The biopsychosocial impacts of anxiety on overactive bladder in women.

AIMS: Links between emotional state and the bladder have long been recognized, as psychological comorbidity is a common feature of overactive bladder (OAB). However, how psychological factors might contribute to the development and severity of OAB remains unclear. Therefore, we sought to examine the effect of anxiety on OAB with a specific focus on bladder hypersensitivity. METHODS: In a sample of 120 adult women with OAB, we compared those with at least mild anxiety (PROMIS Anxiety score ≥55) to those with lower anxiety. Analyses focused on patient-reported questionnaires assessing urinary symptom severity and quality of life, psychological stress symptoms, general somatic symptoms, and results of quantitative sensory testing (QST), including temporal summation to heat pain (TSP). TSP was used to index elevated C-fiber responsiveness (i.e., central sensitization). RESULTS: Thirty-six (30%) women had at least mild anxiety. While there were no group differences for urinary symptom severity, more anxious women reported worse OAB-specific quality of life, greater psychological stress burden, higher stress reactivity, and greater somatic symptoms. On QST, there were no differences between anxiety groups for pain threshold (43.6 ± 3.1°C vs. 44.0 ± 3.1°C, p = 0.6) and tolerance (47.3 ± 1.5°C vs. 47.4 ± 1.6°C, p = 0.7). However, those with anxiety had significantly higher TSP than those without anxiety (6.0 ± 4.8 vs. 3.7 ± 3.9, p = 0.006), indicating greater central sensitization. CONCLUSIONS: Women with OAB and at least mild anxiety symptoms reported greater psychosocial burdens (i.e., psychological stress, stress reactivity, OAB-specific QOL) and somatic symptom severity and demonstrated greater central sensitization on QST than those without anxiety. These findings support the hypothesis that anxiety and psychological stress impact hypersensitivity mechanisms that may underlie and contribute to OAB, although further research is needed to better understand how and to what extent.

Compensatory coping and depression in women with interstitial cystitis/bladder pain syndrome.

INTRODUCTION: Women with genitourinary pain, a hallmark symptom of interstitial cystitis/bladder pain syndrome (IC/BPS), are at a two- to four-fold risk for depression as compared to women without genitourinary pain. Despite the pervasive impact of IC/BPS on psychological health, there is a paucity of empirical research on understanding the relation between IC/BPS and psychological distress. It has been previously reported that women with overactive bladder use increased compensatory coping and these behaviors are associated with heightened anxiety and stress. However, it is unknown whether a similar pattern emerges in IC/BPS populations, as ICBPS and OAB share many similar urinary symptoms. The current study examined the relationship between compensatory coping behaviors and symptoms of psychological distress in a sample of women with IC/BPS to inform understanding of risk and potential mechanisms for intervention. METHOD: This was a secondary analysis of an observational cohort of women with bladder symptoms. Fifty-five adult women with IC/BPS completed validated assessments of genitourinary symptoms, emotional distress, and bladder coping behaviors. Five compensatory coping behaviors were summed to create a total Bladder Coping Score. Linear regression examined associations between individual coping behaviors, total compensatory coping scores, and other risk variables. RESULTS: Most (93%) participants reported use of at least one compensatory coping behavior. Age, education level, history of vaginal birth, and symptom severity were all associated with greater compensatory coping scores, and anxiety was not. Beyond the influence of symptom severity, higher levels of depression were significantly associated with higher compensatory coping scores. DISCUSSION: Greater compensatory coping was associated with increased depression but not anxiety, suggesting different profiles of coping and psychological distress may exist among different types of bladder dysfunction.

Electronic Delivery of Pain Education for Chronic Overlapping Pain Conditions: A Prospective Cohort Study.

