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bladder pain syndrome
Urological Science 26 (2015) 206e209
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Original article
Dyspareunia and chronic pelvic pain in patients with interstitial cystitis/bladder pain syndrome Ming-Huei Lee a, b, *, Wei-Chih Chen b, Chui-De Chiu c, d, Huei-Ching Wu a, b a
Central Taiwan University of Science and Technology, Taiwan, ROC Department of Urology, Feng-Yuan Hospital, Ministry of Health and Welfare, Taichung, Taiwan, ROC c Department of Psychology, The Chinese University of Hong Kong, Hong Kong d Clinical and Health Psychology Centre, The Chinese University of Hong Kong, Hong Kong b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 May 2014 Received in revised form 10 June 2015 Accepted 13 July 2015 Available online 21 August 2015
Objective: A previous study established that interstitial cystitis/bladder pain syndrome (IC/BPS) patients had significantly more dyspareunia and fear of pain than healthy controls. We evaluated the relationships between lower urinary tract symptoms and dyspareunia in IC/BPS patients. Materials and methods: A total of 156 IC/BPS female patients were included in this study. The diagnosis was made on the consensus of IC/PBS proposed by the Society for Urodynamics and Female Urology criteria in 2008. All women completed measures of pain severity (visual analog scale) and bladder symptom severity [IC Symptom Index, IC Problem Index, and the Pelvic Pain and Urinary/Frequency (PUF) scale]. Respondents were asked to recall if they experienced any sexual pain during or after sexual intercourse in the past 1 year. Cystoscopic hydrodistension during general anesthesia was performed for 5 minutes and maximal bladder capacity was also measured. Bivariate analyses were performed using chi-square and independent Student t tests. Results: Of the women with a current sexual partner, 61% (96/156) reported dyspareunia during or after sexual intercourse. Of the 96 dyspareunia respondents, 46% (44/96) reported pain in the bladder only, 43% (41/96) in the vagina only, and 11% (11/96) in both the bladder and the vagina. Patients with dyspareunia complained of more severe urological pain (p ¼ 0.02), a higher PUF scale score (p < 0.01), and larger anesthetic maximal bladder capacity (p ¼ 0.04) than patients without dyspareunia. However, patients with dyspareunia at the bladder only had more severe urgency sensation (p < 0.01) but no differences in pain, PUF scale, severity of glomerulation, and maximal bladder capacity than those with dyspareunia at the vagina only. Conclusion: IC/BPS women with dyspareunia have significantly more severe urological pain and a higher PUF scale score than women without dyspareunia. Physicians should consider sexual pain disorder in the management of patients with IC/BPS and use the PUF scale to evaluate not only IC-specific lower urinary tract symptoms, but also sexual pain disorder. Copyright © 2015, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: bladder pain syndrome dyspareunia interstitial cystitis
1. Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by a constellation of symptoms, including pelvic pain, pressure, and discomfort perceived to be related to the bladder with frequency, persistent urge, or nocturia in the absence
* Corresponding author. The Executive Office, Feng-Yuan Hospital, Department of Health, 9F, Number 100, Ankang Road, Fongyuan District, Taichung 42055, Taiwan, ROC. E-mail address: [email protected] (M.-H. Lee).
of bacterial infection or other identified pathologic disease. The prevalence of IC/BPS, as reported by the Rand Interstitial Cystitis Epidemiology study, was estimated to be 2.70e6.53% in the United States.1 Dyspareunia is defined as pain experienced during or after sexual intercourse, and may be due to an organic and/or psychological cause.2 IC/BPS, a potential cause of sexual pain in women, should be considered in the differential diagnosis for dyspareunia because it is estimated to occur in 49e90% of women with IC/BPS.3 In a recent caseecontrol study comparing 215 patients with IC/ BPS to 823 controls, Peters et al4 reported more dyspareunia, more
http://dx.doi.org/10.1016/j.urols.2015.07.004 1879-5226/Copyright © 2015, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
M.-H. Lee et al. / Urological Science 26 (2015) 206e209
fear of pain, and less sexual desire and ability to achieve orgasm in women with IC/BPS than in healthy controls. Another study also revealed that women with IC/BPS symptoms experienced very high levels of sexual dysfunction.5 Moreover, IC/BPS patients are resistance to penetration due to fear of pain. The reason why sexual intercourse may exacerbate the symptoms is that penetration can cause more pain and mechanical trauma to the vestibule and urethra, and can exacerbate urological and pain symptoms of IC/BPS.6 Recently, Nickel et al7 reported the UPOINT (Urinary, psychosocial, organ specific, infection, neurogenic/systemic, tenderness) phenotyping system can classify patients with IC/BPS according to clinically relevant domains. Being included in the tenderness domain predicted more severe general symptoms measured by the IC Symptom Index (ICSI) and the Pelvic Pain and Urinary/Frequency (PUF) scale, as well as urgency. We proposed that patients diagnosed of IC/BPS with the presence of dyspareunia could be a specific phenotype and compared as a separate group with a pure IC/ BPS without presence of dyspareunia. The purpose of this study is to examine the relationships between lower urinary tract symptoms including the symptom profile, using validated questionnaires, duration of symptoms, anesthetic maximal bladder capacity (MBC), severity of glomerulation, and dyspareunia in IC/BPS patients. 