Cystalgia in women and men

Cystalgia is an outdated term that has disappeared from the use of both domestic and foreign medical literature. What does cystalgia mean? Translated from Greek means "bladder" plus "pain". They identified the inexplicable disorders of urination that occur in women. A more appropriate definition is interstitial cystitis, which includes numerous 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 a painful bladder syndrome / interstitial cystitis (PBS / IC) [Hanno et al. 2005]. [1]Recently, the European Society for the Study of Interstitial Cystitis (ESSIC) proposed the name “bladder pain syndrome” (BPS) [van de Merwe et al. 2008]. [2]

Epidemiology

The lack of clear diagnostic criteria does not allow us 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 showed that cystalgia ranged from 1 for every 100,000 to 5.1 for every 100,000 in the general population; but an updated epidemiological study conducted in 2006 shows that up to 12% of women may have early symptoms of intercitial cystitis. [3]

Causes of the cystalgia

Pathology develops due to a violation of the functions of the neuromuscular structures of the bladder, the cause of which lies in:

• hormonal disorders;
• genital diseases;

The study determined the relationship 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], are  [6]found in urothelium of the bladder and its own plate in cystalgia. However, there remains considerable doubt as to whether these results are causal or a response to the cause.

• urogenital tuberculosis with damage to the bladder; [7]
• allergic edema of his neck. [8]
• infections

It was previously believed that bacterial infection is the main cause of the changes observed 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 conclusion, and it is now generally accepted that infection is not the cause of cystalgia.

• environmental factors;

Studies have also shown that symptoms of cystalgia worsen with stress, spicy foods, and smoking. A recent “Preceding IC” study reported that pain in 97% worsened with certain foods and drinks, such as alcohol, citrus fruits, coffee, sodas, tea, chocolate, and tomatoes [Warren et al. 2008] is  [11]comparable to data from the database of interstitial cystitis (ICDB), where 262 of 270 (97%) patients reported increased pain [Simon et al. 1997]. [12]

• genetic predisposition.

Studies have shown that IC is more common in twins with chronic fatigue syndrome. Warren and colleagues recently studied the prevalence of cystalgia in first-line relatives in patients with cystalgia, reporting that in adult first-line women, the prevalence of cystalgia is 17 times higher than in the general population [Warren et al. 2004]. [13]They also studied the prevalence of cystalgia in monozygous and dizygotic twins, reporting a greater consistency of interctitial cystitis among monozygotic twins compared to dizygotic twins, suggesting genetic causes of cystalgia [Warreni et al. 2001]. [14]

Risk factors

The main engines of cystalgia are psychogenic factors. Chronic pain over the bosom is associated with a response to arousal 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 as 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 the altered permeability of the epithelium (theory of epithelial dysfunction), mast cell activation and increased sensitivity of the afferent nerve play a decisive role. [16] A significant role in the pathogenesis of pathology is assigned to mast cells containing vasoactive and inflammatory mediators. They react to substance P, other irritants (stress, allergens, hormones, bacteria).

The mucous substance protects the bladder from the penetration of toxins, carcinogens, microorganisms, potassium salts contained in urine. Changes in it lead to a violation of permeability, the passage of potassium ions through urothelium, depolarization of nerves. In patients, an increase in the number of nerve endings containing one of the tachykinins (substance P), a receptor responsible for the smooth muscle contraction, is detected. Cystalgia is also believed to be a visceral neuropathic pain syndrome, 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] Hypersensitivity of sensory afferents of the bladder can also be the cause of increased pain or hyperalgesia. [18], [19]

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

Another “trigger” includes female hormones, especially estradiol. It was found that perivascular sensitive nerve endings are hypersensitive to SP, which leads to a local cascade of neurogenic inflammatory reactions that are responsible for 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 release of estrogen, which releases histamine from mast cells, followed by secretion of SP [Pang et al. 1995a]. [22]Similarly, stress can aggravate cystalgia symptoms due to the release of corticotropin releasing factor (CRF) and subsequent mast cell activation [Theoharides et al. 2004]. [23]

Symptoms of the cystalgia

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

A long period is characteristic of the course of the disease: from several months to a dozen years. Quiet episodes alternate with relapses, the duration of which varies. To connect the first signs (pain, aggravated by filling the bladder, mainly daytime urges) in the absence of infection in the urine, causeless exacerbations with cystalgia are not immediately possible. A substantiated diagnosis is usually given to women after 5 years, with men it is more difficult, they will need at least 7 years.

