Cognitive Behavioral Therapy for Chronic Pelvic Pain: What Is It and Does It Work?

PURPOSE: Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome in women and men and chronic prostatitis/chronic pelvic pain syndrome in men, is a common, often disabling urological disorder that is neither well understood nor satisfactorily treated with medical treatments. The past 25 years have seen the development and validation of a number of behavioral pain treatments, of which cognitive behavioral therapy (CBT) is arguably the most effective. CBT combines strategies of behavior therapy, which teaches patients more effective ways of behaving, and cognitive therapy, which focuses on correcting faulty thinking patterns. As a skills-based treatment, CBT emphasizes "unlearning" maladaptive behaviors and thoughts, and replacing them with more adaptive ones that support symptom self-management. MATERIALS AND METHODS: This review describes the rationale, technical procedures, and empirical basis of CBT. RESULTS: While evidence supports CBT for treatment-refractory chronic pain disorders, there is limited understanding of why or how CBT might work, for whom it is most beneficial, or the specific UCPPS symptoms (eg, pain, urinary symptoms) it effectively targets. This is the focus of EPPIC (Easing Pelvic Pain Interventions Clinical Research Program), a landmark NIH trial examining the efficacy of low-intensity, home-based CBT for UCPPS relative to a nonspecific comparator featuring self-care recommendations of AUA guidelines. CONCLUSIONS: Systematic efforts to increase both the efficiency of CBT and the way it is delivered (eg, home-based treatments) are critical to scaling up CBT, optimizing its therapeutic potential, and reducing the public health burden of UCPPS.

Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS).

BACKGROUND: Urologic chronic pelvic pain syndrome (UCPPS) encompasses several common, costly, diagnoses including interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome that are poorly understood and inadequately treated with conventional medical therapies. Behavioral strategies, recommended as a first-line treatment for managing symptoms, are largely inaccessible, time and labor intensive, and technically complex. The Easing Pelvic Pain Interventions Clinical Research Program (EPPIC) is a clinical trial examining the efficacy of low-intensity cognitive behavioral therapy (Minimal Contact CBT or MC-CBT) for UCPPS and its durability 3 and 6 months post treatment. Additional aims include characterizing the operative processes (e.g., cognitive distancing, context sensitivity, coping flexibility, repetitive negative thought) that drive MC-CBT-induced symptom relief and pre-treatment patient variables that moderate differential response. METHODS: UCPPS patients (240) ages 18-70 years, any gender, ethnicity, and race, will be randomized to 4-session MC-CBT or a credible, non-specific education comparator (EDU) that controls for the generic effects from simply going to treatment. Efficacy assessments will be administered at pre-treatment, 2 weeks, and 3 and 6 months post treatment-week acute phase. A novel statistical approach applied to micro-analytic mediator assessment schedule will permit the specification of the most effective CBT component(s) that drive symptom relief. DISCUSSION: Empirical validation of a low-intensity self-management therapy transdiagnostic in scope has the potential to improve the health of chronic pelvic pain patients refractory to medical therapies, reduce social and economic costs, conserve health care resources, as well as inform evidence-based practice guidelines. Identification of change mechanisms and moderators of treatment effects can provide proactive patient-treatment matching fundamental to goals of personalized medicine. TRIAL REGISTRATION: Clinicaltrials.gov NCT05127616. Registered on 9/19/21.

Cross-sectional Survey-based Study of Underrepresented Minorities in Urology Academic Leadership Roles.

OBJECTIVE: To define the current proportion of underrepresented minority (URM) academic urologists in leadership positions. METHODS: A cross-sectional observational study of leadership positions in active United States Urology Residency Programs in 2020 was conducted. Academic urologists in leadership positions were electronically mailed a survey asking about personal and professional demographics. Self-reported variables including administrative position, race, and ethnicity were collected and analyzed. RESULTS: Over the study period, 133 urologists completed the survey out of a possible 320 academic urologists for a response rate of 41.6%. Overall, African-Americans represented 9.0%, Hispanics represented 3.8%, and American Indians/Alaska Natives made up 0.8% of leadership roles in the study sample. African-Americans comprised 8.5% (4 of 47) and Hispanics comprised 2.1% (1 of 47) of department chairs. African-Americans made up 7.4% (4 of 54) and Hispanics made up 1.9% (1 of 54) of program directors. The highest proportion of African-Americans in leadership positions was seen in oncology (18.2%), minimally invasive surgery (18.2%), and general urology (10%). The only subspecialties with Hispanics in leadership positions were in andrology/sexual medicine (16.7%) and female urology (15.4%). There were no reported URMs in leadership positions in endourology, neurourology, pediatrics, and reconstructive urology. CONCLUSIONS: To our knowledge, this study is the first to quantify the representation of URM urologists in academic leadership. There are multiple subspecialties without URMs in leadership positions. This information is vital to understanding the presence and lack of racial representation of the leadership of our field.