2. Materials and methods 2.1. Patients This is a retrospective cross-sectional study. The study included 156 female patients with a diagnosis of IC/BPS from January 2009 to February 2014. The diagnosis was made on the consensus of IC/BPS proposed by the Society for Urodynamics and Female Urology criteria in 2008. All patients were diagnosed on the basis of chronic (> 6 weeks) pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder accompanied by at least one other urinary symptom, such as frequency, persist urge, or nocturia, in the absence of infection or other identifiable causes.8 All other confusable diseases including neurogenic bladder, urolithiasis, and chronic urinary tract infection that could cause pelvic symptoms were excluded by standardized history and physical examination. Cystoscopic hydrodistension was performed using general anesthesia to rule out any other confusable disease such as carcinoma in situ and also to provide a temporal therapeutic effect. Although glomerulations were not a requirement for the diagnosis of IC/BPS, all of the patients had different degrees of glomerulations instead of classical Hunner's ulcer. 2.2. Measures All patients were asked to provide information on their age, IC/ BPS symptom onset, and education level, and to recall if they experienced sexual pain during or after sexual intercourse in the past year. All the respondents had engaged in vaginal sex in the past year. There were two questions for dyspareunia history: (1) “Do you feel pain during or after sexual intercourse?” and (2) “At which site was the pain located (bladder, vagina, or both)?”. Urogenital prolapse, vaginal candidiasis, and cervical, uterine, and ovarian cancers were excluded. All IC/BPS women completed a symptomatic questionnaire: (1) IC/BPS symptoms, including frequency, urgency, nocturia, and pain, were assessed using the O'LearyeSant Questionnaire as ICSI and IC Problem Index (ICPI).9 The PUF scale was also completed, which assessed both pelvic pain and urinary symptoms, as well as pain associated with sexual activity.10 (2) Pain and urgency were assessed by visual analog pain and urgency scales (VAS-pain and
207
VAS-urgency), with scores ranging from 0 (no symptom) to 10 (the worse symptom imaginable). Cystoscopic hydrodistension was applied under general anesthesia, and the bladder was distended to the maximal capacity for 5 minutes with a pressure of 80e100 cmH2O. During cystoscopic hydrodistension, anesthetic MBC was measured. Severity of glomerulation was classified, according to the ESSIC (European Society for the Study of Interstitial Cystitis/Painful Bladder Syndrome) classification, as Grades 1e4.11 2.3. Statistical analysis One-way analysis of variance was used in patients positive or negative for sexual pain and pain in the bladder or vagina. We used Chi-square tests to evaluate the associations between dyspareunia condition (presence or absence) and severity of glomerulation. Significance was set at p 0.05. The analyses were performed with SPSS version 21.0 software (SPSS Inc., Chicago, IL, USA). 3. Results The questionnaire survey was completed by 156 patients. The mean age of the patients with IC/PBS in this study was 43.8 ± 12.6 years, with a mean symptom duration of 8.0 ± 8.2 years (range 1e38 years). For ICSI, ICPI, and PUF the average scores were 13.1 ± 3.4, 11.8 ± 3.1, and 19.8 ± 5.9, respectively. The mean VAS-pain and VASurgency scores were 5.3 ± 2.9 and 6.6 ± 2.2, respectively. The average MBC was 696.8 ± 213.8 mL. Severity of glomerulation was classified according to the ESSIC classification as Grade 1. Of all women with a current sexual partner, 61% (96/156) reported dyspareunia during or after sexual intercourse. Of the 96 respondents with dyspareunia, 46% (44/96) reported pain in the bladder only, 43% (41/96) in the vagina only, and 11% (11/96) in both the bladder and the vagina (Fig. 1). Table 1 shows various measures between women positive or negative for sexual pain, which were analyzed using one-way analysis of variance. There was a significant difference in pain severity, PUF scale score, and MBC reported by patients with dyspareunia versus those without dyspareunia. Table 2 lists patients with dyspareunia at the bladder only who reported more severe urgency (p ¼ 0.03) and larger MBC (p ¼ 0.04) compared to those without dyspareunia. Table 3 shows that when examining patients with dyspareunia at the vagina only versus those without dyspareunia, no difference was found in bladder symptom and MBC. There were no differences in symptomatic severity and MBC between patients with dyspareunia at the bladder and those at the vagina. There were no differences in the severity of glomerulation between patients positive and negative for dyspareunia (p ¼ 0.18). Moreover, dyspareunia at the vagina only and that at the bladder only showed no differences in severity of glomerulation (p ¼ 0.23, vagina only; p ¼ 0.24, bladder only). 4. Discussion Dyspareunia is a common symptom among patients with IC/ BPS. The most frequent association between IC/BPS and dyspareunia is pelvic floor dysfunction. Many patients with IC/BPS have concurrent pelvic floor dysfunction, including symptoms such as muscle tenderness and spasms. It has been reported that the prevalence of pelvic floor dysfunction in patients with IC/BPS ranged from 50% to 87%.12 In our data, about 60% of IC/BPS patients complained of dyspareunia. Patients with dyspareunia have severe suprapubic pain, but not lower urinary tract symptoms, compared with patients
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M.-H. Lee et al. / Urological Science 26 (2015) 206e209
Fig. 1. Prevalence of dyspareunia and pain in the bladder and the vagina.
