Review of Bladder Pain and Referred T12–L2 Input as One Etiology for Interstitial Cystitis

Abstract

Background The etiology of interstitial cystitis (IC)/bladder pain syndrome (BPS) remains a mystery. Based on two patients, whose IC/BPS was relieved by resection of injured iliohypogastric (IH) and ilioinguinal (II) nerves, injured by endoscopic prostatectomy in the first patient and a stretch/traction injury in the second patient, a referred pain pathway is hypothesized that can be applied to patients with IC/BPS and previous abdominal wall surgery/injury.

Methods The known neurophysiology of bladder function was reviewed as were the pathways for accepted referred pain syndromes.

Results Perception of bladder filling occurs by impulses generated from stretch receptors in the bladder wall, traveling along visceral afferent fibers that enter the thoracolumbar spinal cord at T12, L1, and L2, the same location as the sympathetic outflow to the viscera and the same location as some of the visceral afferents from the bladder. The II and IH nerves originate from T12, L1, and sometimes L2 somatic, dorsal root ganglia. It is hypothesized that somatic afferent pain impulses, from the lower abdominal wall, are misinterpreted as visceral afferent impulses from the bladder, giving rise to the urinary frequency and urgency of IC/BPS. Resecting injured cutaneous afferents (II and IH) permitted long-term IC/BPS relief in the first patient for 59 months and in the second patient for 30 months. Neural inputs from the sacral visceral afferents and sacral somatic afferents did not appear to be involved in this referred pain pathway.

Conclusion Nerve blocks of the T12 -L2 spinal nerves in patients with bladder pain who also have had abdominal wall surgery/injury may identify IC/BPS patients for whom resection of the II and IH nerves may prove beneficial in obtaining lasting IC/BPS relief.

Keywords

bladder pain - ilioinguinal - iliohypogastric

• References

• 1 Hano P. Editorial comment to hypersensitive bladder: a solution to confused terminology and ignorance concerning interstitial cystitis. Int J Urol 2014; 21 (Suppl. 01) 48
• 2 Clemens JQ, Link CL, Eggers PW, Kusek JW, Nyberg Jr LM, McKinlay JB. ; BACH Survey Investigators. Prevalence of painful bladder symptoms and effect on quality of life in black, Hispanic and white men and women. J Urol 2007; 177 (04) 1390-1394
• 3 Verghese TS, Riordain RN, Champaneria R, Latthe PM. Complementary therapies for bladder pain syndrome: a systematic review. Int Urogynecol J Pelvic Floor Dysfunct 2016; 27 (08) 1127-1136
• 4 Pazin C, de Souza Mitidieri AM, Silva AP, Gurian MB, Poli-Neto OB, Rosa-E-Silva JC. Treatment of bladder pain syndrome and interstitial cystitis: a systematic review. Int Urogynecol J Pelvic Floor Dysfunct 2016; 27 (05) 697-708
• 5 Chai TC, Birder LA. Physiology and Pharmacology of the Bladder and Urethra. In: Wein AJ, Kavoussi LR. , eds. Campbell-Walsh Urology. 14th ed. Philadelphia, PA: Elsevier;
• 6 le Feber J, van Asselt E, van Mastrigt R. Afferent bladder nerve activity in the rat: a mechanism for starting and stopping voiding contractions. Urol Res 2004; 32 (06) 395-405
• 7 Choudhary M, van Asselt E, van Mastrigt R, Clavica F. Neurophysiological modeling of bladder afferent activity in the rat overactive bladder model. J Physiol Sci 2015; 65 (04) 329-338
• 8 Gillespie JI, Markerink-van Ittersum M, de Vente J. Sensory collaterals, intramural ganglia and motor nerves in the guinea-pig bladder: evidence for intramural neural circuits. Cell Tissue Res 2006; 325 (01) 33-45
• 9 Yoo PB, Woock JP, Grill WM. Somatic innervation of the feline lower urinary tract. Brain Res 2008; 1246: 80-87
• 10 Learmonth JR. Contribution to the neurophysiology of the urinary bladder in man. Brain 1931; 54 (02) 147-176
• 11 Learmonth JR. The value of neurosurgery in certain vesical conditions. J Am Med Assoc 1932; 98 (08) 632-636
• 12 Romanes GJ. Cunningham's Textbook of Anatomy, 10th ed. London, United Kingdom: Oxford University Press; 1964
• 13 Liszka TG, Dellon AL, Manson PN. Iliohypogastric nerve entrapment following abdominoplasty. Plast Reconstr Surg 1994; 93 (01) 181-184
• 14 Dellon AL. Pelvic pain. In: Pain Solutions. 2nd ed. Lightning Source; 2007: 328-330
• 15 Doran FSA. The sites to which pain is referred from the common bile-duct in man and its implication for the theory of referred pain. Br J Surg 1967; 54 (07) 599-606
• 16 Rab M, Ebmer And J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg 2001; 108 (06) 1618-1623
• 17 Lee CH, Dellon AL. Surgical management of groin pain of neural origin. J Am Coll Surg 2000; 191 (02) 137-142
• 18 Langley JN, Anderson HK. The Innervation of the Pelvic and adjoining Viscera: Part VII. Anatomical Observations. J Physiol 1896; 20 (4-5): 372-406
• 19 Piri G. Clinical Contributions to the Surgery of the Autonomic Nervous System IV. The Cure of Tuberculous Cystitis, Italian Arch Surg 1930; 27: 454-482
• 20 Dellon AL, Amadio PC. James R. Learmonth: the first peripheral nerve surgeon. J Reconstr Microsurg 2000; 16 (03) 213-217
• 21 Talaat M. Afferent impulses in the nerves supplying the urinary bladder. J Physiol 1937; 89 (01) 1-13
• 22 Scott WJM, Schroeder CF. Denervation of the bladder for intractable pain. Ann Surg 1938; 108 (04) 730-740
• 23 Warren JW, Langenberg P, Greenberg P, Diggs C, Jacobs S, Wesselman U. Sites of pain from painful Interstitial Cystitis/Bladder Pain Syndrome. J Urol 2008; 180 (04) 1373-1377
• 24 Lai HH, Gardner V, Ness TJ, Gereau IV RW. Segmental hyperalgesia to mechanical stimulus in interstitial cystitis/bladder pain syndrome: evidence of central sensitization. J Urol 2014; 191 (05) 1294-1299
• 25 Mui J, Allaire C, Williams C, Yong PJ. Abdominal wall pain in women with chronic pelvic pain. J Obstet Gynaecol Can 2016; 38 (02) 154-159
• 26 Kyloh M, Nicholas S, Zagorodnyuk VP, Brookes SJ, Spencer NJ. Identification of the visceral pain pathway activated by noxious colorectal distension in mice. Front Neurosci 2011; 5: 16
• 27 Spencer NJ, Zagorodnyuk V, Brookes SJ, Hibberd T. Spinal afferent nerve endings in visceral organs: recent advances. Am J Physiol Gastrointest Liver Physiol 2016; 311 (06) G1056-G1063