Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study.

BACKGROUND: No current standardized set of pelvic floor muscle (PFM) outcome measures have been specifically tested for their applicability in a general female chronic pelvic pain (CPP) population. We aimed to compare PFM function between a randomly selected population-based sample of women with CPP and age-matched pain-free controls using multiple standardized intravaginal examination measures recommended by the International Continence Society. METHODS: This was a cross-sectional, population-based and controlled study with randomly selected participants among women in Denmark. We reported blinded findings from a set of standardized vaginal PFM examination manoeuvres in 50 female participants (24 with CPP, 26 pain free). A preliminary pilot study ensured the intra- and intertester reliability of the test procedure. PFM outcomes were resting tone, relaxation capacity, strength, surface electromyographic activity and mechanosensitivity. Statistical analyses included unpaired t-tests, Fisher's exact tests and Mann-Whitney tests. RESULTS: The examination protocol was a reliable and predictable clinical measurement of associated PFM dysfunction in female CPP. Women with CPP had higher PFM resting tone and decreased maximal PFM strength and relaxation capacity compared with pain-free controls. Enhanced PFM pressure-pain sensitivity measured by palpometry during examination was also associated to CPP. CONCLUSION: This controlled, single-blinded study with randomly selected participants provides new population-based information regarding associated PFM dysfunction in women with CPP using multiple intravaginal examination methods. However, to identify women with CPP who will benefit from a physiotherapeutic specialized intervention, future prospective randomized controlled trials using these reliable and predictive outcomes are needed.

Female chronic pelvic pain is highly prevalent in Denmark. A cross-sectional population-based study with randomly selected participants.

Background and purpose Female chronic pelvic pain is a significant clinical problem that burdens the health care services and work productivity, and leads to disability and reduced quality of life among the women affected. A recent systematic review reported worldwide prevalence rates for female chronic pelvic pain ranging from 2.1% to 24%. Our aim was to assess the prevalence, characteristics, and factors associated with chronic pelvic pain among women living in Denmark, and to compare these findings with a pain-free reference group. Secondly, we evaluated the impact of pain on daily life in women suffering from chronic pelvic pain. Methods A cross-sectional postal survey of the prevalence of chronic pelvic pain was undertaken in a randomly selected general female population in Denmark (N = 2500). Inclusion criteria were: (a) ≥18 years of age and (b) living in the Capital region or the region of Zealand in Denmark. Statistical analyses included prevalence percentage rates, chi-square tests, Mann-Whitney tests, and unpaired T-tests. Logistic regression analysis was used to identify the significant independent variables and to estimate their simultaneous impact on chronic pelvic pain. The results were expressed as odds ratio and 95% confidence intervals. All tests were two-tailed and significance levels were set at p < 0.05. Results 1179 (48%) women living in representative areas of Denmark responded. The prevalence of chronic pelvic pain was 11% (n = 130) in women ≥18 years with a prevalence of 13.6% (n = 87) in women of reproductive age; 6.2% (n = 73) women experienced at least moderate average pain intensity (numerical rating scale ≥4). Self-reported diagnosis of irritable bowel syndrome (20%), bladder pain syndrome/interstitial cystitis (3%), vulvodynia (9%), endometriosis (8%), and pelvic surgery in the preceding 6 months (5%) were more prevalent in cases compared to pain-free reference subjects (p = 0.00). Chronic pelvic pain interfered with daily life "all the time" in 5% of the women, "sometimes" in 72.3%, and "not at all" in 22.7%. Factors independently associated with chronic pelvic pain were age, country of birth, and former pelvic trauma or pelvic surgery (p < 0.05). No association was found between chronic pelvic pain and selected socio-demographic factors (residential area, educational level, cohabitation status and employment status). Conclusions Female chronic pelvic pain appears highly prevalent (11%) in Denmark (6.2% with moderate to severe pain). Women of reproductive age had a slightly increased prevalence (13.6%). Although the reported prevalence is based on 48% (N = 1179) of the invited sample, dropout analyses found that respondents did not deviate from non-respondents. Therefore, we considered the reported prevalence rate representative for the total sample and generalisable to the general female population in Denmark. This study was cross-sectional, and relied on association-based analyses. Consequently, causality between age groups, country of birth, former pelvic surgeries and pelvic traumas and experiences of chronic pelvic pain remains unknown. Implications In order to improve prevention and treatment of chronic pelvic pain in Denmark, high quality, population-based cohort studies and randomised clinical trials are essential. The demand for trustworthy chronic pelvic pain prevalence estimates might also inspire political attention and hereby facilitate funding for further development of treatment and research.

Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review.

Background and purpose Chronic pelvic pain (CPP) is a debilitating condition among women with a major impact on health-related quality of life, work productivity and health care utilisation. The exact prevalence of chronic pelvic pain is not known, but 3.8% is commonly suggested. Musculoskeletal dysfunction is frequently cited as a possible aetiology. Physiotherapy is therefore recommended as one treatment modality. The aim of this systematic review was to source and critically evaluate the evidence for an effect of physiotherapy on pain, physical activity and quality of life in the treatment of female CPP. Methods Electronic databases, conference proceedings, text books and clinical guidelines were searched for quantitative, observational, and prospective clinical intervention studies of female chronic pelvic pain where physiotherapy was a sole or significant component of the intervention. Trial inclusion, data extraction according to predefined criteria and risk of bias assessment were performed by two independent authors. Methodological quality of the included clinical intervention studies was assessed using The Cochrane Collaboration's tool for assessing risk of bias. Review Manager (RevMan) version 5.0 was used for data analysis. Effect estimates (relative risk, mean difference and mean change) with 95% confidence intervals were calculated for the above outcomes. For significant outcomes the numbers needed to treat were calculated. Results The search strategy identified 3469 potential articles. Of these, 11 articles, representing 10 studies, met the inclusion criteria. There were 6 randomised clinical trials, 1 cohort study and 3 case series. Methodological quality was dependent on study type. Accordingly, level of evidence was judged higher in randomised clinical trials than in the other study types. Physiotherapy treatments varied between studies and were provided in combination with psychotherapeutic modalities and medical management. This did not allow for the 'stand-alone' value of physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions, outcome measures and times of follow-up, prevented meta-analysis. Narrative synthesis of the results, based on effect estimates and clinically relevant pain improvement, disclosed some evidence to support an effect of multidisciplinary intervention and Mensendieck somatocognitive therapy on female chronic pelvic pain. Conclusion Chronic pelvic pain in women is a major health care problem with no specific therapies and poor prognosis. There seems to be some evidence to support the use of a multidisciplinary intervention in the management of female chronic pelvic pain. Somatocognitive therapy is a new approach that appears to be promising and randomised clinical trials are underway in order to establish its evidence base. Implications Based on the findings of this review, recommendations for physiotherapy in chronic pelvic pain clinical guidelines, textbooks and narrative reviews should be interpreted with caution due to the lack of a sufficient evidence base. Only small and largely non-randomised studies have been undertaken of physiotherapeutic interventions and this greatly limits the available evidence on which to base clinical practice. High quality randomised clinical trials are therefore urgently needed.

Unenhanced computed tomography in acute renal colic reduces cost outside radiology department.

