Small-fiber Neuropathy Likely in Women With Complex Chronic Pelvic Pain and Autonomic Bladder Dysfunction

Patients with small-fiber neuropathy or polyneuropathy (SFN) are apt to develop chronic pain, which can occur anywhere in the body. Elise J.B. De, MD, a urologist in the Department of Urology at Massachusetts General Hospital, and colleagues previously reported in Pain Medicine that up to 64% of patients with complex refractory or multisystem pelvic pain had biopsy-proven SFN.

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SFN often produces autonomic symptoms. In the same paper, the group described 15 patients with SFN who underwent video urodynamic studies (VUDS), of whom nine exhibited bladder neck obstruction (BNO) and six had atony or inability to mount a bladder contraction.

Given these associations, Dr. De, Sarah Mozafarpour, MD, a clinical fellow in surgery in the Mass General Department of Urology, and colleagues recently explored further. In Neurourology and Urodynamics, they say patients with complex chronic pelvic pain (CPP) who had autonomic bladder dysfunction were more likely to have SFN than those without bladder dysfunction.

Methods

The study included 55 adults with complex CPP, defined as either (a) pelvic pain that persisted for more than six months despite first-line treatments, or (b) pelvic pain that co-occurred with other chronic pain syndromes, such as migraine, irritable bowel syndrome, interstitial cystitis, fibromyalgia, gastroesophageal reflux disease, lower back pain, endometriosis or vulvodynia.

Presence of SFN

• Primary analysis—Four patients were excluded because of urodynamic confounders. Of the remaining 51 (43 female, eight male), 39 underwent subspecialty autonomic neurology evaluation and VUDS. Those with autonomic bladder dysfunction (either BNO or detrusor underactivity) were more likely to have SFN (OR, 11.11; P=0.001)
• Secondary analysis—Of the original 55 patients, 43 (36 female, seven male) completed autonomic neurology evaluation. 38 (65%) were diagnosed with SFN

SFN in Women

Men were removed from further analysis because obstructive parameters and detrusor underactivity are not comparable in women and men. 32 of the women with complex CPP underwent both subspecialty neurology evaluation and VUDS:

• 23 (72%) had SFN
• Women with autonomic bladder dysfunction were more likely than those without to have SFN (OR, 9.5; P=0.007)
• Postvoid residual and clinical complaints of urge urinary incontinence were each significantly more likely in women with SFN than in those without

VUDS Findings in Women

19 (83%) of the women who had both complex CPP and SFN exhibited autonomic bladder dysfunction: seven (30%) had detrusor underactivity, and 12 (52%) had BNO.

Offering More to Patients

The findings of this study have two converse potential benefits:

• Identifying SFN-related autonomic bladder dysfunction in patients with complex CPP suggests additional approaches to pain treatment, such as treating BNO with alpha-blockers, botulinum toxin and neuromodulation
• Identifying autonomic bladder dysfunction in patients with complex CPP suggests the need for evaluation for SFN (a table in the article lists other symptoms that should raise suspicion for SFN)

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