Management of pelvic organ prolapse in the elderly - is there a role for robotic-assisted sacrocolpopexy?

Abdominal sacrocolpopexy is considered the gold standard treatment for symptomatic pelvic organ prolapse (POP). Since its introduction, robotic-assisted sacrocolpopexy has emerged as a popular minimally invasive alternative to open repair. Epidemiologic data suggest that the number of women seeking surgical treatment for POP will increase to ~50% by 2050, and many of these women will be elderly. Advanced age should not preclude elective POP surgery. Substantial data suggest that medical comorbidities and other preoperative markers may be more important than age in predicting adverse surgical outcomes. POP surgery in the elderly has been extensively studied and found to be safe, but there is a paucity of information regarding robotic-assisted sacrocolpopexy in this population. Data are only beginning to emerge regarding the safety and efficacy of robotic surgery in the elderly, with most studies focusing on oncologic procedures. Preliminary studies in this setting suggest that elderly patients may benefit from a minimally invasive approach, although given their limited physiologic reserves, appropriate patient selection is essential. The purpose of this review article is to evaluate the stepwise management of POP in the elderly female, with a focus on the safety and feasibility of a robotic approach.

Robotic sacrocolpopexy.

Pelvic organ prolapse (POP) is a prevalent condition with 1 in 9 women seeking surgical treatment by the age of 80 years. Goals of treatment are relief and prevention of symptoms, and restoration of pelvic floor support. The gold standard for surgical treatment of POP has been abdominal sacrocolpopexy (ASC). However, emerging technologies have allowed for more minimally invasive approach including the use of laparoscopic assisted sacrocolpopexy and robotic assisted sacrocolpopexy (RASC). We performed a PubMed literature search for sacrocolpopexy, "robotic sacrocolpopexy" and "RASC" and reviewed all retrospective, prospective and randomized controlled trials. The techniques, objective and subjective outcomes and complications are discussed. The most frequent technique involves a polypropylene Y mesh attached to the anterior and posterior walls of the vagina with the single arm attached to the sacrum. Multiple concomitant procedures have been described including hysterectomy, anti-incontinence procedures and concomitant vaginal prolapse repairs. There are few studies comparing RASC to ASC, with the longest follow-up data showing no difference in subjective and objective outcomes. Anatomic success rates have been reported at 79-100% with up to 9% of patients requiring successive surgery for recurrence. Subjective success is poorly defined, but has been reported at 88-97%. Most common complications are urinary retention, urinary tract infection, bladder injury and vaginal mucosal injury. Mesh exposure is reported in up to 10% of patients. RASC allows for a minimally invasive approach to treatment of POP with comparable outcomes and low complication rates.

Neurogenic lower urinary tract dysfunction: how, when, and with which patients do we use urodynamics?

Neurogenic lower urinary tract dysfunction (NLUTD) affects many patients and requires close monitoring. Initial studies establishing patients at risk for upper tract disease revealed that high detrusor leak point pressures were predictive of upper tract disease. Urodynamics in patients with NLUTD have specific challenges. Initial studies in patients after an acute injury should be delayed until after the spinal shock phase. In children with spinal dysraphism, studies should be done early to established potential risk. The goals are maintaining low bladder pressures, decreasing risk of infection, and maintaining continence.

Low incidence of prostate cancer identified in the transition and anterior zones with transperineal biopsy.

