Objective
The objective of the study was to compare subjects with interstitial cystitis/painful bladder syndrome (IC/PBS) with controls on prior surgeries.
Study Design
IC/PBS subjects were compared with matched controls on surgeries and possible surgical indications prior to their index dates.
Results
Adjusted for demographic variables, logistic regression showed subjects exceeded controls in surgeries longer than 12 months and less than 1 month before the index date. However, addition of possible surgical indications showed chronic pelvic pain (CPP) to have a strong association with IC/PBS, whereas associations with surgeries were reduced to nonsignificance.
Conclusion
Although women with IC/PBS were more likely to have experienced prior surgeries than controls, the apparent indications for surgeries, not the surgeries themselves, were stronger risk factors for IC/PBS. In particular, a prior history of CPP had a strong association with IC/PBS. Several features of study design, including extensive medical record review, suggest that prior CPP was not undiagnosed IC/PBS. Further investigation of CPP may yield insight into the pathogenesis of IC/PBS.
Interstitial cystitis/painful bladder syndrome (IC/PBS) is characterized by pain perceived to be coming from the bladder, urinary urgency and frequency, and nocturia. Its etiology is unknown. For years IC/PBS case series have reported apparently high numbers of IC/PBS patients with a history of hysterectomy and other pelvic surgeries. Hall et al and Ingber et al confirmed this observation in comparisons with controls. However, no study has compared cases with controls prior to onset of IC/PBS symptoms. Others have reported urinary symptoms beginning after hysterectomy. Taken together, these observations generate the hypothesis that hysterectomy and possibly other pelvic surgeries identify women at risk for IC/PBS or are even initiators of IC/PBS.
Seeking clues to the pathogenesis of IC/PBS, we have tested this hypothesis in a case-control study, Events Preceding IC (EPIC). Specifically we hypothesized that significantly more cases than controls experienced pelvic surgeries, especially just before IC/PBS onset.
Materials and Methods
Detailed methods of EPIC have been reported. This was a study of women with IC/PBS symptoms for 12 months or less recruited nationally through urologists and patient support groups and controls recruited by random digit dialing and matched on sex, age, and national region. The index date for each case was the date of onset of IC/PBS symptoms, and for each matched control, it was a date at an equivalent interval prior to her initial interview. A female interviewer queried pre-index date exposures. At semiannual follow-ups, 2 cases were dropped from the study because other diseases with symptoms possibly mimicking IC/PBS were diagnosed.
Each participant was asked the following: “At any time before your index date of _____, did you have any type of surgery that required anesthesia (ie, general anesthesia, an epidural or spinal, or a regional block, not including local anesthesia or intravenous sedation)?” If she answered yes, she was asked the number of surgeries at any time in her life, within 12 months, and within 1 month before her index date and, in these time periods, about surgeries that required placement of foreign material, dental procedures and these pelvic operations: hysterectomy (and age), other uterine surgery, ovarian surgery including bilateral oophorectomy (and age), tubal ligation, bladder surgery, nonabortion dilation and curettage (D&C), and other pelvic surgery (and specific types). We did not determine whether multiple procedures were performed at the same operation.
For possible surgical indications, we asked for self-reported physician diagnoses of endometriosis (diagnosed by laparoscopy or other surgery) or uterine fibroids and for self-report of urinary stones, vaginal objects requiring removal by a physician, urethral or genital straddle trauma, or automobile accidents requiring medical care. Infertility was inability to conceive for 12 months or longer.
We also included in this analysis 11 syndromes previously shown in the EPIC study to be more common in IC/PBS subjects than controls prior to their index dates: chronic fatigue (CFS), fibromyalgia (FM), irritable bowel (IBS), sicca, migraine, depression, panic, asthma, allergies, vulvodynia, and chronic pelvic pain (CPP). The presence of prior CPP was based on response to a question modified from Mathias et al: “pelvic pain, either constantly or off and on, for 3 months or more. By pelvic pain I mean pain below the belly button or in the female organs.”
