Journal of Pain & Palliative Care Pharmacotherapy. 2014;Early Online:1–3. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.972006
ORIGINAL ARTICLE
A New Paradigm in Chronic Bladder Pain
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Dicle Univ. on 11/06/14 For personal use only.
Ursula Wesselmann A B STRA CT The concept of visceral pain has moved from organ-centered disease to a conceptualization based on pathophysiological mechanisms, integrating psychosocial and sexual dimensions. The terms painful bladder syndrome and bladder pain syndrome have been coined to include all patients with bladder pain. There is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes IC/BPS is likely to be underdiagnosed and undertreated in both men and women IC/BPS requires a multidisciplinary team approach toward management. This report is adapted from paineurope 2014; Issue 2, ©Haymarket Medical Publications Ltd, and is presented with permission. Paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS pain, visceral, bladder, interstitial cystitis, multidisciplinary approach
Over the past 15 years, the concept of “chronic visceral pain” as a disease has received increased attention, particularly from the medical subspecialties of urology and gynecology. Intense research efforts aimed at identifying and treating end-organ pathology, such as infection or inflammation, have demonstrated that a causal relationship to chronic visceral (pelvic) pain symptoms is uncommon. Moving away from this organ-centered understanding of chronic pain located in the abdominal and pelvic areas to a conceptualization based on pathophysiological mechanisms of pelvic/abdominal pain, and integrating psychosocial and sexual dimensions, has resulted in a transformation of the field that is reflected in all areas from research to clinical practice.1,2
CHRONIC BLADDER PAIN—A DISEASE IN ITS OWN RIGHT A prominent example of a chronic visceral pain syndrome where such a transformation has occurred is bladder pain. While interstitial cystitis (IC) was initially regarded as a bladder disease, it is now recognized that there is a heterogeneous group of still poorly defined disorders, which present with pain perceived in the bladder area and urinary symptoms.1,3–5 The terms painful bladder syndrome and bladder pain syndrome (BPS) have been coined to include all patients with bladder pain.6 The broader definition of IC/BPS as “an unpleasant sensation perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes” suggested by the Society for Urodynamics and Female Urology, has been used in both the European and US urological guidelines for the diagnosis and treatment of these conditions.7,8 Estimated prevalence data of IC/BPS vary on the basis of case definitions and populations studied, ranging from 0.06 to 30%.1 Female predominance of IC/BPS has been reported in previous studies, but a recent study showed that the prevalence of IC/BPS symptoms in men approaches that
Ursula Wesselmann, MD, PhD, is Professor of Anesthesiology and Neurology at the University of Alabama at Birmingham School of Medicine, Birmingham, Alabama. This report is adapted from paineurope 2014; Issue 2, ©Haymarket Medical Publications Ltd, and is presented with permission. Paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Ursula Wesselmann, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama. (E-mail: [email protected]).
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J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Dicle Univ. on 11/06/14 For personal use only.
