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Voiding symptoms in chronic pelvic pain (CPP)
European Journal of Obstetrics & Gynecology and Reproductive Biology 107 (2003) 185–190
Voiding symptoms in chronic pelvic pain (CPP) Purana van Os-Bossagha,b,*, Trudy Polsb, Wim C.J. Hopc, Arthur M. Bohnend, Mark E. Vierhouta, Aat C. Drogendijka a
Department of Obstetrics and Gynecology, University Hospital Dijkzigt/Erasmus University Rotterdam, The Netherlands b Research Group Social Health (OMG/UWV/GAK), P.O. Box 213, 3000 AE Rotterdam, The Netherlands c Department of Epidemiology and Biostatistics, University Hospital Dijkzigt/Erasmus University Rotterdam, The Netherlands d Department of General Practice, University Hospital Dijkzigt/Erasmus University Rotterdam, The Netherlands Received 15 March 2002; received in revised form 9 July 2002; accepted 9 July 2002
Abstract Objective: To establish the prevalence of voiding symptoms in CPP patients. Study design: Sixty women with chronic pelvic pain (CPP), aged 23–79 (mean: 48) years completed a questionnaire mainly addressing lower abdominal pain and voiding symptoms. Symptoms occurring often, almost always, or always for more than 6 months were considered present and serious. A group of 31 consecutive cases of non-CPP women aged 18–77 (mean: 49) years were selected to serve as controls. Results: The following symptoms were found in the CPP group: incontinence: 43%; inadequate voluntary control of the urethral sphincter: 50%; inability to postpone: 37%; urge: 37%; nocturia 2x: 18%; dysuria: 12%; cystitis: 37%; urge-induced pain: 20%; pain-induced urge: 18%; strain to initiate voiding: 6%; strain to continue voiding: 17%; incomplete voiding: 37%. Two or more voiding symptoms were present in 63% of the CPP group. All urinary symptoms were more often present in the CPP group than in the controls. Conclusion: A substantial subgroup of CPP patients has voiding symptoms. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: CPP; Incontinence; Pelvic pain; Urge
1. Introduction The prevalence of minor to serious urinary incontinence in Dutch women aged 35–79 years, is about 27% [1]. Serious incontinence has been defined as involuntary loss of urine, occurring at least once a week, and in amounts larger than a few drops, all other incontinence being ‘minor’ [1]. It has been postulated that disorders of the lower urinary tract may present themselves as symptoms of chronic pelvic pain (CPP) [2]. The occurrence of urinary symptoms has been attributed to (amongst others) the urethral syndrome, the symptoms of which have been summarized by Bodner as urinary urgency, dysuria, frequency and suprapubic discomfort [3]. Hesitancy, incomplete bladder emptying, weak stream and symptoms unrelated to the urinary tract (such as back discomfort) may also be present [3]. Lower abdominal pain and voiding symptoms of unknown etiology also occur in interstitial cystitis (IC) [4,5]. Both the urethral syndrome and IC are * Corresponding author. Tel.: þ31-10-4404719; fax: þ31-10-4404001. E-mail address: [email protected] (P. van Os-Bossagh).
diagnosed by excluding physical disorders in the presence of voiding symptoms, and both syndromes overlap each other in symptoms of an irritable bladder in the absence of infectious agents. In IC suprapubic pain is the prominent feature whereas in the urethral syndrome voiding symptoms are predominant. Other more vaguely defined disorders found with voiding symptoms and ‘painful bladder’ (sometimes with organic abnormalities) are detrusor myopathy, chronic non-specific cystitis and eosinophilic cystitis. Because some women with voiding symptoms present chronic lower abdominal pain as the main complaint in the presence of one or more IC exclusion criteria, many of these patients, suspected to have CPP, are eventually referred to a gynecologist. This study was designed to establish the prevalence of voiding symptoms in CPP patients. In case age was expected to influence a particular symptom, data on women less than/ older than 50 years were compared; these age-related data were also compared with data from similar studies. The CPP population of the present study consists exclusively of women visiting our outpatient clinic; we also investigate whether the prevalence of specific voiding symptoms
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in this group differs from a sample of non-CPP patients visiting the same gynecological outpatient clinic.
2. Materials and methods 2.1. Study population This clinical pilot study was approved by the Medical Ethics Committee of the University Hospital. The first 60 consecutive women referred to our outpatient clinic because of chronic lower abdominal pain of unknown origin and diagnosed with CPP were invited to participate; all agreed and all gave informed consent. The CPP population of our hospital generally consists of relatively severe cases. In all women participating in this study the diagnosis CPP was established by at least two physicians. To comply with the inclusion criteria, patients had to have lower abdominal pain without evident urological-, genital-, or digestive tract pathology. Moreover, lower abdominal pain had to occur often, almost always or always, for 6 months or longer. In all patients endometriosis was ruled out by laparoscopy. Women not menstruating because of having undergone hysterectomy or because of other reasons (as well as those who were not sexually active) were not excluded. All patients underwent gynecological examination. Organic causes of pelvic pain were excluded by echoscopic and laparoscopic examinations, if these had not been administered within 3 months prior to the study. None of the subjects was known to have (had) low back injuries, perineal trauma, hematuria or urethra dilations. When urinary problems occurring often or (almost) always were reported, urological diseases were excluded by routine urological, urodynamic and cystoscopic examinations, if women had not undergone one or more of these examinations within 3 months prior to the study. Patients with nocturia who were known to have cardiovascular disorders, and those with severe mental disorders in medical history, were excluded. We also selected a control group of 31 consecutive cases of women, irrespective of age, visiting our outpatient clinic in connection with routine gynecological examination (14 women), menopausal complaints (six women), menstrual disorders (six women), and descensus uteri (five women). In both groups the majority of the women were middle class women of average education and all were of Caucasian origin and Dutch nationality. 2.2. Questionnaire In a preliminary phase of this study, we supplied a ‘provisional’ questionnaire to 25 women complaining of chronic lower abdominal pain whether or not accompanied by voiding problems, whilst clear pathological evidence was lacking. We used the feedback from this orientation study to prepare the final version of the questionnaire. From our
