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Management of Bladder Pain Syndrome (GTG 70 - Dec 2016), Differential…
Management of Bladder Pain Syndrome
(GTG 70 - Dec 2016)
Epidemiology
Definition (ESSIC)
: Pelvic pain, pressure, or discomfort, perceived to be related to the bladder, lasting at least 6 months, and accompanied by at least 1 other urinary symptom, for example persistent urge to void or frequency, in the absence of other identifiable causes.
Definition (AUA)
: An unpleasant sensation (pelvic pain, pressure, or discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifable causes.
Previous terms
: Interstitial cystitis, painful bladder syndrome
Chronic condition with unknown aetiology
:
Diagnosis of exclusion
with no definitive diagnostic test
Prevalence: 2.3-6.5%
Between
2 to 5 times more common in women
than men
Clinical Presentation
Common symptoms
Bladder/pelvic pain
Urgency
Frequency
Nocturia
Symptoms may be life-long as BPS is a chronic condition with periods of
fluctuating symptom severity
Exclude other possible causes of bladder pain
Previous pelvic surgery
Urinary tract infections
Sexually transmitted infections
Bladder disease
Auto-immune disease
Pain
Commonly reported sites
: Bladder, urethra, vagina
Description
: Pressure and aching to burning sensation
Aggravating factors
Stress (61%)
Sexual intercourse (50%)
Restrictive clothing (49%)
Acidic beverages (54%)
Coffee (51%)
Spicy foods (46%)
Relieving factors
: Voiding (57-73%)
History-taking
Location and duration of pain
Relationship to bladder filling and emptying
Characteristics of pain: Trigger factors, onset, correlation with other events, description
History of sexual or physical abuse (associated with pelvic pain)
Use of oral contraception (associated with BPS symptoms)
Urinary symptoms
Quality of life
Conditions commonly associated with BPS
Irritable bowel syndrome
Vulvodynia
Endometriosis
Fibromyalgia
Chronic fatigue syndrome
Autoimmune: SLE, Sjogren's syndrome
Examination
Genitalia
: Atrophic changes, prolapse, vaginitis, trigger point tenderness over urethra/vestibular glands/vulval skin/ bladder
Features of dermatosis
including vulval or vestibular disease
Pelvic
: Evaluation of introitus and tenderness during insertion or opening of speculum, superficial/deep vaginal tenderness, tenderness of pelvic floor muscles
Abdominal
: Exclude bladder distension due to urinary retention, hernias, and painful trigger points on palpation
Exclude cervical pathology
Effect on quality of life
Low self-esteem, sexual dysfunction, and reduced QOL
QOL can be assessed formally using questionnaires
: King's Health Questinonaire, EuroQOL, or Short-Form 36 Health Survey
Management
BPS is a chronic pain syndrome
and principles of chronic pain management should be used
Conservative
Dietary modification
: Avoidance of caffeine, carbonated drinks, tea, coffee, chocolate, tomatoes, citrus fruits, alcohol, and other acidic foods and drinks.
87.6% of patients
reported symptomatic improvement.
Stress management (80.5%)
Listening to music (64.5%)
Relaxation techniques (76.4%)
Meditation (66.8%)
Regular exercise: 65.2% of patients
symptomatic improvement
Acupuncture
: Limited data suggesting improvement
Analgesia for bladder or pelvic pain
:
Between 30-61%
of patients presenting with chronic pelvic pain have BPS. Advise simple analgesia and avoid opioids for long-term chronic pain. Early referral to a
pain clinic
should be considered for refractory symptoms.
When to refer to secondary care
: Patients who fail to respond to conservative treatment after 3-6 months
Pharmacological
Oral amitriptyline or cimetidine
Improvement in urinary urgency, frequency, and pain scores
Adverse side effects: Dry mouth, constipation, sedation, weight gain, blurred vision
Note Cimetidine not licensed for BPS
Intravesical therapy
Lidocaine
: Local anaesthetic that acts by blocking sensory nerve fibres in the bladder.
Hyaluronic acid (Cystistat)
: NNT 1.31; given in a weekly regimen for up to 4-10 weeks.
Injection of botulinum toxin A (Botox)
: 7% of patients needed post-treatment self-catheterisation
Dimethyl sulfoxide (DMSO)
: Full eye examination needed prior to treatment and 6 monthly bloods for U&Es, LFTs, and FBC. Side effects include a garlic like taste and odour on breath and skin, and bladder spasms.
Heparin
: 56% of patients achieved clinical remission over 3 months and 50% of patients had symptomatic control after 1 year
Chondroitin sulfate
: Symptomatic improvement shown with combination of hyaluronic acid and chondroitin sulfate
Further treatment options
Should only be considered after referral to a pain clinic and discussion at MDT
Cystoscopic fulguration and laser treatment, and transurethral resection of lesions if Hunner lesions identified at cystoscopy
: Hunner lesions do not respond to oral treatments and require surgery. They are usually diagnosed by cystoscopy with the appearance of a well-demarcated, reddish, mucosal lesion lacking in the normal capillary structure, which usually bleeds.
Neuromodulation (nerve stimulation) in the form of posterior tibial or sacral neuromodulation
1. Posterior tibial nerve stimulation (PTNS)
: Requires a fine needle being inserted 5 cm cephalad from the medial malleolus and posterior to the margin of the tibia at the site of the posterior tibial nerve. Treatment regimen weekly for 10-12 weeks.
