The UPOINT System for the Clinical Phenotyping of Chronic Pelvic Pain by Nickel, Shoskes and Racily was the first proposed subtyping system for chronic pelvic and bladder pain. It asked physicians to look at and beyond the bladder in six different areas, including:
- what urinary symptoms are present?
- what’s the condition of the bladder (i.e. Hunner’s lesions)?
- does the patient have other related conditions (i.e. IBS)?
- what is the health of the pelvic floor muscles?
- does the patient struggle with anxiety / depression?
- has any infection been found?
Based upon the answers to these questions, they urged doctors to create a custom treatment plan for each patient. This “whole body” approach has been validated in multiple research studies and serves as the foundation for the Canada Urology Associations Guidelines For IC/BPS that were released in 2016.
UPOINT has been remarkably helpful when assessing the chronic prostatitis population however for IC, it has key limits because most IC patients have some degree of bladder symptoms and bladder wall dysfunction. Original co-author Dan Shoskes and colleagues have adapted these guidelines to create a new system for use specifically with IC, called INPUT. This asks physicians to assess five distinct areas:
- I – Is any infection present?
- N – Does the patient also have any other neurologic or systemic conditions
- P – Does the patient have any anxiety / depression or other psychosocial issues?
- U – Does the patient have Hunner’s ulcers (now known as lesions)
- T – Does the patient have tight or dysfunctional pelvic floor muscles.
They tested this system with 239 men and women. The incidence of domains was Infection 11%, Neurologic/Systemic 51%, Psychosocial 81%, Ulcers 18% and Tenderness 85%. Patients had, on average, 2.46 domains and 65% had 2 or 3 positive domains. Only 5% had none. The greater the number of domains, the great the symptoms. Hunners lesions increased symptom scores. They conclude that the INPUT system replicates the validity and clinical utility of the UPOINT system. They also believe that patients may benefit from multimodal therapy up front for each extra domain rather than relying on the sequential tiered approach found in the AUA Guidelines.
There will, undoubtedly, be many proposed subtyping systems in the years to come both at the clinical level and also at the pathological level as they study biopsy samples. I find that the 5 subtypes proposed by Christopher Payne MD in 2015 to be remarkably useful in the education of patients however it does not offer the same validity testing that the UPOINT and INPUT system has. Payne proposed five subtypes:
- Hunner’s lesions
- Bladder Wall Driven
- Pelvic Floor Driven
- Pudendal Neuralgia
- Functional Somatic Syndrome / Central Sensitization
Both systems have good points thus we have to look at what they have omitted to determine their value. Neither the UPOINT or the INPUT system consider the role of pudendal nerve entrapment or pudendal neuralgia. It also has some naming challenges in that Hunner’s ulcers are now called Hunner’s lesions. In contrast, the Payne system doesn’t evaluate for anxiety or depression which is clearly important for assessing that patients overall health and quality of life. I can foresee a proposal which blends the best of both!
Crane A, et al. IMPROVING THE UTILITY OF CLINICAL PHENOTYPING IN INTERSTITIAL CYSTITIS/PAINFUL BLADDER SYNDROME: FROM UPOINT TO INPUT. JUROL April 2017 Volume 197, Issue 4, Supplement, Pages e386–e387