Chronic Pelvic Pain Associated with the Bladder

Chronic Pelvic Pain Associated with the Bladder:
We Know It Exists but How Should
We Name It?
Juan Diego Villegas-Echeverri, MD
Claudia Camila Giraldo-Parra, MD
Advanced Laparoscopy and Pelvic Pain Center
Clinica Comfamiliar
Pereira, Colombia – SA
[email protected]
Chronic pelvic pain (CPP) could be defined as a non-cyclical pain of at least three months’
duration involving the pelvis, anterior abdominal wall, lower back, and/or buttocks, and serious
enough to cause disability or to necessitate medical care. It is a non-malignant pain with related
negative cognitive, behavioral and social consequences. It affects approximately 1 in every 7
women and a vast number of patients will not look for medical assistance or will be misdiagnosed or under treated. Many gynecologic and non gynecologic disorders are described as being
associated with chronic pelvic pain and that’s why the multidisciplinary approach to patients with
CPP is mandatory.
A complete and focused H&P will direct not only the diagnostic algorithm but also adapt the
management and prognosis.
Laparoscopy has been used as the Gold Standard for the diagnosis and treatment of CPP. At
least 40 – 60% of gynecologic laparoscopies are used to diagnose and treat women with chronic
pelvic pain but unfortunately almost half of those patients will have a so-called negative
laparoscopy. Multiple reasons can explain the absence positive findings at laparoscopy:
• Gynecologic teaching traditionally does not focus on etiologies different from endometriosis
(syndromes originating from the bladder or the gastrointestinal system are frequently not considered).
• The lack of experience of the physician approaching
pain patients.
• The presence of a condition not able to be diagnosed at laparoscopy.
Negative results of a laparoscopy do not exclude disease or mean there is no organic basis for
the patient’s pain.
The chronic pelvic pain associated with the bladder is probably one of the most frequent causes
of CPP missed at laparoscopy.
For a long time, the bladder was considered a very rare cause of CPP. However, in the last few
years has emerged as a consistent and more common than previously recognized cause of pelvic
pain.
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Chronic Pelvic Pain
Associated with the Bladder:
We Know It Exists but How
Should We Name It?
1
Board of Directors
3
Mark Your Calendars
4
Join Us
4
The President’s Perspective
5
Call for IPPS Vision
Contributions
6
Address Corrections
Requested
6
Nomenclature issues. Moving away from and back to
Interstitial Cystitis
Louis Mercier may have been the first to report a case of interstitial
cystitis (IC) in 1836. But it was a little later that Alexander J. Skene, a
gynecologist from New York, actually used for the first time the term
interstitial cystitis in the book Diseases of the Bladder and Urethra in Women
in 1887. He stated “when the disease has destroyed the mucus membrane
partly or wholly and extended to the muscular parietes, we have what is known
as interstitial cystitis”
In Baltimore in 1914, Guy Leroy Hunner documented non-trigonal
ulcers and bladder epithelial damage associated with interstitial cystitis.
In 1978, Patrick C. Walsh first used the term glomerulations and Messing and Stamey pointed them as an indicator of the presence of the
disease.
In 1987, the NIH-NIDDK (National Institute of Diabetes and Digestive
and Kidney Disease) came with the criteria for the diagnosis of interstitial
cystitis. This was probably the first structured forma proposal of diagnostic standards in IC.
Interstitial cystitis as established by NIH-NIDDK Workshop on
IC (August 1987)
Automatic inclusions
· Hunner’s ulcer
Positive factors
· Pain on bladder filling relieved by emptying
· Pain (suprapubic, pelvic, urethral, vaginal or perineal)
· Glomerulations on cystoscopy (75% quadrants) at bladder
distension (defined arbitrarily as 80cm water pressure for 1
minute)
· Decreased compliance on cystometrogram
Automatic exclusions
· < 18 years old
· Benign or malignant bladder tumours
· Radiation cystitis
· Tuberculous cystitis
· Bacterial cystitis
· Vaginitis
· Cyclophosphamide cystitis
· Symptomatic urethral diverticulum
· Uterine, cervical, vaginal or urethral cancer
· Active herpes
· Bladder or lower ureteral calculi
· Waking frequency < five times in 12 hours
· Nocturia < two times
· Symptoms relieved by antibiotics, urinary antiseptics, urinary
analgesics (for example phenazopyridine hydrochloride)
· Duration < 12 months.