interviews with these 25 women we learned that items in the questionnaire demanding precision in counting and supplying data from memory, (e.g. frequency of voiding, involuntary urine loss, etc.) needed to be revised. Asking patients to keep a diary of such items was not practical because of the large number of questions which would have to be included. In the final questionnaire, (addressing, amongst other items, voiding symptoms) women of both groups were asked to mark the occurrence of their symptoms on a five-point scale (never or hardly ever, sometimes, often, almost always and always). Of the 119 questions, 27 addressed items on voiding symptoms. 2.3. Validation Women were asked to return the completed questionnaire within 1 week. Within 2 weeks after return of the completed questionnaire, patients were invited to the clinic for an extensive interview to ensure that all questions were well understood. This applied particularly to the item ‘urinary urgency’, to ensure that if urge had been reported this was in accordance with ICS criteria, defined as a strong desire to void accompanied by fear of leakage or fear of pain [6]. Moreover, the questionnaire was validated by applying construct validity, internal consistent and content validity tests (data not shown). Later, the validation procedure was applied again in a sample of women from the general population [7]. Examples of some questions on voiding symptoms are given in Table 1. 2.4. Data analysis Data reduction was applied by considering symptoms which occurred often, almost always or always, as being present and serious. When analyzing the questions addressing urinary incontinence, an arbitrary division was made between ‘serious’ and ‘minor’ incontinence, roughly in line with the definition of Rekers et al. [8]. Serious incontinence was defined as incontinence occurring often, almost always or always, in amounts of more than a few drops of urine for at least 6 months. All other incontinence was designated as not being present. Some of our results were compared with results from epidemiological studies on samples of the Dutch female population of comparable age [8]. Loss of urine associated with sneezing, laughing, coughing and/or physical exercise (at least two affirmative answers) was regarded as a positive stress incontinence symptom. Loss of urine in association with the need to void was designated as urge incontinence. We have defined the presence of symptoms of stress incontinence together with urge incontinence as mixed incontinence [8]. ‘Inability to control sphincter’ was established by analyzing the question on whether or not the patients were able to postpone voiding when they felt the need to void. Significance level was set at P < 0:05. Percentages were compared by applying Fisher’s exact test.
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Table 1 Some representative items addressing voiding symptoms used in the present study, originally presented in Dutch in our CPP questionnaire [7] I have pain in my lower abdomen, not counting pain during menstruation My lower abdominal pain radiates to the lower back If I compare my present condition with the past, then there are days when I feel a frequent and almost irresistible need to void, even when I have not been drinking much Within a few minutes after I have passed urine, I feel the need to void again I have a burning pain during voiding When I feel the need to void, it takes some time before I can start passing urine After voiding, I feel that I have emptied my bladder completely Compared to the past, my urine stream is . . . (same, rather weak, weak, different, notably, . . .) When I feel I have to void, I am able to postpone voiding Once I feel I have to void, I have leakage before I have reached the toilet I have to void at night time When I get pain in my lower abdomen and/or when my pain becomes worse, I feel an almost irresistible need to void When I have to void, I get more pain in my lower abdomen or my pain becomes worse If I wanted, I could stop voiding halfway I have to strain in order to be able to start voiding I have to strain in order to be able to go on voiding Patients were asked to tick off one of the following alternatives after each statement: never or hardly ever, sometimes, often, almost always or always.
3. Results 3.1. Patient characteristics Mean age of the CPP patients was 48 (range: 23–79) years. Generally, the medical history of these women showed years of visits to different specialists due to problems associated with chronic lower abdominal pain. Mean age of the controls was 49 (range: 18–77) years. At the time of the study none of the CPP patients had descensus uteri. However, 52% (31/60) had—sometime in the pastundergone hysterectomy. (The main reason for hysterectomy was in 23% (7/31) lower abdominal pain, in 32% (10/ 31) descensus uteri, and in 45% (14/31) other reasons— mainly menstrual disorders). The percentage of women having undergone hysterectomy was significantly higher in the CPP group (31/60; 52%) than in the control group (8/31; 26%) (P ¼ 0:025). None of the women was diagnosed with IC at the time of the study. 3.2. Prevalence of voiding symptoms In CPP patients and controls we analyzed the prevalence of: (I) symptoms of urinary incontinence and dysfunction of the urethral sphincter (all types of incontinence, involuntary control of the urethral sphincter and inability to postpone); (II) symptoms of irritation of the lower urinary tract (urge, nocturia, dysuria, cystitis, urge-induced lower abdominal pain and pain-induced urge); and (III) symptoms of pelvic floor spasticity (strain to initiate voiding, strain to continue voiding and incomplete voiding). The prevalence of these symptoms in both groups was compared and the results are summarized in Table 2. Serious urinary urgency was reported by 37% of the CPP patients; nine of these women also experienced urge within a few minutes of having emptied the bladder.
An interesting finding in the present study is that in 11 (18%) of the CPP patients urge was triggered or increased by lower abdominal pain (pain-induced urge), and in 12 (20%) lower abdominal pain was triggered or increased by urge (urge-induced pain). Eight patients had both pain-induced urge and urge-induced pain. None of the 12 women with urge-induced pain had relief from pain after voiding. Of the 22 (37%) women with serious postponement problems, 10 also had urinary urgency. Nocturia, once or more, was reported by 42 (70%) of the women; nocturia, twice or more, was reported by 11 (18%) (Table 2) (mean age: 54; median: 52; range: 31–79 years). Seven women (12%) had dysuria. Subjective inadequate function of the urethral sphincter was established in 35 (55%) individuals who reported never or only sometimes being able to willfully interrupt voiding. Serious urinary incontinence, i.e. incontinence occurring often or (almost) always, in amounts larger than a few drops of urine (irrespective of the type) was reported by 26 (43%) CPP patients. We compared this finding with the results of an earlier population study on urinary incontinence in women of comparable age [8]. In the latter study the prevalence of mild to serious incontinence was 26%; this percentage was significantly lower than the percentage of serious urinary incontinence in our group of CPP women (Table 3). The percentage of women with positive symptoms of serious stress incontinence was extremely high in our study group (15 women; 25%). We compared our data on different types of incontinence with those of Rekers et al. [8] who (for the sake of comparison) investigated the prevalence of mild to serious incontinence of different types in pre-menopausal as well as in post-menopausal women (in total 1213 women) selected from 1299 women who had participated in a previous study [8]. They excluded peri-menopausal women, defined by them as those not menstruating regularly but who had experienced menses in the preceding year (86/1299; 7%).
