Algorithm-based Mobile Texting Platform for the Self-management of Interstitial Cystitis/Bladder Pain Syndrome: Pilot Study Evaluating Feasibility, Usability and Potential Utility.

INTRODUCTION: We developed an algorithm-based mobile texting platform for promoting self-management in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). Our aim was to measure the feasibility, usability, and potential utility of the platform. MATERIAL AND METHODS: A texting platform that delivered four treatment modules (education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and an automated weekly message over six weeks was developed. Feasibility and usability were determined using patient engagement (proportion of platform messages to which patients responded) and System Usability scale. Satisfaction with patient-physician communication questionnaire, Pain Self-Efficacy Scale, and Interstitial Cystitis Symptom and Problem Index were administered before and after the intervention. RESULTS: Engagement with the platform in 52 female patients with IC/BPS [median age (IQR) 40 (30-48) years] was 76.9%. The commonest module selected by patients was pelvic floor physical therapy (50%) followed by cognitive behavioral therapy (34%), and guided mindfulness (15%). System Usability score (median, IQR) was 87 (83-95), indicating high usability. Satisfaction with patient-physician communication improved significantly (median change 4, IQR 1-9, p< .001). Pain self-efficacy score improved from moderate impairment at baseline to minimal impairment at six weeks (median change 10, IQR 2-18, p < .001). Urinary symptoms scores also improved (median change Interstitial Cystitis Symptom Index -3, IQR -5, -1.5, p < .001, Problem Index -2, IQR 5.5, -0.5, p <.001). CONCLUSION: An automated mobile platform has the potential for improving access to self-management strategies and easing clinicians' challenge of counseling IC/BPS patients during time-limited in-person visits.

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.

Gynecological associated disorders and management.

BACKGROUND: Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management. METHODS: An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed. RESULTS: Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery. CONCLUSION: Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.

Hunner lesion versus non-Hunner lesion interstitial cystitis/bladder pain syndrome.

BACKGROUND: Global consensus on the standardization of terminology for interstitial cystitis/bladder pain syndrome is lacking and is in the formative stages. The Workshop on Hunner lesion versus non-Hunner lesion at the 2018 International Consultation on Interstitial Cystitis Japan discussed prevalence, performance and outcome of endoscopy, the role of histopathology, and markers. METHODS: A panel of experts reviewed the literature regarding Hunner lesion vs. non-Hunner lesion interstitial cystitis/bladder pain syndrome. RESULTS: The prevalence of Hunner lesion has been reported to be 5-57%. Older age and smaller anatomic bladder capacity were associated with Hunner lesions. Cystoscopy using local anesthesia is not adequate in diagnosing interstitial cystitis but is needed to rule out confusable diseases. Cystoscopy with hydrodistention and redistention of the bladder is considered standard. A Hunner lesion is visualized as a quite typical inflammatory reaction: a reddened mucosal area with small vessels radiating towards a central scar, splitting at distension, usually associated with a waterfall bleeding pattern. Biopsies from the inflamed area show inflammatory infiltrates, granulation tissue, detrusor mastocytosis, and fibrin deposits. Ablation of Hunner lesions includes transurethral resection of lesions, fulguration, laser ablation, and cortical steroid injections. Mast cell density is a somewhat controversial matter, described differently in different studies: marked increase in Hunner lesion vs. non-Hunner lesion in the majority of studies, no difference in a few. Nitric oxide appears to be a definitive marker in distinguishing Hunner lesion vs. non-Hunner lesion disease. Macrophage migration inhibitory factor is elevated in Hunner lesion patients. Increased level of urinary proinflammatory genes expression has also been found in Hunner lesion subjects. CONCLUSIONS: Hunner lesion patients are clinically and pathologically distinct from non-Hunner lesion bladder pain syndrome patients.

Thermal and Mechanical Pain Thresholds of Women With Provoked Localized Vulvodynia: A Pilot Study.