BACKGROUND: Unenhanced multidetector computed tomography (UMDCT) is well established as the procedure of choice for radiologic evaluation of patients with renal colic. The procedure has both clinical and financial consequences for departments of surgery and radiology. However, the financial effect outside the radiology department is poorly elucidated. PURPOSE: To evaluate the financial consequences outside of the radiology department, a retrospective study comparing the ward occupation of patients examined with UMDCT to that of intravenous urography (IVU) was performed. MATERIAL AND METHODS: A total of 594 consecutive patients were admitted for renal colic during two 6-month periods. One hundred seventy-three consecutive patients were examined with IVU in 2000 and 421 with UMDCT in 2005. The only difference between the two groups was the imaging procedure. The duration of hospital stay and pathology findings were registered. RESULTS: In 50% of the patients undergoing UMDCT, a stone was found; a stone was found or suspected in 40% of patients undergoing IVU. Patients undergoing IVU stayed significantly longer in the ward than patients examined by UMDCT (P<0.0001). The new procedure (UMDCT) saved the hospital USD 265,000 every 6 months compared to the use of IVU. CONCLUSION: Use of UMDCT compared to IVU in patients with renal colic leads to cost savings outside the radiology department.

Sensory bladder disorders.

Sensory bladder disorders include disorders involving abnormal sensations resulting from many diseases of the urinary bladder. In a proportion of patients no cause can be found and if pain or pelvic pressure is a part of the symptomatology, they are labelled as having painful bladder syndrome (PBS). In a subgroup of these patients abnormal findings can be demonstrated at cystoscopy and/or by histological examination of bladder biopsies. These patients are categorised as having interstitial cystitis (IC). This paper looks into the differential diagnosis, evaluation and treatment of patients with PBS.

Lower urinary tract symptoms in the danish population: a population-based study of symptom prevalence, health-care seeking behavior and prevalence of treatment in elderly males and females.

OBJECTIVE: To estimate the prevalence of LUTS in the elderly Danish population. Furthermore to evaluate the quality of life, the health-care seeking behavior and the prevalence of treatment with relation to LUTS. METHODS: A mailed questionnaire was sent to a random sample of 8700 men and 1000 females above 50-years. The questionnaire included five demographic questions, the I-PSS and questions concerning previous physician contact and treatment with relation to LUTS. RESULTS: The questionnaire was returned by 61.5% of the males and 47.7% of the females. The median I-PSS was 4 in males and 3 in females. Overall 28% of males and 20% of females had significant LUTS (I-PSS>7). A significant increase in the total burden of symptoms with increasing age was found in males whereas a clear age-trend was not found in females. Overall 9.2% of males and 8.2% of females had seen a physician within the last two years for voiding problems. A high proportion of subjects with moderate or even severe symptoms had not seen a physician within two years due to voiding problems. Of males 13.3% had previous been or were currently being treated for voiding problems while the corresponding number in females was 10.9%. These subjects had significantly more symptoms than untreated age-matched subjects. CONCLUSION: Lower urinary tract symptoms are common in elderly Danish males and females. Overall the same pattern for health-care seeking behavior with regard to LUTS is seen in males and females and the overall treatment prevalence is similar. For both genders it is worth noting that a substantial proportion of subjects with a high symptom burden had not visited their physician within two years and further that subjects who have been treated for LUTS have a higher symptom levels than their untreated peers.

Safety and efficacy of alfuzosin 10 mg once-daily in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a pooled analysis of three double-blind, placebo-controlled studies.

OBJECTIVES: To examine the efficacy and safety of a once-daily formulation of alfuzosin in a pooled analysis of three parallel, randomized, double-blind, placebo-controlled 3-month studies of patients with lower urinary tract symptoms (LUTS) consistent with clinical benign prostatic hyperplasia. PATIENTS AND METHODS: Patients were randomized to receive alfuzosin, 10 mg once-daily (473) or placebo (482) for 12 weeks. Primary efficacy criteria were improvements in the International Prostate Symptom Score (IPSS) and peak urinary flow rate (PFR). RESULTS: Alfuzosin significantly improved the mean (sd) IPSS, by - 6.0 (5.1) vs - 4.2 (5.7) with placebo (P < 0.005) and the PFR, by + 2.3 (3.8) vs + 1.1 (3.1) ml/s with placebo (P < 0.001), irrespective of prostate size. The significant improvement in LUTS included the irritative and the obstructive subscore of the IPSS and the nocturia criterion; the PFR increased rapidly and significantly, from the first visit (14 days). The quality-of-life score also improved significantly in alfuzosin-treated patients. Alfuzosin was well tolerated; the number of withdrawals for adverse events was comparable in both treatment groups. The most frequently reported adverse event was dizziness (placebo 2.9%, alfuzosin 6.1%). There were no significant changes in blood pressure with alfuzosin compared with placebo, including in elderly and hypertensive patients. Sexual adverse events were rare (abnormal ejaculation, 0.6%). CONCLUSIONS: The once-daily formulation of alfuzosin, administered at 10 mg with no dose titration is effective, with a good safety profile, especially in elderly and hypertensive patients.

