Pelvic Pain And Surgeries In Women Before Interstitial Cystitis/Painful Bladder Syndrome - Chronic Pelvic Pain, BPS And Pelvic Surgical Procedures

UroToday - For years, bladder pain syndrome series have reported apparently high numbers of BPS patients with a history of hysterectomy and other pelvic surgeries. No study has compared cases with controls prior to onset of BPS symptoms. In the EPIC study (Events Preceding Interstitial Cystitis) John Warren's research group hypothesized that significantly more cases than controls experienced pelvic surgeries, especially just before onset of BPS symptoms. The EPIC study was a study of women exhibiting BPS symptoms for 12 months or less recruited nationally through urologists and patient support groups and controls recruited by random digit dialing and matched on sex, age, and national region.


Dr. Patricia Langenberg from Baltimore and her colleagues from around the country studied the EPIC data derived from 312 BPS cases and 313 controls that completed the study. Before their index dates, significantly more BPS cases than controls reported surgeries, including most of the specific pelvic surgeries queried. At greater than 12 months prior to the index date (onset of BPS or study entry for controls) the cases had more surgeries, including laparoscopy, D&C, nonhysterectomy uterine surgery, and "other" pelvic surgeries. Between 1 and 12 months, cases and controls did not differ. At less than 1 month, cases exceeded controls. Surgical procedures within one month of diagnosis included hysterectomies, ovarian surgeries including bilateral oophorectomies, and other pelvic surgeries.


The authors comment that more BPS cases had surgeries than matched controls and that cases had greater numbers of surgeries. Further analysis demonstrated that the associations of surgeries with BPS may have been confounded by the stronger associations of several possible indications for surgery. Specifically, inclusion of chronic pelvic pain in logistic regression analysis reduced to nonsignificance the association of surgeries with BPS. The authors strongly believe that the prior chronic pelvic pain was not simply undiagnosed BPS, and by extension that the increase of pelvic surgical procedures that preceded the diagnosis was not unnecessary surgery related to a missed diagnosis of BPS. They support this belief based on 3 foundations: 1)chronic pelvic pain began more than 12 months before onset of BPS symptoms in 73% of cases; 2)treating physicians did not consider chronic pelvic pain prior to the index date to be BPS; and 3) reviewed medical records did not support such a preexisting diagnosis.


The authors conclude that chronic pelvic pain appears to be a strong predictor of BPS. It is not clear to this correspondent that the onset of chronic pelvic pain can be reliably determined to be unrelated to onset of BPS or can be reliably separated from BPS by patient or physician given the way the syndrome is defined.
This is an excellent report from a very productive BPS center, that is highly recommended, and those interested in BPS will find it worth taking the time to review it carefully.


Langenberg PW, Wallach EE, Clauw DJ, Howard FM, Diggs CM, Wesselmann U, Greenberg P, Warren JW



Am J Obstet Gynecol. 2009 Dec 18. Epub ahead of print.


doi:10.1016/j.ajog.2009.10.866



UroToday Contributing Editor Philip M. Hanno, MD, MPH



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