Jen Graham 28/03/14

DefinitionsEpidemiologyClinical AssessmentAetiologyManagement

Poorly defined Initially defined in research settingPelvic Pain + Urinary storage

symptomsHeterogenous spectrum of disorders Inflammation is only present in a

small subset of patients IC vs PBS or BPS

Bladder Pain Syndrome (BPS) is the occurrence of persistent or recurrent pain perceived in the urinary bladder region accompanied by at least one other

symptom e.g. pain worsening with bladder filling, day-time and/or night time urinary frequency

In the absence of “confusable conditions” e.g. urinary tract infection

Mostly women (10:1 F:M)

No difference in race or ethnicity Genetic component may be present Age ≥18

Median age 42-45 at diagnosis

Associations: allergies, functional somatic syndromes - IBS,

fibromyalgia, CFS autoimmune - Sjogren’s syndrome, SLE depression

Variable due to inconsistent definitions

Difficult to diagnose and treatNo pathological criteria define the

disease

Large variation 0.06%-30% Mainly <1% in most populations

Made on the basis of: History Examination Urinalysis Cystoscopy with hydrodistension +/-

biopsy

Nature of the pain is key Pain/pressure discomfort perceived to be related

to bladder, increasing with increasing bladder content

Located suprapubically but may radiate to groins, vagina, rectum or scrotum

Relieved by voiding, but returns Aggravated by food or drink

Other LUTS – frequency, urgency, haematuria Urological diseases (incl. UTI)

- Previous pelvic operations- Previous pelvic radiation treatment

Other PMH e.g. Autoimmune disease

Abdomen / bladder Males:

DRE Females:

PV for pain mapping of vulval regiontenderness of urethra, trigone and

bladdersuperficial/ deep vaginal tendernesstenderness of pelvic floor (levator,

adductor)

Validated symptoms score

Can be helpful in monitoring response to treatment

MSUUrine cytologyEMU x3 (if sterile pyuria)ChlamydiaOther tests guided by history

e.g. Foreign travel

Under GA Fill to maximum capacity and distend

for 3 minutes at 80-100 cmH2O Empty and measure volume and look

for bleeding 2nd look only fill to 1-2/3 bladder

capacity Inspect bladder

Cystoscopy + biopsy may differentiate different subtypes

Development of glomerulations is a positive prognostic sign

Inflammation often leading to small capacity fibrotic bladders

Reddened mucosa Hunner’s Ulcers in 5-

10% Small vessels radiating

to central scar Scar ruptures at

bladder distension leading to waterfall-type bleeding

Likely to be multifactorial1. Urinary infections used to be thought to be initial insult

UTI/urgency more frequent during childhood in subsequent sufferers

2. Mast cells ? Causative or secondary Frequently associated with PBS/IC bladder, also present in non

IC bladders Active allergies exacerbate symptoms

3. Epithelial permeability Deficiencies in glycosaminoglycan (GAG) layer Exposes submucosal nerve endings to noxious urine

components 4. Neurogenic Inflammation

Abnormal sensory nerve activity 5. Autoimmunity6. Hormonal

IC / PBS not curable Try to make patient as self-reliant as

possible Manage expectations of patient Lots of potential treatments → lots of

potential treatment combos Spontaneous temporary remission can

be short lived and unrelated to therapy (up to 20% in placebo studies)

Behavioural Dietary Pharmacological Intravesical Surgical

Interstitial cystitis database study noted >180 treatment modalities for IC/PBS with poor results in the majority of cases

Behavioural bladder training in patients who predominately have

frequency / urgency with little pain Diet

no real affect in altering diet (little more than placebo), though there are many lists of foods to avoid

Intravaginal electrical stimulation effective in alleviating pain

Acupuncture conflicting evidence, may be beneficial not a recommended / evidenced based

therapy

Analgesics Often disappointing effect on visceral pain of

BPS Amitriptyline

Blocks h1 histaminergic receptors and decreases mast cell activity.

Decreases painful nociception by inhibition of reuptake of serotonin and noradrenaline

Cimetidine H2 receptor antagonist

Pentosan polysulphate sodium (Elmiron) Heparin analogue Thought to substitute defect in GAG layer

Given via intermittent catheterPentosan polysulphate

Glycoprotein replacing deficient GAG layerHyaluronic acid (Cystistat)Chondroitin sulphateDimethyl sulphoxide (DMSO)

Chemical solvent that penetrates cell membranes

Claimed to have analgesia, anti-inflammatory and muscle relaxant effects

HydrodistensionTransurethral resection of Hunner’s

ulcers Intratrigonal botox Neuromodulation

Denervation procedures Cystectomy/cystoplasty