LETTER TO THE EDITOR

Bladder pain syndrome (BPS): Symptom differences between type 3CBPS and non-type 3C BPS

Jo€rgen Quaghebeur and Jean-Jacques Wyndaele

Department of Urology, University Antwerp, Wilrijk, Belgium

Keywords:

Bladder pain syndrome, interstitial cystitis,questionnaire

History

Received 13 September 2014Revised 19 October 2014Accepted 23 October 2014

The diagnosis and prevalence of symptoms in patientswith interstitial cystitis (IC) remains a challenge. The differ-ence in symptoms between a Hunner’s lesion [InternationalSociety for the Study of Bladder Pain Syndrome (ESSIC)type 3C] and bladder pain syndrome (BPS) is unclear. Weextensively searched and evaluated publications that showthe ability of symptom evaluation by the use of question-naires differentiating ESSIC type 3C bladders from BPS [1].Only publications suggesting symptom differences based onquestionnaire results were included, although the terminologyused in the following text conforms with that used in theoriginal publication, and therefore does not meet ESSICstandards.

Patients with IC and BPS represent a heterogeneous popu-lation presenting with a wide variety of symptoms.A comparison of age cohorts shows that dyspareunia, exter-nal genital pain, frequency, urgency and dysuria are morecommon in younger patients. In older patients, Hunner’slesions are more frequent and accompanied by nocturia andurinary incontinence [2]. A study by Bogart et al. suggeststhat IC and BPS have the same cluster of symptoms [3].Peeker and Fall suggest that, compared to the non-ulcer type,classic IC appears different with regard to symptomatic,endoscopic and histological findings, and their response tovarious forms of treatment differs [4]. Here, for symptomaticdifferences, Peeker and Fall [4] refer to Koziol et al. [5].Although, some differences in symptoms were suggested inthis study, the results show that only haematuria can ade-quately discriminate between the two categories with highsensitivity and high specificity [5]. Using National Institute

of Diabetes and Digestive and Kidney Diseases (NIDDK) cri-teria, Peeker and Fall show that the non-ulcer-type patientsare younger at diagnosis and symptom onset, and have sig-nificant differences in bladder capacity under general anaes-thesia [6]. Women with ulcerative and non-ulcerative IC/BPSshow no differences in the Interstitial Cystitis Symptom/Problem Indexes (ICSI-PI) and Rome III criteria. Patientswith an ulcer are older and less employed, void more, andhave more nocturia and a smaller bladder capacity than thosewithout an ulcer. Patients without an ulcer report morechronic diagnoses [e.g. fibromyalgia, migraines, temporo-mandibular joint disorders, and higher Center for Epidemio-logic Studies Depression Scale (CES-D) and SymptomIntensity Scale (SIS) scores]. Differences have been shown inthe number of comorbid diagnoses and symptoms in IC/BPSbetween subtypes and controls [7]. Killinger et al. assessedIC/BPS subtypes, aiming to indicate key differences [8]. Sim-ilar triggers for certain foods, exercise and stress are found inboth groups. Ulcerative patients report more pain with vagi-nal penetration compared to non-ulcerative patients. Similarnumbers of pain areas were shown, and the ICSI-PI, McGillPain Questionnaire Short Form (MPQ-SF) and Brief PainInventory (BPI) scores were the same. On the MPQ-SF,ulcerative pain is described as sharp, stabbing and burninghot, whereas non-ulcerative patients describe the pain asaching, cramping and tender. It was concluded that no signif-icant differences in pain are found between subtypes [8]. ThePelvic Pain and Urgency/Frequency (PUF) and O’Leary–Santquestionnaires do not have sufficient specificity to serve as adiagnostic indicator discriminating patients with or withoutIC, but can be used for screening. In this study, the ICgroup was compared with a group “without IC” (e.g. cancer,urinary incontinence, urinary tract infection, kidney stone,neurogenic bladder, benign prostatic hyperplasia), which

Correspondence: Professor Jean-Jacques Wyndaele MD, Department ofUrology, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem,Belgium. E-mail: jean-jacques.wyndaele@Uantwerpen.be

http://informahealthcare.com/sjuISSN: 2168-1805 (print), 2168-1813 (electronic)

Scand J Urol, 2014; Early Onlne: 1–2� Informa Healthcare. DOI: 10.3109/21681805.2014.982170

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does not mean BPS [9]. The O’Leary–Sant has been shownto have a high sensitivity but low specificity for differentiat-ing IC from non-IC, and should not be used to differentiateIC [10].

The literature did not indicate specific questionnaires ableto show symptom differences between type 3C and non-type3C BPS. We suggest using the ESSIC guideline to differenti-ate between subgroups in BPS. The interpretation of theterminology used in these publications is problematic in theactual context. The questionnaires do not seem to differenti-ate between subtypes.

Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the contentand writing of the paper.

References

[1] van de Merwe JP, Nordling J, Bouchelouche P, Bouchelouche K,Cervigni M, Daha LK, et al. Diagnostic criteria, classification,and nomenclature for painful bladder syndrome/interstitial cysti-tis: an ESSIC proposal. Eur Urol 2008;53:60–7.

[2] Rais-Bahrami S, Friedlander JI, Herati AS, Sadek MA,Ruzimovsky M, Moldwin RM. Symptom profile variability of

interstitial cystitis/painful bladder syndrome by age. BJU Int2012;109:1356–9.

[3] Bogart LM, Berry SH, Clemens JQ. Symptoms of interstitial cys-titis, painful bladder syndrome and similar diseases in women:a systematic review. J Urol 2007;177:450–6.

[4] Peeker R, Fall M. Treatment guidelines for classic and non-ulcerinterstitial cystitis. Int Urogynecol J Pelvic Floor Dysfunct2000;11:23–32.

[5] Koziol JA, Adams HP, Frutos A. Discrimination between theulcerous and the nonulcerous forms of interstitial cystitis bynoninvasive findings. J Urol 1996;155:87–90.

[6] Peeker R, Fall M. Toward a precise definition of interstitialcystitis: further evidence of differences in classic and nonulcerdisease. J Urol 2002;167:2470–2.

[7] Peters KM, Killinger KA, Mounayer MH, Boura JA. Are ulcera-tive and nonulcerative interstitial cystitis/painful bladdersyndrome 2 distinct diseases? A study of coexisting conditions.Urol 2011;78:301–8.

[8] Killinger KA, Boura JA, Peters KM. Pain in interstitialcystitis/bladder pain syndrome: do characteristics differ in ulcera-tive and non-ulcerative subtypes? Int Urogynecol J 2013;24:1295–301.

[9] Kushner L, Moldwin RM. Efficiency of questionnaires used toscreen for interstitial cystitis. J Urol 2006;176:587–92.

[10] Xu L, Zhang P, Zhang N, Yang Y, Wu ZJ, Zhang CH, et al.[Efficiency of O’Leary–Sant symptom index and problem indexin the diagnosis of interstitial cystitis]. Zhonghua Yi Xue Za Zhi2013;93:3347–50.

2 J. Quaghebeur & J.-J. Wyndaele Scand J Urol, 2014; ( ): 1–2

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