Department of Obstetrics/Gynecology, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL.
Department of Biostatistics, NorthShore University HealthSystem, Evanston, IL.
Am J Obstet Gynecol. 2018 Jul;219(1):84.e1-84.e8. doi: 10.1016/j.ajog.2018.04.030. Epub 2018 Apr 25.
Dysmenorrhea is a common risk factor for chronic pain conditions including bladder pain syndrome. Few studies have formally evaluated asymptomatic bladder pain sensitivity in dysmenorrhea, and whether this largely reflects excess pelvic symptom reporting due to comorbid psychological dysfunction.
We sought to determine whether bladder hypersensitivity is more common among women reporting moderate or greater dysmenorrhea, without chronic pain elsewhere, after accounting for anxiety and depression. Demonstrating this would suggest that dysmenorrhea might be an early clue for visceral or widespread pain hypersensitivity and improve understanding of potential precursors to bladder pain syndrome.
We compared cohorts of regularly menstruating women, without symptoms of chronic pain elsewhere, reporting (1) moderate-to-severe dysmenorrhea (n = 98) and (2) low levels or no menstrual pain (n = 35). Participants underwent rapid bladder filling following a standard water ingestion protocol, serially rating bladder pain and relative urgency during subsequent distension. Potential differences in bladder volumes were controlled for by sonographic measurement at standard cystometric thresholds. Bladder sensitivity was also measured with complementary measures at other times separately including a simplified rapid filling test, palpation of the bladder wall, and through ambulatory self-report. Anxiety and depression were evaluated with the National Institutes of Health Patient-Reported Outcomes Measurement Information System measures.
Women with moderate-to-severe dysmenorrhea reported more urinary symptoms than controls and had a lower maximum capacity (498 ± 18 mL vs 619 ± 34 mL, P < .001) and more evoked bladder filling pain (0-100 visual analog scale: 25 ± 3 vs 12 ± 3, P < .001). The dysmenorrhea-bladder capacity relationship remained significant irrespective of menstrual pain severity, anxiety, depression, or bladder pain (R = 0.13, P = .006). Severity of menstrual pain predicted evoked bladder pain (R = 0.10, P = .008) independent of anxiety (P = .21) and depression (P = .21). Women with moderate-to-severe dysmenorrhea exhibiting provoked bladder pain (24/98, 24%) also reported higher pain during the screening rapid bladder test (P < .001), in response to transvaginal bladder palpation (P < .015), and on prospective daily diaries (P < .001) than women with dysmenorrhea without provoked bladder pain.
Women experiencing moderate-to-severe dysmenorrhea also harbor a higher pain response to naturally evoked bladder distension. Noninvasive bladder provocation needs to be tested further longitudinally in those with dysmenorrhea to characterize the course of visceral sensitivity and determine if it may help predict individuals at risk for developing subsequent pain in the bladder or elsewhere.
痛经是一种常见的慢性疼痛疾病的危险因素，包括膀胱疼痛综合征。很少有研究正式评估痛经患者无症状的膀胱疼痛敏感性，也没有研究评估这种敏感性是否主要反映了由于共病心理功能障碍而导致的盆腔症状过度报告。
我们旨在确定在考虑焦虑和抑郁后，是否有更多报告中度或重度痛经（无其他慢性疼痛）的女性表现出膀胱过度敏感。如果能够证明这一点，那么这将表明痛经可能是内脏或广泛疼痛过度敏感的早期线索，并有助于了解膀胱疼痛综合征的潜在前兆。
我们比较了两个队列的定期月经来潮的女性，她们（1）报告有中度至重度痛经（n=98）和（2）报告低水平或无月经疼痛（n=35）。参与者在标准的水摄入方案后进行快速膀胱充盈，在随后的扩张过程中依次对膀胱疼痛和相对紧迫性进行评分。通过在标准膀胱测压阈值处进行超声测量来控制潜在的膀胱容积差异。膀胱敏感性也通过其他时间的补充测量来评估，包括简化的快速充盈试验、膀胱壁触诊和日常自我报告。焦虑和抑郁通过美国国立卫生研究院患者报告的结果测量信息系统进行评估。
与对照组相比，报告中度至重度痛经的女性报告了更多的尿症状，并且其最大容量较低（498±18ml 比 619±34ml，P<.001），诱发膀胱充盈疼痛也更多（0-100 视觉模拟评分：25±3 比 12±3，P<.001）。痛经与膀胱容量之间的关系仍然显著，无论月经疼痛的严重程度、焦虑、抑郁或膀胱疼痛如何（R=0.13，P=0.006）。月经疼痛的严重程度预测了诱发的膀胱疼痛（R=0.10，P=0.008），独立于焦虑（P=0.21）和抑郁（P=0.21）。报告中度至重度痛经且伴有诱发性膀胱疼痛（24/98，24%）的女性在快速膀胱筛查试验中也报告了更高的疼痛（P<.001），在经阴道膀胱触诊时（P<.015）和在日常前瞻性日记中（P<.001）也报告了更高的疼痛，而无诱发性膀胱疼痛的痛经女性则没有。
经历中度至重度痛经的女性对自然诱发的膀胱扩张也有更高的疼痛反应。需要进一步在有痛经的患者中进行非侵入性膀胱激发试验的纵向研究，以明确内脏敏感性的病程，并确定其是否有助于预测随后发生膀胱或其他部位疼痛的风险。