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Journal of Pain & Palliative Care Pharmacotherapy
in women, raising the concern that this condition may be under-diagnosed and under-treated in men.9 At present, there is no universally accepted etiology for IC/BPS and proposed etiologies—which are not mutually exclusive—include inflammation, mast cell activation, urothelial dysfunction/glycosaminoglycan defects, abnormal neuronal function, presence of antiproliferative factor, autoimmune mechanisms, genetic predisposition and early-in-life experiences.10 These multiple etiologies reflect the heterogeneity of the patient population. Clinical observations suggest that there is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes. These observations could be explained neurophysiologicaly by referred visceral pain mechanisms from other visceral and somatic areas with overlapping spinal cord projections.11 There is increasing evidence of the co-occurrence of IC/BPS with chronic pain syndromes in other nonpelvic body areas (for example, with fibromyalgia),12 raising the question of systemic alterations of pain modulation mechanisms. Epidemiological studies have suggested that IC/BPS may be part of a more generalized systemic disorder,13,14 and it has been proposed that IC/BPS is a functional somatic syndrome rather than a urological condition.4
TRANSFORMING BLADDER PAIN RESEARCH AND CLINICAL MANAGEMENT The shift in conceptualizing IC/BPS as a systemic disease has resulted in new approaches in basic science and clinical research of bladder pain as well as in the clinical management of this visceral pain syndrome. The National Institutes of Health in the United States has launched a multidisciplinary research network,15 embracing a systemic “whole body” approach in the study of IC/BPS focusing on five major areas:
• epidemiology of disease; • phenotyping of urological and nonurological symptoms; • neuroimaging/neurobiology studies; • identification of biomarkers of disease; and • characterizations of organ crosstalk/pain pathways. Recognizing IC/BPS as a visceral pain syndrome and realizing the sometimes marked differences in the expression and function of receptors in visceral and somatic pathways has led to new pharmacological research explorations of previously overlooked potential therapeutic targets.16,17 Clinical guidelines have been developed in several countries over the last 10 years
proposing n integrated approach to IC/BPS by a multidisciplinary team of healthcare providers.1,6–8 The need for a multidisciplinary team approach to IC/BPS will require changes in the healthcare system to allow a coordinated involvement of multiple teams, beyond the historic boundaries of medical subspecialties and of primary and secondary care. This has recently been addressed in The British Pain Society’s Pelvic Pain Patient Pathway Map18 and in the Pain Report of the Institute of Medicine in the United States, issued at the request of Congress as part of President Obama’s health reform legislation.19 The shift in the conceptualization of visceral pain has created the need for a forum for clinicians and researchers to interact in a multidisciplinary fashion. In 2013, the first World Congress on Abdominal and Pelvic Pain took place in Amsterdam, The Netherlands. It is a new initiative in the world of visceral pain and was set up by three organizations active in the field of pelvic pain that joined forces to organize this unique meeting. These events are an important step forward and highlight a condition that is often under-recognized, despite its high impact on the quality of life of the patient and high societal burden. This area is evolving and extremely important, as visceral pain is the most frequent form of pain.17 Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES [1] Engeler DS, Baranowski AP, et al. Eur Urology. 2013;64(3):431–439. [2] Wesselmann U. Eur J Pain. 1999;3:189–191. [3] Baranowski AP, Abrams P, et al. Eur Urology. 2008;53(1):33–36. [4] Potts JM, Payne CK. Pain. 2012;153:755–758. [5] Wesselmann U. Urology 2001;57(6 Suppl 1):32–39. [6] Fall M, Baranowski AP, et al. Eur Urology. 2010;57(1):35–48. [7] Engeler DS, Baranowski AP, et al. Guidelines on chronic pelvic pain. EAU. 2013. [8] Hanno PM, Burks DA, et al. J Urology. 2011;185(6):2162–2170. [9] Suskind AM, Berry SH, et al. J Urology. 2013;189(1):141–145. [10] Vij M, Srikrishna S, et al. Eur J Obstet Gyn R B. 2012;161(1):1–7. [11] Wesselmann U, Burnett AL, et al. Pain. 1997;73(3):269–294. [12] Clauw DJ, Schmidt M, et al. J Psychiat Res. 1997;31(1):125–131. [13] Bullones Rodriguez MA, Afari N, et al. J Urology. 2013;189(1 Suppl):S66–74. [14] Warren JW, Howard FM, et al. Urology. 2009;73(1):52-57. [15] MAPP research network. Multi-Disciplinary Approach to the Study of Chronic Pelvic Pain. Available from: www. mappnetwork.org (accessed 8 April 2014).
Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives on Pain & Palliative Care
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Dicle Univ. on 11/06/14 For personal use only.
[16] Blackshaw LA. Br J Pharm. 2014;171(10):2528– 2536. [17] Wesselmann U, Baranowski AP, et al. Drug Disc Today: Therap Strategies 2009;6(3):89–95. [18] Baranowski AP, Lee J, et al. Br J Anaesth. 2014;112:452– 459.
C
2014 Informa Healthcare USA, Inc.
3
[19] Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Available from: www.iom.edu/Reports/ 2011/Relieving-Pain-in-America-A-Blueprint-for-transformingPrevention-Care-Education-Research.aspx (accessed 8 April 2014).