· Involuntary bladder contractions (urodynamics)
· Capacity > 400 cc, absence of sensory urgency
Two positive factors are necessary for inclusion in
study population.
These strict criteria, when applied systematically in the clinical
practice, exclude more than two thirds of the patients with IC. So
they are currently used only for clinical trial purposes.
condition’s prevalence far exceeds the number of diagnosed patients
and predicted that cystoscopy with hydrodistension would become
less common as a diagnostic tool.
Also in 2003, at the Consultation on Interstitial Cystitis in Japan (ICICJ),
the need for a new approach became evident, because it was clear that
terminology and diagnosis about the painful bladder differed enormously among centers around the world.
In September 2006, the ESSIC (European Society for the Study of Interstitial Cystitis) proposed a consensus on definitions, diagnosis, and classification on various aspects of IC. It was agreed to name the disease
Bladder pain syndrome (BPS). They proposed this term based on the axial
structure of the IASP classification on painful syndromes. Pain is a main
finding in patients when diagnosed under the BPS definition. It would
be diagnosed on the basis of chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder accompanied by at
least one other urinary symptom such as the persistent urge to void or
urinary frequency. Urgency is not included in the defi
n. The ESSIC
also names a number of confusable diseases that must be excluded. Is
not clear but it can be assumed that the presence of a confusable disease
discards BPS and cannot be considered as a possible co
itant entity.
Source: European Society for the Study of IC/PBS (ESSIC) www.essic.eu
Eur.Urol. 2008 Jan;53(1):60-7. Epub 2007 Sep 20.
Moreov er, the ESSIC in clud es the use of cystoscopy wi th
hydrodistension and biopsy, if indicated, for the diagnosis of BPS/IC to
document the type of BPS/IC. Results of hydrodistension are denoted
grades 1-3 with an increasing grade of severity in appearance, and a
second symbol of A, B or C indicating the increasing grade of severity
at biopsy findings. For example, BPS-2C indicates a patient with BPS
symptoms who demonstrated glomerulations during hydrodistension
and had a positive biopsy.
Although proposed some years before, in 2002, The International Continence Society (ICS) defined the term Painful Bladder Syndrome (PBS/IC)
as the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night time
frequency, in the absence of proven urinary infection other obvious
pathology. At this time the ICS stated that Interstitial cystitis is an specific diagnosis (part of PBS) and requires confirmation by typical cystoscopic and histological features.
In 2003 the National Institute of Health indicated that PBS/IC should
not be a cystoscopic findings-based but a symptom-based diagnosis.
The NIH also recommended not using the restrictive diagnostic criteria
for IC proposed in 1987 by the NIDDK. The NIH also declared that the
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Source: European Society for the Study of IC/PBS (ESSI www.essic.eu
Eur.Urol. 2008 Jan;53(1):60-7. Epub 2007 Sep 20.
During a transition period, the ESSIC also proposed the name Bladder
Pain Syndrome/Interstitial Cystitis (BPS/IC) could be used parallel to BPS.
This suggested nomenclature caused certain opposition
only among
patient groups (omitting the name interstitial cystitis might cause serious problems in different health systems by affecting reimbursement
or possibility for patients to gain disability benefits) but also among
some clinicians.
In February 2007, the Association of Reproductive Health Professionals
and the Interstitial Cystitis Association held the Consensus Meeting on
Interstitial Cystitis in Washington DC and developed statements concerning the definition and nomenclature of the condition. In their opinion, the nomenclature of IC/PBS may need to change, bu change should
not be undertaken now because there is insufficient evidence to support a change. Any change in nomenclature should be ev
ased.
This group favors retaining IC in whatever name is considered in the
future and positioning it first, as in IC/PBS.
Participants did not determine if IC/PBS is a local or a systemic disease by agreeing that there is currently a deficiency evidence-based
literature in this area.
Participants also agreed that the results of currently available diagnostic techniques — in particular cystoscopy with hydrodistention under general anesthesia with or without bladder biopsy—often do not
correlate with the severity of IC/PBS symptoms. The cystocopy then, is
not a useful routine tool for the diagnosis and prognosis of the disease.
In summary, the Chronic Pelvic Pain associated with the bladder,
described more than 150 years ago, is a common cause of complaint for
a large number of women. There are many reasons to explain why
today it is a frequently undiagnosed and mistreated entity as there is a
lack agreement about nomenclature, definitions or diag stic standards.
