Non-Hunner's Interstitial Cystitis Is Different from Hunner's Interstitial Cystitis and May Be Curable by Uterosacral Ligament Repair

Abstract

Background: The posterior fornix syndrome (PFS) was first described in 1993 as a predictably occurring group of symptoms: chronic pelvic pain (CPP), urge, frequency, nocturia, emptying difficulties/urinary retention, caused by uterosacral ligament (USL) laxity, and cured by repair thereof.

Summary: Our hypothesis was that non-Hunner's interstitial cystitis (IC) and PFS are substantially equivalent conditions. The primary objective was to determine if there was a causal relationship between IC and pelvic organ prolapse (POP). The secondary objective was to assess whether other pelvic symptoms were present in patients with POP-related IC and if so, which ones? How often did they occur? A retrospective study was performed in 198 women who presented with CPP, uterine/apical prolapse (varying degrees), and PFS symptoms, all of whom had been treated by posterior USL sling repair. We compared their PFS symptoms with known definitions of IC, CPP, and bladder symptoms. To check our hypothesis for truth or falsity, we used a validated questionnaire, "simulated operations" (mechanically supporting USLs with a vaginal speculum test to test for reduction of urge and pain), transperineal ultrasound and urodynamics.

Key messages: 198 patients had CPP and 313 had urinary symptoms which conformed to the definition for non-Hunner's IC. The cure rate after USL sling repair was CPP 74%, urge incontinence 80%, frequency 79.6%, abnormal emptying 53%, nocturia 79%, obstructive defecation 80%. Our findings seem to support our hypothesis that non-Hunner's IC and PFS may be similar conditions; also, non-Hunner IC/BPS may be a separate or lesser disease entity from "Hunner lesion disease". More rigorous scientific investigation, preferably by RCT, will be required.

Keywords: Chronic pelvic pain; Interstitial cystitis; Posterior fornix syndrome; Urinary urgency; Uterosacral ligaments.

Fig. 1

Diagnostic algorithm. A “shorthand” diagnostic method where symptoms indicate which ligaments are causing which prolapse and which symptoms. The connective tissue structures fall naturally into 3 zones of causation. Ticking symptom occurrence diagnoses ligament defect and serves as a guide to surgery. For example, nocturia and pelvic pain are almost exclusively caused by “USL”; laxity; stress incontinence, by pubourethral laxity “PUL.” We have entered quantum of symptoms in numbers instead of ticking the boxes. The conditions in all 3 columns are caused by ligament laxity. Only some conditions in the right column can be attributed to IC, as defined [2]. Anterior zone runs from external meatus to bladder neck, and comprises EUL (external urethral ligament); PUL (pubourethral ligament); and suburethral vaginal hammock. Middle zone runs from bladder neck to anterior cervical ring and comprises PCF (pubocervical fascia); CL (cardinal ligament); and ATFP (arcus tendineus fascia pelvis). Posterior zone runs from USL (uterosacral ligament); RVF (rectovaginal fascia); to PB (perineal body). The height of the bar indicates probability of causation.

Fig. 2

Integral theory system diagnostic pathway-specific symptoms in the ITSQ questionnaire [8] indicate which ligaments/fascias may be damaged. The symptoms are transferred to the diagnostic algorithm; the diagnosis from the algorithm is checked by vaginal examination [6] to confirm specific ligament laxity; the causative ligaments are then checked by “simulated operations,” i.e., mechanical support of pubourethral and uterosacral ligaments to observe change in symptoms.

Fig. 3

“Simulated operation” to support uterosacral ligaments “USL.” 3D view of PUL and USL attachments to the pelvic brim (circle). A gently inserted speculum mechanically supports USLs. “L” indicates USL laxity. Lax USLs (laxity indicated by wavy lines) cannot support the “VPs” and these fire of impulses to the cortex which are interpreted as pain. Wavy lines in the muscles LP and LMA which contract against USLs indicate weakened muscle forces, as a muscle requires a firm insertion USL point to exert optimal force. The wavy form of the vagina indicates looseness; it cannot be stretched sufficiently to support the urothelial stretch receptors “N” which now fire off excess afferents to activate the micturition reflex prematurely. The cortex interprets these impulses as “urge.” The speculum mechanically supports USLs, “N” and stretches vagina to reverse the above processes; the patient reports lessening of pain and urge. LP, levator plate; LMA, conjoint longitudinal muscle of the anus.

Fig. 4

Mechanism for CPP by stimulation of the VP. Left figure 3D view of organs and VP which serves as a type of “relay” for end organ afferents from bladder “B,” lower abdominal and pelvic muscles “M,” vagina/vulva “V,” rectum “R.” G = force of gravity which stimulates VP if they are not sufficiently supported by USLs. By permission S Muctar. Right figure 3D view showing pathways of impulses to and from the cortex (small arrows) via the hypogastric (Frankenhauser) plexus (T11-L2). And the effect of USL laxity “L.”