Sessione dolore pelvico cronico: prevenzione e diagnosi

SESSIONE DOLORE PELVICO CRONICOSESSIONE DOLORE PELVICO CRONICO
PREVENZIONE E DIAGNOSIPREVENZIONE E DIAGNOSI
M. VotteroM. Vottero
Città della Salute e della ScienzaCittà della Salute e della Scienza
TorinoTorino

The 2013 EAU Guidelines on Chronic Pelvic Pain:The 2013 EAU Guidelines on Chronic Pelvic Pain:
Is Management of Chronic Pelvic Pain a Habit,Is Management of Chronic Pelvic Pain a Habit,
a Philosophy, or a Science? 10 Years of Development.a Philosophy, or a Science? 10 Years of Development.
D.S. Engler, A.P. Baranowski et Al.
European Urology 64 (2013) 431-439
The name given to a disease can have majorThe name given to a disease can have major
implications; however,implications; however, arriving at a diagnosis is notarriving at a diagnosis is not
an easy processan easy process in view of the many dimensionsin view of the many dimensions
that need to be considered.that need to be considered.

Diagnosis and treatment of chronic bacterial prostatitisDiagnosis and treatment of chronic bacterial prostatitis
and chronic prostatitis / chronic pelvic pain syndrome:and chronic prostatitis / chronic pelvic pain syndrome:
a consensus guideline.a consensus guideline.
J. Rees, M. Abrahams et Al.
BJU International 2015; 116: 509-525
There is no “gold standard” for a definitiveThere is no “gold standard” for a definitive
diagnosis of chronic prostatitis / chronic pelvic paindiagnosis of chronic prostatitis / chronic pelvic pain
syndrome.syndrome.

EAU Guidelines on Chronic Pelvic PainEAU Guidelines on Chronic Pelvic Pain
M. Fall, A.P. Baranowski et Al.
• Basic investigations must be undertakenBasic investigations must be undertaken to ruleto rule
out “well defined”out “well defined” pathologies.pathologies.
• Further investigations should be done for specificFurther investigations should be done for specific
investigations (eg, for subdivision of a paininvestigations (eg, for subdivision of a pain
syndrome).syndrome).

• Pain associated with a well described diseasePain associated with a well described disease
process requires that the disease be treated as theprocess requires that the disease be treated as the
priority.priority.
• When there is pain in absence of an obviousWhen there is pain in absence of an obvious
ongoing disease process, we are dealing with aongoing disease process, we are dealing with a
pain syndrome.pain syndrome.

Comprehensive investigationsComprehensive investigations
1)1) satisfies patient and physician that nothingsatisfies patient and physician that nothing
treatable has gone undetected,treatable has gone undetected,
2)2) risks strengthening the the patient’ beliefs inrisks strengthening the the patient’ beliefs in
biomedical solutions as the only route andbiomedical solutions as the only route and
3)3) may make harder to create a transition tomay make harder to create a transition to
management strategies.management strategies.

……howeverhowever
engaging a chronic pain model at an early stageengaging a chronic pain model at an early stage
runs the risk of failure to detect a treatable causeruns the risk of failure to detect a treatable cause
of pain and possibly a serious disease.of pain and possibly a serious disease.

Gruppo Tecnico per la BPS/IC del Piemonte eGruppo Tecnico per la BPS/IC del Piemonte e
della VDA (2012).della VDA (2012).
• Decreto Ministero della Sanità 279/2001.Decreto Ministero della Sanità 279/2001.
• Centro Regionale di Coordinamento per leCentro Regionale di Coordinamento per le
Malattie Rare.Malattie Rare.
• Creazione PDTA.Creazione PDTA.

Criteri DiagnosticiCriteri Diagnostici
Valutazioni Cliniche:Valutazioni Cliniche:
• Esame Obiettivo Pelvico;Esame Obiettivo Pelvico;
• Calibraggio Uretrale (facoltativo);Calibraggio Uretrale (facoltativo);
• ER (maschio);ER (maschio);
• Diario Minzionale (3 gg);Diario Minzionale (3 gg);
• VASVAS
• Pelvic Pain and Urgency/Frequency scale,Pelvic Pain and Urgency/Frequency scale,
O’Leary Sant IC, QOL (IPSS)O’Leary Sant IC, QOL (IPSS)