OBJECTIVE: To examine the impact of educational materials for chronic overlapping pain conditions (COPCs), the feasibility of delivering materials online, and to explore its impact on self-reported self-management applications at 3-month follow-up. DESIGN: Prospective cohort study. SETTING: Online. SUBJECTS: Individuals from a university-wide active research repository with ≥1 coded diagnostic COPC by ICD-9/10 in the medical record. METHODS: We determined the number of COPCs per participant as indicated by diagnostic codes in the medical record. Consenting participants completed self-report questionnaires and read educational materials. We assessed content awareness and knowledge pre- and post-exposure to education. Comprehension was assessed via embedded questions in reading materials in real time. Participants then completed assessments regarding concept retention, self-management engagement, and pain-related symptoms at 3-months. RESULTS: N = 216 individuals enrolled, with 181 (84%) completing both timepoints. Results indicated that participants understood materials. Knowledge and understanding of COPCs increased significantly after education and was retained at 3-months. Patient characteristics suggested the number of diagnosed COPCs was inversely related to age. Symptoms or self-management application did not change significantly over the 3-month period. CONCLUSIONS: The educational materials facilitated teaching of key pain concepts in self-management programs, which translated easily into an electronic format. Education alone may not elicit self-management engagement or symptom reduction in this population; however, conclusions are limited by the study's uncontrolled design. Education is likely an important and meaningful first step in comprehensive COPC self-management.

Factors associated with urinary incontinence in a community sample of young nulligravid women.

AIMS: The aim of this study is to identify factors associated with urinary incontinence (UI) in a community sample of young nulligravid women. METHODS: This was a secondary analysis from a cross-sectional survey-based study of cisgender women aged 18 to 25 years recruited through a national registry of research volunteers. Participants completed validated questionnaires assessing toileting behaviors, lower urinary tract symptoms (LUTS), and bowel symptoms. Women were excluded from analysis if currently pregnant, any prior pregnancy, cystectomy, or any neurologic disease including spinal cord injury, stroke, or multiple sclerosis. Analyses determined the prevalence of symptoms and evaluated candidate risk factors for UI. RESULTS: Final analyses included 964 women (mean age, 22.6 ± 2.0). Monthly UI was identified in 295 (30.6%) subjects, with mixed UI being the most common (56.9%; n = 168). Seventy-two women (7.4%) reported fecal incontinence (FI) and 24 (3.5%) women reported both UI and FI. After multivariable regression modeling, UI was associated with an intermittent urine stream and the delayed voiding toileting behavior subscale. CONCLUSIONS: UI in this cohort of young nulliparous women was highly prevalent and warrants further study as to the cause. Therapeutic guidelines to prevent UI and LUTS may need to be adjusted by targeting populations earlier than traditionally considered.

Proximal location of explanted midurethral slings is associated with urinary storage symptoms.

AIM: To examine the location of midurethral slings (MUS) at the time of excision to determine associations between presenting symptoms and sling location at explant. METHODS: We performed an IRB approved, retrospective review of MUS explants between January 2011 and March 2016. Symptoms and physical examination findings were compared between women with slings explanted from the mid-urethra (MU) and women with slings explanted from the proximal urethra/bladder neck (PU/BN). RESULTS: We included 95 consecutive women who underwent MUS explant in the analysis. Presenting symptoms included pain in 69 women (72.6%), urinary urgency in 66 (66.5%), voiding dysfunction in 55 (57.9%), urge urinary incontinence (UUI) in 41 (43.2%), stress urinary incontinence in 34 (35.8%), and recurrent urinary tract infections in 22 (23.2%). At sling explant, 2 (2.1%) slings were found at the distal urethra, 33 (34.7%) at the MU and 60 (63.2%) at the PU/BN. Women with slings explanted from the PU/BN were more likely to present with urgency (78.3% vs 54.5%; P = 0.017) and UUI (53.3% vs 27.3%; P = 0.015) and less likely to present with pain on examination (48.3% vs 75.8%; P = 0.01). CONCLUSIONS: The majority of MUS requiring explant in this cohort were found at the PU/BN. The most common presenting symptom before MUS explant was pain, followed by urgency and voiding dysfunction. PU/BN location of MUS is likely a factor in the development of urgency and UUI in women who ultimately undergo explant.

Posttraumatic stress disorder in interstitial cystitis/bladder pain syndrome: Relationship to patient phenotype and clinical practice implications.