2. Sacral nerve modulation
: Insertion of a test lead tunnelled under the skin, transmitted onto the nerve roots exiting the S3 foramen,causing stimulation of the pelvic and pudendal nerves.
Oral cyclosporin A
Improvements in bladder capacity, voiding volumes, pain, and decreased urinary frequency; however symptoms recurred with treatment cessation.
Side effects: Hypertension, gingival hyperplasia, facial hair growth
Cystoscopy with or without hydrodistension
: Variable symptomatic improvement with symptoms usually recurring within 6 months. Bladder rupture is a possible complication of prolonged distension with a diseased bladder.
Major surgery
: Total cystectomy and urinary diversion in the form of supratrigonal cystectomy with bladder augmentation, bowel or supratrigonal cystectomy, and orthotopic neobladder formation will likely need intermittent self-catheterisation (ISC), and patients must be aware of the likelihood of persistent pelvic and pouch pain postsurgery. Urinary diversion in the form of an ileal conduit (with or without simple cystectomy) will not require ISC.
Treatments NOT recommended
Oral hydroxyzine
: Not effective
Oral pentosan polysulfate (PPS)
: Not effective. Adverse effects of diarrhoea, vomiting, rectal bleeding, and alopecia.
Long term antibiotics
: High rate of adverse effects (80%)
Intravesical resiniferatoxin
: No improvement and causes pain
Intravesical Bacillus Calmette-Guerin
: Adverse effects of arthralgia, infection, and headaches
Long term oral glucocorticoids
: Adverse effect profile
High pressure long duration hydrodistension
: May cause bladder rupture or sepsis
MDT
Physiotherapy
: Consider referral as BPS symptoms may be improved with physical therapy
Massage therapy (74.2%)
Physical therapy (61.5%)
Physical therapy with internal treatment (66.1%)
Psychological support or counselling
: Consider referral for refractory BPS if impacting on QOL
Consider
referral to a pain clinic or clinical psychologist
if conservative and oral treatments have failed, before commencing intravesical treatments or neuromodulation
Investigations
Bladder diary
(frequency volume chart)
Useful for initial assessment: Patients with BPS classically
void small volumes
, so this is useful in identifying severity of storage symptoms
First morning void
is a useful indicator of functional capacity of the bladder
Estimation of residual urine volumes
after micturition should be assessed using bladder scans if there are concerns about incomplete bladder emptying
Food diary
: Used to record food intake and association with pain, to identify if specific foods cause flare-up of symptoms
Urine dipstick/MC&S
Exclude UTI
. Consider MC&S for testing for acid-fast bacilli if there is sterile pyuria.
Causes of sterile pyuria
: Urinary tract calculi, partially treated UTIs, bladder carcinoma in-situ
Urinary ureaplasma and chlamydia
: Consider in symptomatic patients with negative urine cultures and pyuria
Urine cytology and cystoscopy
Consider if persistent microscopic haematuria
Consider if suspicion of urological malignancy
Investigations NOT recommended to diagnose BPS
Bladder biopsies
Pathological features
: Inflammatory infiltrates, detrusor mastrocytosis, granulation tissue, fibrosis
May be used to classify BPS or indicated to exclude other pathologies such as carcinoma in situ
Hunner lesions
: Present in
type 3 BPS
and can be associated with
reduced bladder capacity in 11.7% of women
Cystoscopy and hydrodistension
Characteristic findings: Post-distension glomerulations, reduced bladder capacity, bleeding
Required to diagnose/exclude other conditions mimicking BPS
Expected to be normal in majority of patients with BPS
Risk of bladder perforation and rupture
Potassium sensitivity, urodynamic assessment, urinary biomakers
Consider
urodynamic tests
if co-existing BPS and overactive bladder (and/or stress urinary incontinence and/or voiding dysfunction) not responsive to treatment
Urodynamic studies
: Pain on bladder filling, reduced first sensation to avoid, and reduced bladder capacity are consistent with BPS
Detrusor overactivity is seen in approximately
14% of patients
with BPS
Classification of Severity
3 published BPS symptom questionnaires
University of Wisconsin IC Scale
O'Leary-Sant IC Symptom Index and IC Problem Index
Pelvic Pain and Urgency/Frequency Scale
Used to assess
baseline severity
of BPS and
response to treatment
Use of
visual analogue scales for pain
should be considered to assess severity of pain in BPS
BPS and Pregnancy
Effect of pregnancy on severity of BPS can be variable
BPS treatment options considered safe in pregnancy
:
Amitriptyline and intravesical heparin
(unlikely to be absorbed from the bladder, cross the placenta, and is not excreted in breast milk)
Other drugs used in BPS
Lidocaine
: Crosses placenta, no known safety information
Systemic corticosteroids
: No known teratogenic effects, long-term effects on hypothalamic-pituitary-ovarian axis
Intravesical corticosteroids
: Absorption unknown
Sacral nerve stimulators
: Should not be placed in pregnancy, unknown effect on fetus
DMSO
: Teratogenic in animal studies
Differential Diagnoses
Malignancy: Bladder carcinoma/carcinoma in-situ, cervical, uterine, ovarian cancer
Infection: Urinary, genital tract, STIs
Overactive bladder
Radiation cystitis or drug-mediated cystitis: Cyclophosphamide, ketamine
Bladder outlet obstruction or incomplete bladder emptying
Calculus of the bladder or lower ureter
Urethral diverticulum
Pelvic organ prolapse
Endometriosis
Pudendal nerve entrapment or pelvic floor muscle related pain
Irritable bowel syndrome
Diverticular disease of bowel