CONTEXT: Vulvodynia is a chronic pain condition defined as vulvar pain lasting at least 3 months in the absence of gross anatomic or neurologic findings. Provoked, localized vulvodynia (PLV), a subtype of vulvodynia, is characterized by vestibular pain in response to light touch. The cause of PLV remains largely unknown, and triggering events have yet to be determined. OBJECTIVE: To evaluate vestibular and peripheral experimental pain thresholds in patients with PLV to further define the somatosensory profile of these patients. METHODS: After informed consent was provided, eligible participants completed a questionnaire and underwent quantitative sensory testing at the forearm and posterior vestibule. Detection and pain thresholds to thermal (cold and heat) and mechanical (pressure) stimuli were measured. RESULTS: Seventeen participants with PLV and 16 control participants were included. Participants in the PLV group scored lower on the patient health questionnaire 9 (PHQ-9) compared with those in the control group (P<.05) and had higher ratings of self-reported genital pain with sex (P<.001) and daily activity (P<.05). Forearm pain thresholds to cold (P<.01) and heat (P<.01) stimuli were also lower in the PLV group compared with those in the control group. Vestibular pain thresholds to cold (P<.05) and pressure (P<.01) stimuli were also lower in the PLV group. CONCLUSION: Lower scores on the PHQ-9 and higher self-reported genital pain ratings of patients with PLV highlight the significant impact of this poorly understood condition on quality of life. Quantitative sensory testing results demonstrated that vestibular cold allodynia may be a somatosensory feature of PLV. Reduced forearm pain thresholds in these patients suggest altered sensory processing at extrapelvic sites, although it is unclear whether these measurements are related to central sensitization.

Sequence of Pelvic Examination Affects Patient-Reported Pain.

OBJECTIVE: The purpose of this trial is to compare patient-reported pain based on the sequence of the pelvic examination and to assess the relationship between pain during the examination and quality of life, self-esteem, and sexual function. METHODS: A randomized controlled trial of women presenting for annual gynecologic examinations. Women were assigned to either group A: a Q-tip touch test, speculum examination, then bimanual examination or group B: Q-tip touch test, bimanual examination, then speculum examination. The primary outcome was visual analog scales to assess pain at baseline and after each portion of the examination. Secondary outcomes were responses to questionnaires for self-esteem, quality of life, and sexual function. RESULTS: Of 200 women who enrolled, 192 (96%) completed all visual analog scale data points. Each portion of the examination caused minimal pain over baseline in each group. Pain during the speculum examination was higher than pain during the bimanual examination in both groups (P = 0.007 and P < 0.001). Group B, however, had significantly higher pain scores after the speculum examination than group A (P = 0.044). The groups did not differ on bimanual pain scores (P = 0.76). Pain scores were not statistically different when analyzed by age, parity, sexual activity, sexual orientation, education, or previous hysterectomy. Within both groups, patients who documented having any pain after the speculum examination or the bimanual examination were also more likely to have lower quality of life scores (P < 0.001 and P < 0.001). CONCLUSIONS: Pain associated with the speculum examination was lower in those undergoing speculum before bimanual examination. Speculum pain was greater than bimanual pain in both groups. Most patients reported minimal or no pain during the different portions of the examination.

The fundamentals of chronic pelvic pain assessment, based on international continence society recommendations.

AIMS: Chronic pelvic pain (CPP) is defined as a noncyclical pain that has duration of at least 6 months and can lead to decreased quality of life and physical performance. The pain can be attributed to problems in the pelvic organs and/or problems in related systems, and possible psycho-social attributes may contribute to the manifestation. Due to the complex nature, CPP syndromes are multifactorial and the terminology needs to reflect the setting. METHODS: The current review is a synthesis of key aspects of the recent International Continence Society Standardization for Terminology in CPP Syndromes. RESULTS: Nine domains can be used for a detailed description of CPP. They include four domains specific to the pelvic organs (lower urinary tract, female genital, male genital, gastrointestinal), two related to other sources of pain which may be perceived in the pelvis (musculoskeletal, neurological) and three which may influence the response to the pain or its impact on the individual (psychological, sexual, and comorbidities). For an individual patient with CPP, each domain should be reviewed in terms of symptoms and signs, noting that positive findings could reflect either a primary cause or a secondary consequence. The findings will guide further evaluations and subsequent treatment. CONCLUSION: We present a synthesis of the standard for terminology in CPP syndromes in women and men, which serves as a systematic framework to consider possible sources of pain (pelvic organs or other sources) and the individual responses and impact.

