Bladder pain syndrome

1. Bladder pain syndrome
Interstitial cystitis
Aamir saad fazaa
Department of urology
3rd grade
2021

2.  A syndrome of mystery in urology

3. The AUA guideline defines IC/BPS
“Unpleasant sensation(pain ,pressure or discomfort)
perceived to be related to the urinary bladder ,
associated with LUTS > 6+ weeks duration, in the
absence of infection or other identifiable causes.”
ESSIC define BPS as :chronic (>6 months) pelvic pain ,pressure or discomfort
perceived to be related to urinary bladder ,accompanied by at least one other
urinary symptoms such as urgency or frequency.

4. Epidemiology
Epidemiology studies of BPS/IC suffer from the lack of a universally accepted
definition
The first population-based study included patients with IC in Helsinki :
18.1 per 100,000 women and 10.6 per 100,000 population
300 per100,000 women
30 per 100,000 men in the United States
1.2 per 100,000 in Japan
female to male preponderance of 5:1

5. Etiology
BPS/IC has a Multifactorial etiology .
Defective bladder epithelium ,
mast cell activation,
neurogenic inflammation,
C fiber activation
Relux sympathetic dystrophy of bladder
Bladder autoimmune response
Urinary toxin or allergen
or some combination of these and other factors leading to a self perpetuating
Process resulting in chronic bladder pain and voiding dysfunction

6. Urothelial dysfunction (GAG)
glycosaminoglycane layer defect/inhibition of urothelial proliferation (APF)

7. Signs & symptoms
PAIN: suprapubic or pelvic
Bladder pain that worsens with bladder filling and is alleviated with voiding
Dysuria
Urinary frequency & urgency
Nocturia: mild to severe (1to >12 times per night)
Spasm of the rectum and levator ani muscles
Anterior vaginal wall,suprapubic region, and pelvic floor muscle tenderness on pelvic
examination

8. Women
◦ Dyspareunia
◦ Female sexual dysfunction
Men
◦ Pain at the tip of the penis, the groin, or the testes
◦ Ejaculation often produces pain owing to severe spasm of the pelvic floor
◦ Prostate, bladder, testes, and epididymis tenderness

9. Diagnosis
NIDDK criteria 1987 and modified NIDDK 1988 :
The most successful attempt to define a clinical useful definition of IC

10. NIDDK criteria
The National Institute of Diabetes and
Digestive and Kidney Diseases
Inclusion criteria:
1. Hunner’s ulcers
2. Glomurolations on endoscopy
3. Pain on bld filling relieved by emptying
4. Pain (suprapubic,perineal,pelvic,urethral)
5. Decreased bld compliance on cystometrogram
need 2 pos to confirm

11. Exclusion criteria
1. < 18 years
2. Bld tumors
3. TB cyst
4. Bacterial cystitis
5. Gyn carcinomas
6. Active herpes
7. Bld calculi
8. Frequency < 5 in 12 hours
9. Nocturia < 2
10. Symptoms relieved by antibiotics or urin analgesics
11. Bld cap > 400 ML
12. Duration < 12 months

12. NIH criteria
National Institutes of Health
Diagnostic Criteria for Interstitial Cystitis :
Category A: At least one of the following cystoscopic findings:
1. Diffuse glomerulations (≥10 per quadrant) in at least 3 quadrants of the bladder
2. A classic Hunner’s ulcer
Category B: At least one of the following symptoms:
1. Pain associated with the bladder
2. Urinary urgency

13. In addition, a patient must not have any of the
following conditions, symptoms , or history:
• Age <18 years
• Urination frequency while awake < 8 times per day
• Nocturia < twice per night
• Maximal bladder capacity >350 cc while patient is awake
• Absence of an intense urge to void with bladder filled to 100 cc of gas or 150 cc of water, with
medium filling rate during cystoscopy
• Symptoms persistent < 9 months
• Symptoms relieved by microbial agents, anticholinergics, or antispasmodics
• Urinary tract or prostate infection in the past three months
• Involuntary bladder contractions
• Active genital herpes or vaginitis
• Urethral diverticulum
• Uterine, cervical, vaginal, or urethral cancer within the past five years
• History of cyclophosphamide, chemical, tuberculous, or radiation cystitis
• History of bladder tumors

14. Cystoscopy
1.The classic picture is elusive ulcers with apperance of patches of red mucosa first
described by Hunner 1914 (Hunner’s ulcer)

