Clinical profile of comorbid dysmenorrhea and bladder sensitivity: a cross-sectional analysis

Abstract

Background: Antecedents of chronic pelvic pain are not well characterized, but pelvic organ visceral sensitivity is a hallmark of these disorders. Recent studies have identified that some dysmenorrhea sufferers are much more likely to exhibit comorbid bladder hypersensitivity. Presumably, these otherwise healthy women may be at higher risk of developing full-blown chronic bladder pain later in life. To encourage early identification of patients harboring potential future risk of chronic pain, we describe the clinical profile of women matching this putative pain-risk phenotype.

Objective(s): The objectives of the study were to characterize demographic, menstrual, pelvic examination, and psychosocial profiles of young women with comorbid dysmenorrhea and bladder hypersensitivity, defined using a standardized experimental visceral provocation test, contrasted with healthy controls, pure dysmenorrhea sufferers, and women with existing bladder pain syndrome.

Study design: This prospective cohort study acquired data on participants with moderate to severe dysmenorrhea (n = 212), healthy controls (n = 44), and bladder pain syndrome (n = 27). A subgroup of dysmenorrhea patients was found on screening with noninvasive oral water challenge to report significantly higher bladder pain during experimentally monitored spontaneous bladder filling (>15 out of 100 on visual analogue scale, based on prior validation studies) and separately defined as a group with dysmenorrhea plus bladder pain. Medical/menstrual history and pain history were evaluated with questionnaires. Psychosocial profile and impact were measured with validated self-reported health status Patient Reported Outcomes Measurement Information System short forms and a Brief Symptom Inventory for somatic sensitivity. Pelvic anatomy and sensory sensitivity were examined via a standardized physical examination and a tampon provocation test.

Results: In our largely young, single, nulliparous cohort (24 ± 1 years old), approximately a quarter (46 out of 212) of dysmenorrhea sufferers tested positive for the dysmenorrhea plus bladder pain phenotype. Dysmenorrhea-only sufferers were more likely to be African American (24%) than healthy controls (5%, post hoc χ2, P = .007). Pelvic examination findings did not differ in the nonchronic pain groups, except for tampon test sensitivity, which was worse in dysmenorrhea plus bladder pain and dysmenorrhea sufferers vs healthy controls (2.6 ± 0.3 and 1.7 ± 0.2 vs 0.7 ± 0.2, P < .05). Consistent with heightened pelvic sensitivity, participants with dysmenorrhea plus bladder pain also had more nonmenstrual pain, dysuria, dyschezia, and dyspareunia (P's < .05). Participants with dysmenorrhea plus bladder pain had Patient Reported Outcomes Measurement Information System Global Physical T-scores of 47.7 ± 0.9, lower than in women with dysmenorrhea only (52.3 ± 0.5), and healthy controls 56.1 ± 0.7 (P < .001). Similarly, they had lower Patient Reported Outcomes Measurement Information System Global Mental T-score than healthy controls (47.8 ± 1.1 vs 52.8 ± 1.2, P = .017). Similar specific impairments were observed on Patient Reported Outcomes Measurement Information System scales for anxiety, depression, and sleep in participants with dysmenorrhea plus bladder pain vs healthy controls.

Conclusion: Women with dysmenorrhea who are unaware they also have bladder sensitivity exhibit broad somatic sensitivity and elevated psychological distress, suggesting combined preclinical visceral sensitivity may be a precursor to chronic pelvic pain. Defining such precursor states is essential to conceptualize and test preventative interventions for chronic pelvic pain emergence. Dysmenorrhea plus bladder pain is also associated with higher self-reported pelvic pain unrelated to menses, suggesting central nervous system changes are present in this potential precursor state.

Keywords: bladder hypersensitivity; chronic pelvic pain; dysmenorrhea.

Conflict of interest statement

Conflicts of interest: F.F.T. is a consultant for AbbVie and UroShape, is on speaker’s bureau for AbbVie, and receives royalties from UpToDate. SS is a consultant for Olympus, Emmi, and Allergan, and an owner of Klaas, LLC. D.C. reports grants and personal fees from Aptinyx and Pfizer and personal fees from Daiichi Sankyo, Intec Pharma, Eli Lilly and Company, Samumed, Theravance, Tonix, Williams & Connolly LLP, and Zynerba.

The remaining authors report no conflict of interest.

Copyright © 2019 Elsevier Inc. All rights reserved.

Figures

Figure 1.. Comparative pain symptoms of women with dysmenorrhea and controls

Bars indicate mean self-reported pain and symptoms scores and SEM in each of the four groups. VAS – visual analogue score (0–100), DYS – dysmenorrhea, DYSB – dysmenorrhea with bladder pain sensitivity, BPS – bladder pain syndrome. + designates p

Figure 2.. Comparative patient reported outcomes in dysmenorrhea and controls

Bars indicate mean PROMIS (Patient-Reported Outcomes Measurement Information System) and SEM in each of the four groups. DYS – dysmenorrhea, DYSB – dysmenorrhea with bladder pain sensitivity, BPS – bladder pain syndrome. + designates p