without dyspareunia. In addition, a higher PUF score has been found in patients with dyspareunia. Sub-PUF score analysis showed that the reason why the PUF score is higher in patients positive for dyspareunia is according to higher sexual pain score and suprapubic pain score. It implied that patients with dyspareunia seemed to belong to the severe group and might have a poor quality of life. A subgroup analysis was carried out according to the area of dyspareunia. We observed that IC/BPS patients always complained of two types of dyspareunia, pain in the vagina and bladder irritation. No difference was observed in symptom severity between patients with dyspareunia restricted to a gynecological organ (vagina) and those without dyspareunia. The reason why dyspareunia is restricted to the vagina is unclear. It can be reasoned that the urinary and reproductive systems are embryologically related, and “cross-talk” conditions that affect one system may also affect the other.6 A recent study reported that 93% of women seeking care in a gynecological pelvic pain clinic have some urinary symptoms as well.13 Dyspareunia restricted to vagina may be one of subgroups of IC/BPS patients from a gynecological cause or distinct entities entirely with similar symptoms. However, IC/BPS patients with dyspareunia radiated to the urinary system (bladder) show more severe lower urinary tract symptoms (urgency). One possible reason may be that mechanical irritation of the bladder during intercourse may cause discomfort, and repeated trauma can exacerbate symptoms of IC/BPS.14 A recent study by Professor Nickel and coworkers,7 with regard to difference
Table 1 Differences between severity of symptoms measured by VAS-pain scale, urgency, ICSI, ICPI, and PUF scale, and the presence or absence of dyspareunia using one-way ANOVA and Chi-square test.
Age (y) Symptom duration ICSI ICPI VAS-pain VAS-urgency PUF MBC Glomerulations Grade 1 Grade 2 Grade 3 Grade 4
Absence of dyspareunia (n ¼ 60)
Presence of dyspareunia (n ¼ 96)
p
45.51 ± 12.9 8.40 ± 7.8
42.11 ± 12.0 8.01 ± 8.6
0.06 0.83
13.03 ± 3.3 11.75 ± 2.9 4.56 ± 3.3 6.38 ± 2.1 18.18 ± 5.5 654.25 ± 205.3
13.21 ± 3.5 11.82 ± 3.2 5.76 ± 2.5 6.81 ± 2.3 20.69 ± 5.8 724.11 ± 214.6
0.76 0.88 0.01* 0.27 0.009* 0.04*
4 (6.6) 15 (25) 16 (26.6) 25 (41.6)
4 (4.1) 15 (15.6) 29 (30.2) 48 (50.0)
0.18
Data are presented as n (%) or mean ± SD. *p < 0.05. ANOVA ¼ analysis of variance; ICPI ¼ Interstitial Cystitis Problem Index; ICSI ¼ Interstitial Cystitis Symptom Index; MBC ¼ maximal bladder capacity; PUF ¼ pelvic pain and urinary/frequency; VAS ¼ visual analog scale.
of symptom severity based on UPOINT classification, revealed that patients positive for tenderness domain had more severe bladder symptoms compared to negative patients (VAS-urgency and ICSI, as well as the PUF scale), but no difference was observed in the VASpain score. Dyspareunia radiated to the bladder may be a potential progressive phenotype of these IC/BPS patients. Interestingly, our results indicate that IC/BPS patients with dyspareunia radiated to the bladder had larger MBC than those without dyspareunia. Moreover, there is no difference in severity of glomerulation, which means that the differences in MBC were not mainly caused by severity of glomerulation. In a recent study, Colaco et al15 reported that IC/BPS patients with small bladder capacity (MBC < 400 mL) showed a different gene expression from IC/BPS patients with normal capacity and healthy control groups. IC/BPS patients with dyspareunia radiated to the bladder have larger bladder capacity but severe lower urinary tract symptoms (urgency score), which imply that the underlying etiology may differ between patients negative for dyspareunia and those with dyspareunia radiated to the bladder. The IC/BPS patients with dyspareunia might be a specific phenotype compared with a pure IC/BPS without the presence of dyspareunia. Further basic research is required in order to examine the possibility of further phenotyping. Treatment of IC/BPS patients with dyspareunia is multimodal and challenging due to various causes, in addition to overlapping biological, psychological, and interpersonal etiologies.16 A recent study showed that a reduction in IC/BPS symptoms has a positive impact on sexual functioning.17 Therapy should be focused on suprapubic pain, a landmarked symptom of IC/BPS, including
Table 2 Comparison of patients negative for dyspareunia and those with pain in the bladder using one-way ANOVA, post hoc analysis, and Chi-square test.
Age (y) Symptom duration ICSI ICPI VAS-pain VAS-urgency PUF MBC Glomerulations Grade 1 Grade 2 Grade 3 Grade 4
Absence of dyspareunia (n ¼ 60)
Dyspareunia at bladder (n ¼ 44)
p
45.51 ± 12.9 8.40 ± 7.8
40.04 ± 10.3 8.45 ± 8.7
0.07 0.99
13.03 ± 3.3 11.75 ± 2.9 4.56 ± 3.3 6.38 ± 2.1 18.18 ± 5.5 654.25 ± 205.3
13.88 ± 3.3 12.14 ± 3.0 5.93 ± 2.5 7.56 ± 2.0 20.60 ± 5.5 753.88 ± 230.6
0.48 0.87 0.08 0.03* 0.10 0.04*
4 (6.6) 15 (25) 16 (26.6) 25 (41.6)
3 (6.8) 6 (13.6) 17 (38.6) 18 (40.9)
0.24
Data are presented as n (%) or mean ± SD. *p < 0.05. ANOVA ¼ analysis of variance; ICPI ¼ Interstitial Cystitis Problem Index; ICSI ¼ Interstitial Cystitis Symptom Index; MBC ¼ maximal bladder capacity; PUF ¼ pelvic pain and urinary/frequency; VAS ¼ visual analog scale.
M.-H. Lee et al. / Urological Science 26 (2015) 206e209 Table 3 Comparison of patients negative for dyspareunia and those with pain in the vagina, using one-way ANOVA, post hoc analysis, and Chi-square test.
