Crane Alice, Lloyd Jessica, Shoskes Daniel A
Glickman Urological and Kidney Institute, Cleveland, Ohio, USA.
Can J Urol. 2018 Apr;25(2):9250-9254.
The phenotyping system UPOINT has proven effective in classifying patients with Urologic Pelvic Pain Syndromes in a clinically meaningful way and to guide therapy. While highly successful in men with chronic pelvic pain syndrome (CPPS), UPOINT is more limited in patients with interstitial cystitis/painful bladder syndrome (IC/PBS) since by definition all patients have the urinary and organ specific phenotype. Furthermore, AUA guidelines recommend a sequential tiered approach to therapy rather than the multimodal UPOINT scheme. We sought to modify UPOINT to be more practical and efficacious for IC/PBS.
We developed a new phenotype by removing the urinary and organ specific domains from UPOINT and adding a Hunner's ulcers (U) domain, since these patients benefit from phenotype specific therapies (fulguration, cyclosporine). This yields 'INPUT': infection, neurologic/systemic, psychosocial, ulcers and tenderness of muscles. We applied this system retrospectively to our previously validated upointmd.com IC/PBS database. Symptoms were measured by the Genitourinary Pain Index (GUPI) (valid for men and women). The database was searched for patients with complete data to assess the INPUT domains and include GUPI. Men were included if they reported pain relieved by voiding and/or presence of Hunner's ulcers. Groups were compared with ANOVA, Mann-Whitney, t test or chi squared when appropriate and correlated with Spearman r.
There were 239 patients, 154 female (64%) with age range 18-79 (mean 41.8). Incidence of domains was infection 11%, neurologic/systemic 51%, psychosocial 81%, ulcers 18% and tenderness 85%. Mean total domains was 2.46 (range 0-5) and 65% had 2 or 3 positive domains while only 5% had none. There was a stepwise increase in GUPI score with increasing number of positive INPUT domains (ANOVA for differences between groups p < 0.0001. Correlation by Spearman r = 0.355 p < 0.0001). Presence of Hunner's ulcers increased mean symptom score (25.7 versus 29.7, p = 0.004) and indeed each of the domains significantly increased total GUPI score except for Infection.
The INPUT phenotype in IC/PBS appears to replicate the validity and potential clinical utility of UPOINT in CPPS. Patients have a diversity of phenotypes and more positive domains correlate with more severe symptoms. Since 95% of patients have at least 1 positive domain it may benefit patients to receive multimodal therapy up front for these extra domains (eg. pelvic floor physical therapy, fulguration of ulcers) rather than relying on a sequential tiered approach.
表型分析系统UPOINT已被证明能以一种具有临床意义的方式对泌尿系统盆腔疼痛综合征患者进行分类并指导治疗。虽然UPOINT在慢性盆腔疼痛综合征（CPPS）男性患者中非常成功，但在间质性膀胱炎/疼痛性膀胱综合征（IC/PBS）患者中其作用较为有限，因为根据定义，所有患者都具有泌尿系统及器官特异性表型。此外，美国泌尿外科学会（AUA）指南推荐采用序贯分层治疗方法，而非多模式UPOINT方案。我们试图对UPOINT进行修改，使其对IC/PBS更实用、更有效。
我们通过从UPOINT中去除泌尿系统及器官特异性领域，并添加Hunner溃疡（U）领域来开发一种新的表型，因为这些患者可从表型特异性治疗（电灼、环孢素）中获益。这就产生了“INPUT”：感染、神经/全身、心理社会、溃疡和肌肉压痛。我们将该系统回顾性应用于我们之前验证过的upointmd.com IC/PBS数据库。症状通过泌尿生殖系统疼痛指数（GUPI）进行测量（对男性和女性均有效）。在数据库中搜索具有完整数据的患者，以评估INPUT领域并纳入GUPI。如果男性患者报告排尿可缓解疼痛和/或存在Hunner溃疡，则将其纳入。当适当时，采用方差分析（ANOVA）、曼-惠特尼检验、t检验或卡方检验对各组进行比较，并与Spearman相关系数r进行相关性分析。
共有239例患者，其中154例为女性（64%），年龄范围为18 - 79岁（平均41.8岁）。各领域的发生率分别为：感染11%，神经/全身占51%，心理社会占81%，溃疡占18%，压痛占85%。平均总领域数为2.46（范围0 - 5），65%的患者有2个或3个阳性领域，而只有5%的患者没有阳性领域。随着阳性INPUT领域数量的增加，GUPI评分呈逐步上升趋势（组间差异的方差分析p < 0.0001。Spearman相关系数r = 0.355，p < 0.0001）。Hunner溃疡的存在使平均症状评分增加（25.7对29.7，p = 0.004），实际上除感染外，每个领域均显著增加了总GUPI评分。
IC/PBS中的INPUT表型似乎再现了UPOINT在CPPS中的有效性和潜在临床实用性。患者具有多种表型，更多的阳性领域与更严重的症状相关。由于95%的患者至少有1个阳性领域，对于这些额外的领域（如盆底物理治疗、溃疡电灼），患者一开始接受多模式治疗可能比依赖序贯分层治疗更有益。
