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Bladder Pain Syndrome—Current Concepts and Management Guidelines

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Bladder Pain Syndrome—Current Concepts and Management Guidelines Review Article Bladder Pain Syndrome—Current Concepts and Management Guidelines Jain A To cite: Jain A. Bladder Pain Senior Consultant Urogynaecology Syndrome—Current Concepts Institute of Urology and Robotic Surgery and Management Guidelines. Medanta The Medicity Pan Asian J Obs Gyn, Gurugram, Haryana, India May–Aug 2018, Vol. 1, Issue 1, (page 12-16). Received on: Accepted on: ABSTRACT Source of Support: Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic debilitating condition with increasing incidence globally. Despite of regular update of guidelines by different regulatory Conflict of Interest: bodies still there is a lack of consensus regarding the definition. It is still under reported in India. A single, standardised reporting method would help clini- cians to understand and communicate best treatment options to these patients. The purpose of this article is give an overview of the current guidelines regarding diagnosis and management of this disease. Keywords: Interstitial cystitis, Bladder pain syndrome, Chronic pelvic pain, Hunner’s lesion BACKGROUND suffering in a similar manner.5 Therefore more relaxed diagnosing criteria have been proposed by different Bladder Pain Syndrome/Interstitial cystitis(BPS/IC) is regulatory bodies including the one used by Japanese,6 considered as a chronic debilitating condition with a American Urological Association7 or by the European severely negative impact on a patient’s quality of life. Society for Study of Interstitial Cystitis.8 It was felt that Its prevalence ranges from 52 to 500/100,000 in females pelvic pain which was related to micturition cycle and compared to 8–41/100,000 in males,1 and its incidence presented with lower urinary tract symptoms could be is increasing globally. categorized as single entity ‘Bladder Pain Syndrome’.7 The term ‘Interstitial cystitis’ was first described by It included different terms in use like interstitial cystitis, Skene in 1887,2 who mentioned about destruction of painful bladder syndrome, urethral syndrome, trigonitis mucous membrane of bladder by inflammation, which under one category to avoid confusions. But still a single appeared to spread into the wall of urinary bladder. definition or diagnostic criteria for this condition, could Later Guy Leroy Hunner, a Boston gynaecologist, from not be agreed upon. Johns Hopkins, for the first time in 1914 described a Today most acceptable definition as proposed by the symptom complex of bladder pain associated with Society for Urodynamics and Female Urology (SUFU) is a unique cystoscopic finding of mucosal lesions, the “An unpleasant sensation (pain, pressure, discomfort) “elusive ulcer”, later termed Hunner’s ulcer.3 For a perceived to be related to the urinary bladder, number of years, this finding was the hallmark of IC. associated with lower urinary tract symptoms of more The ulcer was thought to be the cause of symptoms in than six weeks duration, in the absence of infection or these women. other identifiable causes.”9 With this, treatment can Based on this, this condition was first defined by the be started early after a relatively short symptomatic National Institute of Diabetes and Digestive and Kidney period, while definitions that require longer symptom Diseases in the late 1980s.4 Later it was noted in many durations (i.e., six months) can withhold the treatment studies that the diagnosis can be missed in more than for longer period, resulting in increased duration of 60% of patients once these strict criteria are applied, patient suffering. especially those without typical Hunner’s ulcer but 12 Bladder Pain Syndrome—Current Concepts and Management Guidelines The European Association of Urology (EAU) also • History of neurological disease to rule out Neurogenic embraces the term BPS, but reserved the term IC bladder (‘Burning character’ of pain suggestive of for a subset of patients with findings of chronic neuropathic pain) inflammation extending submucosally; on cystoscopy, • Pain at anus or getting relieved after passing stools, hydrodistention, and/or bladder biopsy.8 may suggest an intestinal pathology. Other important points, which should be included in CLINICAL APPROACH TO A PATIENT history are WITH SUSPECTED IC/BPS • History suggestive of aetiology: allergies to food or The diagnosis is based on the symptom complex with drugs/allergic bronchitis or bronchial asthma/other subjective perception of bladder as a source and after allergic disorders like Seasonal hay fever or urticaria/ excluding other identifiable causes for the symptoms. autoimmune disorders High clinical index of suspicion is the key to diagnosis. It • History of obstructive symptoms: in women due to