A new paradigm in chronic bladder pain

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A new paradigm in chronic bladder pain

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http://www.paineurope.com/articles/a-ne ... adder-pain

A new paradigm in chronic bladder pain

Published 3 June 2014

A growing awareness of the complexity of chronic bladder pain requires changes in the healthcare system to allow co-ordination of the multidisciplinary team, says Professor Ursula Wesselmann

Key learning points
  • The concept of visceral pain has moved from organ-centred disease to a conceptualisation based on pathophysiological mechanisms, integrating psychosocial and sexual dimensions
  • The terms painful bladder syndrome and bladder pain syndrome have been coined to include all patients with bladder pain
  • There is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes
  • IC/BPS is likely to be under-diagnosed and under-treated in both men and women
  • IC/BPS requires a multidisciplinary team approach toward management
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Over the last 15 years, the concept of ‘chronic visceral pain’ as a disease has received increased attention, particularly from the medical subspecialties of urology and gynaecology. Intense research efforts aimed at identifying and treating end-organ pathology, such as infection or inflammation, have demonstrated that a causal relationship to chronic visceral (pelvic) pain symptoms is uncommon. Moving away from this organ-centred understanding of chronic pain located in the abdominal and pelvic areas to a conceptualisation based on pathophysiological mechanisms of pelvic/abdominal pain, and integrating psychosocial and sexual dimensions, has resulted in a transformation of the field that is reflected in all areas from research to clinical practice.1,2

Chronic bladder pain – a disease in its own right

A prominent example of a chronic visceral pain syndrome where such a transformation has occurred is bladder pain. While interstitial cystitis (IC) was initially regarded as a bladder disease, it is now recognised that there is a heterogeneous group of still poorly defined disorders, which present with pain perceived in the bladder area and urinary symptoms.1,3–5 The terms painful bladder syndrome (PBS) and bladder pain syndrome (BPS) have been coined to include all patients with bladder pain.6 The broader definition of IC/BPS as ‘an unpleasant sensation perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes’ suggested by the Society for Urodynamics and Female Urology, has been used in both the European and US urological guidelines for the diagnosis and treatment of these conditions.7,8

Estimated prevalence data of IC/BPS vary based on case definitions and populations studied, ranging from 0.06 to 30%.1 Female predominance of IC/BPS has been reported in previous studies, but a recent study showed that the prevalence of IC/BPS symptoms in men approaches that in women, raising the concern that this condition may be under-diagnosed and under-treated in men.9 At present there is no universally accepted aetiology for IC/BPS and proposed aetiologies – which are not mutually exclusive – include inflammation, mast cell activation, urothelial dysfunction/glycosaminoglycan defects, abnormal neuronal function, presence of antiproliferative factor, autoimmune mechanisms, genetic predisposition and early-in-life experiences.10 These multiple aetiologies reflect the heterogeneity of the patient population.

Clinical observations suggest that there is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes. These observations could be explained neurophysiologically by referred visceral pain mechanisms from other visceral and somatic areas with overlapping spinal cord projections (Figure 1).11 There is increasing evidence of the co-occurrence of IC/BPS with chronic pain syndromes in other non-pelvic body areas (for example, with fibromyalgia),12 raising the question of systemic alterations of pain modulation mechanisms. Epidemiological studies have suggested that IC/BPS may be part of a more generalised systemic disorder,13,14 and it has been proposed that IC/BPS is a functional somatic syndrome rather than a urological condition.4

Figure 1: Schematic drawing showing the innervation of the pelvic floor in females.11
Image

Transforming bladder pain research and clinical management

The shift in conceptualising IC/BPS as a systemic disease has resulted in new approaches in basic science and clinical research of bladder pain as well as in the clinical management of this visceral pain syndrome. The National Institutes of Health in the US have launched a multidisciplinary research network,15 embracing a systemic ‘whole body’ approach in the study of IC/BPS focusing on five major areas:
  1. epidemiology of disease;
  2. phenotyping of urological and non-urological symptoms;
  3. neuroimaging/neurobiology studies;
  4. identification of biomarkers of disease; and
  5. characterisations of organ crosstalk/pain pathways.
Recognising IC/BPS as a visceral pain syndrome and realising the sometimes marked differences in the expression and function of receptors in visceral and somatic pathways has led to new pharmacological research explorations of previously overlooked potential therapeutic targets.16,17 Clinical guidelines have been developed in several countries over the last 10 years proposing an integrated approach to IC/PBS by a multidisciplinary team of healthcare providers.1,6–8

The need for a multidisciplinary team approach to IC/BPS will require changes in the healthcare system to allow a coordinated involvement of multiple teams, beyond the historic boundaries of medical subspecialties and of primary and secondary care. This has recently been addressed in the British Pain Society’s Pelvic Pain Patient Pathway Map18 and in the Pain Report of the Institute of Medicine in the US, issued at the request of Congress as part of President Obama’s health reform legislation.19

The shift in the conceptualisation of visceral pain has created the need for a forum for clinicians and researchers to interact in a multidisciplinary fashion. In 2013, the 1st World Congress on Abdominal and Pelvic Pain took place in Amsterdam, The Netherlands. It is a new initiative in the world of visceral pain and was set up by three organisations active in the field of pelvic pain that joined forces to organise this unique meeting.

These events are an important step forward and highlight a condition that is often under-recognised, despite its high impact on the quality of life of the patient and high societal burden. This area is evolving and extremely important, as visceral pain is the most frequent form of pain.17

Ursula Wesselmann is professor of anaesthesiology and neurology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, US


References
1.Engeler DS, Baranowski AP, et al. European Urology 2013;64(3):431–439.
2.Wesselmann U. European Journal of Pain 1999;3:189–191.
3.Baranowski AP, Abrams P, et al. European Urology 2008;53(1):33–36.
4.Potts JM, Payne CK. Pain 2012;153:755–758.
5.Wesselmann U. Urology 2001;57(6 Suppl 1):32–39.
6.Fall M, Baranowski AP, et al. European Urology 2010;57(1):35–48.
7.Engeler DS, Baranowski AP, et al. Guidelines on Chronic Pelvic Pain. EAU, 2013.
8.Hanno PM, Burks DA, et al. Journal of Urology 2011;185(6):2162–2170.
9.Suskind AM, Berry SH, et al. Journal of Urology 2013;189(1):141–145.
10.10. Vij M, Srikrishna S, et al. European Journal of Obstetrics, Gynaecology and Reproductive Biology 2012;161(1):1–7.
11.Wesselmann U, Burnett AL, et al. Pain 1997;73(3):269–294.
12.Clauw DJ, Schmidt M, et al. Journal of Psychiatric Research 1997;31(1):125–131.
13.Bullones Rodriguez MA, Afari N, et al. Journal of Urology 2013;189(1 Suppl):S66–74.
14.Warren JW, Howard FM, et al. Urology 2009;73(1):52-57.
15.MAPP research network. Multi-Disciplinary Approach to the Study of Chronic Pelvic Pain. Available from: http://www.mappnetwork.org (accessed 8 April 2014).
16.Blackshaw LA. British Journal of Pharmacology 2014;171(10):2528–2536.
17.Wesselmann U, Baranowski AP, et al. Drug Discovery Today: Therapeutic Strategies 2009;6(3):89–95.
18.Baranowski AP, Lee J, et al. British Journal of Anaesthesia 2014;112:452–459.
19.Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Available from: http://www.iom.edu/Reports/2011/Relievi ... earch.aspx (accessed 8 April 2014).


Date of preparation: May 2014; MINT/PPR-14011
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