The evaluation and management of female sexual dysfunction.

Female sexual dysfunction has complex physiologic and psychological components that require a detailed screening, history, and physical examination. Our goal in this review is to provide family physicians with insights and practical advice to help screen, diagnose, and treat female sexual dysfunction, which can have a profound impact on patients' most intimate relationships.

A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society.

AIMS: Terms used in the field of chronic pelvic pain (CPP) are poorly defined and often confusing. An International Continence Society (ICS) Standard for Terminology in chronic pelvic pain syndromes (CPPS) has been developed with the aim of improving diagnosis and treatment of patients affected by chronic pelvic pain syndromes. The standard aims to facilitate research, enhance therapy development and support healthcare delivery, for healthcare providers, and patients. This document looks at the whole person and all the domains (organ systems) in a systematic way. METHODS: A dedicated working group (WG) was instituted by the ICS Standardisation Steering Committee according to published procedures. The WG extracted information from existing relevant guidelines, consensus documents, and scientific publications. Medline and other databases were searched in relation to each chronic pelvic pain domain from 1980 to 2014. Existing ICS Standards for terminology were utilized where appropriate to ensure transparency, accessibility, flexibility, and evolution. Consensus was based on majority agreement. RESULTS: The multidisciplinary CPPS Standard reports updated consensus terminology in nine domains; lower urinary tract, female genital, male genital, gastrointestinal, musculoskeletal, neurological aspects, psychological aspects, sexual aspects, and comorbidities. Each is described in terms of symptoms, signs and further evaluation. CONCLUSION: The document presents preferred terms and definitions for symptoms, signs, and evaluation (diagnostic work-up) of female and male patients with chronic pelvic pain syndromes, serving as a platform for ongoing development in this field. Neurourol. Urodynam. 36:984-1008, 2017. © 2016 Wiley Periodicals, Inc.

A novel approach to mesh revision after sacrocolpopexy.

Pelvic organ prolapse (POP) is the herniation of pelvic organs to or beyond the vaginal walls. POP affects 50% of parous women; of those women, 11% will need surgery based on bothersome symptoms. Transvaginal mesh has been used for vaginal augmentation since the 1990s. Complications from mesh use are now more prominent, and include chronic pelvic pain, dyspareunia, vaginal mesh erosion, and urinary and defecatory dysfunction. Presently, there is no consensus regarding treatment of these complications. Reported herein are two cases of women with defecatory dysfunction and pain after sacrocolpopexy who underwent mesh revision procedures performed with both urogynecologic and colorectal surgery.

Complementary and alternative medical therapies for interstitial cystitis: an update from the United States.

The diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) has shifted from organ-specific to a multifactorial, multidisciplinary and individualized approach. Patients with refractory and debilitating symptoms may respond to complementary and alternative medical treatments (CAM). Through CAM therapies, practitioners assist the patient to be at the center of their care, empowering them to be emotionally and physically involved. Multi-disciplinary care, including urology, gynecology, gastroenterology, neurology, psychology, physiotherapy and pain medicine, is also identified to be the crux of adequate management of patients with chronic pelvic pain because of its variable etiology. The purpose of this review is to emphasize these changes and discuss management strategies.

Pentosan polysulfate sodium for treatment of interstitial cystitis/bladder pain syndrome: insights from a randomized, double-blind, placebo controlled study.