This symptomatology is characteristic for the most part for women (the ratio of the incidence of women and men is 9: 1). They also suggest cystalgia in pregnant women, this is facilitated by a change in the hormonal background as one of the factors causing the pathology.

Complications and consequences

In the absence of treatment or insufficient level, the disease has serious consequences and complications. Chronic cystitis, pyelonephritis, nephrosclerosis, reflux, and renal failure are possible.

Diagnostics of the cystalgia

Cystalgia is not easy to diagnose, it is a diagnosis of exclusion. Currently, it is widely believed that the diagnosis of cystalgia should be based on symptoms along with the exclusion of similar conditions, such as pelvic pain, urinary tract infection (UTI), candida infections, endometriosis, pelvic organ prolapse, gynecological or urological malignancies, hyperactivity of the 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 associated with the bladder and is accompanied by at least one or two symptoms of urination disorder, such as constant urination or frequent urination. In addition, tests such as biopsy or cystoscopy with hydrodistension are not necessary for the diagnosis of cystalgia, but can help classify the types of interstitial cystitis.

Patients with cystalgia may also experience relapses of pain due to seasonal allergies and sexual intercourse [Parsons, 2002]. [24]Emptying generally relieves pain [Metts, 2001],  [25]and therefore patients can often urinate in small volumes to relieve pain when filling the bladder. Patients with cystalgia are more often diagnosed with other concomitant diseases, such as IBS [Novi et al. 2005], [26]inflammatory bowel disease, allergies, fibromyalgia, and systemic lupus erythematosus (SLE) [Alagiri et al. 1997]. [27]A urination diary can be useful for determining the frequency, nocturia, and the presence of triggers such as allergies, certain foods, and / or sexual intercourse [Nickel, 2004]. [28]Symptom screening, such as a pelvic pain and urgency questionnaire (PUF) and O'Leary-Sant IC symptoms and indices [Parsons et al. 2002a]. [29]

You have to apply various methods, including taking an anamnesis, filling out a special questionnaire test, which records the frequency of urges, the volume of urine, the interval between urination and other information that helps to determine the severity of symptoms, a vaginal examination.

Most often, a gynecological examination reveals soreness of the bladder. Urodynamics is normal, with the exception of increased sensitivity of the bladder and low capacity. Urinalysis, urine culture, and cystoscopy are also normal. [30]

In the analysis of urine, the presence of infections, fungi, bacteria, degenerative cells is determined. To identify genital infections that may accompany the disease, take a vaginal smear.

Of the methods of instrumental diagnostics, pelvic ultrasound, MRI, CT, urethrocystography with a contrast agent are used. But the final diagnosis can be made by stretching the bladder with fluid under anesthesia, receiving a mirror image of it (hydrodistension). Having discovered the changes, they take the material for a biopsy.

Differential diagnosis

Differentiate cystalgia with such diagnoses as:

• irritated bladder;
• urethral syndrome;
• chronic nonspecific cystitis;
• urgent and rapid urgency syndrome;
• gynecological inflammation;
• endometriosis;
• urinary tuberculosis;
• malignant neoplasms.

Interstitial cystitis is often mistakenly diagnosed as prostatitis and benign prostatic hyperplasia in men. 

Treatment of the cystalgia

The 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 various pharmacological and non-pharmacological approaches [Nickel and others. 2005]. [32]

Therapeutic measures to eliminate cystalgia include: restoring normal urination, eliminating pain, increasing the capacity of the bladder.

Prevention

A healthy lifestyle, moderate physical activity, proper nutrition, proper hygienic care of the external genitourinary organs, timely treatment of problems that arise, avoidance of provoking factors will prevent cystolgia.

Forecast

Recognition of the disease in the early stages and treatment gives a favorable prognosis, patients remain working, their quality of life improves, otherwise disability may follow.