Urinary symptoms and Micromotions of bladder wall in chronic pelvic pain (CPP)

Chronic lower abdominal pain of unknown origin in women has intrigued many investigators. It is the gynecologist in particular to whom patients with this syndrome address for relief. AB a matter of fact not less than approximately 10% of patients visiting gynaecologists do so in cOlmection with CPP (I). Chronic pelvic pain (CPP) is defined as a more or less continuous pain in the lower abdomen of unknown cause that has lasted for at least 6 months (2-5). Deep dyspareunia and radiation of pain to the lower back may also be present. Approximately 37% of women with CPP furthennore have urinary urgency although the results of urological exatninations are nonnal (see section II) (6). Although most studies on CPP have been carried out on women of feltile age, there are indications that this syndrome is not specifically reslIicted to patients in that age group. In a SlIldy involving 60 consecutive cases of CPP of all ages, 43% of the women hmled out to be 50 years or older (mean: 48; median: 48; range: 23-79 years) (see section II) (6,7). Different concepts about the origin of CPP have resulted in a wide variety of natnes given to tllis clinical feahrre (8), dependent on the diagnostic approach of the physician consulted by the patient (9

New concepts in relation to urge and detrusor activity

Investigations of micromotion characteristics of bladder wall strips and pressure wave phenomena in total bladders in vitro and in vivo indicate that micromotion phenomena occur in the bladder wall. Local contractions can occur without an increase in tension or pressure, because other parts are in antiphase. Local contractions stretch surrounding tissues, which can stimulate fast stretch receptors. Synchronisation of these micromotion phenomena appears to be possible. Hence, above threshold levels urge can theoretically occur, even in the absence of a pressure increase. This hypothesis could explain the weak relation between urge and pressure. The distinction between motor and sensory urge could be artifactual based on a misunderstanding of fundamental bladder wall processes

The potential role of unregulated autonomous bladder micromotions in urinary storage and voiding dysfunction; overactive bladder and detrusor underactivity

The isolated bladder shows autonomous micromotions, which increase with bladder distension, generate sensory nerve activity, and are altered in models of urinary dysfunction. Intravesical pressure resulting from autonomous activity putatively reflects three key variables; the extent of micromotion initiation, distances over which micromotions propagate, and overall bladder tone. In vivo, these variables are subordinate to the efferent drive of the central nervous system. In the micturition cycle storage phase, efferent inhibition keeps autonomous activity generally at a low level, where it may signal “state of fullness” while maintaining compliance. In the voiding phase, mass efferent excitation elicits generalized contraction (global motility initiation). In lower urinary tract dysfunction, efferent control of the bladder can be impaired, for example due to peripheral “patchy” denervation. In this case, loss of efferent inhibition may enable unregulated micromotility, and afferent stimulation, predisposing to urinary urgency. If denervation is relatively slight, the detrimental impact on voiding may be low, as the adjacent innervated areas may be able to initiate micromotility synchronous with the efferent nerve drive, so that even denervated areas can contribute to the voiding contraction. This would become increasingly inefficient the more severe the denervation, such that ability of triggered micromotility to propagate sufficiently to engage the denervated areas in voiding declines, so the voiding contraction increasingly develops the characteristics of underactivity. In summary, reduced peripheral coverage by the dual efferent innervation (inhibitory and excitatory) impairs regulation of micromotility initiation and propagation, potentially allowing emergence of overactive bladder and, with progression, detrusor underactivity

Voiding symptoms in chronic pelvic pain (CPP).

OBJECTIVE: To establish the prevalence of voiding symptoms in CPP patients. STUDY DESIGN: Sixty women with chronic pelvic pain (CPP), aged 23-79 (mean: 48) years completed a questionnaire mainly addressing lower abdominal pain and voiding symptoms. Symptoms occurring often, almost always, or always for more than 6 months were considered present and serious. A group of 31 consecutive cases of non-CPP women aged 18-77 (mean: 49) years were selected to serve as controls. RESULTS: The following symptoms were found in the CPP group: incontinence: 43%; inadequate voluntary control of the urethral sphincter: 50%; inability to postpone: 37%; urge: 37%; nocturia > or =2X: 18%; dysuria: 12%; cystitis: 37%; urge-induced pain: 20%; pain-induced urge: 18%; strain to initiate voiding: 6%; strain to continue voiding: 17%; incomplete voiding: 37%. Two or more voiding symptoms were present in 63% of the CPP group. All urinary symptoms were more often present in the CPP group than in the controls. CONCLUSION: A substantial subgroup of CPP patients has voiding symptoms