overview of the current complementary and alternative (CAM) treatment options for women with chronic pelvic pain (CPP).

Recent findings

II.Recent studies on chronic pain at cellular, molecular and network level and their interaction with the immune system has unfolded several mechanisms for pain making it promising to explore the alternative paradigm to manage the incredibly complex chronic pelvic pain condition where multifactorial etiology often limits successful outcomes.

Summary

III.The multifactorial nature and complexity in establishing the underlying diagnosis in CPP limits predictable response to traditional medical and interventional options. Complementary and alternative options have been studied to improve outcomes. Incorporation of exercise-based CAM, pelvic floor physical therapy, acupuncture and cognitive behavioral therapy are suggested to show promising results but well powered randomized studies are needed to draw conclusions on their efficacy. Evidence for non-opioid alternatives such as oral cannabinoids are preliminary and may emerge to be safe and effective.

Compliance With Pelvic Floor Physical Therapy in Patients Diagnosed With High-Tone Pelvic Floor Disorders

OBJECTIVE

The primary objective of this study was to describe patient compliance with pelvic floor physical therapy (PFPT) for high-tone pelvic floor disorders (HTPFD) and to compare patients who are compliant with prescribed therapy to those who are not. The secondary objective is to describe second-line treatments offered for HTPFD for returning patients.

METHODS

This is a retrospective cohort study of women with a HTPFD who were prescribed PFPT at a tertiary care referral center. Patients were excluded if they had a primary diagnosis of urinary incontinence, had undergone prior PFPT, or if PFPT was part of preoperative planning. Noncompliance with PFPT was defined as not being formally discharged from therapy by the treating therapist.

RESULTS

Data on PFPT compliance were available for 662 patients (87.3%). A total of 128 patients (19.4%) were fully compliant. Noncompliant patients were more likely to smoke and to have mental health disease compared with compliant patients (18% vs 8.7%, P = 0.01, and 50.4% vs 37.5%, P = 0.009, respectively). A total of 285 patients (43.1%) returned to their prescribing provider. Noncompliant patients were less likely to return to their provider: 63.4% versus 29.7%, P = <0.0001. Of the patients who returned, 183 (64.2%) were offered second-line treatment.

CONCLUSIONS

Only 1 in 5 patients referred to PFPT for management of a high-tone pelvic floor disorder is compliant with the recommended therapy. Patients who are noncompliant are less likely to return to their prescribing provider, and less than half of referred patients return. Sixty percent of patients who return are offered second-line treatment.

Symptom and Quality of Life Improvements After Pelvic Floor Physical Therapy in a Clinical Population of Women With Pelvic Pain and Other Symptoms

OBJECTIVES

This study aimed to evaluate changes in validated symptom scores at intake and discharge in women undergoing pelvic floor physical therapy (PFPT) for pain and other pelvic floor symptoms.

METHODS

Consecutive women starting PFPT during 1 year were reviewed. History, demographics, and Pelvic Floor Distress Inventory Questionnaire - Short Form 20 (PFDI) total and domain scores (Pelvic Organ Prolapse Distress Inventory-6, Urogenital Distress Inventory-6, Colorectal-Anal Distress Inventory-8), Pelvic Floor Impact Questionnaire (PFIQ-7), and pain levels on a numeric rating scale (NRS) were collected at intake and discharge. Data were analyzed with descriptive statistics and sign tests.

RESULTS

Of 474 women, mean age was 50.3 ± 16.7 years (range, 18-87 years) and the most common indication for PFPT was pelvic pain (208/474; 43.9%). In women with complete data, pretreatment to posttreatment median scores improved on the PFDI (77.3 vs 41.8; P < 0.0001), Urogenital Distress Inventory (37.5 vs 16.0; P < 0.0001), and PFIQ (58.0 vs 19.0; P < 0.0001), and the minimal clinically important difference was met for the PFDI, PFIQ, and Colorectal-Anal Distress Inventory. Women with primarily pelvic pain (n = 208) achieved significant improvements in PFDI, PFIQ, and NRS scores (P < 0.0001 for all) as well as the minimal clinically important difference for these measures. Pain patients with a history of pelvic surgery (n = 50) also had significant improvements in PFIQ and NRS but not PFDI scores.

CONCLUSIONS

Most women referred to PFPT demonstrated symptom improvements as measured by validated instruments.

Managing Interstitial Cystitis/Bladder Pain Syndrome in Older Adults

In this review, the current literature regarding pharmacotherapy treatment strategies available for the management of interstitial cystitis/bladder pain syndrome in older adults is addressed. The focus is on those treatments described by the American Urologic Association guidelines, organized according to clinical phenotype. Symptoms at presentation can vary with age, with older adults being more likely to experience nocturia, urinary incontinence, and Hunner's lesions than their younger counterparts. As such, treatment of interstitial cystitis/bladder pain syndrome should follow an individualized multimodal plan based on the patient's unique phenotype(s), starting with the most conservative options and escalating as needed. The side-effect profile and medication interactions should be reviewed, especially when treating older adults, requesting the aid of pharmacists or the primary care physician as needed to safely provide treatment.

Interdisciplinary Teams in Endometriosis Care

Endometriosis-associated chronic pelvic pain can at times be a complex problem that is resistant to standard medical and surgical therapies. Multiple comorbidities and central sensitization may be at play and must be recognized with the help of a thorough history and physical examination. If a complex pain problem is identified, most endometriosis expert reviews and guidelines recommend multidisciplinary care. However, there are no specific recommendations about what should be the components of this approach and how that type of team care should be delivered. There is evidence showing the effectiveness of specific interventions such as pain education, physical therapy, psychological therapies, and pharmacotherapies for the treatment of chronic pain. Interdisciplinary team models have been well studied and validated in other chronic pain conditions such as low back pain. The published evidence in support of interdisciplinary teams for endometriosis-associated chronic pain is more limited but appears promising. Based on the available evidence, a model for an interdisciplinary team approach for endometriosis care is outlined.