Age (y) Symptom duration ICSI ICPI VAS-pain VAS-urgency PUF MBC Glomerulations Grade 1 Grade 2 Grade 3 Grade 4
Absence of dyspareunia (n ¼ 60)
Dyspareunia at vagina (n ¼ 41)
p
45.51 ± 12.9 8.40 ± 7.8
45.43 ± 13.0 7.89 ± 9.0
0.99 0.95
13.03 ± 3.3 11.75 ± 2.9 4.56 ± 3.3 6.38 ± 2.1 18.18 ± 5.5 654.25 ± 205.3
12.36 ± 3.8 11.15 ± 3.6 5.22 ± 2.6 6.11 ± 2.3 19.44 ± 5.7 730.88 ± 172.9
0.65 0.60 0.58 0.84 0.57 0.15
4 (6.6) 15 (25) 16 (26.6) 25 (41.6)
1 (2.4) 8 (19.5) 11 (26.8) 21 (51.2)
0.23
Data are presented as n (%) or mean ± SD. * p < 0.05. ANOVA ¼ analysis of variance; ICPI ¼ Interstitial Cystitis Problem Index; ICSI ¼ Interstitial Cystitis Symptom Index; MBC ¼ maximal bladder capacity; PUF ¼ pelvic pain and urinary/frequency; VAS ¼ visual analog scale.
targeting the bladder and pelvic floor muscle. Pharmacological therapy, including pentosan polysulfate sodium therapy, intravesical bladder therapy, or botulinum toxin A injection, was suggested for the bladder. Specific treatment strategies for pelvic floor muscle also included physical therapy and muscle relaxants. There are several limitations to this study. First, the analysis of all conditions is based on self-reported questionnaires, although they are all validated. Second, more severe cases (higher scores in ICSI, ICPI, and PUF) were included. Third, the lack of information on a previous history of abuse or psychological dysfunction, nonbladder syndrome condition, and the possibility of vulvodynia and endometriosis are covariates and associated with dyspareunia and lower urinary tract symptoms. 5. Conclusion IC/BPS women with dyspareunia have significantly more severe urological pain and a higher PUF scale score than women without dyspareunia. Patients with dyspareunia radiated to the urinary system (bladder) show more severe lower urinary tract symptoms (urgency) and larger anesthetic MBC. Physicians should consider sexual pain disorder in the management of patients with IC/BPS and use the PUF scale to evaluate not only IC-specific lower urinary tract symptoms but also sexual pain disorder.
209
Conflicts of interest The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript. Sources of funding No funding was received for the work described in the article. References 1. Berry SH, Elliott MN, Suttorp M, Bogart LM, Stoto MA, Eggers P, et al. Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United States. J Urol 2011;186:540e4. 2. Weijmar Schultz W, Basson R, Binik Y, Eschenbach D, Wesselmann U, Van Lankveld J. Women's sexual pain and its management. J Sex Med 2005;2: 301e16. 3. Padmadas SS, Stones RW, Matthews Z. Dyspareunia and urinary sensory symptoms in India: population-based study. J Sex Med 2006;3:114e20. 4. Peters KM, Killinger KA, Carrico DJ, Ibrahim IA, Diokno AC, Graziottin A. Sexual function and sexual distress in women with interstitial cystitis: a caseecontrol study. Urology 2007;70:543e7. 5. Bogart LM, Suttorp MJ, Elliott MN, Clemens JQ, Berry SH. Prevalence and correlates of sexual dysfunction among women with bladder pain syndrome/ interstitial cystitis. Urology 2011;77:576e80. 6. Myers DL, Aguilar VC. Gynecologic manifestations of interstitial cystitis. Clin Obstet Gynecol 2002;45:233e41. 7. Nickel JC, Shoskes D, Irvine-Bird K. Clinical phenotyping of women with interstitial cystitis/painful bladder syndrome: a key to classification and potentially improved management. J Urol 2009;182:155e60. 8. Hanno P, Dmochowski R. Status of international consensus on interstitial cystitis/bladder pain syndrome/painful bladder syndrome: 2008 snapshot. Neurourol Urodyn 2009;28:274e86. 9. O'Leary MP, Sant GR, Fowler Jr FJ, Whitmore KE, Spolarich-Kroll J. The interstitial cystitis symptom index and problem index. Urology 1997;49(5A Suppl.): 58e63. 10. Parsons CL, Dell J, Stanford EJ, Bullen M, Kahn BS, 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. Urology 2002;60:573e8. 11. Nordling J, Anjum FH, Bade JJ, Bouchelouche K, Bouchelouche P, Cervigni M, et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol 2004;45:662e9. 12. De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J, Hoebeke P. Pelvicfloor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU Int 2000;85:889e93. 13. Cheng C, Rosamilia A, Healey M. Diagnosis of interstitial cystitis/bladder pain syndrome in women with chronic pelvic pain: a prospective observational study. Int Urogynecol J 2012;23:1361e6. 14. Simonelli C, Eleuteri S, Petruccelli F, Rossi R. Female sexual pain disorders: dyspareunia and vaginismus. Curr Opin Psychiatry 2014;27:406e12. 15. Colaco M, Koslov DS, Keys T, Evans RJ, Badlani GH, Andersson KE, et al. Correlation of gene expression with bladder capacity in interstitial cystitis/bladder pain syndrome. J Urol 2014;192:1123e9. 16. Wehbe SA, Whitmore K, Kellogg-Spadt S. Urogenital complaints and female sexual dysfunction (part 1). J Sex Med 2010;7:1704e13. quiz 1703, 1714e5. 17. Nickel JC, Parsons CL, Forrest J, Kaufman D, Evans R, Chen A, et al. Improvement in sexual functioning in patients with interstitial cystitis/painful bladder syndrome. J Sex Med 2008;5:394e9.