Valutazioni Strumentali Obbligatorie:Valutazioni Strumentali Obbligatorie:
• Esame Urine, Urinocoltura, citologia urinaria;Esame Urine, Urinocoltura, citologia urinaria;
• Tampone Uretrale (Chlamydia, Micoplasmi);Tampone Uretrale (Chlamydia, Micoplasmi);
• Tampone Vaginale (Chlamydia, Micoplasmi);Tampone Vaginale (Chlamydia, Micoplasmi);
• Eco AS/AI con RPM;Eco AS/AI con RPM;
• Cistoscopia con idrodistensione (80 cm) inCistoscopia con idrodistensione (80 cm) in
rachianestesia / generale completarachianestesia / generale completa

Valutazioni Strumentali Facoltative:Valutazioni Strumentali Facoltative:
• Esame Urodinamico Completo;Esame Urodinamico Completo;
• Ricerca BK;Ricerca BK;
• Biopsia Vescicale Profonda (detrusore, bleu diBiopsia Vescicale Profonda (detrusore, bleu di
metilene / Giemsa);metilene / Giemsa);

Criteri Diagnostici +Criteri Diagnostici +
Procedure amministrativeProcedure amministrative
• Inserimento registro MARAREInserimento registro MARARE
• Certificato Esenzione temporanea o definitivaCertificato Esenzione temporanea o definitiva
• Prescrizione Piano TerapeuticoPrescrizione Piano Terapeutico

Condom Use and the Risk of Recurrent PelvicCondom Use and the Risk of Recurrent Pelvic
Inflammatory Disease, Chronic Pelvic Pain, or InfertilityInflammatory Disease, Chronic Pelvic Pain, or Infertility
Following an Episode of Pelvic Inflammatory Disease.Following an Episode of Pelvic Inflammatory Disease.
R.B. Ness, H. Randall et Al.
American Journal of Public Healt. Vol 94:1327-1329 (2004)
• 684 sexually active women;684 sexually active women;
• mean f-u 35 months;mean f-u 35 months;
• PERSISTENT USE REDUCED THE RISK OF RECURRENTPERSISTENT USE REDUCED THE RISK OF RECURRENT
PID, CHRONIC PELVIC PAIN AND INFERTILITY.PID, CHRONIC PELVIC PAIN AND INFERTILITY.

Diet and its Role in IC / BPS and comorbid conditions.Diet and its Role in IC / BPS and comorbid conditions.
J.I. Friedlaner et al.
BJU International 109 (2012) 1584-1591
• Up to 90% of patients report sensietivities to a wideUp to 90% of patients report sensietivities to a wide
variety of commestibles;variety of commestibles;
• Mechanisms suggested to be responsable: peripheral andMechanisms suggested to be responsable: peripheral and
central neural upregulation, urothelial dysfunction, organcentral neural upregulation, urothelial dysfunction, organ
cross talk;cross talk;
• Citrus fruits, tomatoes, vitamin C, artificial sweeteners,Citrus fruits, tomatoes, vitamin C, artificial sweeteners,
coffee, tea, charbonated and alcoholic beverages and spicycoffee, tea, charbonated and alcoholic beverages and spicy
foods exacerbate symptoms;foods exacerbate symptoms;
• Calcium glycerofosfate and sodium bicarbonate improveCalcium glycerofosfate and sodium bicarbonate improve
symptoms.symptoms.

Diet and its Role in IC / BPS and comorbid conditions.Diet and its Role in IC / BPS and comorbid conditions.
J.I. Friedlaner et al.
BJU International 109 (2012) 1584-1591

• CPP is associated with changes in the CNS thatCPP is associated with changes in the CNS that
mantain the perception of pain in the absence ofmantain the perception of pain in the absence of
acute injury.acute injury.
• Changes magnify the perception so thatChanges magnify the perception so that
nonpainful stimuli are perceived as painfulnonpainful stimuli are perceived as painful
((allodyniaallodynia) and painful stimuli are perceived as) and painful stimuli are perceived as
more painful than expected (more painful than expected (hyperalgesiahyperalgesia).).

• The changes occur throughout the wholeThe changes occur throughout the whole
neuroaxis.neuroaxis.
• The central changes are responsible for some ofThe central changes are responsible for some of
thethe psycological changespsycological changes, wich also modify pain, wich also modify pain
mechanisms in their own right.mechanisms in their own right.