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Table 2 Frequency of the occurrence of urinary symptoms in CPP and non-CPP (controls) gynecological outpatients Urinary symptoms
CPP (n ¼ 60)
Controls (n ¼ 31)
P-valuea
I. Urinary incontinence and dysfunction of the urethral sphincter 1. Incontinence (stress, urge and other types of incontinence)b 2. Inadequate voluntary control of the urethral sphincter 3. Inability to postpone
26 (43) 30 (50) 22 (37)
8 (26) 7 (23) 9 (29)
0.103 0.014 0.495
II. Irritative symptoms 4. Urge 5. Nocturia 2x 6. Dysuria 7. Recurrent cystitis 8. Urge-induced lower abdominal pain 9. Pain-induced urinary urgency
22 11 7 22 12 11
(37) (18) (12) (37) (20) (18)
3 (10) 1 (3) 0 (0) 5 (16) 0 (0) –c
0.006 0.053 0.091 0.054 0.007 –c
III. Pelvic floor spasticity 10. Strain to initiate voiding 11. Strain to continue voiding 12. Incomplete voiding
6 (10) 10 (17) 22 (37)
0 (0) 0 (0) 5 (16)
0.091 0.014 0.002
Some women reported two or more symptoms. Only symptoms reported to occur often, almost always or always, have been designated as being present (values in parentheses are in percentage). a Fisher’s exact test. b Only cases of involuntary urine loss, occurring often or (almost) always, in amounts larger than a few drops. c Controls had no lower abdominal pain.
The percentage of our CPP patients with serious stress incontinence was significantly higher than the percentage of pre- and post-menopausal Dutch population with stress incontinence (mild cases included) (Table 4). When adding the number of mixed incontinent women (four patients) to those with stress incontinence, this percentage rises to 32%. This percentage is also significantly higher than that in a female population of comparable age in whom mild to serious stress incontinence (women with mixed incontinence included) was found to be 17% (Table 4) (P ¼ 0:005). Comparison of the frequency of the occurrence of urinary symptoms between our CPP group and 31 non-CPP outpatients reveals that all symptoms of irritation of the lower urinary tract, as well as all symptoms of pelvic floor spasticity, are more often present in the CPP group than in the controls. This difference is in all cases significant with the exception of dysuria and strain to initiate voiding which show a trend (Table 2). Inability to voluntarily control the urethral sphincter was also reported significantly more often by the CPP group. However, there were no significant differences between the two groups for the inability to postpone, and there was a trend for urinary incontinence Table 3 Prevalence of serious incontinence in 60 women with CPP aged 23–79 years compared with a sample of 1299 women with mild to serious urinary incontinence aged 35–79 years (Rekers et al. [8])* Current study (n ¼ 60)
Rekers et al. (n ¼ 1299)
n
Percentage of all women
n
Percentage of all women
43
344
26
26 *
P ¼ 0:004; Fisher’s exact test.
to occur more frequently in CPP than in controls. Of the eight controls who had urinary incontinence, six had positive symptoms of stress incontinence and in two the cause was unknown. No urge incontinence was reported by the control group. In all but one of the controls with stress incontinence no organic cause of these symptoms was found. There was no significant difference in the occurrence of stress incontinence between our CPP patients and the control group (15/ 60 in CPP versus 6/31 in controls; P ¼ 0:798). The prevalence of one or more serious urinary symptoms in the CPP patients was 83%. Mean number of urinary symptoms was 3.4 (range: 0–12). Approximately 63% (38/ 60) of the women had two or more and 33% (20/60) had five or more of the symptoms listed in Table 2. The prevalence of one or more serious urinary symptoms in the control group was 58%, significantly lower than in CPP (P ¼ 0:023).
Table 4 Serious urinary incontinence in 60 CPP patients (aged 23–79 years) compared with all cases of incontinence in a sample of pre- or postmenopausal female population (aged 35–79 years) (Rekers et al. [8]) Urinary incontinence
Current study (n ¼ 60a)
Rekers et al. (n ¼ 1213)b
P-value*
Stress incontinence Urge incontinence Mixed incontinence Unknown
15 2 4 5
64 53 151 47
<0.001 1.000 0.301 0.076
(25) (3) (7) (8)
(5) (4) (12) (4)
Values in parentheses are in percentage. a Pre-, peri- or post-menopausal women. b About 7% of (i.e. peri-menopausal women) participating in the study have been excluded. * Fisher’s exact test.
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As there were more hysterectomy patients in the CPP group, it was analyzed whether there was any relationship between hysterectomy and voiding symptoms in each group separately. No such relationship was found (in CPP: P ¼ 0:745), (in controls: P ¼ 1:0). Similarly, within each group no relationship was found between hysterectomy and the presence of any of the symptoms (separately) in Table 2. Therefore, hysterectomy does not confound the comparison between CPP and controls. 3.3. Influence of age on urinary symptoms The occurrence of nocturia (twice or more) showed no significant difference between CPP women younger than and older than 50 years (4/34 (12%) versus 7/26 (27%); P ¼ 0:182). In CPP women aged 50 years there is a trend for nocturia (twice or more) to be related to urinary urgency (P ¼ 0:080); this trend was not seen in those younger than 50 years. Of the CPP women with urge, 50% were 50 years or younger; in patients without urge this percentage was 69% (difference not significant). The percentage of incontinent CPP patients showed no significant difference between those less than and those older than 50 years (data not shown); inadequate voluntary control of the urethral sphincter was reported significantly more often by CPP women aged 50 years and older: 12/34 (35%) in age group <50 years versus 18/26 (69%) in age group 50 years (P ¼ 0:018). There was no significant difference between the two groups for the remaining symptoms listed in Table 2.