Increased urinary leukotriene E4 and eosinophil protein X excretion in patients with interstitial cystitis.

PURPOSE: The role of cysteinyl containing leukotriene C4, D4 and E4, and eosinophil protein X in interstitial cystitis is unknown. Leukotriene E4, the end product of cysteinyl containing leukotrienes, and eosinophil protein X are markers of the activation of mast cells and eosinophils, respectively. Cysteinyl containing leukotrienes are potent and specific chemoattractants for eosinophils. We compared the urinary excretion of leukotriene E4 and eosinophil protein X in patients with interstitial cystitis and in healthy controls. MATERIALS AND METHODS: Morning spot urine samples from nine patients with interstitial cystitis who fulfilled National Institute of Diabetes and Digestive and Kidney Diseases criteria were collected on the day of cystoscopy with biopsies. Aliquots of urine specimens were immediately centrifuged and the supernatants were stored at -80C until use. Urine samples from 9 healthy women served as controls. Urinary leukotriene E4 and eosinophil protein X were measured by enzyme immunoassay and radioimmunoassay, respectively. All determinations were performed in duplicate and normalized to urine creatinine. RESULTS: Leukotriene E4 and eosinophil protein X were significantly increased in the morning urine of patients with interstitial cystitis compared with controls. The mean urinary excretion of leukotriene E4 plus or minus standard deviation was 148.8 +/- 62.5 and 62.2 +/- 17.5 ng./mmol. creatinine in patients and controls (p = 0.003), while the mean urinary excretion of eosinophil protein X was 109.7 +/- 70.4 and 43.7 +/- 22.0 microg./mmol. creatinine, respectively (p = 0.01). All urine cultures were negative. The mean mast cell count in detrusor biopsies in the interstitial cystitis group was 41 cells per mm.2 (range 5 to 84). Eosinophilic granulocytes were occasionally observed in the submucosa but not in the detrusor. CONCLUSIONS: Our study shows that patients with interstitial cystitis and detrusor mastocytosis have increased urinary leukotriene E4 and eosinophil protein X. It is possible that cysteinyl containing leukotrienes and eosinophil protein X are involved in the pathogenesis of interstitial cystitis. Urinary leukotriene E4 and eosinophil protein X may be useful markers for assessing the grade of activation of mast cells and eosinophils in patients with interstitial cystitis and/or for confirming the diagnosis. However, it remains to be investigated whether the increase in urinary leukotriene E4 and eosinophil protein X correlates with interstitial cystitis symptoms.

Buttock placement of the implantable pulse generator: a new implantation technique for sacral neuromodulation--a multicenter study.

OBJECTIVE: In the standard operation procedure for sacral neuromodulation, the implantable pulse generator (IPG) is implanted in a subcutaneous pocket at the lower part of the anterior abdominal wall. This procedure requires a long operation time and three incisions. With the IPG in the abdominal wall, some patients complain of displacement or pain at the IPG site postoperatively. By modifying the technique of placement of the IPG, these disadvantages are overcome. METHODS: Between August 1999 and July 2000, 39 patients underwent a buttock implant of the IPG. In 2 of these patients the position of the IPG was changed from abdominal region to the buttock. During follow-up, complications concerning the operation and location of the IPG were compared to the published literature. RESULTS: Operation time is reduced in all patients by approximately 1 h. No repositioning of the patient is required during surgery. Only a short subcutaneous tunnel is required to connect the lead to the IPG. Pain at the level of the IPG was noted in 10% of the patients, which needed no further treatment. No infections were seen and the IPG did not displace postoperatively. CONCLUSION: Buttock placement of the IPG in sacral nerve stimulation leads to shorter operation time; only two incisions are needed instead of three and a shorter subcutaneous tunnel is needed. Using this technique there are less complications and a lower re-operation rate.