PURPOSE: Determine the incidence of anterior (AZ) and transition (TZ) zone prostate cancers using a transperineal mapping approach. METHODS: A retrospective review of 137 patients with history of previous negative biopsy undergoing transperineal saturation biopsy for an elevated prostate-specific antigen (PSA), high-grade prostate intraepithelial neoplasia, atypical small acinar proliferation history, or abnormal digital rectal exam. The number of biopsy cores was determined by prostate volume and obtained using a predefined template. The electronic medical records were reviewed for patients' clinical and pathological characteristics. RESULTS: Forty-one of 137 patients (31.4%) had positive biopsy for prostate adenocarcinoma; 11 were from 24-core, 19 from 36-core, and 11 from 48-core sampling. Glands > 45 mL had a mean of 1.7 previous biopsies and a PSA of 9.1 ng/mL. Glands < 30 mL were 1.3 and 6.3 ng/mL and glands 30-45 mL were 1.4 and 6.5 ng/mL. Glands < 45 mL had a higher number of positive biopsies per total cores. Seven patients chose active surveillance while 34 chose treatment. Of the 36- and 48-cores biopsies, 2.2% and 1.5%, respectively, were positive in the TZ. One patient was AZ-positive, 1 was TZ-positive, and 18 were peripheral zone (PZ)-positive alone. Twelve patients had cancer detected in PZ and TZ. Two patients developed urinary retention and one had a urine infection. CONCLUSION: Transperineal saturation biopsy is a safe and efficacious method of prostate cancer detection in patients with previous negative biopsy and high suspicion for cancer. Few cancers were found to originate in the TZ or AZ alone. We recommend that initial biopsy templates should sample PZ with less focus on the TZ.

Clinical correlates of renal angiomyolipoma subtypes in 209 patients: classic, fat poor, tuberous sclerosis associated and epithelioid.

PURPOSE: Angiomyolipomas classically present radiographically as fat containing lesions but some fail to demonstrate fat content. Histologically confirmed angiomyolipomas uniformly follow a benign course but rare epithelioid variants of angiomyolipoma can recur and metastasize. We investigated the clinical, radiographic and histological characteristics of each angiomyolipoma subtype. MATERIALS AND METHODS: Pertinent data were recorded for 209 patients surgically treated for angiomyolipoma in 219 kidneys from 1981 to 2007. Classic and fat poor angiomyolipomas were classified radiographically based on the presence or absence of fat and classified histologically based on the presence of triphasic, monophasic or epithelioid histology. RESULTS: Median radiographic size was 3.2, 4.9 and 10 cm in patients with a single angiomyolipoma (59% of patients), multiple angiomyolipomas and tuberous sclerosis (probable or definite), respectively. In these 3 groups 65%, 47% and 33% of lesions were not suspected radiographically (fat poor angiomyolipoma). Fat poor angiomyolipomas were more commonly single, smaller and in older patients. Triphasic histology was evident in 76% of angiomyolipomas with 16% demonstrating a predominance of 1 component and 8% containing epithelioid features. Despite potentially aggressive findings in 18% (eg presence within the perinephric fat, lymph node involvement) no angiomyolipoma recurred during a mean followup of 3.4 years (range 0 to 24). A total of 28 (13%) patients with angiomyolipoma had concomitant renal cell carcinoma. CONCLUSIONS: A surprisingly high number of resected angiomyolipomas was not suspected radiographically indicating the importance of precise radiographic characterization to minimize nephrectomy for fat poor angiomyolipoma, which should remain a research priority. In this sizeable single institution series no triphasic, monophasic or epithelioid angiomyolipoma recurred despite potentially aggressive findings in a substantial proportion of cases.

Conservative management of giant symptomatic angiomyolipomas in patients with the tuberous sclerosis complex.

OBJECTIVE: To present two patients with the tuberous sclerosis complex in whom giant angiomyolipomas (AMLs) were managed conservatively for >20 years, as large (>4 cm) symptomatic AMLs are generally treated with embolization or nephrectomy because of the risks of haemorrhage. PATIENTS AND METHODS: The first patient initially presented with bilateral renal AMLs replacing >70% of his parenchymal volume, and a large left renal cyst. Since presentation he was hospitalized three times, but has had no transfusions or procedures to treat his AMLs. His renal function has remained stable during this 21-year interval. The second patient initially presented with bilateral renal AMLs that were not amenable to nephron-sparing surgery. After removing her nonfunctioning left kidney, the 24-cm AML in her right kidney was managed conservatively for >20 years, during which she had 44 transfusions and 11 hospitalizations before uncomplicated right nephrectomy and subsequent need for haemodialysis. CONCLUSION: Conservative management of AMLs can preserve renal function for >20 years in patients with tuberous sclerosis at high risk of end-stage renal disease.