Probably the term Bladder Pain Syndrome is the most accurate to describe the CPP associated with the bladder but the inclusion of IC to the
term (BPS/IC) has to be considered during a transition period. Work is
needed to unify terms and promote the use of validated diagnostic
tools.
Bibliography
1. Butrick CW. Patients With Chronic Pelvic Pain: Endometriosis or
Interstitial Cystitis/Painful Bladder Syndrome? JSLS (2007)
11:182–189.
2. Fall M, Baranowski AP, Fowler CJ, et al. EAU guidelines on chronic
pelvic pain. Eur Urol 2004;46:681–9.
3. Van de Merwe JP, Nordling J, Bouchelouche P et al. Diagnostic
Criteria, Classification, and Nomenclature for Painful Bladder
Syndrome/Interstitial Cystitis: An ESSIC Proposal. Eur Urol 2008;
53:60–67.
4. Chung M, Chung RP, Gordon D, Jennings C. The Evil Twins of Chronic
Pelvic Pain Syndrome: Endometriosis and Interstitial Cystitis. JSLS
2002;6:311-314.
5. Association of Reproductive Health Professionals. Interstitial Cystitis
Association. Outcome of the Washington, DC Consensus Meeting on
Interstitial Cystitis/Painful Bladder Syndrome: A Multidisciplinary
Meeting of Researchers, Clinicians, and Patients. Washington, DC
Consensus Group on IC/PBS. February 10, 2007.
6. Prostatitis: Disorders of the Prostate, NIDDK Publication, 1998;
Available: http://www.niddk.nih.gov/health/urolog/summary/
prstitis/prstitis.htm
7. Interstitial cystitis. NIH Publication No. 94-3220, 1994; Available http:/
/www.niddk.nih.gov/health/urolog/pubs/cystitis/cystitis.htm
8. Mercier, LA. Memoire sur certaines perforations spontanees de la vessie
non decrites jusqu’a ce jour. Gaz Med Paris 1836;4:257-263
9. Skene AJC. Diseases of the Bladder and Urethra in Women. New York:
Wm Wood, 1887;167
10. Hunner GL. A rare type of bladder ulcer in women: report of cases.
Trans south Surg Gynecol Assoc 1915;27:247-292
11. Gillenwater JY, Wein AJ. Summary of the NIADDK workshop on
interstitial cystitis, National Institutes of Health, Bethesda, MD. J Urol
1988:203-205
12. Nickel JC. Interstitial cystitis. A chronic pelvic pain syndrome.
Med Clin North Am. 2004 Mar;88(2):467-811
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13. Parsons CL, Dell J, Stanford EJ, Bullen M, KahnBS, Waxell T et al.
increased prevalence of interstitial cystitis: previously unrecognized
urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urol
2002;60:573-8
14. Mayer R. Interstitial cystitis pathogenesis and treatment. Curr Opin
Infect Dis. 2007;20(1):77-82
15. Waxman JA, Sulak PJ, Kuehl TJ. Cystoscopic findings consistent with
interstitial cystitis in abnormal women undergoing tubal ligation. J
urol 1998; 160: 1663-7
16. Denson MA, Griebling TL, Cohen MB, Kreder KJ. Comparison of cystoscopic and histological finding in patients with suspected interstitial
cystitis. J urol 2000;164: 1908-11
17. Theoharis CT, Grannum RS. Immunomodulators for treatment of
interstitial cystitis. Urology reviews. 2004;30: 156-60
18. Bouchelouche K, Nordling J. Recent developments in the management
of interstitial cystitis. Curr Opin Urol. 2003;13(4):309-13
Board of Directors
2007 - 2008
Executive Committee
Fred M. Howard, MD, MS, FACOG
Charles W. Butrick, MD
President
John Steege, MD
Vice President
Howard T. Sharp, MD, FACOG
Secretary/Treasurer
Richard P. Marvel, MD
Past President
Alfredo Nieves, MD, FACOG, DAAPM
Directors
Alex Childs, MD
Maurice K. Chung, RPh, MD, FACOG, ACGE
Michael Hibner, MD
Thomas Janicki, MD
Georgine Lamvu, MD, MPH, FACOG
Susan Parker, PT
Stephanie Prendergast, PT
John C. Slocumb, MD, SMH
Amy Stein, PT
R. William Stones, MD, FACOG
Juan D. Villegas Echeverri, MD
Jerome Weiss, MD
Michael Wenof, MD
Advisory Board
Stanley John Antolak, JR., MD
Rollin Ward Bearss, MD
James F. Carter, MD. FACOG
Margaret A. Coffman, MSN, ARNP
Beverly Jane Collett, MD
Daniel Doleys, PhD
Sarah Fox, MD
Melissa Kubic, PT
Philip Reginald, MD
Mark Your Calendars!