4. Discussion In this study the significant differences (as well as the trends in the differences) found in the frequency of occurrence of symptoms of irritation of the lower urinary tract and of pelvic floor spasticity between CPP and non-CPP women (all selected from our gynecological outpatient clinic) imply that these results were not influenced by our choice of a hospital-based population. Approximately 37% of the CPP patients completing the questionnaire reported to have often, or (almost) always, urinary urgency. In all cases routine urological and urodynamic examinations were normal, except in three women who proved to have bladder instability. The relatively high occurrence of serious urgency, i.e. urge experienced often or (almost) always in these women, can not be due to advancing age: 65% of the CPP women were 50 years and 87% were 60 years. Although, 37% (22 women) of the CPP group had serious postponement problems, only five of these were urge incontinent, with the majority reaching the toilet dry. This could mean that in CPP we are dealing with a mainly afferent (sensory) phenomenon.
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As none of the patients were found to have urethral obstruction, it is remarkable that 37% had (subjective) incomplete bladder emptying. Spasm of the anterior pelvic floor would be an interesting explanation were it not that the high frequency of the occurrence of stress incontinence in these women stipulates otherwise. A phenomenon independent of the texture of the pelvic floor may be responsible for the subjective experience of voiding symptoms in CPP. Spontaneous activity of bladder wall, shown to be significantly higher in CPP than in non-CPP patients, may be responsible for afferent stimuli resulting in premature urgency and other subjective voiding symptoms such as (subjective) incomplete bladder emptying. There was no significant difference in the percentage of patients with serious urinary incontinence between CPP patients younger than 50 years and those aged 50 years or older. This agrees with the results from Rekers et al. [8], who showed that the rate of incontinence in post-menopausal women was not significantly different from that in premenopausal women. However, in our CPP patients (aged 23–79 years) the prevalence of incontinence was significantly higher than in a female population of comparable age; this was also the case for women aged 50 years or older. These differences would have been more striking had mild cases of incontinence been included in our study (as was the case in the study of Rekers et al. [8]). When adding the number of mixed incontinent women (four patients) to those with stress incontinence, the total stress incontinence percentage rises to about 32%. This percentage is significantly higher than the corresponding value in a female population of comparable age in whom stress incontinence (including women with mixed incontinence) was reported to be 17% [8] (P ¼ 0:005). The high percentage of stress incontinence (32%) in our CPP patients is a remarkable finding. The relatively low percentage of urge incontinence (10%; urge incontinence þ mixed incontinence) in the CPP patients in this study is as impressive as the high rate of stress incontinence, especially in light of the high occurrence of the frequency of urinary urgency (37%) in these women. In our CPP group, the number of urinary symptoms cooccurring was extremely high; 63% had at least two symptoms and 35% had five symptoms or more. The presence of urinary symptoms in females with chronic lower abdominal pain seems therefore indicative for the diagnosis CPP. This suggests that, at least in a subgroup of CPP patients, we are dealing with a chronic painful bladder syndrome, resembling the urethral syndrome. Because IC should be kept in mind when evaluating the female patient with chronic lower abdominal pain and urinary symptoms, special attention should be given to the exclusion criteria of this syndrome. One of these criteria is the absence of nocturia. Of the 50 CPP patients in the present study with at least one urinary symptom, in 24% (12 patients) IC can with certainty be excluded on the ground of the complete absence of nocturia. If the absence of serious
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nocturia (twice or more) would be maintained as an exclusion criterion in IC, the percentage of CPP women with urinary symptoms, in whom IC can be excluded, would rise to 78% (39/50 women). The remaining 22% was not diagnosed with IC by our urologist despite severe voiding symptoms and suprapubic pain. Nonetheless, 22% of the women diagnosed by us with CPP could theoretically somewhere in the future develop symptoms severe enough to justify cystoscopy and could possibly turn out to have IC. Voiding symptoms such as urgency, incontinence, incomplete voiding, strain to initiate and/or continue voiding, etc. all in the absence of evident organic disorders, occur frequently in chronic pelvic pain without obvious cause. These symptoms, together with the relatively frequent occurrence of urge-induced pain and vice versa, suggest the existence of a painful bladder condition in (a subgroup of) CPP. A (functional) disturbance at the level of the central nervous system, with interaction between sensory messages, arriving from different structures within the pelvis, may be the cause of this condition.
5. Conclusions This study including 60 relatively severe cases of CPP patients aged 23–79 years has demonstrated that: 1. The prevalence of two or more voiding symptoms is high (68%). 2. The occurrence of urinary stress incontinence is significantly higher than in the general female population. 3. A substantial subgroup of these women has voiding symptoms resembling the urethral syndrome. 4. Either the same source of afferent stimuli might be responsible for the experience of lower abdominal pain and urinary urgency, or there is an interaction between these sensations, at the level of the higher centers. 5. The presence of irritative urinary symptoms in the presence of chronic lower abdominal pain and in the
absence of obvious organic disorders, does not exclude but rather supports the diagnosis CPP.
6. Condensation A survey among 60 women attending a gynecologic outpatient clinic for chronic pelvic pain revealed a high prevalence of voiding symptoms.
Acknowledgements The authors thank Prof. J.L.H.R. Bosch, MD, PhD., urologist for his valuable advice. We also thank Prof. J. Passchier, PhD., psychologist for his advice on the settings, the validity tests and the analysis of the results.