is equally important not to over diagnose this condition. pelvic floor spasm, in men due to prostatic pathology or stricture urethra • Recent change in diet, like health drinks, excessive HISTORY tea/green tea/coffee/dark chocolates or something Pain or discomfort in lower abdomen and/or urogenital else which the patient wasn’t used to earlier eg. area. change of diet due to geographical translocation. Patient will never have fear of leaking urine but would • Recent drug treatment for unrelated disease not be able to hold urine due to increase in pain with • History of associated diseases/co- morbidities like bladder filling. This vary symptom differentiate it from fibromyalgia, irritable Bowel syndrome, anxiety, OAB (Overactive Bladder) as a cause of Urgency. stress or migraine.They might be of importance in The patients often learn to quickly empty their the identification of various phenotypes. bladder to avoid pain in BPS leading to increase in Frequency. At night also, the patient wakes up because of pain rather than a desire to pass urine due to full EXAMINATION bladder. General: Gait of the patient, Mental state of the patient, The classical presentation is immense urge with Somatic signs of anxiety like pallor, sweating etc. increasing suprapubic pain or discomfort as bladder Abdominal examination: any masses, any abdominal fills, which is usually relieved by voiding although soon tenderness especially suprapubic, previous surgical returning. Descriptions of discomfort may vary like scars. “pressure”, “burning”, “pricking” or “sharp”. Sometimes pain can be felt at locations other than suprapubic Local examination: Any area of tenderness in region like urethra, vagina, lower abdomen and back, perineum, tone of the pelvic floor muscle and trigger medial aspect of the thigh or inguinal area as referred points need to be noted. Any Myofascial bands must pain.9 also be looked for. Tenderness on pressing anterior History of following confusable diseases should also fornix may indicate presence of BPS. be elicited to exclude other causes. Neurological examination: If indicated • Prior pelvic surgery • Urinary stone disease INVESTIGATIONS • Pelvic inflammatory disease: presence of vaginal discharge The investigations are primarily aimed at excluding the • Vulvovaginitis: It will be associated with superficial diseases with specific aetiology Dyspareunia ( Deep Dyspareunia indicates BPS). • Frequency volume chart gives a fair idea of the • Prior pelvic radiation functional bladder capacity. This serves a valuable • Infertility evidence to objectively evaluate the progress of • Pelvic endometriosis: Pain intensity increases usually disease and its response to treatment. The voided around menstrual cycle. volume, spacing in between and the number of voids can be objective parameters for further intervention. Pan Asian J Obs Gyn, May–Aug 2018, Vol 1, Issue 1, (page 12-16) 13 Jain A • Urine analysis: The absence of pus cells in the • While evaluating a case of suspected BPS, all urinary sediments, leucocyte esterase (LE) or nitrite confusable disease entities must be carefully in the urine sample almost excludes the diagnosis excluded. Table 2 enlists such diseases which might of urinary infection. Presence of red blood cells in mimic BPS in clinical presentation. urine should indicate a detailed evaluation of the urinary tract starting with the urine cytology for MANAGEMENT OF IC/BPS PATIENT malignant cells. • Ultrasonography (optional)of the urinary tract to Education exclude any pelvic pathology likely to be the cause The management of these patients begins with detailed of symptoms, including significant post void residual discussion of the disease entity and prognosis. It must urine ( especially in presence of symptoms of voiding be emphasized that the treatment might be prolonged dysfunction). and the relief might be slow to appear. There could • Anesthetic challenge test (optional)is a simple test to be need to change medications during the course of demonstrate that the pain is indeed originating from treatment as this is a heterogeneous entity and so are bladder. 20 ml of 1% lignocaine may be instilled in the treatment modalities. bladder by a per urethral soft small calibre catheter after evacuating any urine from the bladder. There is an immediate relief from pain which stays for Oral Non-specific Medication almost an hour or more. This indicates that the pain Urine Alkalisers: Simply changing the acidic pH of is indeed originating from bladder. But this is not a urine to neutral or slightly alkaline can reduce the pain specific test as pain due to any bladder inflammation in such patients. would be relieved on instilling lignocaine in bladder. Amitriptyline (Tryptomer) is a tricyclic antidepressant However, it is very useful when differentiating and has central and peripheral action. Apart
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