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Original article
Dyspareunia and chronic pelvic pain in patients with interstitial cystitis/bladder pain syndrome Ming-Huei Lee a, b, *, Wei-Chih Chen b, Chui-De Chiu c, d, Huei-Ching Wu a, b a
Central Taiwan University of Science and Technology, Taiwan, ROC Department of Urology, Feng-Yuan Hospital, Ministry of Health and Welfare, Taichung, Taiwan, ROC c Department of Psychology, The Chinese University of Hong Kong, Hong Kong d Clinical and Health Psychology Centre, The Chinese University of Hong Kong, Hong Kong b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 May 2014 Received in revised form 10 June 2015 Accepted 13 July 2015 Available online 21 August 2015
Objective: A previous study established that interstitial cystitis/bladder pain syndrome (IC/BPS) patients had significantly more dyspareunia and fear of pain than healthy controls. We evaluated the relationships between lower urinary tract symptoms and dyspareunia in IC/BPS patients. Materials and methods: A total of 156 IC/BPS female patients were included in this study. The diagnosis was made on the consensus of IC/PBS proposed by the Society for Urodynamics and Female Urology criteria in 2008. All women completed measures of pain severity (visual analog scale) and bladder symptom severity [IC Symptom Index, IC Problem Index, and the Pelvic Pain and Urinary/Frequency (PUF) scale]. Respondents were asked to recall if they experienced any sexual pain during or after sexual intercourse in the past 1 year. Cystoscopic hydrodistension during general anesthesia was performed for 5 minutes and maximal bladder capacity was also measured. Bivariate analyses were performed using chi-square and independent Student t tests. Results: Of the women with a current sexual partner, 61% (96/156) reported dyspareunia during or after sexual intercourse. Of the 96 dyspareunia respondents, 46% (44/96) reported pain in the bladder only, 43% (41/96) in the vagina only, and 11% (11/96) in both the bladder and the vagina. Patients with dyspareunia complained of more severe urological pain (p ¼ 0.02), a higher PUF scale score (p < 0.01), and larger anesthetic maximal bladder capacity (p ¼ 0.04) than patients without dyspareunia. However, patients with dyspareunia at the bladder only had more severe urgency sensation (p < 0.01) but no differences in pain, PUF scale, severity of glomerulation, and maximal bladder capacity than those with dyspareunia at the vagina only. Conclusion: IC/BPS women with dyspareunia have significantly more severe urological pain and a higher PUF scale score than women without dyspareunia. Physicians should consider sexual pain disorder in the management of patients with IC/BPS and use the PUF scale to evaluate not only IC-specific lower urinary tract symptoms, but also sexual pain disorder. Copyright © 2015, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: bladder pain syndrome dyspareunia interstitial cystitis
1. Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic disease characterized by a constellation of symptoms, including pelvic pain, pressure, and discomfort perceived to be related to the bladder with frequency, persistent urge, or nocturia in the absence
* Corresponding author. The Executive Office, Feng-Yuan Hospital, Department of Health, 9F, Number 100, Ankang Road, Fongyuan District, Taichung 42055, Taiwan, ROC. E-mail address: [email protected] (M.-H. Lee).
of bacterial infection or other identified pathologic disease. The prevalence of IC/BPS, as reported by the Rand Interstitial Cystitis Epidemiology study, was estimated to be 2.70e6.53% in the United States.1 Dyspareunia is defined as pain experienced during or after sexual intercourse, and may be due to an organic and/or psychological cause.2 IC/BPS, a potential cause of sexual pain in women, should be considered in the differential diagnosis for dyspareunia because it is estimated to occur in 49e90% of women with IC/BPS.3 In a recent caseecontrol study comparing 215 patients with IC/ BPS to 823 controls, Peters et al4 reported more dyspareunia, more
http://dx.doi.org/10.1016/j.urols.2015.07.004 1879-5226/Copyright © 2015, Taiwan Urological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
M.-H. Lee et al. / Urological Science 26 (2015) 206e209
fear of pain, and less sexual desire and ability to achieve orgasm in women with IC/BPS than in healthy controls. Another study also revealed that women with IC/BPS symptoms experienced very high levels of sexual dysfunction.5 Moreover, IC/BPS patients are resistance to penetration due to fear of pain. The reason why sexual intercourse may exacerbate the symptoms is that penetration can cause more pain and mechanical trauma to the vestibule and urethra, and can exacerbate urological and pain symptoms of IC/BPS.6 Recently, Nickel et al7 reported the UPOINT (Urinary, psychosocial, organ specific, infection, neurogenic/systemic, tenderness) phenotyping system can classify patients with IC/BPS according to clinically relevant domains. Being included in the tenderness domain predicted more severe general symptoms measured by the IC Symptom Index (ICSI) and the Pelvic Pain and Urinary/Frequency (PUF) scale, as well as urgency. We proposed that patients diagnosed of IC/BPS with the presence of dyspareunia could be a specific phenotype and compared as a separate group with a pure IC/ BPS without presence of dyspareunia. The purpose of this study is to examine the relationships between lower urinary tract symptoms including the symptom profile, using validated questionnaires, duration of symptoms, anesthetic maximal bladder capacity (MBC), severity of glomerulation, and dyspareunia in IC/BPS patients. 