Karen Raphael, PhD
|
National Report—Is there a connection between abuse and interstitial cystitis? A study presented at the 2006 AUA annual meeting linked the
two, raised a storm of controversy, and prompted more studies that confirmed higher rates of abuse in women with IC or lower
urinary tract symptoms than in controls. But have those studies answered the question? Should research keep asking it? More
important, do the findings imply that abused patients should be treated differently or that urologists should ask patients
about possible abuse?
Kenneth M. Peters, MD
|
Abuse estimates in women with IC and in those with LUTS ranged widely in these studies, from just 3.8% for "late effects of
child abuse" in an HMO records review by J. Quentin Clemens, MD, et al (J Urol 2008; 179:2222-5) to as high as 49% reporting any abuse and 33% reporting sexual abuse in a study by Kenneth M. Peters, MD,
and colleagues (J Urol 2007; 178:891-5) that kicked off the controversy.
Why are rates so different? Except for the records review, investigators asked patients about their abuse history. As Kristene
Whitmore, MD, chair and professor of urology and female pelvic medicine and reconstructive surgery at Drexel University College
of Medicine in Philadelphia, pointed out, "It's how you ask the question."
To demonstrate, Dr. Whitmore's group asked patients about abuse by using simple questions, similar to those asked in Dr. Peters'
case-control study, and through a validated questionnaire that described abuse specifically (both answered privately). Simple
questions yielded an 11% rate of physical abuse and a 28% rate of sexual abuse, but the validated questionnaire figures yielded
31% for physical abuse, 36% for sexual abuse, and 21% for childhood sexual abuse (Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:1683-6). "A validated tool may provide more comprehensive information regarding abuse," Dr. Whitmore said.
The study led by Dr. Peters, chairman of the urology department at Beaumont Hospital, Royal Oak, MI, also identified differences
in responses based on how questions about abuse were asked. This report included data from a case-control survey study and
face-to-face interviews. The survey questionnaire asked if the women had ever experienced any form of abuse, and if so, what
type. That yielded an overall abuse rate of 38%, a physical abuse rate of 17%, and a sexual abuse rate of 18%. All rates were
significantly greater than for controls. Patient interviews yielded much higher figures: 49% for any abuse and 33% for sexual
abuse. Interviews also yielded a 17% rate of childhood abuse.
However, the rates elicited with simple questioning reported in both studies seem to align with national averages. Published
abuse rates, most likely generated from simple questions, rather than from validated questionnaires, are 15% to 25% for sexual,
15% to 25% for childhood sexual, and 5% to 28% for physical abuse of women, Dr. Whitmore's group reported. Only sexual abuse
was statistically significantly higher than the national range, "but not by much," Dr. Whitmore told Urology Times.
These two cross-sectional studies using self-report are supported by an unpublished study presented at the 2008 AUA annual
meeting that showed a relationship between sexual trauma and LUTS in a Veterans Administration referral population of women
(J Urol 2008; 179; 4:537, abs. 1571), and a study published late in 2008 found more pain and fewer voiding symptoms in abused women
than in non-abused women with IC (J Urol 2008; 180:2029-33).
Longitudinal studies of abused patients would be needed to verify a relationship between abuse and IC or chronic pain. An
answer from such a study "would trump 15 studies that have come before," Howard Goldstein, DO, told Urology Times. Dr. Goldstein was first author with Dr. Whitmore in Philadelphia on her study of abuse and IC. He is now director of research
and education at the Center for Urogynecology and Pelvic Surgery in Newark, DE.
Just such a study has been done by Karen Raphael, PhD, professor of psychiatry at New Jersey Medical School, Newark, who studies
psychiatric and psychosocial factors in chronic pain conditions. Her longitudinal study followed 676 children (half of them
female) with court-documented abuse and neglect into adulthood and compared their rate of adult pain with that in 520 matched
controls. The study found no relationship between any type of childhood abuse and adult pain.
"Overall findings also related to pelvic pain," Dr. Raphael said. "This was based on self-report, as assessed in the somatization
subscale of the Diagnostic Interview Schedule."
Because the patients may not have fully experienced their risk period for developing pain syndromes, Dr. Raphael followed
them further into middle adulthood. The study, as yet unpublished but presented last fall at the International Association
for the Study of Pain's World Congress on Pain, showed a modest relationship between abuse and pain, which was significant
only for those who also had post-traumatic stress disorder, she told Urology Times.
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