Bladder Pain Syndrome or Interstitial Cystitis 2017-08-05T17:03:54+00:00

BLADDER PAIN SYNDROME

DEFINITION:

Bladder Pain Syndrome (BPS) previously called Interstitial Cystitis (IC) is an unpleasant sensation (pain, pressure, and discomfort) perceived to be related to the urinary bladder of more than six weeks duration and in the absence of bladder infection or other identifiable causes.

What is the difference between BPS and Overactive bladder?

BPS patients urinate to avoid or to relieve pain; patients with overactive bladder, on the other hand, urinate to avoid urine leakage. In other words, patients with BPS will not leak but will have escalating discomfort with bladder filling whereas women with overactivity of the bladder will start leaking with urgency and do not have pain.

Pain (including sensations of pressure and discomfort) is the hallmark symptom of BPS.

Where is the discomfort or pain located in patients with BPS?

These patients report varying degrees of discomfort all the way from intense pain that doubles them over to pelvic pressure and discomfort as though someone is squeezing from the inside. Sometimes they report a sensation of pressure as though something is going to fall out of the vagina. At the vaginal opening, they may complain of irritation, pain with sexual penetration or they may have itching.

Thus the discomfort could be throughout the pelvis—in the urethra, vulva, vagina, rectum—and in extra-genital locations such as the lower abdomen and back. Patients may also notice pain that worsens with specific foods or drinks and/or worsens with bladder filling or improves with urination.

Patients use other words to describe symptoms, especially “pressure” and may actually deny “pain”.

Increased frequency of urination is almost universal (92%) in patients with BPS.

SYMPTOMS

  • An urgent need to urinate, both in the daytime and during the night
  • Pressure, pain and tenderness around the bladder, pelvis and perineum (the area between the anus and vagina). This pain and pressure may increase as the bladder fills and decrease as it empties in urination.
  • A bladder that won’t hold as much urine as it did before
  • Pain during sexual intercourse
bladder pain syndrome

CAUSE:

The exact cause of BPS is unknown and there are many theories.

  1. Inflammation/Injury theory: The bladder lining (urothelium) is composed of the GAG (glycosaminoglycan) layer that acts as a barrier between urine and the nerves in the bladder wall. Breakdown in the GAG layer exposes the bladder nerves to chemical irritants in the urine and leads to the activation of the C fibers that are responsible in pain transmission.
  2. Autoimmune theory: This is where certain body tissues are considered foreign and a reaction is mounted against the tissues by the patient’s own immune system. This leads to release of chemical mediators which in turn lead to stimulation of bladder nerves resulting in increased pain and decreased bladder capacity.

DIAGNOSIS:

History

  • urinary urgency, frequency and bladder pressure
  • No complaints of urinary leakage
  • worsening pressure and discomfort with bladder filling
  • sensation of incomplete bladder emptying
  • Symptoms are similar to a bladder infection, however the urinalysis is completely negative and the urine culture is also negative.
  • Patients may complain of pelvic pain unrelated to the bladder or symptoms of irritable bowel syndrome such as alternating diarrhea and constipation.
  • They may also have pain during intercourse, both at the initial penetration at the vulva (Vulvodynia) and also with deep penetration.
  • Some women complain of vulvar irritation and may have been misdiagnosed as having frequent yeast infections of the vagina.

Examination

  • Vulvodynia (pain at the vaginal opening) has been reported in 25% to 51% of patients with a diagnosis of BPS, The most sensitive physical examination test for vulvodynia is the Q-tip touch test, done by exerting slight pressure using a Q-tip in a clockwise fashion around the introitus (vaginal opening). Pain during examination indicates a positive test.
  • 78% to 85% of patients have been found to have levator myalgia (pelvic muscle spasm and pain). To assess for levator myalgia, one finger is placed in the vagina and the pelvic muscle is felt. If muscle spasm exists, a tight band is felt at approximately 7 o’clock or 5 o’clock. If the patient reports pain with palpation, she has levator myalgia.
  • Patient may experience referred pain in the back, flank, or elsewhere in the pelvis.
  • Palpation of the bladder also results in pain.

Urinary voiding diaries are very important as they will highlight the true frequency and the amount the patient urinates every time. In most cases, the patient is going to the bathroom very frequently and are urinating just small amounts.

Urodynamic testing is performed in patients with urgency and frequency symptoms where the diagnosis is unclear especially if they are also complaining of incontinence (urine leakage). This test involves filling the bladder while assessing the bladder pressures.

Cystoscopy: This test involves looking inside the bladder with a light and a camera. It is done in the office under local anesthesia. It is especially if relevance in women who have blood in the urine or have a history of smoking.

MANAGEMENT:

Patient Education: It is important to educate the patient as to the urinary tract anatomy and function. The kidneys essentially filter the blood and make the urine. This urine is then sent down the tubes (one ureter on each side) to the bladder. The bladder, situated behind the pubic bone, stores the urine until it is time to urinate. Then the bladder contracts and the urine is released to the outside through another tube, the urethra.

bladder pain management
bladder pain treatment

Most patients feel better after trying one or more of the following treatments:

Avoiding consumption of large amount of fluids and also avoiding bladder irritants especially caffeinated beverages. Click here for a list of bladder irritants.

The patient is also informed that stress can worsen her symptoms of bladder pain syndrome. Therefore de-stressing activities such as yoga or mindfulness is very important to help with this problem.

Patients with pelvic muscle spasm may benefit from this. Also, pelvic floor therapy would help with symptoms of urgency and frequency. This is done in the office without any anesthesia and is done once a week for 4-6 weeks.