PURPOSE: We compared the efficacy and safety of the currently recommended dose of pentosan polysulfate sodium with a third of the daily dose and with placebo. MATERIALS AND METHODS: In this multicenter, double-blind, randomized, placebo controlled study 368 adults with interstitial cystitis/bladder pain syndrome, defined as an ICSI total score of 8 or greater and a score of greater than 0 on the 4 ICSI component items, received pentosan polysulfate sodium 100 mg once daily or 3 times daily, or matching placebo for 24 weeks. Study eligibility was not based on cystoscopy findings. ICSI was administered at baseline, and at weeks 4, 8, 12, 18 and 24. Unblinded interim analysis performed at 6 years with 54% of the target number of 645 patients enrolled resulted in early study termination. RESULTS: There was no statistically significant difference between the pentosan polysulfate sodium group and the placebo group or between the 2 pentosan polysulfate sodium groups for the primary end point, defined as responder achieving a 30% or greater reduction from the baseline ICSI total score at study end. This primary end point was achieved by 48 of 118 patients (40.7%) in the placebo group, and by 51 of 128 (39.8%) and 52 of 122 (42.6%) in the pentosan polysulfate sodium 100 mg once daily and 3 times daily groups, respectively. Pentosan polysulfate sodium was well tolerated with a similar percent of patients (range 10.2% to 13.3%) across the groups discontinuing due to an adverse event. CONCLUSIONS: Results of this study in a broad population of patients with symptoms consistent with interstitial cystitis revealed no treatment effect vs placebo for pentosan polysulfate sodium at the currently established dose or at a third of the daily dose.

The impact of neuropathic pain in the chronic pelvic pain population.

PURPOSE: Patients with chronic pelvic pain disorders often present with neuropathic features. We examined a cohort of patients with a primary complaint of chronic pelvic pain for the presence of neuropathic pain symptoms. MATERIALS AND METHODS: Patients with chronic pelvic pain disorders from 2 tertiary referral centers were prospectively evaluated. The validated S-LANSS (Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs) survey was used to examine pain symptoms of neuropathic origin. Patients completed SF-12v2™ to assess mental/physical health domains. The 2-tailed t test and chi-square analysis were used to compare physical and mental component summaries in patients with vs without neuropathic symptoms. RESULTS: A total of 142 patients mean age of 45 years were included in analysis. Of the patients 72.5% with chronic pelvic pain carried more than 1 primary diagnosis. The S-LANSS survey identified symptoms suggestive of neuropathic pain in 44 patients (31%). A greater proportion of patients with a neuropathic component had altered sensation in the affected area (86.4% vs 24.5%). Patients with neuropathic pain scored 4.28 and 5.45 points lower on the physical and mental component summaries (p = 0.053 and 0.008, respectively). CONCLUSIONS: A large proportion of patients with chronic pelvic pain present with neuropathic features and report decreased quality of life compared with the general population. Those with neuropathic symptoms have significantly lower quality of life than those without such symptoms. Clinicians can identify patients to use targeted therapies and use a multidisciplinary approach to care.

Urogynecological causes of pain and the effect of pain on sexual function in women.

Female Sexual Dysfunction (FSD) is a complex biopsychosocial phenomenon. Screening, identifying and managing urogenital and sexual symptoms often result in significant improvement in women's quality of life. Providers must proactively question patients about possible presence of FSD. When a sexual problem is present, identify the type of FSD, counsel patients on the appropriate approaches to treatment. No single therapeutic approach is effective in treating all types of FSD.

Sacral nerve stimulation during pregnancy: case report and review of the literature.

BACKGROUND: The use of sacral nerve stimulation during pregnancy is not recommended because of the unknown effects on the offspring. There is a paucity of literature on the subject. CASE: A 25-year-old woman who had a sacral nerve stimulator for severe interstitial cystitis/bladder pain syndrome had 2 successful pregnancies. Against medical advice, she kept the stimulator activated for symptom control during the pregnancies. The first child was later diagnosed with chronic motor tic disorder, and the second had a pilonidal sinus at birth. Whether this outcome is related to the neurostimulator is unknown. The efficacy of sacral nerve stimulation decreased after each pregnancy. CONCLUSION: The safety of sacral nerve stimulation in pregnancy has not been well established. Until further research is done, we recommend that women of reproductive age with a sacral nerve stimulator be advised about contraception and that the device should be deactivated before or as soon as pregnancy is confirmed.

When to suspect interstitial cystitis.

The symptom profile and comorbidities associated with this painful condition can make it difficult to diagnose--unless you know what to look for.

Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction.