The cysteinyl leukotriene D4 receptor antagonist montelukast for the treatment of interstitial cystitis.

PURPOSE: The presence of leukotriene D4 receptors in human detrusor myocytes and increased urinary leukotriene E4 in patients with interstitial cystitis and detrusor mastocytosis imply a role for cysteinyl containing leukotrienes as proinflammatory mediators in this disease. We examined the efficacy of the cysteinyl leukotriene 1 receptor antagonist montelukast for treating patients with interstitial cystitis and detrusor mastocytosis. MATERIALS AND METHODS: Ten women in whom interstitial cystitis was diagnosed according to National Institute of Diabetes and Digestive and Kidney Diseases criteria and who also had detrusor mastocytosis with a minimum of 28 mast cells per mm.2 muscle tissue were included in this study. Patients received a single dose of montelukast daily for 3 months. The efficacy of treatment was determined by 24-hour urinary frequency, nocturia and pain using visual analog scales. RESULTS: After 1 month of montelukast treatment there was a statistically significant decrease in 24-hour urinary frequency, nocturia and pain which persisted during the 3 months of treatment. After 3 months 24-hour urinary frequency had decreased from 17.4 to 12 voidings (p = 0.009), nocturia had decreased from 4.5 to 2.8 (p = 0.019) and pain had decreased from 46.8 to 19.6 mm. on a visual analog scale (p = 0.006). No side effects were observed during treatment. CONCLUSIONS: Montelukast treatment resulted in significant improvement in urinary frequency and pain. Its efficacy for decreasing urinary frequency and pain imply a role of leukotriene receptor antagonists for managing interstitial cystitis but further placebo controlled clinical studies are needed.

The action of cysteinyl-leukotrienes on intracellular calcium mobilization in human detrusor myocytes.

OBJECTIVE: To investigate the presence of leukotriene D4 receptors in fura-2-loaded human detrusor smooth muscle cells (DSMCs) by examining the ability of leukotriene D4 to raise intracellular-free Ca2+ concentration ([Ca2+]i), to determine the origin of the leukotriene D4-mediated rise in [Ca2+]i and to investigate whether the specific leukotriene D4 receptor antagonist montelukast inhibits the Ca2+ response induced by leukotriene D4. MATERIALS AND METHODS: Detrusor muscle biopsies were obtained from patients with benign noninvasive bladder diseases undergoing cystoscopy. DSMCs were isolated using an explant technique and maintained in culture. Only primary cultures or cells passaged up to three times were used for experiments. DSMCs were characterized with immunohistochemical staining and their identity confirmed by transmission electron microscopy. [Ca2+]i was measured in single DSMCs using the Ca2+ probe fura-2 and fluorescence-ratio microscopy. RESULTS: Immunohistochemical staining showed that 80-99% of the cells were positive for smooth muscle alpha-actin. The ultrastructural features of the cultured cells were those of smooth muscle cells and showed no differentiation in a fibroblastic or myofibroblastic direction. Leukotriene D4 increased the level of [Ca2+]i in a dose-dependent manner. Calcium was mobilized almost exclusively from intracellular Ca2+ stores. There was a dose-dependent inhibition of the increase in [Ca2+]i by montelukast. CONCLUSION: The present study is the first to show the presence of specific leukotriene D4 receptors in human detrusor myocytes. This may have implications for a potential pathophysiological role of leukotriene D4 in patients with interstitial cystitis and other functional or inflammatory bladder disorders.