Patients with interstitial cystitis/bladder painful syndrome (IC/BPS) and chronic prostatitis/chronic pelvic pain (CP/CPP) show higher risks of some non-urologic associated somatic syndromes (NUASS), including irritable bowel syndrome (IBS), fibromyalgia (FM), vulvodynia, general fatigue, headaches and temporo- mandibular disorders, and frequently present with pain unrestricted to the pelvic area. In addition higher odds of comorbid autoimmune or neurological diseases and multiple allergies and sensitivities can be identified in these patients. These overlapping conditions and a more largely extended pain are consistent with a shared pathogenetic mechanism represented by central sensitization. 
Aims of this study were to investigate NUASS accompanying urologic chronic pelvic pain, and pain location in a group of patients affected by IC/BPS and CP/CPP, and to assess the relationships with urinary symptoms and severity of pain.

Forty- one patients with IC/BPS were prospectively enrolled in an observational study. Patients completed questionnaires about their medical history, course of disease and medications. NUASS and other concomitant, autoimmune and neurological diseases were assessed by a detailed, self- reported history. According to a pain body mapping, patients were classified as having pelvic pain only (PP) only, PP beyond the pelvis and widespread pain. A pain numeric rating scale (PNRS: 0 = worst pain imaginable; 10 = no pain) was used to investigate the severity of pain. In order to evaluate urinary symptoms, all the patients underwent the recording of the 3-day voiding diary and uroflowmetry with measurement of post-void urinary residual volume. All cases underwent cystoscopy with hydro-distension.

There were 14 males and 27 females; mean age was 57.5 ± 15.4 yrs. Mean ± SD duration of pelvic pain was 5.2 ± 1.4 yrs. NUASS were identified in 31 (75.6%) cases, alone or in multiple combinations, and the most frequently observed associated somatic diseases were IBS and gastro- oesophageal reflux in 14.6% of cases respectively (Graph). Autoimmune conditions were detected in 6 patients (Graph). According to the pain body map, PP only was observed in 26.8% of patients, PP beyond the pelvis in 58.6% and widespread pain in 14.6% of cases. Mean ± SD score of PNRS was 4.16 ± 1.07 in patients with PP only, 4.18 ± 1.05 in patients with pain beyond the pelvis and 3.79 ± 0.8 in patients with widespread pain. Frequency of urinary symptoms is showed in the Table. Significant relationships were identified between IBS and nocturia (p< 0.001), and between gastro- oesophageal reflux disease and urinary urgency (p< 0.002). Patients with widespread pain presented with a more severe pain and a more frequent nocturia (p< 0.005, and p=0.03, respectively). On cystoscopy with hydro-distension, no Hunner lesion was identified; 8 patients (6 females, 2 males) showed glomerulations and hyperaemic or bleeding mucosa. In these cases, pelvic pain only was observed in 5 patients (with concomitant depression in 2 and rheumatic fever in 1). In the remaining 3 patients, all affected by pain beyond the pelvis, presence of IBS, gastro- oesophageal reflux and sarcoidosis were identified.

According to the literature, our study confirms a high prevalence of PP beyond the pelvis (58.6%) in patients affected by IC/BPS and CP/CPPS. Prevalence of NUASS, isolated or in multiple combinations, was really elevated (75.6%), a result which is somewhat higher than that reported in the literature. Interestingly, in our study more nocturia and urinary urgency were significantly associated with IBS and gastro-oesophageal reflux, which are commonly observed in patients with chronic pelvic pain. These associations can indicate a more disturbing effect of IBS and gastro-oesophageal reflux on urinary symptoms, but also can represent objective findings of a shared pathogenetic mechanism in patients with IC/BPS and CP/CPPS. Another important result in our study was the significant association between a widespread location of pain with a more severe pain and a more frequent nocturia, which indicates a greater impairment in those patients with a more extended painful disease. Indeed, data from the literature cannot still clarify whether and why different clinical phenotypes are linked to difference in pain severity. Interestingly, our study shows that NUASS and autoimmune disorders can be detected also in patients with bladder alterations indicative of IC/BPS type 2, in whom pain is not exclusively localized only into the pelvic area.

Patients with IC/BPS and CP/CPPS are affected by a high prevalence of pain not restricted to the pelvic area, and present with a high percentage of non- urologic associated somatic syndromes, particularly IBS and gastro-oesophageal reflux, and autoimmune diseases, which can all contribute to affect urinary symptoms. It should be a usual clinical behaviour to perform a detailed evaluation of patients with IC/BPS and CP/CPPS in order to identify cases with concomitant non- urologic or autoimmune diseases and to detect the extension of pain, to better apply additional systemic therapies directed to centrally mediated mechanisms.

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