Treatment of Interstitial Cystitis/Bladder Pain Syndrome: A Contemporary Review

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating condition affecting approximately 3% of the female population. IC/BPS is defined as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than six weeks duration, in the absence of infection or other identifiable cause. This condition is known to have a profound negative impact on quality of life. There are few well-studied treatment options and no cure for this condition, which is therefore challenging to treat. The purpose of this narrative review is to summarise the contemporary literature, including the Canadian Urological Association (CUA) and American Urological Association (AUA) guidelines, on various treatment options that exist for IC/BPS, including conservative therapies, oral therapies, intravesical therapies, and more invasive surgical options. Most importantly, this review highlights the need for an individualised, multimodal approach to the treatment of IC/BPS.

Clinical Management of Bladder Pain Syndrome/Interstitial Cystitis: A Review on Current Recommendations and Emerging Treatment Options

Bladder pain syndrome (BPS) is a chronic condition characterized by pelvic pain or pressure which is perceived to be originating from the bladder, accompanied by one or more urinary symptoms, including frequency, urgency and nocturia. The precise etiology of BPS is not fully understood. Chronic bacterial infection, defective glycosaminoglycan (GAG) layer of the bladder urothelium, inappropriate activation of mast cells in the suburothelial layer of the bladder, autoimmune-mediated mechanisms and autonomic nervous system dysfunction have all been implicated. Treatments targeted at each of these mechanisms have been developed with mixed outcomes. High-quality research into the treatment options is lacking and it is difficult to draw definite conclusions. The treatment approach is multimodal and should be patient specific, targeting the symptoms which they find most bothersome. Conservative treatment, including patient education, behavioural modification, dietary advice, stress relief and physical therapy is an essential initial management strategy for all patients. If no response is observed, oral treatments such as amitriptyline are likely to offer the greatest response. Cystoscopy is essential to phenotype patients, and Hunner lesion directed therapy with fulguration or resection can be performed at the same time. Intravesical instillation of DMSO or lidocaine, detrusor injections of botulinum toxin A and neuromodulation can be used if initial management fails to improve symptoms. Oral cyclosporin can be trialled in those experienced with its use; however, it is associated with significant adverse events and requires intense monitoring. Lastly, radical surgery should be reserved for those with severe, unremitting BPS, in which quality of life is severely affected and not improved by previously mentioned interventions. Future work investigating exact aetiological factors will help target the development of efficacious treatment options, and several promising oral and intravesical treatments are emerging.

Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis

BACKGROUND

Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide-ranging treatment options, used alone or in combination, with limited evidence. A network meta-analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS.

OBJECTIVES

To conduct a network meta-analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS).

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible.

DATA COLLECTION AND ANALYSIS

We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random-effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta-analysis of head-to-head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories.

MAIN RESULTS

We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low-certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD -1.27, 95% CrI -3.25 to 0.71; low-certainty evidence), daytime frequency (MD -2.41, 95% CrI -6.85 to 2.05; very low-certainty evidence) or nocturia (MD 0.01, 95% CrI -2.53 to 2.50; very low-certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low-certainty evidence) or reduced pain (MD 0.42, 95% CrI -1.04 to 1.91; low-certainty evidence), frequency (MD -0.37, 95% CrI -5.00 to 3.44; very low-certainty evidence) or nocturia (MD -1.20, 95% CrI -3.62 to 1.28; very low-certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD -0.33, 95% CrI -1.71 to 1.03), frequency (MD -0.91, 95% CrI -3.24, 1.29) or nocturia (MD -0.04, 95% CrI -1.35 to 1.27). The certainty of this evidence was always very low.

AUTHORS' CONCLUSIONS

We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base.

Clinical presentation and characteristics of pelvic floor myofascial pain in patients presenting with constipation

BACKGROUND

Patients with pelvic floor myofascial pain (PFMP) have puborectalis tenderness on digital rectal examination (DRE). Little is known about its significance to anorectal function in patients presenting with constipation.

AIM

To characterize demographics, clinical characteristics, findings on anorectal manometry (ARM), diagnosis of rectal evacuation disorder (RED), colonic transit [normal (NTC) or slow (STC)], and imaging in constipated patients with PFMP and compare these features to constipation without PFMP.

METHODS

We performed an electronic medical records review of patients with constipation evaluated by a single gastroenterologist between January 2008 and February 2019. Patients with PFMP were compared to controls with constipation but without PFMP (1:2 ratio).

KEY RESULTS

A total of 98 PFMP cases and 196 controls were identified. Constipated patients with PFMP were more likely to have RED [OR 7.59 (3.82-15.09), P < .01]; controls were more likely to have either NTC [OR 4.25 (1.45-12.42), P < .01] or STC [OR 3.57 (1.45-8.78), P < .01]. RED in patients with PFMP is supported by comparison to controls: On DRE, they had increased resting tone [OR 2.25 (1.33-3.83), P < .01] and paradoxical contraction of the puborectalis upon simulated evacuation [OR 3.41 (1.94-6.00), P < .01]; on ARM, they had higher maximum resting pressure (102.9 mmHg vs 90.7 mmHg, P < .01) and lower rectoanal pressure gradient (-39.4 mmHg vs -24.7 mmHg, P < .01).

CONCLUSIONS/INFERENCES

In constipated patients, PFMP is highly associated with RED. Its presence provides a valuable clue regarding the etiology of a patient's constipation; it should be assessed in all patients with constipation and should also be an additional target for management.