References [1] Rekers H, Drogendijk AC, Valkenburg H, Riphagen F. Urinary incontinence in women from 35 to 79 years of age: prevalence and consequences. Eur J Obstet Gynaecol Reprod Biol 1992;43:229–34. [2] Summitt RL. Urogynecologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am 1993;20(4):685–8. [3] Bodner DR. The urethral syndrome. Urol Clin North Am 1988; 15:699–704. [4] Holm-Bentzen M, Jacobsen F, Nerstrom B, et al. Painful bladder disease: clinical and pathoanatomical differences in 115 patients. J Urol 1987;138(3):500–2. [5] Tooze-Hoboson P, Gleeson C, Cardozo L. Interstitial cystitis—still an anigma after 80 years. Br J Obstet Gynaecol 1996;103:621–4. [6] Abrams P, Blaivas JG, Stanton SL, Andersen JT. The standardisation of terminology of lower urinary tract function. Scand J Urol Nephrol 1988;(Suppl 114):5–19. [7] Van Os-Bossagh P, Pols T, Hop WCJ, Nelemans T, Erdmann W, Drogendijk AC, et al. Questionnaire as diagnostic tool in chronic pelvic pain (CPP): a pilot study. Eur J Obstet Gynaecol Reprod Biol 2002;103(2):173–8. [8] Rekers H, Drogendijk AC, Valkenburg H, et al. The menopause, urinary incontinence and other symptoms of the genito-urinary tract. Maturitas 1992;15:101–11.
Voiding symptoms in chronic pelvic pain (CPP) Purana van Os-Bossagha,b,*, Trudy Polsb, Wim C.J. Hopc, Arthur M. Bohnend, Mark E. Vierhouta, Aat C. Drogendijka a
Department of Obstetrics and Gynecology, University Hospital Dijkzigt/Erasmus University Rotterdam, The Netherlands b Research Group Social Health (OMG/UWV/GAK), P.O. Box 213, 3000 AE Rotterdam, The Netherlands c Department of Epidemiology and Biostatistics, University Hospital Dijkzigt/Erasmus University Rotterdam, The Netherlands d Department of General Practice, University Hospital Dijkzigt/Erasmus University Rotterdam, The Netherlands Received 15 March 2002; received in revised form 9 July 2002; accepted 9 July 2002
Abstract Objective: To establish the prevalence of voiding symptoms in CPP patients. Study design: Sixty women with chronic pelvic pain (CPP), aged 23–79 (mean: 48) years completed a questionnaire mainly addressing lower abdominal pain and voiding symptoms. Symptoms occurring often, almost always, or always for more than 6 months were considered present and serious. A group of 31 consecutive cases of non-CPP women aged 18–77 (mean: 49) years were selected to serve as controls. Results: The following symptoms were found in the CPP group: incontinence: 43%; inadequate voluntary control of the urethral sphincter: 50%; inability to postpone: 37%; urge: 37%; nocturia 2x: 18%; dysuria: 12%; cystitis: 37%; urge-induced pain: 20%; pain-induced urge: 18%; strain to initiate voiding: 6%; strain to continue voiding: 17%; incomplete voiding: 37%. Two or more voiding symptoms were present in 63% of the CPP group. All urinary symptoms were more often present in the CPP group than in the controls. Conclusion: A substantial subgroup of CPP patients has voiding symptoms. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: CPP; Incontinence; Pelvic pain; Urge
1. Introduction The prevalence of minor to serious urinary incontinence in Dutch women aged 35–79 years, is about 27% [1]. Serious incontinence has been defined as involuntary loss of urine, occurring at least once a week, and in amounts larger than a few drops, all other incontinence being ‘minor’ [1]. It has been postulated that disorders of the lower urinary tract may present themselves as symptoms of chronic pelvic pain (CPP) [2]. The occurrence of urinary symptoms has been attributed to (amongst others) the urethral syndrome, the symptoms of which have been summarized by Bodner as urinary urgency, dysuria, frequency and suprapubic discomfort [3]. Hesitancy, incomplete bladder emptying, weak stream and symptoms unrelated to the urinary tract (such as back discomfort) may also be present [3]. Lower abdominal pain and voiding symptoms of unknown etiology also occur in interstitial cystitis (IC) [4,5]. Both the urethral syndrome and IC are * Corresponding author. Tel.: þ31-10-4404719; fax: þ31-10-4404001. E-mail address: [email protected] (P. van Os-Bossagh).
diagnosed by excluding physical disorders in the presence of voiding symptoms, and both syndromes overlap each other in symptoms of an irritable bladder in the absence of infectious agents. In IC suprapubic pain is the prominent feature whereas in the urethral syndrome voiding symptoms are predominant. Other more vaguely defined disorders found with voiding symptoms and ‘painful bladder’ (sometimes with organic abnormalities) are detrusor myopathy, chronic non-specific cystitis and eosinophilic cystitis. Because some women with voiding symptoms present chronic lower abdominal pain as the main complaint in the presence of one or more IC exclusion criteria, many of these patients, suspected to have CPP, are eventually referred to a gynecologist. This study was designed to establish the prevalence of voiding symptoms in CPP patients. In case age was expected to influence a particular symptom, data on women less than/ older than 50 years were compared; these age-related data were also compared with data from similar studies. The CPP population of the present study consists exclusively of women visiting our outpatient clinic; we also investigate whether the prevalence of specific voiding symptoms
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in this group differs from a sample of non-CPP patients visiting the same gynecological outpatient clinic.
