Functional urological disorders, such as overactive bladder syndrome (OAB), urological pain syndromes: bladder pain syndrome/interstitial cystitis (BPS/IC)) and chronic pelvic pain syndrome (CPPS) are highly prevalent. They are frequently interrelated and characterized by a chronic course and considerable treatment resistance. 
Functional urological disorders are strongly associated with affective symptoms and have a negative impact on quality of life, functional urological disorders are strongly associated with affective symptoms and have a negative impact on quality of life (1). A  hypothetical bladder-gut-brain axis (BGBA) (2) is described previously. The concept can be used as a foundation for common pathways of functional urological, gastrointestinal and affective disorders. Co-occurrence of functional disorders on the one hand, and mood and anxiety disorders on the other, are common and associated with greater symptom severity. Dysregulation of the BGBA can evolve into the direction of false alarm, provoking physical and emotional distress eventually resulting in psychiatric disorders, as well as bodily distress as functional somatic disorders. Dysregulation can lead to alarm falsification which is an exaggerated response to neutral stimuli. Since, complex multidirectional interactions are likely to occur, given psychiatric disorders can have effects on the bladder-gut brain axis also. With more threats, which can be physical threats like an infection, but also psychological threats, over time, vulnerability increases and resilience decreases leading to a greater symptom burden and physical defense reactions (i.e., urgency, voiding frequency, vomiting, diarrhea – the symptoms of underlying functional disorders) as well as pain, anxiety, and decreased mood. 
The hypothesis is that poor treatment outcomes are attributable to underlying but undetected mental disorders. Secondary that multidisciplinary treatment is effective and patients will visit less medical specialists and will have fewer consultations at health care professionals and/or treatment will lead to less symptom burden. 
The aims of study are to investigate the effect of integrated outpatient care by a urologist and a psychiatrist on the symptomatology of patients with functional urological disorders in a tertiary referral Pelvic Care Centre.

It is a retrospective observational cohort study in functional urological disorders in combination with psychosomatic co-morbidity. When treatment by a urologist alone was not sufficient, the suitability for a multidisciplinary approach was considered and offered i) if there was a susceptibility for psychiatric comorbidity, ii) if diagnostic procedures did not reveal a treatable somatic cause or iii) if multiple failed somatic treatments did not relieve complaints.
Patients diagnosed with overactive bladder syndrome and urological pain syndromes were included by two urologists, according to the ICS criteria. Based on the DSM V criteria, psychiatric evaluation by history and mental status examination was performed by a psychiatrist. 
Included patients received the following questionnaires after finishing treatment: Hospitality Anxiety and Depression Scale (HADS), OAB-Questionnaire or Interstitial Cystitis Symptom Index and Problem Index (ICSI or ICPI) or National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) (depending on their diagnosis), and a health consumption questionnaire. Furthermore, a Patient Global Impression of Improvement and a degree of change were evaluated by telephone interview.
All patients received psycho-education about the bladder-brain axis and the alarm falsification model. Successive treatment regimens consisted of prescribing serotonin reuptake inhibitors (SSRIs) (e.g., sertraline, escitalopram) in affective conditions or serotonin noradrenalin reuptake inhibitors (SNRIs) (e.g., duloxetine) in affective conditions with chronic pain, augmented with atypical antipsychotics (e.g., quetiapine) and/or psychotherapy (cognitive behavioral therapy (CGT), acceptance and commitment therapy (ACT), etc.) if indicated.

A total number of 77 patients were selected for the study. Median time between first urological consultation and multidisciplinary consultation was 3.9 months [1.9-13.1]. The majority of patients complaint were urological pain syndrome (48%) and OAB (37.7 %), 31 patients were male and 46 females. Duration of treatment (i.e., starting point of the multidisciplinary consultation) and time of final consultation at the urologist was 11.2 months [5.6- 24] and for the final consultation at the psychiatrist 9.4 months. 
Figure 1 illustrates the multidisciplinary treatment approach and shows that 71.4% of patients started with antidepressants (SSRIs or SNRIs) and atypical antipsychotics were augmented in 22.8% of the cases to achieve maximum therapeutic benefit (i.e. augmentation strategy).  

A significant reduction in HADS-Depression score was found (p = 0.001) after multidisciplinary treatment. The GAF score increased from 61 to 80, leading to no more than slight impairment in social, occupational or school functioning. Patients reported their situation as better in comparison with before multidisciplinary treatment. An association was found between pelvic pain and anxiety (p = 0.032) and panic disorder (p = 0.040). Psychological trauma was found to be associated with depression  (p = 0.044), with an odds ratio of 2.93 [1.01-8.50]. Psychological trauma coincided in 62.3% of patients with urological pain syndromes and in 83.3% with pelvic pain.

To our knowledge, this is the first observational cohort study on integrated psycho-somatic treatment of functional urological disorders with psychosomatic comorbidity. The current study reveals a pre-post comparison before and after multidisciplinary treatment by urologist and psychiatrist. A significant reduction in HADS-Depression scores was observed, and the global assessment of functioning shows an improvement in functioning. Furthermore, at follow up only a slight impairment in social, occupational or school functioning (e.g., temporarily failing behind in schoolwork) had remained, indicating that earlier treatment refractoriness was redressed.
In this selected refractory OAB, BPS and CPPS cohort including patients who are assumed to have psychiatric comorbidity, an association between pelvic pain and anxiety and more specifically with panic disorder has been recognized. 
There are limitations to this study, the relatively small sample size and selection bias in a tertiary referral centre, nevertheless the outcomes are important and can lead to novel treatment approach in a multidisciplinary setting for patients with refractory symptoms .

Functional urological patients, previously refractory to urological treatment, benefit from an integrated care approach by urologists and psychiatrists. Explanation about the bladder-brain axis and the alarm falsification model enlightens understanding of urological and psychological contributions to functional syndromes and creates an opportunity for integrated care.

Vrijens D, Drossaerts J, van Koeveringe G, Van Kerrebroeck P, van Os J, Leue C. Affective symptoms and the overactive bladder - a systematic review. J Psychosom Res. 2015;78(2):95- 108
Leue C, Kruimel J, Vrijens D, Masclee A, van Os J, van Koeveringe G. Functional urological disorders: a sensitized defence response in the bladder–gut–brain axis. Nature Reviews Urology. 2017;14(3):153-63