PURPOSE: The relationship between exposure to abuse and interstitial cystitis/bladder pain syndrome (IC/BPS) is well-documented. However, studies have yet to examine posttraumatic stress disorder (PTSD), which develops following exposure to trauma and worsens health outcomes in chronic pain. We aimed to assess the prevalence and impact of PTSD in patients with IC/BPS, including their relation to genitourinary symptom presentation and widespread pain phenotype. MATERIALS AND METHODS: We recruited 202 participants with chronic pain from an academic medical center and classified 64 individuals as IC/BPS based on validated epidemiological criteria. Participants completed self-reported questionnaires assessing trauma exposure, PTSD symptoms, emotional distress, pain, and urinary symptoms. Wilcoxon rank-sum tests assessed study aims comparing IC/BPS to other chronic pain. RESULTS: Although elevated, IC/BPS trauma exposure rates were equivalent to that of other chronic pain conditions in the sample. Despite this equivalence, in comparison, IC/BPS patients had significantly higher rates of PTSD symptoms, with 42% meeting provisional diagnostic criteria for PTSD. Among IC/BPS, those meeting provisional criteria for PTSD had significantly higher incidence of lifetime sexual abuse, childhood trauma, and presentations consistent with the widespread pain phenotype. In IC/BPS, there was no association between PTSD and genitourinary symptoms, but provisional PTSD was associated with more pain, emotional distress, and poorer quality of life. CONCLUSIONS: We recommend that patients with IC/BPS and widespread pain have ongoing screening and monitoring of PTSD. We recommend using trauma-informed care practices with these patients to increase trust and safety, which could improve treatment compliance and follow-up.

Psychosocial co-morbidities in Interstitial Cystitis/Bladder Pain syndrome (IC/BPS): A systematic review.

AIMS: Psychosocial factors amplify symptoms of Interstitial Cystitis (IC/BPS). While psychosocial self-management is efficacious in other pain conditions, its impact on an IC/BPS population has rarely been studied. The objective of this review is to learn the prevalence and impact of psychosocial factors on IC/BPS, assess baseline psychosocial characteristics, and offer recommendations for assessment and treatment. METHOD: Following PRISMA guidelines, primary information sources were PubMed including MEDLINE, Embase, CINAHL, and GoogleScholar. Inclusion criteria included: (i) a clearly defined cohort with IC/BPS or with Chronic Pelvic Pain Syndrome provided the IC/BPS cohort was delineated with quantitative results from the main cohort; (ii) all genders and regions; (iii) studies written in English from 1995 to April 14, 2017; (iv) quantitative report of psychosocial factors as outcome measures or at minimum as baseline characteristics. RESULTS: Thirty-four of an initial 642 articles were reviewed. Quantitative analyses demonstrate the magnitude of psychosocial difficulties in IC/BPS, which are worse than average on all measures, and fall into areas of clinical concern for 7 out of 10 measures. Meta-analyses shows mean Mental Component Score of the Short-Form 12 Health Survey (MCS) of 40.80 (SD 6.25, N = 2912), where <36 is consistent with severe psychological impairment. Averaged across studies, the population scored in the range seen in clinical depression (CES-D 19.89, SD 13.12, N = 564) and generalized anxiety disorder (HADS-A 8.15, SD 4.85, N = 465). CONCLUSION: The psychological impact of IC/BPS is pervasive and severe. Existing evidence of treatment is lacking and suggests self-management intervention may be helpful.

Phenotyping women with detrusor underactivity by presumed etiology: Is it plausible?

AIMS: Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies. METHODS: A retrospective review was performed at a single institution from 2011 to 2015 to identify patients with symptoms of UAB. Patients were excluded if they were male, had anti-incontinence, or pelvic organ prolapse (POP) surgery within 1 year, or the UDS did not demonstrate DU as defined within. Subjects were stratified by etiology into four cohorts: cardiovascular disease manifestations (CV), cardiac risk factors (CVR), neurologic (N), or idiopathic (I). Patient demographics, comorbidities, symptomatology, physical exam, and UDS parameters were compared. RESULTS: A total of 200 patients met inclusion criteria (CV: n = 53 [26.5%], CVR: n = 44 [22%] N: n = 81 [40.5%], I: n = 22 [11%]). Women in the CV cohort were significantly older and more likely to be post-menopausal (P < 0.001). There were no differences between cohorts for BMI (P = 0.48), recurrent UTI (P = 0.63), history of urinary retention (AUR) (P = 0.65), POP (0.49), American Urological Association Symptom Score (AUA-SS) (P = 0.06), presenting symptomatology [urgency, frequency, urgency urinary incontinence, AUR, incomplete emptying, hesitancy, UTI (P = 0.97)], or UDS parameters (first sensation [P = 0.25], normal desire [P = 0.80], strong desire [P = 0.58], capacity [P = 0.11], Qmax [P = 0.50], Pdet at Qmax [P = 0.22], post-void residual [P = 0.82]). CONCLUSIONS: Though differences were observed between cohorts for age and menopausal status, clinical or urodynamic parameters did not demonstrate distinct differences across presumed categories of etiology, suggesting that the etiology of DU may be multifactorial. Neurourol. Urodynam. 36:1151-1154, 2017. © 2016 Wiley Periodicals, Inc.