2. Materials and methods 2.1. Patients This is a retrospective cross-sectional study. The study included 156 female patients with a diagnosis of IC/BPS from January 2009 to February 2014. The diagnosis was made on the consensus of IC/BPS proposed by the Society for Urodynamics and Female Urology criteria in 2008. All patients were diagnosed on the basis of chronic (> 6 weeks) pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder accompanied by at least one other urinary symptom, such as frequency, persist urge, or nocturia, in the absence of infection or other identifiable causes.8 All other confusable diseases including neurogenic bladder, urolithiasis, and chronic urinary tract infection that could cause pelvic symptoms were excluded by standardized history and physical examination. Cystoscopic hydrodistension was performed using general anesthesia to rule out any other confusable disease such as carcinoma in situ and also to provide a temporal therapeutic effect. Although glomerulations were not a requirement for the diagnosis of IC/BPS, all of the patients had different degrees of glomerulations instead of classical Hunner's ulcer. 2.2. Measures All patients were asked to provide information on their age, IC/ BPS symptom onset, and education level, and to recall if they experienced sexual pain during or after sexual intercourse in the past year. All the respondents had engaged in vaginal sex in the past year. There were two questions for dyspareunia history: (1) “Do you feel pain during or after sexual intercourse?” and (2) “At which site was the pain located (bladder, vagina, or both)?”. Urogenital prolapse, vaginal candidiasis, and cervical, uterine, and ovarian cancers were excluded. All IC/BPS women completed a symptomatic questionnaire: (1) IC/BPS symptoms, including frequency, urgency, nocturia, and pain, were assessed using the O'LearyeSant Questionnaire as ICSI and IC Problem Index (ICPI).9 The PUF scale was also completed, which assessed both pelvic pain and urinary symptoms, as well as pain associated with sexual activity.10 (2) Pain and urgency were assessed by visual analog pain and urgency scales (VAS-pain and
207
VAS-urgency), with scores ranging from 0 (no symptom) to 10 (the worse symptom imaginable). Cystoscopic hydrodistension was applied under general anesthesia, and the bladder was distended to the maximal capacity for 5 minutes with a pressure of 80e100 cmH2O. During cystoscopic hydrodistension, anesthetic MBC was measured. Severity of glomerulation was classified, according to the ESSIC (European Society for the Study of Interstitial Cystitis/Painful Bladder Syndrome) classification, as Grades 1e4.11 2.3. Statistical analysis One-way analysis of variance was used in patients positive or negative for sexual pain and pain in the bladder or vagina. We used Chi-square tests to evaluate the associations between dyspareunia condition (presence or absence) and severity of glomerulation. Significance was set at p 0.05. The analyses were performed with SPSS version 21.0 software (SPSS Inc., Chicago, IL, USA). 3. Results The questionnaire survey was completed by 156 patients. The mean age of the patients with IC/PBS in this study was 43.8 ± 12.6 years, with a mean symptom duration of 8.0 ± 8.2 years (range 1e38 years). For ICSI, ICPI, and PUF the average scores were 13.1 ± 3.4, 11.8 ± 3.1, and 19.8 ± 5.9, respectively. The mean VAS-pain and VASurgency scores were 5.3 ± 2.9 and 6.6 ± 2.2, respectively. The average MBC was 696.8 ± 213.8 mL. Severity of glomerulation was classified according to the ESSIC classification as Grade 1. Of all women with a current sexual partner, 61% (96/156) reported dyspareunia during or after sexual intercourse. Of the 96 respondents with dyspareunia, 46% (44/96) reported pain in the bladder only, 43% (41/96) in the vagina only, and 11% (11/96) in both the bladder and the vagina (Fig. 1). Table 1 shows various measures between women positive or negative for sexual pain, which were analyzed using one-way analysis of variance. There was a significant difference in pain severity, PUF scale score, and MBC reported by patients with dyspareunia versus those without dyspareunia. Table 2 lists patients with dyspareunia at the bladder only who reported more severe urgency (p ¼ 0.03) and larger MBC (p ¼ 0.04) compared to those without dyspareunia. Table 3 shows that when examining patients with dyspareunia at the vagina only versus those without dyspareunia, no difference was found in bladder symptom and MBC. There were no differences in symptomatic severity and MBC between patients with dyspareunia at the bladder and those at the vagina. There were no differences in the severity of glomerulation between patients positive and negative for dyspareunia (p ¼ 0.18). Moreover, dyspareunia at the vagina only and that at the bladder only showed no differences in severity of glomerulation (p ¼ 0.23, vagina only; p ¼ 0.24, bladder only). 4. Discussion Dyspareunia is a common symptom among patients with IC/ BPS. The most frequent association between IC/BPS and dyspareunia is pelvic floor dysfunction. Many patients with IC/BPS have concurrent pelvic floor dysfunction, including symptoms such as muscle tenderness and spasms. It has been reported that the prevalence of pelvic floor dysfunction in patients with IC/BPS ranged from 50% to 87%.12 In our data, about 60% of IC/BPS patients complained of dyspareunia. Patients with dyspareunia have severe suprapubic pain, but not lower urinary tract symptoms, compared with patients
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M.-H. Lee et al. / Urological Science 26 (2015) 206e209
Fig. 1. Prevalence of dyspareunia and pain in the bladder and the vagina.