Limbic associated Pelvic Pain: a Hypothesis to Explain theLimbic associated Pelvic Pain: a Hypothesis to Explain the
Diagnostic Relationships and Features of Patients withDiagnostic Relationships and Features of Patients with
CPP.CPP.
B. W. Fenton.
Medical Hypotheses 69 (2007) 282-286
Pain perception:Pain perception:
• Lateral, somatosensory system involved in discriminationLateral, somatosensory system involved in discrimination
of pain, location and intensity;of pain, location and intensity;
• Medial system mediates anticipatory, fearful, affectiveMedial system mediates anticipatory, fearful, affective
quality of pain (anterior cingulate cortex; amygdala).quality of pain (anterior cingulate cortex; amygdala).
Disruption of afferent arm of the LAPP cycleDisruption of afferent arm of the LAPP cycle

Increased Brain Gray Matter in the Primary SomatosensoryIncreased Brain Gray Matter in the Primary Somatosensory
Cortex in Associated with Increased Pain and MoodCortex in Associated with Increased Pain and Mood
DisturbsDisturbs
In Patients with BPS/ICIn Patients with BPS/ICE. A. Kairys, T. Schmidt-Wilcke et Al.
The Journal of Urology 193 (2015) 131-137
• MAPP network (5 sites);MAPP network (5 sites);
• 33 female patients with BPS/IC without comorbidities and33 female patients with BPS/IC without comorbidities and
33 age and gender matched controls taken from the larger33 age and gender matched controls taken from the larger
sample underwent structural magnetic resonance imagingsample underwent structural magnetic resonance imaging

Segmental Hyperalgesia to Mechanical Stimulus inSegmental Hyperalgesia to Mechanical Stimulus in
IC / BPS: Evidence of Central SensitizationIC / BPS: Evidence of Central Sensitization
H.H. Lai, Vivien Gardner et Al.
The Journal of Urology 191 (2014) 1294-1299

Changes in Afferent Activity after Spinal Cord Injury.Changes in Afferent Activity after Spinal Cord Injury.
W.C. de Groat, N. Yoshimura.
Neurourology and Urodynmics 29 (2010) 63-76

Urinary Symptoms as a Prodrome of BPS / IC.Urinary Symptoms as a Prodrome of BPS / IC.
J.W. Warren, U. Wesselmann et al.
Urology vol.83, issue 5 (2014) 1035-1040
• 312 female, mean age 42.3 years;312 female, mean age 42.3 years;
• Three prodroic symptoms are more common in BPS /ICThree prodroic symptoms are more common in BPS /IC
cases: pelvic pain with urinary features, frequency, bladdercases: pelvic pain with urinary features, frequency, bladder
pain alone.pain alone.

• In prodromal women the median age of the erliestIn prodromal women the median age of the erliest
urinary symptoms “more than other people” was 20 years;urinary symptoms “more than other people” was 20 years;
• Three prodromic symptoms are more common in BPS /ICThree prodromic symptoms are more common in BPS /IC
cases: pelvic pain with urinary features, frequency, bladdercases: pelvic pain with urinary features, frequency, bladder
pain alone;pain alone;

• NBSs: chronic fatigue syndrome, irritable bowel syndrome;NBSs: chronic fatigue syndrome, irritable bowel syndrome;
fibromyalgia, sicca syndrome, migraine, depression, panicfibromyalgia, sicca syndrome, migraine, depression, panic
disorder, allergya, vulvodynia.disorder, allergya, vulvodynia.
• The prodrome associated with priorThe prodrome associated with prior NBSsNBSs predictedpredicted
poor prognosis for BPS/IC.poor prognosis for BPS/IC.
• Recognition of prodromal symptoms might provideRecognition of prodromal symptoms might provide
opportunities for prevention of fully manifest BPS/IC.opportunities for prevention of fully manifest BPS/IC.

a Philosophy, or a Science? 10 Years of Developmenta Philosophy, or a Science? 10 Years of Development..

Chronic Pelvic Pain Syndrome / Bladder Pain Syndrome :Chronic Pelvic Pain Syndrome / Bladder Pain Syndrome :
Taking Stock, Looking Ahead: ICI-RS 2011.Taking Stock, Looking Ahead: ICI-RS 2011.
P. Hanno, K.E. Andersson et Al.
Neurourology and Urodynamics 31:375-383 (2012)

Sessione dolore pelvico cronico: prevenzione e diagnosi

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Sessione dolore pelvico cronico: prevenzione e diagnosi