Patients with pelvic floor spasm may benefit from muscle relaxant therapy. This could be manual massage of the pelvic floor muscles, pelvic floor therapy with continuous stimulation or certain types of medications such as Flexeril or Baclofen.

This drug helps regulate the C fibers that carry the sensation of pain.  Patients are typically started at 25 mg with a target dose of 50 to 75 mg daily.

What are the side effects of Amitriptyline? Drowsiness is the main side-effect. Therefore this medication is given at bedtime. The major advantage of giving Amitriptyline at bedtime is that if the patient has increased nighttime frequency, this will also improve. Success rates of amitriptyline by patient-reported symptoms range from 64% to 90%.

For mild intermittent symptoms, patients may find relief with the bladder analgesic phenazopyridine. Patients should be warned that this particular medication can discolor the urine bright orange.

The use of antihistamines in BPS is based on modulating the cells that produce inflammation (mast cells). Hydroxyzine (Vistaril), an antihistamine, is given as a starting dose of 10 mg and titrated upward to 100 mg nightly. It has a rapid onset in 30 minutes. The main adverse effect is dry mouth.

This is another medication that is effective for patients with bladder or pelvic pain. It, too, stabilizes the C fibers and is usually given in three times a day dosing. The dose is usually started at 100 mg three times a day and then gradually increased all the way up to 2700 mg daily, if necessary. Lyrica or pregabilin is another medication similar to Neurontin that helps with the pelvic pain.

Pentosan polysulfate (PPS) is a medication that is approved by the Food and Drug Administration (FDA) for BPS. It stabilizes the GAG layer lining of the bladder and therefore prevents the lining from breaking down and the urine from coming in contact with the bladder nerves. This is a slow process and it may take 3 to 6 months of therapy before the patient notices improvement. The peak response is noted after 32 weeks of use. The side effects are dyspepsia and reversible hair loss. Also, Elmiron is costly.

Patients with BPS may find relief from pain flares with delivery of solutions of dimethyl sulfoxide (DMSO), heparin, triamcinolone and lidocaine into the bladder.

Bladder instillations are typically delivered through a small-diameter catheter. The bladder is drained, and using a syringe, the instillation solution is administered through the catheter. The patient is counseled to keep the solution in her bladder for at least 30 minutes and then urinate. Dimethyl sulfoxide (DMSO) is anti-inflammatory, heparin (stabilizes the GAG layer), lidocaine (local anesthetic), and triamcinolone (anti-inflammatory) has been shown to be effective in immediate relief of pain.

This is the filling of the bladder with fluid under anesthesia.

How is hydrodistention performed? The bladder is filled with sterile water until the fluid level starts backing up in the tubing. The bag is held 6-8 inch above the belly level to maintain a pressure head of 60-80 mm Hg. This maximal bladder capacity is noted and the bladder distention is held for 3 to 5 minutes. The bladder is then emptied and filled a second time.  Sometimes, during the refill, Hunner ulcers (star-like scar tissue), petechial hemorrhages or glomerulations (significant redness) may be seen.  A steroid may be injected under the Hunner’s ulcers.

How does hydrodistention work? Under anesthesia, the bladder is filled past the sensory threshold of the C fibers and this may reset the nerves. Also, the GAG layer of the bladder may regenerate and thereby insulate the C (pain) nerve fibers from getting exposed to the urine.

Who is a good candidate for hydrodistention?  Though anyone could benefit from this, it is typically useful in women who have reduced bladder capacity as noted on the urinary voiding diaries. Therefore, it is very important to keep the urinary diaries.

How often does this need to be repeated? Individuals experiencing improvement in symptoms for greater than 6 months are candidates for repeat procedures.

What are the possible complications of this procedure?  Complications are rare. Some patients may experience difficulty in emptying their bladder after this procedure and may need a catheter for a short time ( <1%). Rupture/tearing of the bladder is very rare and unlikely to happen at the low pressure distention that is now used for this procedure. We have never seen a bladder rupture.

Sacral nerve modulation or InterStim is a treatment that would help BPS patients mainly complaining of urgency and frequency. This procedure involves placement of a thin lead near the tail bone where the bladder nerve emerges. The stimulation of this nerve may help with the urgency and frequency problem. Interstim is not indicated for the management of pelvic pain.

Botox is administered in the bladder and helps relax the bladder muscle. This is indicated for patients with urgency and frequency. Botox is done in the office under local anesthesia and patients go home within the hour of the procedure.

  • Quercetin has been shown to have some benefit. It belongs to a group of plant pigments called flavonoids that give many fruits, flowers, and vegetables their colors. Flavonoids, such as quercetin, are antioxidants. Quercetin has an an anti-inflammatory and antihistamine effect. This way they may help with the pain associated with BPS. The dosage is 500 mg 1-2 times a day.
  • Prelief is a medication that helps neutralize the acidity of certain food items. It contains calcium glycerophosphate that helps make the pH more basic or alkaline. It is usually taken as 2 tablets with each meal.
  • Pyridium or phenazopyridine is a prescription or an over-the-counter (azo) medication that relieves bladder pain and spasms. It is taken as 200 mg three times a day with meals.
  • Drug combinations of hyoscyamine/methanamine/methylene blue/phenylsalicylate are also beneficial in patients with BPS. The dose is 1 tab 3-4 times a day as needed for bladder pain.
  • Hyoscyamine, is an antispasmodic, and can be used by itself especially in patients who also have irritable bowel syndrome. The dose is usually 0.375 mg of the extended release version every 12 hours, not to exceed 1.5 mg daily.
  • Other over-the-counter medications containing pumpkin seed, soy germ or cranberry extracts may also be beneficial in some cases.