without dyspareunia. In addition, a higher PUF score has been found in patients with dyspareunia. Sub-PUF score analysis showed that the reason why the PUF score is higher in patients positive for dyspareunia is according to higher sexual pain score and suprapubic pain score. It implied that patients with dyspareunia seemed to belong to the severe group and might have a poor quality of life. A subgroup analysis was carried out according to the area of dyspareunia. We observed that IC/BPS patients always complained of two types of dyspareunia, pain in the vagina and bladder irritation. No difference was observed in symptom severity between patients with dyspareunia restricted to a gynecological organ (vagina) and those without dyspareunia. The reason why dyspareunia is restricted to the vagina is unclear. It can be reasoned that the urinary and reproductive systems are embryologically related, and “cross-talk” conditions that affect one system may also affect the other.6 A recent study reported that 93% of women seeking care in a gynecological pelvic pain clinic have some urinary symptoms as well.13 Dyspareunia restricted to vagina may be one of subgroups of IC/BPS patients from a gynecological cause or distinct entities entirely with similar symptoms. However, IC/BPS patients with dyspareunia radiated to the urinary system (bladder) show more severe lower urinary tract symptoms (urgency). One possible reason may be that mechanical irritation of the bladder during intercourse may cause discomfort, and repeated trauma can exacerbate symptoms of IC/BPS.14 A recent study by Professor Nickel and coworkers,7 with regard to difference
Table 1 Differences between severity of symptoms measured by VAS-pain scale, urgency, ICSI, ICPI, and PUF scale, and the presence or absence of dyspareunia using one-way ANOVA and Chi-square test.
Age (y) Symptom duration ICSI ICPI VAS-pain VAS-urgency PUF MBC Glomerulations Grade 1 Grade 2 Grade 3 Grade 4
Absence of dyspareunia (n ¼ 60)
Presence of dyspareunia (n ¼ 96)
p
45.51 ± 12.9 8.40 ± 7.8
42.11 ± 12.0 8.01 ± 8.6
0.06 0.83
13.03 ± 3.3 11.75 ± 2.9 4.56 ± 3.3 6.38 ± 2.1 18.18 ± 5.5 654.25 ± 205.3
13.21 ± 3.5 11.82 ± 3.2 5.76 ± 2.5 6.81 ± 2.3 20.69 ± 5.8 724.11 ± 214.6
0.76 0.88 0.01* 0.27 0.009* 0.04*
4 (6.6) 15 (25) 16 (26.6) 25 (41.6)
4 (4.1) 15 (15.6) 29 (30.2) 48 (50.0)
0.18
Data are presented as n (%) or mean ± SD. *p < 0.05. ANOVA ¼ analysis of variance; ICPI ¼ Interstitial Cystitis Problem Index; ICSI ¼ Interstitial Cystitis Symptom Index; MBC ¼ maximal bladder capacity; PUF ¼ pelvic pain and urinary/frequency; VAS ¼ visual analog scale.
of symptom severity based on UPOINT classification, revealed that patients positive for tenderness domain had more severe bladder symptoms compared to negative patients (VAS-urgency and ICSI, as well as the PUF scale), but no difference was observed in the VASpain score. Dyspareunia radiated to the bladder may be a potential progressive phenotype of these IC/BPS patients. Interestingly, our results indicate that IC/BPS patients with dyspareunia radiated to the bladder had larger MBC than those without dyspareunia. Moreover, there is no difference in severity of glomerulation, which means that the differences in MBC were not mainly caused by severity of glomerulation. In a recent study, Colaco et al15 reported that IC/BPS patients with small bladder capacity (MBC < 400 mL) showed a different gene expression from IC/BPS patients with normal capacity and healthy control groups. IC/BPS patients with dyspareunia radiated to the bladder have larger bladder capacity but severe lower urinary tract symptoms (urgency score), which imply that the underlying etiology may differ between patients negative for dyspareunia and those with dyspareunia radiated to the bladder. The IC/BPS patients with dyspareunia might be a specific phenotype compared with a pure IC/BPS without the presence of dyspareunia. Further basic research is required in order to examine the possibility of further phenotyping. Treatment of IC/BPS patients with dyspareunia is multimodal and challenging due to various causes, in addition to overlapping biological, psychological, and interpersonal etiologies.16 A recent study showed that a reduction in IC/BPS symptoms has a positive impact on sexual functioning.17 Therapy should be focused on suprapubic pain, a landmarked symptom of IC/BPS, including
Table 2 Comparison of patients negative for dyspareunia and those with pain in the bladder using one-way ANOVA, post hoc analysis, and Chi-square test.
Age (y) Symptom duration ICSI ICPI VAS-pain VAS-urgency PUF MBC Glomerulations Grade 1 Grade 2 Grade 3 Grade 4
Absence of dyspareunia (n ¼ 60)
Dyspareunia at bladder (n ¼ 44)
p
45.51 ± 12.9 8.40 ± 7.8
40.04 ± 10.3 8.45 ± 8.7
0.07 0.99
13.03 ± 3.3 11.75 ± 2.9 4.56 ± 3.3 6.38 ± 2.1 18.18 ± 5.5 654.25 ± 205.3
13.88 ± 3.3 12.14 ± 3.0 5.93 ± 2.5 7.56 ± 2.0 20.60 ± 5.5 753.88 ± 230.6
0.48 0.87 0.08 0.03* 0.10 0.04*
4 (6.6) 15 (25) 16 (26.6) 25 (41.6)
3 (6.8) 6 (13.6) 17 (38.6) 18 (40.9)
0.24
Data are presented as n (%) or mean ± SD. *p < 0.05. ANOVA ¼ analysis of variance; ICPI ¼ Interstitial Cystitis Problem Index; ICSI ¼ Interstitial Cystitis Symptom Index; MBC ¼ maximal bladder capacity; PUF ¼ pelvic pain and urinary/frequency; VAS ¼ visual analog scale.
M.-H. Lee et al. / Urological Science 26 (2015) 206e209 Table 3 Comparison of patients negative for dyspareunia and those with pain in the vagina, using one-way ANOVA, post hoc analysis, and Chi-square test.
