Distinguishing Between Phenotypes of Perceived Bladder Pain

Educational Objectives

The goal of this program is to improve management of perceived bladder pain. After hearing and assimilating this program, the clinician will be better able to:

1. Compare different phenotypes of perceived bladder pain.
2. Administer intravesical therapy in patients with bladder-specific pain symptoms.

Summary

Urologic chronic pelvic pain: includes chronic prostatitis, interstitial cystitis (IC), and chronic pelvic pain syndrome (CPPS); no consensus definition; predicated on the perception of pain or pressure originating from the bladder; patients may experience dyspareunia, incomplete bladder emptying, urgency, or increased frequency; challenges for clinician because symptoms vary from patient to patient and overlap with common genitourinary complaints; IC and CPPS affect ≈8% of the general population; several studies have shown this may be an underestimation of the true prevalence; cost include $100 million annually to the health care system and loss of productivity

Guideline: in 2015, American Urological Association (AUA) guidelines were updated; multiple lines of treatments; first line treatment is pain management and education; cystectomy with or without urinary diversion is the final treatment

Current gaps in approach: patient population with varied heterogeneous symptom; severe pain and treatment resistance are concerns; no reliable clinical biomarkers, making diagnosis difficult; no prognostic indicators to match appropriate interventions in patients

Phenotyping: Ackerman et al (2020) — studied 150 ambulatory women to correlate bladder symptoms to pelvic floor examination and treatment to identify different symptom clusters and match them to treatment outcomes; 3 symptom clusters were identified; myofascial pelvic pain group had pain below the waist, stranguria, urgency and frequency symptoms, and feelings of incomplete bladder emptying; the second group, classic IC patients, had bladder-specific pain symptoms (ie, pain increased with filling, and got better with emptying); third group had pain in the urethra and vagina that did not appear to be associated with bladder filling or emptying; intravesical instillations and bladder analgesics were most effective for bladder pain-specific groups; myofascial pelvic pain group responded overwhelmingly to pelvic floor physical therapy; the third group did not respond well to common treatments

The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) research network: goal was to better characterize patients with IC and identify nonneurologic phenotypes associated with bladder presentation; the speaker’s group used data from the MAPP database, machine learning clustering, and validated instruments (eg, Genitourinary Pain Index [GUPI]); 3 symptom clusters were found; group 1 reported a sensation of incomplete bladder emptying, urinary urgency frequency symptoms, and high symptom severity and bother (aligned with the myofascial pelvic pain group from a previous local pilot study); group 2 had pain below the waist unrelated to micturition and had little impact on bother (best aligned with the nonneurologic pelvic pain group); group 3 had pain that was aggravated by bladder filling and relieved by bladder emptying (aligned with the bladder-specific pain group)

Outcomes comparing MAPP network data with local pilot study in IC

GUPI: a composite score examining genitourinary pain; the myofascial pelvic pain group had the highest scores in the MAPP cohort and the local study and the nonneurologic pelvic pain group had the lowest scores; this pattern persisted for bladder pain, quality-of-life scores, and urinary impact

Psychometric features: body pain involvement showed that patients with myofascial pelvic pain have the highest number of pain sites outside the pelvis (≈9 body sites) compared with nonneurologic pelvic pain and bladder-specific pain groups; showed that this symptom cluster had a more diffuse, regionalized pain than the other 2 groups, which had comparatively localized pelvic pain; myofascial pelvic pain group had the most pain severity

Flare: myofascial pelvic pain group tended to have more flare at baseline, more symptoms, and more episodes; different from the nonneurologic pelvic pain group and the bladder-specific pain group

Sexual dysfunction: the myofascial pelvic pain group tended to have the highest severity and worst scores on Female Sexual Function Index (scores from 0-36); the nonneurologic pelvic pain group had more localized pelvic pain to the vagina and the urethra; these scores were also associated with low sexual relationship scores, low confidence scores, and low self-esteem scores; associations were found with early childhood trauma, anxiety, fatigue, and sleep disturbances

Machine-learning techniques: aid in using a patient's symptoms to predict the symptom cluster using an algorithm and to match them to treatment; speaker opines machine learning allows clinicians target the myofascial pelvic pain group specifically

Speaker’s approach to patient evaluation: ask patients about pain duration, severity, and impact on QoL, relationship with micturition, location of the pain, any extrapelvic features, overactive bladder-like symptoms, and impact of flares and sexual dysfunction in terms of pain; as per data, childhood trauma correlates significantly with the myofascial pelvic pain group; these patients have poor relationships, poor perceived sexual function, fatigue, and sleep disturbances; the goal of machine learning is to obviate the need for a pelvic-floor examination, although the speaker emphasizes the impact and significance of pelvic floor examination; pelvic-floor examination in women involves inserting the index finger into the vaginal canal; in men, the examination is performed through the rectum

Targeted treatment: the myofascial pelvic pain group can be recommended pelvic floor physical therapy; studies show this group also responds well to botulinum toxin in the pelvic floor and possibly neuromodulation; for the bladder-specific pain symptoms group, bladder analgesics and intravesical instillations can be diagnostic and therapeutic measure; it is diagnostic because it can help differentiate between the various symptom clusters; there is no pattern of treatment to which the nonneurologic pelvic pain groups respond

Readings

Ackerman AL, Khalique MU, Ackerman JE, et al. microbial composition defines pelvic pain phenotypes in reproductive-age women. J Clin Transl Sci. 2020 Jun;4(Suppl 1):12–13; Colaco M, Evans R. Current guidelines in the management of interstitial cystitis. Transl Androl Urol. 2015 Dec;4(6):677–683; Digesu GA, Tailor V, Bhide AA, Khullar V. The role of bladder instillation in the treatment of bladder pain syndrome: Is intravesical treatment an effective option for patients with bladder pain as well as LUTS?. Int Urogynecol J. 2020;31(7):1387-1392. doi:10.1007/s00192-020-04303-7; Landis JR, Williams DA, Lucia MS, et al. The MAPP research network: design, patient characterization and operations. BMC Urol. 2014;14:58.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Nettey was recorded at the 26th Annual Innovations in Urologic Practice, held September 16-18, 2022, in Santa Fe, NM, and presented by Grand Rounds in Urology. For information on future CME activities from this presenter, please visit Grandroundsinurology.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

UR452402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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