IPPS Annual Meeting
October 16 – 18, 2008
Buena Vista Palace Hotel & Spa
Lake Buena Vista, Florida
Join Us
Please join us in educating ourselves on how best to treat chronic pelvic pain. With your
help, we can provide relief and a more normal lifestyle for our patients. For membership information, please call (847) 517-8712 or visit our website at www.pelvicpain.org.
page 4
The President’s Perspective
As many of the readers of this publication are already aware, there is some most unhappy news to share
about Paul Perry, MD. Paul has been diagnosed with a rare form of lung cancer, which is apparently
present in both lungs. Unfortunately, the treatment options are few. Paul has resigned as Chairman of the
Board of IPPS, as he prepares to meet this greater challenge.
Paul is one of the “founding fathers” of IPPS, and has been a driving force behind the organization. It’s
clear to all of us that the organization would never have succeeded without his personal energy, organizational skills, and material support. IPPS owes much him.
We all wish Paul well as he deals with this, and offer our prayers and support.
John Steege, MD
______________________________________________________ ________________________________________________________________________
To follow up on the “lumping” vs. “splitting” discussion of the last issue, I thought I would use this occasion to reflect on the
interactions between sexual dysfunction and pelvic pain. We all see these interactions on a regular basis as we deal with pelvic pain,
but perhaps we might look at them from a little different angle, in view of the emerging information about pain and neurologic
function.
A number of studies have now shown that changes in neurologic supply accompany painful conditions. Examples include the vulvar
vestibule in vestibulitis, the lower uterine segment in women with uterine pain, and the peritoneum surrounding endometriosis
implants. In each case, there is either a higher density of unmyelinated pain fibers in the involved tissue (vestibulitis, uterus) or there
are nerve fibers present that are not usually there at all (endometriosis implants). The cause and effect question remains unanswered:
do the nerves appear after pain is generated for other reasons, or are they part of why the pain occurs in the first place?
From the standpoint of the survival of the species, it would make sense for the body to have the capacity to develop ways of detecting
and/or monitoring new dangers or threats. The sensation of pain has always served to warn of something gone wrong: perhaps this
is in play when dealing with internal as well as external sources of danger.
How then can sexual dysfunction become involved in pai Recalling the sexual physiology investigated by Masters and Johnson, it’s
easy to understand how deep dyspareunia might be aggravated by losing the vaginal lubrication and uterine elevation with vaginal
lengthening that normally accompany sexual response. Tender areas of endometriosis, or anything else tender, might more readily
move out of the way when this elevation/lengthening ha
On another level, however, is it possible that the innervation of genital
structures might itself undergo modification once pain has begun? This might explain the occasional patient with true allodynia of the
cervix, or of the vaginal apex after hysterectomy. Sexual dysfunction itself may thereby be an ingredient in the evolution of a visceral
pain syndrome over time. Just an idea.
SAVE THE DATE
Please mark your calendars for the International Pelvic Pain Society’s 2008 Annual Meeting.
When: October 16 – 18, 2008
Where: Buena Vista Palace Hotel & Spa in Lake Buena Vista, Florida
Call for Abstracts: April, 1, 2008
Abstract Submission Deadline: July 1, 2008
Watch the mail in early summer for registration materials and check the website:
www.pelvicpain.org for updates.
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Call for IPPS VISION Contributions
If you wish to contribute an article or column to the
would like to submit information regarding job prospects, or have
comments about the newsletter, please e-mail Ruth Gottmann at [email protected].
Address Corrections Requested
Please notify the IPPS of any changes in your contact
ation, including change of address, phone or fax numbers, and e-mail address.
This information is disseminated only to members and is used for networking, one of our primary missions.
Thank you.
Two Woodfield Lake
1100 E. Woodfield Drive, Suite 520
Schaumburg, IL 60173-5116
Phone: (847) 517-8712
Fax: (847) 517-7229
Website: www.pelvicpain.org
The International Pelvic Pain Society
Two Woodfield Lake
1100 E. Woodfield Drive, Suite 520
Schaumburg, IL 60173-5116
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