Age (y) Symptom duration ICSI ICPI VAS-pain VAS-urgency PUF MBC Glomerulations Grade 1 Grade 2 Grade 3 Grade 4
Absence of dyspareunia (n ¼ 60)
Dyspareunia at vagina (n ¼ 41)
p
45.51 ± 12.9 8.40 ± 7.8
45.43 ± 13.0 7.89 ± 9.0
0.99 0.95
13.03 ± 3.3 11.75 ± 2.9 4.56 ± 3.3 6.38 ± 2.1 18.18 ± 5.5 654.25 ± 205.3
12.36 ± 3.8 11.15 ± 3.6 5.22 ± 2.6 6.11 ± 2.3 19.44 ± 5.7 730.88 ± 172.9
0.65 0.60 0.58 0.84 0.57 0.15
4 (6.6) 15 (25) 16 (26.6) 25 (41.6)
1 (2.4) 8 (19.5) 11 (26.8) 21 (51.2)
0.23
Data are presented as n (%) or mean ± SD. * p < 0.05. ANOVA ¼ analysis of variance; ICPI ¼ Interstitial Cystitis Problem Index; ICSI ¼ Interstitial Cystitis Symptom Index; MBC ¼ maximal bladder capacity; PUF ¼ pelvic pain and urinary/frequency; VAS ¼ visual analog scale.
targeting the bladder and pelvic floor muscle. Pharmacological therapy, including pentosan polysulfate sodium therapy, intravesical bladder therapy, or botulinum toxin A injection, was suggested for the bladder. Specific treatment strategies for pelvic floor muscle also included physical therapy and muscle relaxants. There are several limitations to this study. First, the analysis of all conditions is based on self-reported questionnaires, although they are all validated. Second, more severe cases (higher scores in ICSI, ICPI, and PUF) were included. Third, the lack of information on a previous history of abuse or psychological dysfunction, nonbladder syndrome condition, and the possibility of vulvodynia and endometriosis are covariates and associated with dyspareunia and lower urinary tract symptoms. 5. Conclusion IC/BPS women with dyspareunia have significantly more severe urological pain and a higher PUF scale score than women without dyspareunia. Patients with dyspareunia radiated to the urinary system (bladder) show more severe lower urinary tract symptoms (urgency) and larger anesthetic MBC. Physicians should consider sexual pain disorder in the management of patients with IC/BPS and use the PUF scale to evaluate not only IC-specific lower urinary tract symptoms but also sexual pain disorder.
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Conflicts of interest The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript. Sources of funding No funding was received for the work described in the article. References 1. Berry SH, Elliott MN, Suttorp M, Bogart LM, Stoto MA, Eggers P, et al. Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United States. J Urol 2011;186:540e4. 2. Weijmar Schultz W, Basson R, Binik Y, Eschenbach D, Wesselmann U, Van Lankveld J. Women's sexual pain and its management. J Sex Med 2005;2: 301e16. 3. Padmadas SS, Stones RW, Matthews Z. Dyspareunia and urinary sensory symptoms in India: population-based study. J Sex Med 2006;3:114e20. 4. Peters KM, Killinger KA, Carrico DJ, Ibrahim IA, Diokno AC, Graziottin A. Sexual function and sexual distress in women with interstitial cystitis: a caseecontrol study. Urology 2007;70:543e7. 5. Bogart LM, Suttorp MJ, Elliott MN, Clemens JQ, Berry SH. Prevalence and correlates of sexual dysfunction among women with bladder pain syndrome/ interstitial cystitis. Urology 2011;77:576e80. 6. Myers DL, Aguilar VC. Gynecologic manifestations of interstitial cystitis. Clin Obstet Gynecol 2002;45:233e41. 7. Nickel JC, Shoskes D, Irvine-Bird K. Clinical phenotyping of women with interstitial cystitis/painful bladder syndrome: a key to classification and potentially improved management. J Urol 2009;182:155e60. 8. Hanno P, Dmochowski R. Status of international consensus on interstitial cystitis/bladder pain syndrome/painful bladder syndrome: 2008 snapshot. Neurourol Urodyn 2009;28:274e86. 9. O'Leary MP, Sant GR, Fowler Jr FJ, Whitmore KE, Spolarich-Kroll J. The interstitial cystitis symptom index and problem index. Urology 1997;49(5A Suppl.): 58e63. 10. Parsons CL, Dell J, Stanford EJ, Bullen M, Kahn BS, 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. Urology 2002;60:573e8. 11. Nordling J, Anjum FH, Bade JJ, Bouchelouche K, Bouchelouche P, Cervigni M, et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol 2004;45:662e9. 12. De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J, Hoebeke P. Pelvicfloor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU Int 2000;85:889e93. 13. Cheng C, Rosamilia A, Healey M. Diagnosis of interstitial cystitis/bladder pain syndrome in women with chronic pelvic pain: a prospective observational study. Int Urogynecol J 2012;23:1361e6. 14. Simonelli C, Eleuteri S, Petruccelli F, Rossi R. Female sexual pain disorders: dyspareunia and vaginismus. Curr Opin Psychiatry 2014;27:406e12. 15. Colaco M, Koslov DS, Keys T, Evans RJ, Badlani GH, Andersson KE, et al. Correlation of gene expression with bladder capacity in interstitial cystitis/bladder pain syndrome. J Urol 2014;192:1123e9. 16. Wehbe SA, Whitmore K, Kellogg-Spadt S. Urogenital complaints and female sexual dysfunction (part 1). J Sex Med 2010;7:1704e13. quiz 1703, 1714e5. 17. Nickel JC, Parsons CL, Forrest J, Kaufman D, Evans R, Chen A, et al. Improvement in sexual functioning in patients with interstitial cystitis/painful bladder syndrome. J Sex Med 2008;5:394e9.