ORIGINAL ARTICLE
A New Paradigm in Chronic Bladder Pain
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Dicle Univ. on 11/06/14 For personal use only.
Ursula Wesselmann A B STRA CT The concept of visceral pain has moved from organ-centered disease to a conceptualization based on pathophysiological mechanisms, integrating psychosocial and sexual dimensions. The terms painful bladder syndrome and bladder pain syndrome have been coined to include all patients with bladder pain. There is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes IC/BPS is likely to be underdiagnosed and undertreated in both men and women IC/BPS requires a multidisciplinary team approach toward management. This report is adapted from paineurope 2014; Issue 2, ©Haymarket Medical Publications Ltd, and is presented with permission. Paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS pain, visceral, bladder, interstitial cystitis, multidisciplinary approach
Over the past 15 years, the concept of “chronic visceral pain” as a disease has received increased attention, particularly from the medical subspecialties of urology and gynecology. Intense research efforts aimed at identifying and treating end-organ pathology, such as infection or inflammation, have demonstrated that a causal relationship to chronic visceral (pelvic) pain symptoms is uncommon. Moving away from this organ-centered understanding of chronic pain located in the abdominal and pelvic areas to a conceptualization based on pathophysiological mechanisms of pelvic/abdominal pain, and integrating psychosocial and sexual dimensions, has resulted in a transformation of the field that is reflected in all areas from research to clinical practice.1,2
CHRONIC BLADDER PAIN—A DISEASE IN ITS OWN RIGHT A prominent example of a chronic visceral pain syndrome where such a transformation has occurred is bladder pain. While interstitial cystitis (IC) was initially regarded as a bladder disease, it is now recognized that there is a heterogeneous group of still poorly defined disorders, which present with pain perceived in the bladder area and urinary symptoms.1,3–5 The terms painful bladder syndrome and bladder pain syndrome (BPS) have been coined to include all patients with bladder pain.6 The broader definition of IC/BPS as “an unpleasant sensation perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes” suggested by the Society for Urodynamics and Female Urology, has been used in both the European and US urological guidelines for the diagnosis and treatment of these conditions.7,8 Estimated prevalence data of IC/BPS vary on the basis of case definitions and populations studied, ranging from 0.06 to 30%.1 Female predominance of IC/BPS has been reported in previous studies, but a recent study showed that the prevalence of IC/BPS symptoms in men approaches that
Ursula Wesselmann, MD, PhD, is Professor of Anesthesiology and Neurology at the University of Alabama at Birmingham School of Medicine, Birmingham, Alabama. This report is adapted from paineurope 2014; Issue 2, ©Haymarket Medical Publications Ltd, and is presented with permission. Paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Ursula Wesselmann, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama. (E-mail: [email protected]).
1
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Dicle Univ. on 11/06/14 For personal use only.
2
Journal of Pain & Palliative Care Pharmacotherapy
in women, raising the concern that this condition may be under-diagnosed and under-treated in men.9 At present, there is no universally accepted etiology for IC/BPS and proposed etiologies—which are not mutually exclusive—include inflammation, mast cell activation, urothelial dysfunction/glycosaminoglycan defects, abnormal neuronal function, presence of antiproliferative factor, autoimmune mechanisms, genetic predisposition and early-in-life experiences.10 These multiple etiologies reflect the heterogeneity of the patient population. Clinical observations suggest that there is substantial overlap between IC/BPS and other pelvic/abdominal pain syndromes. These observations could be explained neurophysiologicaly by referred visceral pain mechanisms from other visceral and somatic areas with overlapping spinal cord projections.11 There is increasing evidence of the co-occurrence of IC/BPS with chronic pain syndromes in other nonpelvic body areas (for example, with fibromyalgia),12 raising the question of systemic alterations of pain modulation mechanisms. Epidemiological studies have suggested that IC/BPS may be part of a more generalized systemic disorder,13,14 and it has been proposed that IC/BPS is a functional somatic syndrome rather than a urological condition.4
