Painful bladder syndrome

Interstitial Cystitis/ Painful Bladder Syndrome

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Interstitial Cystitis/ Painful Bladder Syndrome

Interstitial cystitis (IC) is a condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region.  The symptoms vary from case to case and even in the same individual.  People may experience mild discomfort, pressure, tenderness, or intense pain in the bladder and pelvic area.  Symptoms may include an urgent need to urinate, a frequent need to urinate, or a combination of these symptoms.  Pain may change in intensity as the bladder fills with urine or as it empties.  Women’s symptoms often get worse during menstruation.  They may sometimes experience pain during vagina intercourse.

Painful bladder syndrome

Because IC varies so much in symptoms and severity, most researchers believe it is not one, but several diseases.  In recent years, scientists have started to use the terms bladder pain syndrome (BPS) or painful bladder syndrome (PBS) to describe cases with painful urinary symptoms that may not meet the strictest definition of IC.  The term IC/PBS includes all cases of urinary pain that can’t be attributed to other causes, such as infection or urinary stones.  The term interstitial cystitis, or IC, is used alone when describing cases that meet all of the IC criteria established by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

In IC/PBS, the bladder wall may be irritated and become scarred or stiff.  Glomerulations— pinpoint bleeding—often appear on the bladder wall.  Hunner’s ulcers—patches of broken skin found on the bladder wall—are present in 10 percent of people with IC. 

Some people with IC/PBS find that their bladder cannot hold much urine, which increases the frequency of urination.  Frequency, however, is not always specifically related to bladder size; many people with severe frequency have normal bladder capacity when measured under anesthesia or during urologic testing.  People with severe cases of IC/PBS may urinate as many as 60 times a day, including frequent nighttime urination, also called nocturia.

Symptoms

Symptoms of IC or PBS (which are similar to bacterial cystitis) are as follows: 

  • Mild discomfort to tenderness and severe pain in the bladder and pelvic region 
  • Urgency of micturition 
  • Urinary hesitancy/slow flow 
  • Painful micturition/dysuria 
  • Frequency of micturition- sometimes up to 60 times a day in severe cases. Nocturia 
  • Any combination of the above. 

The intensity of pain varies from patient to patient and the pain may change in intensity as the bladder fill up or as it empties. In women, the bladder pain or other symptoms may get worse during menstruation or sexual intercourse. The symptoms may not always be attributed to bladder size and many patients are found to have normal bladder capacity when examined under anaesthesia or during urodynamic studies.  

Causes

Some of the symptoms of IC/PBS resemble those of bacterial infection, but medical tests reveal no organisms in the urine of people with IC/PBS.  Furthermore, people with   IC/PBS do not respond to antibiotic therapy.  

Researchers are working to understand the causes of IC/PBS and to find effective treatments. Many women with IC/PBS have other conditions such as irritable bowel syndrome and fibromyalgia.  

Scientists believe IC/PBS may be a bladder manifestation of a more general condition that causes inflammation in various organs and parts of the body. Researchers are beginning to explore the possibility that heredity may play a part in some forms of IC.  In a few cases, IC has affected a mother and a daughter or two sisters, but it does not commonly run in families.

Diagnosis

1. The basic assessment should include a careful history, physical examination, and laboratory examination to rule in symptoms that characterize IC/BPS and rule out other confusable disorders.

2. Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.

3. Cystoscopy and/or urodynamics should be considered as an aid to diagnosis only for complex presentations; these tests are not necessary for making the diagnosis in uncomplicated presentations

Differential diagnoses include

  • Urinary tract infections/cystitis 
  • Overactive bladder 
  • Urethritis 
  • Urethral syndrome 
  • Bladder stones 
  • Bladder cancer 
  • Chronic prostatitis/epididymitis in men  
  • Endometriosis/ fibroids causing pressure on bladder in women 
  • Vulvodynia

Urinalysis and Urine Culture

Examining urine with a microscope and culturing the urine can detect and identify the primary organisms that are known to infect the urinary tract and that may cause symptoms similar to IC/PBS.  A urine sample is obtained either by catheterization or by the clean catch method.  For a clean catch, the patient washes the genital area before collecting urine midstream in a sterile container.  White and red blood cells and bacteria in the urine may indicate an infection of the urinary tract, which can be treated with an antibiotic.  If urine is sterile for weeks or months while symptoms persist, the doctor may consider a diagnosis of IC/PBS.

Culture of Prostate Secretions

Although not commonly done, in men without a history of culture-documented urinary tract infections, the doctor might obtain prostatic fluid and examine it for signs of a prostate infection, which can then be treated with antibiotics.