2. Materials and methods 2.1. Study population This clinical pilot study was approved by the Medical Ethics Committee of the University Hospital. The first 60 consecutive women referred to our outpatient clinic because of chronic lower abdominal pain of unknown origin and diagnosed with CPP were invited to participate; all agreed and all gave informed consent. The CPP population of our hospital generally consists of relatively severe cases. In all women participating in this study the diagnosis CPP was established by at least two physicians. To comply with the inclusion criteria, patients had to have lower abdominal pain without evident urological-, genital-, or digestive tract pathology. Moreover, lower abdominal pain had to occur often, almost always or always, for 6 months or longer. In all patients endometriosis was ruled out by laparoscopy. Women not menstruating because of having undergone hysterectomy or because of other reasons (as well as those who were not sexually active) were not excluded. All patients underwent gynecological examination. Organic causes of pelvic pain were excluded by echoscopic and laparoscopic examinations, if these had not been administered within 3 months prior to the study. None of the subjects was known to have (had) low back injuries, perineal trauma, hematuria or urethra dilations. When urinary problems occurring often or (almost) always were reported, urological diseases were excluded by routine urological, urodynamic and cystoscopic examinations, if women had not undergone one or more of these examinations within 3 months prior to the study. Patients with nocturia who were known to have cardiovascular disorders, and those with severe mental disorders in medical history, were excluded. We also selected a control group of 31 consecutive cases of women, irrespective of age, visiting our outpatient clinic in connection with routine gynecological examination (14 women), menopausal complaints (six women), menstrual disorders (six women), and descensus uteri (five women). In both groups the majority of the women were middle class women of average education and all were of Caucasian origin and Dutch nationality. 2.2. Questionnaire In a preliminary phase of this study, we supplied a ‘provisional’ questionnaire to 25 women complaining of chronic lower abdominal pain whether or not accompanied by voiding problems, whilst clear pathological evidence was lacking. We used the feedback from this orientation study to prepare the final version of the questionnaire. From our
interviews with these 25 women we learned that items in the questionnaire demanding precision in counting and supplying data from memory, (e.g. frequency of voiding, involuntary urine loss, etc.) needed to be revised. Asking patients to keep a diary of such items was not practical because of the large number of questions which would have to be included. In the final questionnaire, (addressing, amongst other items, voiding symptoms) women of both groups were asked to mark the occurrence of their symptoms on a five-point scale (never or hardly ever, sometimes, often, almost always and always). Of the 119 questions, 27 addressed items on voiding symptoms. 2.3. Validation Women were asked to return the completed questionnaire within 1 week. Within 2 weeks after return of the completed questionnaire, patients were invited to the clinic for an extensive interview to ensure that all questions were well understood. This applied particularly to the item ‘urinary urgency’, to ensure that if urge had been reported this was in accordance with ICS criteria, defined as a strong desire to void accompanied by fear of leakage or fear of pain [6]. Moreover, the questionnaire was validated by applying construct validity, internal consistent and content validity tests (data not shown). Later, the validation procedure was applied again in a sample of women from the general population [7]. Examples of some questions on voiding symptoms are given in Table 1. 2.4. Data analysis Data reduction was applied by considering symptoms which occurred often, almost always or always, as being present and serious. When analyzing the questions addressing urinary incontinence, an arbitrary division was made between ‘serious’ and ‘minor’ incontinence, roughly in line with the definition of Rekers et al. [8]. Serious incontinence was defined as incontinence occurring often, almost always or always, in amounts of more than a few drops of urine for at least 6 months. All other incontinence was designated as not being present. Some of our results were compared with results from epidemiological studies on samples of the Dutch female population of comparable age [8]. Loss of urine associated with sneezing, laughing, coughing and/or physical exercise (at least two affirmative answers) was regarded as a positive stress incontinence symptom. Loss of urine in association with the need to void was designated as urge incontinence. We have defined the presence of symptoms of stress incontinence together with urge incontinence as mixed incontinence [8]. ‘Inability to control sphincter’ was established by analyzing the question on whether or not the patients were able to postpone voiding when they felt the need to void. Significance level was set at P < 0:05. Percentages were compared by applying Fisher’s exact test.
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Table 1 Some representative items addressing voiding symptoms used in the present study, originally presented in Dutch in our CPP questionnaire [7] I have pain in my lower abdomen, not counting pain during menstruation My lower abdominal pain radiates to the lower back If I compare my present condition with the past, then there are days when I feel a frequent and almost irresistible need to void, even when I have not been drinking much Within a few minutes after I have passed urine, I feel the need to void again I have a burning pain during voiding When I feel the need to void, it takes some time before I can start passing urine After voiding, I feel that I have emptied my bladder completely Compared to the past, my urine stream is . . . (same, rather weak, weak, different, notably, . . .) When I feel I have to void, I am able to postpone voiding Once I feel I have to void, I have leakage before I have reached the toilet I have to void at night time When I get pain in my lower abdomen and/or when my pain becomes worse, I feel an almost irresistible need to void When I have to void, I get more pain in my lower abdomen or my pain becomes worse If I wanted, I could stop voiding halfway I have to strain in order to be able to start voiding I have to strain in order to be able to go on voiding Patients were asked to tick off one of the following alternatives after each statement: never or hardly ever, sometimes, often, almost always or always.
3. Results 3.1. Patient characteristics Mean age of the CPP patients was 48 (range: 23–79) years. Generally, the medical history of these women showed years of visits to different specialists due to problems associated with chronic lower abdominal pain. Mean age of the controls was 49 (range: 18–77) years. At the time of the study none of the CPP patients had descensus uteri. However, 52% (31/60) had—sometime in the pastundergone hysterectomy. (The main reason for hysterectomy was in 23% (7/31) lower abdominal pain, in 32% (10/ 31) descensus uteri, and in 45% (14/31) other reasons— mainly menstrual disorders). The percentage of women having undergone hysterectomy was significantly higher in the CPP group (31/60; 52%) than in the control group (8/31; 26%) (P ¼ 0:025). None of the women was diagnosed with IC at the time of the study. 3.2. Prevalence of voiding symptoms In CPP patients and controls we analyzed the prevalence of: (I) symptoms of urinary incontinence and dysfunction of the urethral sphincter (all types of incontinence, involuntary control of the urethral sphincter and inability to postpone); (II) symptoms of irritation of the lower urinary tract (urge, nocturia, dysuria, cystitis, urge-induced lower abdominal pain and pain-induced urge); and (III) symptoms of pelvic floor spasticity (strain to initiate voiding, strain to continue voiding and incomplete voiding). The prevalence of these symptoms in both groups was compared and the results are summarized in Table 2. Serious urinary urgency was reported by 37% of the CPP patients; nine of these women also experienced urge within a few minutes of having emptied the bladder.