TRANSFORMING BLADDER PAIN RESEARCH AND CLINICAL MANAGEMENT The shift in conceptualizing IC/BPS as a systemic disease has resulted in new approaches in basic science and clinical research of bladder pain as well as in the clinical management of this visceral pain syndrome. The National Institutes of Health in the United States has launched a multidisciplinary research network,15 embracing a systemic “whole body” approach in the study of IC/BPS focusing on five major areas:
• epidemiology of disease; • phenotyping of urological and nonurological symptoms; • neuroimaging/neurobiology studies; • identification of biomarkers of disease; and • characterizations of organ crosstalk/pain pathways. Recognizing IC/BPS as a visceral pain syndrome and realizing the sometimes marked differences in the expression and function of receptors in visceral and somatic pathways has led to new pharmacological research explorations of previously overlooked potential therapeutic targets.16,17 Clinical guidelines have been developed in several countries over the last 10 years
proposing n integrated approach to IC/BPS by a multidisciplinary team of healthcare providers.1,6–8 The need for a multidisciplinary team approach to IC/BPS will require changes in the healthcare system to allow a coordinated involvement of multiple teams, beyond the historic boundaries of medical subspecialties and of primary and secondary care. This has recently been addressed in The British Pain Society’s Pelvic Pain Patient Pathway Map18 and in the Pain Report of the Institute of Medicine in the United States, issued at the request of Congress as part of President Obama’s health reform legislation.19 The shift in the conceptualization of visceral pain has created the need for a forum for clinicians and researchers to interact in a multidisciplinary fashion. In 2013, the first World Congress on Abdominal and Pelvic Pain took place in Amsterdam, The Netherlands. It is a new initiative in the world of visceral pain and was set up by three organizations active in the field of pelvic pain that joined forces to organize this unique meeting. These events are an important step forward and highlight a condition that is often under-recognized, despite its high impact on the quality of life of the patient and high societal burden. This area is evolving and extremely important, as visceral pain is the most frequent form of pain.17 Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES [1] Engeler DS, Baranowski AP, et al. Eur Urology. 2013;64(3):431–439. [2] Wesselmann U. Eur J Pain. 1999;3:189–191. [3] Baranowski AP, Abrams P, et al. Eur Urology. 2008;53(1):33–36. [4] Potts JM, Payne CK. Pain. 2012;153:755–758. [5] Wesselmann U. Urology 2001;57(6 Suppl 1):32–39. [6] Fall M, Baranowski AP, et al. Eur Urology. 2010;57(1):35–48. [7] Engeler DS, Baranowski AP, et al. Guidelines on chronic pelvic pain. EAU. 2013. [8] Hanno PM, Burks DA, et al. J Urology. 2011;185(6):2162–2170. [9] Suskind AM, Berry SH, et al. J Urology. 2013;189(1):141–145. [10] Vij M, Srikrishna S, et al. Eur J Obstet Gyn R B. 2012;161(1):1–7. [11] Wesselmann U, Burnett AL, et al. Pain. 1997;73(3):269–294. [12] Clauw DJ, Schmidt M, et al. J Psychiat Res. 1997;31(1):125–131. [13] Bullones Rodriguez MA, Afari N, et al. J Urology. 2013;189(1 Suppl):S66–74. [14] Warren JW, Howard FM, et al. Urology. 2009;73(1):52-57. [15] MAPP research network. Multi-Disciplinary Approach to the Study of Chronic Pelvic Pain. Available from: www. mappnetwork.org (accessed 8 April 2014).
Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives on Pain & Palliative Care
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Dicle Univ. on 11/06/14 For personal use only.
[16] Blackshaw LA. Br J Pharm. 2014;171(10):2528– 2536. [17] Wesselmann U, Baranowski AP, et al. Drug Disc Today: Therap Strategies 2009;6(3):89–95. [18] Baranowski AP, Lee J, et al. Br J Anaesth. 2014;112:452– 459.
C
2014 Informa Healthcare USA, Inc.
3
[19] Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Available from: www.iom.edu/Reports/ 2011/Relieving-Pain-in-America-A-Blueprint-for-transformingPrevention-Care-Education-Research.aspx (accessed 8 April 2014).