Cases and controls were compared by χ 2 and Student t tests. Multiple logistic regression analyses compared them on prior surgeries adjusted for demographic variables and possible surgical indications.
Results
Three hundred twelve IC/PBS cases and 313 controls completed the study. Although matched on sex, age, and region of the country, more cases than controls were white, Jewish, and college educated, and they were more likely to have health insurance and higher annual incomes ( Table 1 ).
| Variable | Cases | Controls | P value |
|---|---|---|---|
| Age in years, mean (SD) | 42.3 (12.6) | 42.9 (13.0) | .56 |
| Race | |||
| White | 300 (96.15) | 266 (85.0) | < .01 |
| Black | 5 (1.6) | 31 (9.9) | — |
| Asian | 2 (0.6) | 2 (0.6) | — |
| American Indian/Alaskan Native | 2 (0.6) | 5 (1.6) | — |
| Refused | 3 (1.0) | 9 (2.9) | — |
| Hispanic | 10 (3.2) | 15 (4.8) | .38 |
| Religion of parents | |||
| Christian | 268 (85.9) | 287 (91.7) | .02 |
| Jewish | 30 (9.6) | 13 (4.2) | .01 |
| Other | 26 (8.3) | 18 (5.8) | .21 |
| Marital status | |||
| Married | 212 (68.0) | 201 (64.2) | .30 |
| Education | |||
| BA degree or higher | 177 (56.7) | 128 (40.9) | < .01 |
| Household income | |||
| >$75k | 122 (39.1) | 80 (25.6) | < .01 |
| Health insurance | 302 (96.8) | 278 (88.8) | < .01 |
Before their index dates, significantly more IC/PBS cases than controls reported surgeries, including most of the specific pelvic surgeries queried ( Table 2 ). “Other” pelvic surgeries did not differ in gastrointestinal (mostly appendectomies) and genital (predominantly cervical) procedures but did differ in urologic surgeries (18 cases vs 2 controls; P < .002): 4 cases had kidney, 5 ureter/stone, 8 bladder, and 1 urethral operations. More cases reported prior operation for prolapse (4 vs none; P = .044). Controls exceeded cases only in prior tubal ligations.
| Surgery | Any time a | >12 mo | 1-12 mo | <1 mo | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cases | Controls | P value | Cases | Controls | P value | Cases | Controls | P value | Cases | Controls | P value | |
| Any type | 282 | 253 | .001 | 264 | 244 | < .0001 | 51 | 42 | .304 | 27 | 8 | .001 |
| Mean number | 3.1 | 2.1 | < .0001 | 2.8 | 1.9 | < .0001 | 0.19 | 0.16 | .459 | 0.09 | 0.02 | .0007 |
| Pelvic | ||||||||||||
| Ovarian | 68 | 47 | .029 | 57 | 45 | .19 | 4 | 2 | .45 | 7 | 0 | .008 |
| BO | 40 | 30 | .200 | 34 | 29 | .50 | 2 | 1 | .62 | 4 | 0 | .044 |
| Hysterectomy | 72 | 49 | .019 | 61 | 47 | .13 | 3 | 2 | .65 | 8 | 0 | .004 |
| Other uterine | 29 | 12 | .006 | 24 | 12 | .038 | 2 | 0 | .25 | 3 | 0 | .12 |
| Tubal ligation | 48 | 77 | .004 | 46 | 70 | .014 | 2 | 6 | .29 | 0 | 1 | .318 |
| Bladder | 18 | 11 | .180 | 16 | 11 | .32 | 2 | 0 | .25 | 1 | 0 | NS |
| Other | 103 | 69 | .002 | 93 | 64 | .007 | 8 | 5 | .40 | 5 | 0 | .03 |
| Laparoscopy b | 62 | 20 | < .001 | 54 | 15 | < .0001 | 4 | 3 | .72 | 4 | 2 | .45 |
| D&C | 79 | 48 | .002 | 74 | 44 | .002 | 2 | 3 | 1.0 | 3 | 1 | .314 |
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