Definition.
Chronic pelvic floor pain most commonly a painful bladder syndrome / interstitial cystitis (PBS / IC) is a series of clinical syndromes with typical urological symptoms such as pelvic, bladder and urethral pain and urinary tract irritation for more than 3 months. It is defined by the International Continence Society (ICS) as pain in the suprapubic region associated with bladder filling with other urological symptoms such as daytime and nocturnal urinary frequency, with the exception of lower urinary tract infection and evidence of other pathological changes. Pain may occur during sexual intercourse or bladder filling and may radiate to the urethra, perineum, lower abdomen, sacrum, inner thighs, or occur after urination. Men may present with testicular, scrotal, and/or perineal pain as well as ejaculatory pain. Tension in the pelvic floor muscles can be found on physical examination in approximately 70% of patients with PBS / IC.
Between 14% and 19% of the population has suffered from pelvic floor pain. The prevalence increases with age, from 10% in young adults to 13% in middle-aged adults and 17% in older adults. Its insidious onset, complex etiology, difficult treatment, low cure rate, and recurrent condition seriously endanger patients’ physical and mental health and quality of life. Chronic pelvic floor pain has a significant impact on the quality of life of patients, such as leading to sexual discomfort, even accompanied by depression or anxiety. Regardless of the cause, the degree of impact of chronic pelvic floor pain is at least comparable to that of myocardial infarction, angina pectoris and Crohn’s disease, and the psychological impact is more severe than that of congestive heart failure and diabetes, with patients suffering long-term economic, physical and mental torture. In recent years, chronic pelvic floor pain has become a public health problem due to its rising incidence. Therefore, there is an urgent need for rapid and effective diagnosis and treatment to improve the patient’s symptoms and quality of life.
Etiology.
Usually, pelvic floor pain is often characterized by chronic symptoms, and it is not easy to find the exact cause. For patients with chronic pelvic floor pain of complex etiology, collaborative diagnosis and treatment by related departments such as urology, gynecology, gastroenterology, psychiatry, and pain medicine are often required.
Gynecological factors: Only 20% of pelvic floor pain is caused by gynecological diseases, such as endometriosis, pelvic inflammatory diseases, pelvic adhesions, uterine fibroids, pelvic stasis syndrome and uterine prolapse, and other pelvic floor dysfunctional diseases and their related surgical treatments.
Non-gynecologic factors: More than 50% of patients have combined urologic disorders, which are aggravated by bladder filling and relieved after urination, including interstitial cystitis (PBS / IC), neurogenic pain, etc. In addition,, gastrointestinal disorders, many pelvic floor pains are often confused with some gastrointestinal disorders due to diffuse and inaccurate localization of gastrointestinal nociception, neurogenic pain, musculoskeletal disorders, neurological disorders and psychological factors.
Treatment.
Non-surgical treatment
1.Dietary treatment
Avoid spicy, tobacco, alcohol, coffee, tea, soda, carbonated drinks, acidic foods such as concentrated fruit juices, tomatoes, citrus and potassium-rich foods such as bananas, etc. Drink more water, eat more fiber-rich foods and keep bowel movements open.
2.Behavioral therapy
Behavioral therapy includes bladder training, quantitative water intake and other therapies. Long-term frequent urination gradually reduces the capacity of the bladder and abnormal bladder reflexes, regular urination can increase the capacity of the bladder, reduce the sensitivity of the bladder and achieve the purpose of slowing down the symptoms.
3.Drug therapy
Pharmacological treatment for PBS/IC includes analgesics, hormonal drugs, antidepressants and psychological adjustment drugs. Clinical treatment is often aimed at relieving pain. If the pain is neurological, the physician may use nerve block therapy for treatment.
4.Bladder perfusion
Bladder perfusion is one of the most important methods of treating PBS/IC. The mechanism of bladder drug perfusion is that there is a dysfunction of the epithelial cells of the urinary tract in patients with IC, and the high concentration of the active ingredient is in direct contact with the epithelial cells. When the perfusion time is short, the absorption of the drug by the bladder wall is less and the systemic effect is less. Compared with oral drugs, bladder drug infusion has the advantages of high concentration of effective drug in the bladder and low systemic effects. The bladder can be infused with one or more drugs, and the commonly used drugs for infusion are dimethyl sulfoxide, heparin, hyaluronic acid, botulinum toxin A, BCG and interleukin steroids, etc.
5.Chinese medicine treatment
Acupuncture treatment, Wang’s “electroacupuncture nerve stimulation therapy” and so on.
6.Transdermal puncture sympathetic nerve block method
It is an innovative treatment developed by the research and injection of urinary incontinence and pelvic floor reconstruction clinic, which effectively blocks the excitability of sympathetic nerves by stimulating sympathetic nerves with drugs, reduces the release of sympathetic impulses, and cuts off the transmission of undesirable signals from the source.
7.Electrical stimulation neuromodulation
Electrical stimulation neuromodulation (sacral neuromodulation, sacral nerve stimulation, pubic nerve stimulation therapy, transcutaneous posterior tibial nerve stimulation, transvaginal electrical stimulation therapy) is an interventional technique that continuously applies low-frequency electrical impulses to specific sacral nerves to excite or inhibit the nerve pathways and regulate the abnormal sacral nerve reflex arcs, thus affecting and regulating the functions of the bladder, urethra/anal sphincter, pelvic floor and other sacral nerve innervation target organs. It is a neuromodulation technique to achieve therapeutic effect.
Surgical treatment.
Cystoscopic hydrodilation is currently the most widely used treatment. By damaging the afferent nerves or detrusor receptors of the bladder to reduce pain and increase bladder capacity, nearly half of patients have relief of symptoms, and the results are even better in patients with reduced bladder capacity.
When non-surgical treatment is ineffective, surgical treatment can be considered. Transurethral electrodesiccation is suitable for ulcerative interstitial cystitis with good recent results but is prone to recurrence, while bladder enlargement and total bladder dissection are highly invasive and should be chosen with caution. In view of the diversity and complexity of the etiology of this disease, comprehensive treatment and combination of drugs may have better results.