Cystalgia in women and men

Cystalgia is an outdated term that has disappeared from use in both domestic and foreign medical literature. What does cystalgia mean? Translated from Greek, it means "bladder" plus "pain." It was used to describe difficult-to-explain urination disorders that occur in women. A more appropriate definition is interstitial cystitis, which includes multiple manifestations of difficulties in emptying the organ. Interstitial cystitis is a syndrome characterized by pain in the bladder and irritating symptoms lasting more than 6 months.

The Interstitial Cystitis Association has labeled cystalgia as painful bladder syndrome/interstitial cystitis (PBS/IC) [Hanno et al. 2005]. [ 1 ] Recently, the European Society for the Study of Interstitial Cystitis (ESSIC) has proposed the name "bladder pain syndrome" (BPS) [van de Merwe et al. 2008]. [ 2 ]

Epidemiology

The lack of clear diagnostic criteria makes it difficult to determine the exact prevalence of cystalgia. Cystalgia occurs in both men and women of all racial and ethnic groups and ages. However, it is more common in women than in men. An early prevalence study estimated that cystalgia ranged from 1 in 100,000 to 5.1 in 100,000 in the general population; however, an updated epidemiological study conducted in 2006 suggests that up to 12% of women may have early symptoms of interstitial cystitis.[ 3 ]

Causes cystalgia

The pathology develops due to dysfunction of the neuromuscular structures of the bladder, the cause of which lies in:

• hormonal disorders;
• diseases of the genital organs;

The study identified a link between interstitial cystitis, endometriosis, and chronic pelvic pain.[ 4 ]

• circulatory disorders in the pelvic organs;
• autoimmune diseases;

Increased CD8+ and CD4+ T lymphocytes [MacDermott et al. 1991], [ 5 ] plasma cells and immunoglobulins such as IgG, IgA and IgM [Christmas, 1994], [ 6 ] are found in the bladder urothelium and lamina propria in cystalgia. However, considerable doubt remains as to whether these findings are causal or a response to a cause.

• urogenital tuberculosis with bladder lesions; [ 7 ]
• allergic swelling of his neck. [ 8 ]
• infections;

Previously, bacterial infection was thought to be the primary cause of the changes seen in cystalgia. Wilkins and colleagues suggested that bacteria such as Gardnerella vaginalis and Lactobacillus may be responsible for the development of cystalgia [Wilkins et al. 1989]. [ 9 ] Domingue and colleagues demonstrated the presence of bacterial 16S rRNA genes in bladder tissue in 29% of patients with cystalgia [Domingue et al. 1995]. [ 10 ] However, several other studies have failed to confirm this finding, and it is now generally accepted that infection is not a cause of cystalgia.

• environmental factors;

Studies have also shown that cystalgia symptoms are worsened by stress, spicy food, and smoking. Recently, the Pre-IC study reported that pain was worsened by certain foods and drinks in 97% of patients [Warren et al. 2008] [ 11 ], comparable to data from the Interstitial Cystitis Database (ICDB), where 262 of 270 (97%) patients reported worsening pain [Simon et al. 1997]. [ 12 ]

• genetic predisposition.

Studies have shown that IC is more common in twins with chronic fatigue syndrome. Recently, Warren and colleagues studied the prevalence of cystalgia in first-degree relatives of patients with cystalgia, reporting that adult first-degree females had a 17-fold higher prevalence of cystalgia than the general population [Warren et al. 2004]. [ 13 ] They also studied the prevalence of cystalgia in monozygotic and dizygotic twins, reporting a higher concordance of intercystitis among monozygotic compared to dizygotic twins, suggesting a genetic basis for the development of cystalgia [Warren et al. 2001]. [ 14 ]

Risk factors

The main drivers of cystalgia development are psychogenic factors. Chronic pain above the pubis is associated with a response to excitation emanating from the central nervous system.

Helicobacter pylori, the causative agent of chronic gastritis, is also considered a risk factor, since both organs (stomach and bladder) have a similar structure, consisting of tubular formations.

Pathogenesis

Cystalgia is considered an irritable bladder syndrome, the etiology of which is difficult to explain. [ 15 ]

Interstitial cystitis is a complex inflammatory condition of the bladder. The pathophysiology of cystalgia is not entirely clear, although altered epithelial permeability (epithelial dysfunction theory), mast cell activation, and increased afferent nerve sensitivity play a crucial role. [ 16 ] A significant role in the pathogenesis of the pathology is attributed to mast cells containing vasoactive and inflammatory mediators. They respond to substance P and other irritants (stress, allergens, hormones, bacteria).

The mucous substance protects the bladder from penetration of toxins, carcinogens, microorganisms, potassium salts contained in urine. Changes in it lead to impaired permeability, passage of potassium ions through the urothelium, depolarization of nerves. Patients have an increased number of nerve endings containing one of the tachykinins (substance P), a receptor responsible for contraction of smooth muscles. Cystalgia is also considered to be a syndrome of visceral neuropathic pain mediated by increased regulation of nerves in the pelvis, spinal cord, and brain. Vasoactive and inflammatory molecules such as SP and NGF secreted by mast cells potentially increase proliferation of nerve fibers [Theoharides et al. 1995]. [ 17 ] Increased sensitivity of sensory afferents of the bladder can also be the cause of increased pain sensation or hyperalgesia. [ 18 ], [ 19 ]

The immune mechanism plays a partial role in the pathophysiology of cystalgia. The parallel between interstitial cystitis and inflammatory bowel diseases is obvious. [ 20 ]

Another "trigger" involves female hormones, particularly estradiol. Perivascular sensory nerve endings have been found to be hypersensitive to SP, resulting in a local cascade of neurogenic inflammatory responses that are responsible for the pathophysiological changes in cystalgia [Marchand et al. 1998]. [ 21 ] This potentially explains the exacerbation of symptoms in women with cystalgia before menstruation due to the surge in estrogen, which causes the release of histamine from mast cells with subsequent secretion of SP [Pang et al. 1995a]. [ 22 ] Similarly, stress may worsen cystalgia symptoms due to the release of corticotropin-releasing factor (CRF) and subsequent activation of mast cells [Theoharides et al. 2004]. [ 23 ]

Symptoms cystalgia

The main symptoms of the disease are frequent urination, imperative and painful, a feeling of incomplete emptying, pain in the bladder, in the perineum, discomfort in the urethra.