Invasion of vaginal epithelial cells by uropathogenic Escherichia coli.

Host-associated reservoirs account for the majority of recurrent and oftentimes recalcitrant infections. Previous studies established that uropathogenic E. coli - the primary cause of urinary tract infections (UTIs) - can adhere to vaginal epithelial cells preceding UTI. Here, we demonstrate that diverse urinary E. coli isolates not only adhere to, but also invade vaginal cells. Intracellular colonization of the vaginal epithelium is detected in acute and chronic murine UTI models indicating the ability of E. coli to reside in the vagina following UTI. Conversely, in a vaginal colonization model, E. coli are detected inside vaginal cells and the urinary tract, indicating that vaginal colonization can seed the bladder. More critically, bacteria are identified inside vaginal cells from clinical samples from women with a history of recurrent UTI. These findings suggest that E. coli can establish a vaginal intracellular reservoir, where it may reside safely from extracellular stressors prior to causing an ascending infection.

The surgical technique and early postoperative complications of the Gynecare Prolift pelvic floor repair system.

INTRODUCTION: The Gynecare Prolift pelvic floor repair system (GPS) comprises a synthetic mesh placed via a transvaginal, transobturator approach. We present our technique focusing on the safety and feasibility of the GPS. MATERIALS AND METHODS: GPS candidates are evaluated in the office with a full history, physical examination, urinalysis and when appropriate, urodynamic evaluation. Patients were offered total vaginal vault prolapse repair or isolated anterior repair dependent of site of defect. Follow-up comprised a full history, physical examination, and global assessment of subjective satisfaction (2 and 6 weeks, 6 months postoperative). Concentration was placed on intraoperative and short-term postoperative complications and assessment of prolapse recurrence. RESULTS: GPS prolapse repair has been used in 12 patients for anterior or total vault prolapse. Mean postoperative follow-up time is 42 weeks. There were no major perioperative complications. De novo enterocele development was seen in one patient without any other incidence of recurrence. No incidence of mesh erosion or sexual dysfunction has been observed. CONCLUSIONS: The GPS is a safe and reproducible system for use in transvaginal repairs of vaginal vault prolapse. Long-term studies are needed to evaluate repair durability and for potential complications.

Trans-Vaginal Mesh Revision: A Comprehensive Review on Etiologies and Management Strategies with Emphasis on Postoperative Pain Outcomes.

The use of polypropylene mesh to augment surgery aimed to correct pelvic organ prolapse and stress urinary incontinence stems largely from the high recurrence rates of native tissue repairs. While objective outcomes were improved, mesh related complications began to emerge that included mesh exposures, extrusions, dyspareunia and other pain issues. However, the indication for and benefit of surgical intervention(s) to address these complications are lacking. We aim to review to current literature regarding postoperative pain outcomes following vaginal mesh revision. Evidence based literature indicates that mesh complications are not rare and surgery that aims to address them generally have an overall benefit. However, studies available are generally small case series of a retrospective nature with short follow up. Some themes are evident: there is a long lag period from mesh insertion to removal; there is a lack of a true denominator of total mesh insertions making it hard to gauge the real scope of the problem; mesh material found not along the expected trocar path or coursing close to neurovascular structures thus raises the possibility of technical errors during insertion. Transvaginal mesh revision(s) for mesh complications generally have a positive effect on pain outcomes, but better controlled studies are needed. Additionally, since technical issues may be a factor in the development of mesh complications, rigorous training and sufficient surgical case volume should be emphasized.