An interesting finding in the present study is that in 11 (18%) of the CPP patients urge was triggered or increased by lower abdominal pain (pain-induced urge), and in 12 (20%) lower abdominal pain was triggered or increased by urge (urge-induced pain). Eight patients had both pain-induced urge and urge-induced pain. None of the 12 women with urge-induced pain had relief from pain after voiding. Of the 22 (37%) women with serious postponement problems, 10 also had urinary urgency. Nocturia, once or more, was reported by 42 (70%) of the women; nocturia, twice or more, was reported by 11 (18%) (Table 2) (mean age: 54; median: 52; range: 31–79 years). Seven women (12%) had dysuria. Subjective inadequate function of the urethral sphincter was established in 35 (55%) individuals who reported never or only sometimes being able to willfully interrupt voiding. Serious urinary incontinence, i.e. incontinence occurring often or (almost) always, in amounts larger than a few drops of urine (irrespective of the type) was reported by 26 (43%) CPP patients. We compared this finding with the results of an earlier population study on urinary incontinence in women of comparable age [8]. In the latter study the prevalence of mild to serious incontinence was 26%; this percentage was significantly lower than the percentage of serious urinary incontinence in our group of CPP women (Table 3). The percentage of women with positive symptoms of serious stress incontinence was extremely high in our study group (15 women; 25%). We compared our data on different types of incontinence with those of Rekers et al. [8] who (for the sake of comparison) investigated the prevalence of mild to serious incontinence of different types in pre-menopausal as well as in post-menopausal women (in total 1213 women) selected from 1299 women who had participated in a previous study [8]. They excluded peri-menopausal women, defined by them as those not menstruating regularly but who had experienced menses in the preceding year (86/1299; 7%).
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Table 2 Frequency of the occurrence of urinary symptoms in CPP and non-CPP (controls) gynecological outpatients Urinary symptoms
CPP (n ¼ 60)
Controls (n ¼ 31)
P-valuea
I. Urinary incontinence and dysfunction of the urethral sphincter 1. Incontinence (stress, urge and other types of incontinence)b 2. Inadequate voluntary control of the urethral sphincter 3. Inability to postpone
26 (43) 30 (50) 22 (37)
8 (26) 7 (23) 9 (29)
0.103 0.014 0.495
II. Irritative symptoms 4. Urge 5. Nocturia 2x 6. Dysuria 7. Recurrent cystitis 8. Urge-induced lower abdominal pain 9. Pain-induced urinary urgency
22 11 7 22 12 11
(37) (18) (12) (37) (20) (18)
3 (10) 1 (3) 0 (0) 5 (16) 0 (0) –c
0.006 0.053 0.091 0.054 0.007 –c
III. Pelvic floor spasticity 10. Strain to initiate voiding 11. Strain to continue voiding 12. Incomplete voiding
6 (10) 10 (17) 22 (37)
0 (0) 0 (0) 5 (16)
0.091 0.014 0.002
Some women reported two or more symptoms. Only symptoms reported to occur often, almost always or always, have been designated as being present (values in parentheses are in percentage). a Fisher’s exact test. b Only cases of involuntary urine loss, occurring often or (almost) always, in amounts larger than a few drops. c Controls had no lower abdominal pain.
The percentage of our CPP patients with serious stress incontinence was significantly higher than the percentage of pre- and post-menopausal Dutch population with stress incontinence (mild cases included) (Table 4). When adding the number of mixed incontinent women (four patients) to those with stress incontinence, this percentage rises to 32%. This percentage is also significantly higher than that in a female population of comparable age in whom mild to serious stress incontinence (women with mixed incontinence included) was found to be 17% (Table 4) (P ¼ 0:005). Comparison of the frequency of the occurrence of urinary symptoms between our CPP group and 31 non-CPP outpatients reveals that all symptoms of irritation of the lower urinary tract, as well as all symptoms of pelvic floor spasticity, are more often present in the CPP group than in the controls. This difference is in all cases significant with the exception of dysuria and strain to initiate voiding which show a trend (Table 2). Inability to voluntarily control the urethral sphincter was also reported significantly more often by the CPP group. However, there were no significant differences between the two groups for the inability to postpone, and there was a trend for urinary incontinence Table 3 Prevalence of serious incontinence in 60 women with CPP aged 23–79 years compared with a sample of 1299 women with mild to serious urinary incontinence aged 35–79 years (Rekers et al. [8])* Current study (n ¼ 60)
Rekers et al. (n ¼ 1299)
n
Percentage of all women
n
Percentage of all women
43
344
26
26 *
P ¼ 0:004; Fisher’s exact test.
to occur more frequently in CPP than in controls. Of the eight controls who had urinary incontinence, six had positive symptoms of stress incontinence and in two the cause was unknown. No urge incontinence was reported by the control group. In all but one of the controls with stress incontinence no organic cause of these symptoms was found. There was no significant difference in the occurrence of stress incontinence between our CPP patients and the control group (15/ 60 in CPP versus 6/31 in controls; P ¼ 0:798). The prevalence of one or more serious urinary symptoms in the CPP patients was 83%. Mean number of urinary symptoms was 3.4 (range: 0–12). Approximately 63% (38/ 60) of the women had two or more and 33% (20/60) had five or more of the symptoms listed in Table 2. The prevalence of one or more serious urinary symptoms in the control group was 58%, significantly lower than in CPP (P ¼ 0:023).
Table 4 Serious urinary incontinence in 60 CPP patients (aged 23–79 years) compared with all cases of incontinence in a sample of pre- or postmenopausal female population (aged 35–79 years) (Rekers et al. [8]) Urinary incontinence
Current study (n ¼ 60a)
Rekers et al. (n ¼ 1213)b
P-value*
Stress incontinence Urge incontinence Mixed incontinence Unknown
15 2 4 5
64 53 151 47
<0.001 1.000 0.301 0.076
(25) (3) (7) (8)
(5) (4) (12) (4)
Values in parentheses are in percentage. a Pre-, peri- or post-menopausal women. b About 7% of (i.e. peri-menopausal women) participating in the study have been excluded. * Fisher’s exact test.