The course of the disease is characterized by a long period: from several months to ten years. Calm episodes alternate with relapses, the duration of which varies. It is not immediately possible to connect the first signs (pain, increasing when the bladder is full, mainly daytime urges) in the absence of infection in the urine, causeless exacerbations with cystalgia. A well-founded diagnosis, as a rule, is made for women after 5 years, with men it is more difficult, for them it will take at least 7 years.

Such symptoms are typical mostly for women (the incidence rate of women and men is 9:1). Cystalgia is also assumed to occur in pregnant women, which is facilitated by changes in hormonal levels as one of the factors in the development of the pathology.

Complications and consequences

The disease, if left untreated or at an insufficient level, has serious consequences and complications. Chronic cystitis, pyelonephritis, nephrosclerosis, reflux, and renal failure are possible.

Diagnostics cystalgia

Cystalgia is not easy to diagnose and is a diagnosis of exclusion. It is now widely accepted that the diagnosis of cystalgia should be based on symptoms along with exclusion of similar conditions such as pelvic pain, urinary tract infection (UTI), candidal infections, endometriosis, pelvic organ prolapse, gynecologic or urologic malignancies, overactive bladder, and chronic prostatitis.

Recently, the European Society for the Study of Interstitial Cystitis (ESSIC) [van de Merwe et al. 2008] defined cystalgia as chronic pelvic pain, pressure, or discomfort that is thought to be related to the bladder and accompanied by at least one or two symptoms of urinary dysfunction, such as a persistent urge to urinate or urinary frequency. In addition, tests such as biopsy or cystoscopy with hydrodistention are not necessary for the diagnosis of cystalgia, but can help classify the types of interstitial cystitis.

Patients with cystalgia may also experience recurrence of pain in association with seasonal allergies and sexual intercourse [Parsons, 2002]. [ 24 ] Typically, voiding relieves pain [Metts, 2001], [ 25 ] and so patients may urinate frequently in small volumes to relieve the pain of filling the bladder. Patients with cystalgia are more likely to be diagnosed with other comorbidities such as IBS [Novi et al. 2005], [ 26 ] inflammatory bowel disease, allergies, fibromyalgia, and systemic lupus erythematosus (SLE) [Alagiri et al. 1997]. [ 27 ] A voiding diary may be useful to establish frequency, nocturia, and the presence of triggers such as allergies, certain foods, and/or sexual intercourse [Nickel, 2004]. [ 28 ] Symptom screening such as the Pelvic Pain and Urgency Questionnaire (PUF) and the O'Leary-Sant IC Symptom and Index [Parsons et al. 2002a] can also be used to obtain this information. [ 29 ]

It is necessary to use various methods, including collecting anamnesis, filling out a special questionnaire-test, which records the frequency of urges, urine volume, interval between urinations and other information that helps determine the severity of symptoms, vaginal examination.

Most often, a gynecological examination reveals bladder tenderness. Urodynamics are normal, except for increased bladder sensitivity and low capacity. General urinalysis, urine culture, and cystoscopy are also normal. [ 30 ]

Urine analysis determines the presence of infections, fungi, bacteria, and degenerative cells. A vaginal smear is taken to detect genital infections that may accompany the disease.

Instrumental diagnostic methods include ultrasound of the pelvic organs, MRI, CT, urethrocystography with a contrast agent. But the final diagnosis can be made by stretching the bladder with fluid under anesthesia, obtaining its mirror image (hydrodistension). Having detected changes, material is taken for biopsy.

Differential diagnosis

Cystalgia is differentiated from the following diagnoses:

• irritable bladder;
• urethral syndrome;
• chronic nonspecific cystitis;
• syndrome of urgent and frequent urges;
• gynecological inflammations;
• endometriosis;
• tuberculosis of the urinary system;
• malignant neoplasms.

Interstitial cystitis is often misdiagnosed as prostatitis and benign prostatic hyperplasia among men.

Treatment cystalgia

Treatment of cystalgia remains empirical. [ 31 ] Patients with interstitial cystitis are usually prescribed multimodal therapy to break the vicious cycle of chronic inflammation at each stage.

Studies have shown that many patients respond well to treatment strategies that use a variety of pharmacological and non-pharmacological approaches [Nickel et al. 2005]. [ 32 ]

Therapeutic measures to eliminate cystalgia include: restoration of normal urination, pain relief, and an increase in bladder capacity.

Prevention

A healthy lifestyle, moderate physical activity, proper nutrition, proper hygienic care of the external genitourinary organs, timely treatment of emerging problems, and avoidance of provoking factors will serve as prevention of cystolgia.

Forecast

Recognition of the disease at early stages and treatment gives a favorable prognosis, patients retain their ability to work, their quality of life improves, otherwise disability may follow.