Cystoscopy under Anesthesia with Bladder Distention

The doctor may perform a cystoscopic examination in order to rule out bladder cancer.  During cystoscopy, the doctor uses a cystoscope—an instrument made of a hollow tube about the diameter of a drinking straw with several lenses and a light—to see inside the bladder and urethra.  The doctor might also distend or stretch the bladder to its capacity by filling it with a liquid or gas.  Because bladder distention is painful for people with IC/PBS, they must be given some form of anesthesia for the procedure.

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Biopsy

A biopsy is a tissue sample that can be examined with a microscope.  Tissue samples of the bladder and urethra may be removed during a cystoscopy.  A biopsy helps rule out bladder cancer.

Treatment

Treatment strategies should proceed using more conservative therapies first, with less conservative therapies employed if symptom control is inadequate for acceptable quality of life; because of their irreversibility, surgical treatments (other than fulguration of Hunner’s lesions) are appropriate only after other treatment alternatives have been exhausted, or at  any time in the rare instance when an end-stage small, fibrotic bladder has been confirmed and the patient’s quality of life suggests a positive risk-benefit ratio for major surgery

Initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences; appropriate entry points into the treatment portion of the algorithm depend on these factors

Multiple, simultaneous treatments may be considered if it is in the best interests of the patient; baseline symptom assessment and regular symptom level reassessment are essential to document efficacy of single and combined treatments

Pain management should be continually assessed for effectiveness because of its importance to quality of life. If pain management is inadequate, then consideration should be given to a multidisciplinary approach and the patient referred appropriately

Conservative methods

1. Diet and lifestyle modification and avoidance of precipitating factors e.g. elimination and or addition of dietary foods. E.g. avoidance of spicy foods, caffeine, chocolate, citrus foods/ soda drinks and cessation of smoking

2. Bladder training techniques- voiding at regular intervals.

3. Exercise and stress management.

4. Oral medication. a. Regular analgesics. b. Pentosan Polysulfate sodium (Elmiron). Onset of improvement is slow and takes months. c. Tricyclic antidepressants can reduce pain, decreases frequency and nocturnal micturition. d. Cimetidine

Interventional methods

Bladder Distention

Many people with IC/PBS have noted an improvement in symptoms after a bladder distention has been done to diagnose the condition. In many cases, the procedure is used as both a diagnostic test and initial therapy. Researchers are not sure why distention helps, but some believe it may increase capacity and interfere with pain signals transmitted by nerves in the bladder. Symptoms may temporarily worsen 4 to 48 hours after distention, but should return to predistention levels or improve within 2 to 4 weeks.

Bladder Instillation

During a bladder instillation, also called a bladder wash or bath, the bladder is filled with a solution that is held for varying periods of time, averaging 10 to 15 minutes, before being emptied.

The only drug approved by the U.S. Food and Drug Administration (FDA) for bladder instillation is dimethyl sulfoxide (Rimso-50), also called DMSO. DMSO treatment involves guiding a narrow tube called a catheter up the urethra into the bladder. A measured amount of DMSO is passed through the catheter into the bladder, where it is retained for about 15 minutes before being expelled. Treatments are given every week or two for 6 to 8 weeks and repeated as needed. Most people who respond to DMSO notice improvement 3 or 4 weeks after the first 6- to 8-week cycle of treatments. Highly motivated patients who are willing to catheterize themselves May, after consultation with their doctor, be able to have DMSO treatments at home. Self-administration is less expensive and more convenient than going to the doctor’s office.

Pentosan Polysulfate Sodium (Elmiron)

This first oral drug developed for IC was approved by the FDA in 1996.  In clinical trials, the drug improved symptoms in 30 percent of patients treated. Doctors do not know exactly how the drug works, but one theory is that it may repair defects that might have developed in the lining of the bladder.

The FDA-recommended oral dosage of Elmiron is 100 milligrams (mg), three times a day. Patients may not feel relief from IC pain for the first 4 months. A decrease in urinary frequency may take up to 6 months. Patients are urged to continue with therapy for at least 6 months to give the drug an adequate chance to relieve symptoms. If 6 months of Elmiron therapy provides no benefit, it is reasonable to stop the drug.

Surgery

Surgery should be considered only if all available treatments have failed and the pain is disabling.  Many approaches and techniques are used, each of which has advantages and complications that should be discussed with a surgeon.  A doctor may recommend consulting another surgeon for a second opinion before taking this step.  Most surgeons are reluctant to operate because some people still have symptoms after surgery.

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