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As there were more hysterectomy patients in the CPP group, it was analyzed whether there was any relationship between hysterectomy and voiding symptoms in each group separately. No such relationship was found (in CPP: P ¼ 0:745), (in controls: P ¼ 1:0). Similarly, within each group no relationship was found between hysterectomy and the presence of any of the symptoms (separately) in Table 2. Therefore, hysterectomy does not confound the comparison between CPP and controls. 3.3. Influence of age on urinary symptoms The occurrence of nocturia (twice or more) showed no significant difference between CPP women younger than and older than 50 years (4/34 (12%) versus 7/26 (27%); P ¼ 0:182). In CPP women aged 50 years there is a trend for nocturia (twice or more) to be related to urinary urgency (P ¼ 0:080); this trend was not seen in those younger than 50 years. Of the CPP women with urge, 50% were 50 years or younger; in patients without urge this percentage was 69% (difference not significant). The percentage of incontinent CPP patients showed no significant difference between those less than and those older than 50 years (data not shown); inadequate voluntary control of the urethral sphincter was reported significantly more often by CPP women aged 50 years and older: 12/34 (35%) in age group <50 years versus 18/26 (69%) in age group 50 years (P ¼ 0:018). There was no significant difference between the two groups for the remaining symptoms listed in Table 2.
4. Discussion In this study the significant differences (as well as the trends in the differences) found in the frequency of occurrence of symptoms of irritation of the lower urinary tract and of pelvic floor spasticity between CPP and non-CPP women (all selected from our gynecological outpatient clinic) imply that these results were not influenced by our choice of a hospital-based population. Approximately 37% of the CPP patients completing the questionnaire reported to have often, or (almost) always, urinary urgency. In all cases routine urological and urodynamic examinations were normal, except in three women who proved to have bladder instability. The relatively high occurrence of serious urgency, i.e. urge experienced often or (almost) always in these women, can not be due to advancing age: 65% of the CPP women were 50 years and 87% were 60 years. Although, 37% (22 women) of the CPP group had serious postponement problems, only five of these were urge incontinent, with the majority reaching the toilet dry. This could mean that in CPP we are dealing with a mainly afferent (sensory) phenomenon.
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As none of the patients were found to have urethral obstruction, it is remarkable that 37% had (subjective) incomplete bladder emptying. Spasm of the anterior pelvic floor would be an interesting explanation were it not that the high frequency of the occurrence of stress incontinence in these women stipulates otherwise. A phenomenon independent of the texture of the pelvic floor may be responsible for the subjective experience of voiding symptoms in CPP. Spontaneous activity of bladder wall, shown to be significantly higher in CPP than in non-CPP patients, may be responsible for afferent stimuli resulting in premature urgency and other subjective voiding symptoms such as (subjective) incomplete bladder emptying. There was no significant difference in the percentage of patients with serious urinary incontinence between CPP patients younger than 50 years and those aged 50 years or older. This agrees with the results from Rekers et al. [8], who showed that the rate of incontinence in post-menopausal women was not significantly different from that in premenopausal women. However, in our CPP patients (aged 23–79 years) the prevalence of incontinence was significantly higher than in a female population of comparable age; this was also the case for women aged 50 years or older. These differences would have been more striking had mild cases of incontinence been included in our study (as was the case in the study of Rekers et al. [8]). When adding the number of mixed incontinent women (four patients) to those with stress incontinence, the total stress incontinence percentage rises to about 32%. This percentage is significantly higher than the corresponding value in a female population of comparable age in whom stress incontinence (including women with mixed incontinence) was reported to be 17% [8] (P ¼ 0:005). The high percentage of stress incontinence (32%) in our CPP patients is a remarkable finding. The relatively low percentage of urge incontinence (10%; urge incontinence þ mixed incontinence) in the CPP patients in this study is as impressive as the high rate of stress incontinence, especially in light of the high occurrence of the frequency of urinary urgency (37%) in these women. In our CPP group, the number of urinary symptoms cooccurring was extremely high; 63% had at least two symptoms and 35% had five symptoms or more. The presence of urinary symptoms in females with chronic lower abdominal pain seems therefore indicative for the diagnosis CPP. This suggests that, at least in a subgroup of CPP patients, we are dealing with a chronic painful bladder syndrome, resembling the urethral syndrome. Because IC should be kept in mind when evaluating the female patient with chronic lower abdominal pain and urinary symptoms, special attention should be given to the exclusion criteria of this syndrome. One of these criteria is the absence of nocturia. Of the 50 CPP patients in the present study with at least one urinary symptom, in 24% (12 patients) IC can with certainty be excluded on the ground of the complete absence of nocturia. If the absence of serious
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nocturia (twice or more) would be maintained as an exclusion criterion in IC, the percentage of CPP women with urinary symptoms, in whom IC can be excluded, would rise to 78% (39/50 women). The remaining 22% was not diagnosed with IC by our urologist despite severe voiding symptoms and suprapubic pain. Nonetheless, 22% of the women diagnosed by us with CPP could theoretically somewhere in the future develop symptoms severe enough to justify cystoscopy and could possibly turn out to have IC. Voiding symptoms such as urgency, incontinence, incomplete voiding, strain to initiate and/or continue voiding, etc. all in the absence of evident organic disorders, occur frequently in chronic pelvic pain without obvious cause. These symptoms, together with the relatively frequent occurrence of urge-induced pain and vice versa, suggest the existence of a painful bladder condition in (a subgroup of) CPP. A (functional) disturbance at the level of the central nervous system, with interaction between sensory messages, arriving from different structures within the pelvis, may be the cause of this condition.
5. Conclusions This study including 60 relatively severe cases of CPP patients aged 23–79 years has demonstrated that: 1. The prevalence of two or more voiding symptoms is high (68%). 2. The occurrence of urinary stress incontinence is significantly higher than in the general female population. 3. A substantial subgroup of these women has voiding symptoms resembling the urethral syndrome. 4. Either the same source of afferent stimuli might be responsible for the experience of lower abdominal pain and urinary urgency, or there is an interaction between these sensations, at the level of the higher centers. 5. The presence of irritative urinary symptoms in the presence of chronic lower abdominal pain and in the
absence of obvious organic disorders, does not exclude but rather supports the diagnosis CPP.
6. Condensation A survey among 60 women attending a gynecologic outpatient clinic for chronic pelvic pain revealed a high prevalence of voiding symptoms.
Acknowledgements The authors thank Prof. J.L.H.R. Bosch, MD, PhD., urologist for his valuable advice. We also thank Prof. J. Passchier, PhD., psychologist for his advice on the settings, the validity tests and the analysis of the results.
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