Open Access

ARTICLE

Improving the utility of clinical phenotyping in interstitial cystitis/painful bladder syndrome: from UPOINT to INPUT

Alice Crane, Jessica Lloyd, Daniel A. Shoskes

Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
Address correspondence to Dr. Jessica C. Lloyd, Glickman Urological and Kidney Institute, 9500 Euclid Avenue, Cleveland, OH 44195 USA

Canadian Journal of Urology 2018, 25(2), 9250-9254.

Abstract

Introduction: The UPOINT phenotyping system has proven effective in classifying patients with urologic pelvic pain syndromes in a clinically meaningful way and guiding multimodal therapy. While highly successful in men with chronic prostatitis/chronic pelvic pain syndrome (CPPS), its utility is more limited in patients with interstitial cystitis/painful bladder syndrome (IC/PBS). This is because all IC/PBS patients, by definition, exhibit urinary and organ-specific symptoms. Furthermore, the AUA guidelines recommend a sequential tiered approach to treatment rather than the concurrent multimodal strategy used in UPOINT. Therefore, we aimed to modify the UPOINT system to make it more practical and effective for use in IC/PBS. Materials and methods: We developed a modified phenotyping system by removing the urinary and organ-specific domains from UPOINT and adding a new domain for Hunner’s ulcers (U), as these patients often benefit from targeted therapies such as fulguration or intravesical cyclosporine. The resulting system was named “INPUT”: Infection, Neurologic/Systemic, Psychosocial, Ulcers, and Tenderness of muscles. This system was applied retrospectively to our previously validated UPOINT database for IC/PBS hosted on upointmd.com. Symptoms were assessed using the Genitourinary Pain Index (GUPI), which is validated for both men and women. Patients with complete data across all INPUT domains and GUPI scores were included in the analysis. Men were included if they reported pain relieved by voiding and/or presence of Hunner’s ulcers. Group comparisons were performed using ANOVA, Mann-Whitney U test, t-test, or chi-square as appropriate, and correlations were assessed using Spearman's rank correlation coefficient. Results: A total of 239 patients were analyzed, including 154 females (64%), aged 18–79 years (mean: 41.8). The distribution of positive INPUT domains was as follows: infection (11%), neurologic/systemic (51%), psychosocial (81%), ulcers (18%), and tenderness (85%). The mean number of positive domains per patient was 2.46 (range: 0–5), with 65% having 2 or 3 domains, and only 5% showing no positive domains. There was a significant stepwise increase in GUPI scores with an increasing number of positive INPUT domains (ANOVA p < 0.0001; Spearman r = 0.355, p < 0.0001). Presence of Hunner’s ulcers was associated with higher symptom scores (25.7 vs. 29.7, p = 0.004). Except for the infection domain, each additional positive domain significantly increased the total GUPI score. Conclusions: The INPUT phenotyping system for IC/PBS demonstrates validity and potential clinical utility similar to that of UPOINT in CPPS. The majority of patients present with multiple domains, and symptom severity correlates with the number of positive domains. Since 95% of patients have at least one positive domain, upfront multimodal therapy targeting specific domains—such as pelvic floor physical therapy for tenderness or fulguration for ulcers—may be more effective than the traditional sequential approach recommended by current guidelines.

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