To study intravaginal diazepam suppositories as adjunctive treatment for high-tone pelvic floor dysfunction (HTPFD) and sexual pain. A retrospective chart review was conducted on 26 patients who received diazepam suppositories as adjuvant therapy to pelvic physical therapy and intramuscular trigger point injections for bladder pain, sexual pain, and levator hypertonus. Pelvic floor muscular tone and pain were assessed by palpation and perineometry; sexual pain was objectively rated by Female Sexual Function Index (FSFI) and the Visual Analog Scale for Pain (VAS-P). Twenty-five out of 26 patients reported subjective improvement with suppository use; six out of seven sexually active patients resumed intercourse. Sexual pain as assessed on FSFI and serial VAS-P improved with diazepam (by 1.44 on 10-point scale, p = 0.14). PFM tone improved during resting (p < 0.001), squeezing (p = 0.014), and relaxation (p = 0.003) phases. Vaginal diazepam suppositories gave a clinically significant improvement in the treatment of HTPFD compared with the usual treatment regimen alone.

Urodynamic testing and interstitial cystitis/painful bladder syndrome.

INTRODUCTION AND HYPOTHESIS: The objective of this study is to evaluate the relationship between symptom severity in interstitial cystitis/painful bladder syndrome, urodynamic testing (UDT), and cystoscopy. METHODS: Charts of subjects who underwent cystoscopy and bladder overdistention (BOD) from January 2006 to July 2007 were reviewed for data points, questionnaires, UDT, and BOD findings. The independent T test and Mann-Whitney U test were performed between questionnaires, urodynamic data, and cystoscopic findings. RESULTS: Significantly lower volumes on all UDT parameters and higher scores on the interstitial cystitis problem index and pain Likert scale were found in subjects who felt pain with filling on UDT. Significantly lower median volumes for certain urodynamic parameters were found in subjects with high pain Likert scores and O'leary-Sant indices and those with grade 3 glomerulations and anesthetic bladder capacities of less than 600 mL on BOD. CONCLUSION: UDT may be a useful adjunctive test in the evaluation of patients with irritative voiding symptoms.

Bilateral S3 stimulator in patients with interstitial cystitis.

OBJECTIVES: To show the value of placing bilateral sacral nerve stimulators in patients diagnosed with interstitial cystitis with the symptoms of frequency, urgency, and pain. METHODS: A retrospective chart review was performed of patients who had had bilateral S3 stimulators placed during a 6-month period. At consultation immediately before undergoing the procedure and on subsequent postoperative visits, these patients completed the Urinary Distress Inventory short form and voiding diaries. Patients were excluded if sacroneuromodulation had been attempted to be placed previously, if patients had any identifiable neurologic deficits, or if they had any evidence of urinary retention. RESULTS: The mean age of the 15 patients was 43.2 years, with a mean follow-up of 14.1 months. Student's t test was used to compare the preoperative and postoperative values. The mean decrease in frequency and nocturia was 10.4 voids (P <0.001) and 2.6 voids (P <0.001), respectively. The change in the Urinary Distress Inventory short form showed that patients had satisfaction postoperatively (P <0.001). Four patients also noted improvement in fecal incontinence after the procedure, with a mean decrease in episodes of 2.75 (P <0.01). CONCLUSIONS: The results of this study have demonstrated that patients with bilateral stimulator placement have a significant decrease in frequency and nocturia with postoperative satisfaction. Also, evidence of possible improvement in the daily episodes of fecal incontinence was demonstrated.

Capsaicin for the treatment of vulvar vestibulitis.

OBJECTIVE: The purpose of this study was to evaluate the use of local capsaicin cream as an effective treatment for patients with documented vulvar vestibulitis syndrome. STUDY DESIGN: A retrospective chart review was performed for patients who received a diagnosis of vulvar vestibulitis syndrome that was treated with capsaicin. Patients performed local application of capsaicin 0.025% cream for 20 minutes daily for 12 weeks. A comparison was made between the pre- and posttreatment Kaufman touch test to evaluate discomfort. The Marinoff dyspareunia scale was also used to assess pre- and posttreatment. RESULTS: The sum of the Kaufman touch test scores before the treatment (13.2 +/- 4.9) compared with the scores after treatment (4.8 +/- 3.8) was statistically improved (P < .001). A significant improvement was also observed at each individual site (P < .001). The Marinoff dyspareunia scale also showed a significant improvement (P < .001). CONCLUSION: Vulvar vestibulitis syndrome that is treated with capsaicin significantly decreases discomfort and allows for more frequent sexual relations.