15. 2. Glomurulations (punctuate petechial hemmorage)
Both can be found in patients without IC and not all patients with IC have them (not
reliable criteria)

16. Potassium test
An intravesical potassium chloride challenge (KCl test)
has been proposed for diagnosis using a 0.4M
potassium chloride solution
Pain and provocation of symptoms by potassium
constitute a positive test. The test is very non specific,
failing to diagnosis at least 25% of BPS/IC
Prospective and retrospective studies looking at the KCl
test for diagnosis in patients presenting with symptoms
of PBS/IC have found no benefit of the potassium test
in comparison with standard techniques of diagnosis

17. Urodynamic
In the IC database 14% of patients had overactive detrusor
There are no data to support or refuse the use of urodynamics in IC

18. Biomarkers of IC
GB-51 , APF , HB-EGF have been suggested
APF (Anti Proliferative Factor) is emerging as the best candidate for a
biomarker for IC but further studies and trials need to be conducted
Negative autocrine effect

19. Differential diagnosis
Cystitis (bacterial , viral , TB ,chemical)
Vaginitis
Tumors of the bladder (benign ,malignant)
Urethral divirticulum
Bld calculi
Prostatitis
Muskoskeletal pain
Neurogenic (prolapsed disk)

20. Treatment

21. Clinical Guidelines
AUA created flowchart of suggested order of treatment
Progress 1st line through 6th line as needed
Conservative treatments first
Avoid surgery if possible
Exception is fulguration of Hunner’s lesions, must be
done first
Multiple simultaneous treatments often best
Pain management should be priority

22. Clinical Guidelines
1st line treatments: conservative
Patient education about IC and treatment options
Behavioral modifications
Timed voiding
Controlled fluid intake
Stress reduction
Avoidance of triggers
Dietary changes: avoid acidic foods, coffee, tea, soda, spicy
foods, artificial sweetener, and alcohol
4 C’s: carbonated, caffeine, citrus, high concentration of vitamin C

23. Physical Therapy
Biofeedback
Soft tissue mobilization
Stretching
Pelvic floor muscle training ?
AUA says avoid

24. 2nd line treatments
A __ Oral treatment
Amitriptyline
Cimetidine
Hydroxyzine
: inhibit histamine receptors to decrease pain signal transmission

25. Pentosan polysulfate (ELMIRON) : repairs damaged GAG layer of bladder mucosa
the only FDA approved
Takes 3-6 months to see effects and only effective in approximately 25% of patients
Elmiron creates a barrier on the bladder wall to prevent irritation.
100 mg capsule by mouth three times a day for a total of 300 mg daily

26. B__ Intra vesical treatments
Dimethyl sulfoxide (DMSO) is only FDA–approved:
anti inflammatory ,analgesic , and muscle relaxant

27.  Heparin : functions as GAG layer for bladder
25000u/10 ml saline holding for 2hours
Twice weekly for 12 w
67% of patients have improvement
 Lidocaine : analgesic
 Lidocaine + corticosteroid

28. 3rd line treatment:HYDRODISTENSION
cystoscopy with short duration, low pressure hydrodistension
Most common treatment, 50% efficacy,
effects last about 6 months
Inflate bladder with saline to 80 cmH2O or
800-1000mL,
Maintain pressure for a few minutes then drain bladder

29. 4th line treatment
neurostimulation
Bilateral S3 nerve stimulators
Significant decrease in frequency and nocturia
Significant improvement in Urinary Distress Inventory short form scores, showing patient
satisfaction
Decrease in episodes of fecal incontinence
TENS for pain relief
External low back or suprapubic placement
Internal placement of device in vagina

30. 5th line treatments
Cyclosporine A
Anti-inflammatory and immunosuppressive
More effective for patients with Hunner’s lesions
85% vs. 30% effective
Intradetrusor botox injection
Risk of requiring intermittent catheterization after treatment
Up to 4 injections, separated by 6 months effective for symptom and pain relief
as well as increasing bladder capacity
Not as effective for patients with Hunner’s lesions

31. 6th line treatment: surgery
Cystoplasty
Part/all of bladder removed and replaced by section of bowel to
function as new bladder
Uncommon
Urinary diversion with/without cystectomy
Section of bowel becomes conduit for ureters, stoma created in
abdomen, allows urine to drain continually into external collection bag
Section of bowel becomes conduit for ureters, drains into
another section of bowel that has become internal pouch that
must be emptied through intermittent self-catheterization
Rarely performed because many patients will still experience
some symptoms, mainly pain, after surgery

32. Thanks alot