Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022 Flashcards
Interstitial Cystitis/Bladder Pain Syndrome
Definition
Chronic disorder and symptoms should be present for at least six weeks with documented negative urine cultures.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Evaluation
A brief neurological exam to rule out an occult neurologic problem. An evaluation for incomplete bladder emptying to rule out occult retention.
A proper hematuria workup should be performed in patients with unevaluated hematuria (+++ in patients with tobacco exposure given the high risk of bladder cancer in smokers).
Urine culture may be indicated even in patients with a negative urinalysis in order to detect lower levels of bacteria that are clinically significant but not readily identifiable with a dipstick or on microscopic exam.
A one-day voiding log, at the very least, should be used to establish the presence of a low volume frequency voiding pattern that is characteristic of IC/BPS.
Pain should be evaluated using the genitourinary pain index (GUPI), interstitial cystitis symptom index (ICSI), or visual analog scale (VAS) in order to gather information regarding pain/discomfort location(s), intensity, characteristics, and to identify factors that exacerbate or alleviate pain or discomfort.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Examens complémentaires
Cystoscopy and/or urodynamics should be considered when the diag- nosis is in doubt; these tests are not necessary for making the diagnosis in uncomplicated presentations.
Cystoscopy can guide therapy and exclude conditions that may mimic IC/BPS such as bladder cancer, bladder stones, and intravesical foreign bodies.
There are no agreed-upon cystoscopic findings diagnostic for IC/BPS; the only consistent cystoscopic finding that leads to a diagnosis is the appearance of Hunner lesions.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Ulcère de Hunner
Cystoscopy remains the only reliable way to di- agnose the presence of Hunner lesions.
If Hunner lesions are found on cystoscopy, triamcinolone injection and/or fulguration can be performed; for those who fail triamcinolone and/or fulguration, oral Cyclosporine A (CyA) and/or other multi-modal therapies may be offered.
Since the odds of identifying Hunner lesions are higher in patients over the age of 50, it is reasonable to offer cystoscopy to men and women over the age of 50. Cystoscopy should also be considered in those who fail conventional therapies but have never had a cystoscopy before to evaluate for the presence or absence of Hunner lesions.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Traitement
Except for patients with Hunner lesions, initial treatment should typically be nonsurgical.
Efficacy of treatment should be periodically reassessed, and ineffective treatments should be stopped.
**Multimodal pain management approaches **(eg, pharmacological, stress management, manual therapy if available) should be initiated. 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.
The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches. IC/ BPS treatment alternatives are characterized by the fact that most treatments may benefit a subset of patients but that no treatment reliably benefits most or all patients.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
IC/BPS Diagnosis and Treatment Algorithm
cf. algorithme
Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible.
Behavioral modification strategies may include: altering the concentration and/or volume of urine, either by fluid restriction or additional hydration; avoidance of certain foods known to be common bladder irritants; use of an elimination diet to determine which foods or fluids may contribute to symptoms; over-the-counter products (eg, nutraceuticals, calcium glycerophosphates, phenazopyridine); techniques applied to trigger points and areas of hypersensitivity (eg, application of heat or cold over the bladder or perineum); strategies to manage IC/BPS flare-ups (eg, meditation, imagery); pelvic floor muscle relaxation; and bladder training with urge suppression.
Other controllable behaviors or conditions that may worsen symptoms in some patients include certain types of exercise (eg, pelvic floor muscle ex- ercises), sexual intercourse, wearing of tight-fitting clothing, and the presence of constipation.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Traitements médicamenteux
Clinicians may prescribe pharmacologic pain management agents (eg, urinary analgesics, acetaminophen, NSAIDs, opioid/non-opioid medications) after counseling patients on the risks and benefits. Pharmacological pain man- agement principles for IC/BPS should be similar to those for management of other chronic pain conditions. Please note that none of of these treatments are indicated specifically for IC/BPS. Pain management alone typically does not constitute sufficient treatment for IC/BPS; a multi- modal approach in which pharmacologic agents are combined with other therapies is likely to be the most effective.
Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as oral medications (listed in alphabetical order; no hierarchy is implied). Option (Evidence Strength: Grades B, B, C, and B)
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Amitriptyline
Amitriptyline (Evidence Strength: Grade B)
Amitriptyline has been shown to be superior to placebo to improve symptoms of IC/BPS; however, AEs are common and, although not life-threatening, have substantial potential to compromise QoL (eg, sedation, drowsiness, nausea).8 Available data suggest that beginning at low doses (eg, 10 mg) and titrating gradually to 75-100 mg if tolerated is an acceptable dosing regimen.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Cimetidine
Cimetidine has been reported to have clinically significant improvement of IC/BPS symptoms, pain, and nocturia with no AEs reported.
Pas disponible en CH selon swissmedicinfo
Disponible en France : Tagamet 200mg 2x/j, 7 euro pour 30 cps.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Hydroxyzine
Atarax (25 mg).
Some studies indicate that patients who report clinically significant improvement have sys- temic allergies; this patient population may be more likely to respond to hydroxyzine. AEs were com- mon and generally not serious (eg, short-term sedation, weakness).
La dose quotidienne maximale est de 100 mg chez l’adulte.
Ajustements posologiques chez les patients adultes insuffisants rénaux (GFR < 60 ml/min).
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Pentosan polysulfate
Pentosan polysulfate (PPS) is the only FDA- approved oral agent for the treatment of IC/BPS and is by far the most-studied oral medication in use for IC/BPS. Results on the effectiveness of PPS have been contradictory; some trials report no differences in symptom improvement, while others show that PPS patients improved compared to those on placebo.
Clinicians should counsel patients who are considering pentosan polysulfate on the potential risk for macular damage and vision-related injuries.
Given these concerns, the FDA approved a new warning label for PPS in June 2020 which states that:
- A detailed ophthalmologic history should be obtained in all patients prior to starting treatment with PPS.
- For patients with preexisting ophthalmologic conditions, a comprehensive baseline retinal examination is recommended prior to starting therapy.
- In addition, a retinal examination is suggested for all patients within six months of initiating treatment and periodically while continuing treatment. If pigmentary changes in the retina develop, then risks and benefits of continuing treatment should be reevaluated, since these changes may be irreversible.
Retiré du marché en France en 2017, pas disponible en Suisse.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Oral cyclosporine A
Oral cyclosporine A may be offered to patients with Hunner lesions refractory to fulguration and/or triamcinolone.
The data on oral CyA suggest clinically significant improvement of IC/BPS symptoms compared to patients on PPS, particularly in patients with Hunner lesions or with active bladder inflammation. However, because of the relatively small number of patients treated, the lack of long-term follow-up data on large numbers of patients, and the potential for serious AEs (eg, immunosuppression, nephrotoxicity), the Panel recommends that patients taking CyA should be closely monitored, especially for renal function and blood pressure.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Instillation
DMSO, heparin, and/or lidocaine may be administered as intravesical treatments (listed in alphabetical order; no hierarchy is implied). Option (Evidence Strength: Grades C, C, and B)
Lidocaine has been shown to significantly improve symptoms in the short-term (ie, less than two weeks) compared to placebo. Alkalinization increases urothelial penetration of lidocaine and therefore is expected to improve efficacy, but it also can increase systemic absorption and potential toxicity.
Interstitial Cystitis/Bladder Pain Syndrome - AUA 2022
Hydrodistension
Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken as a treatment option. Option (Evidence Strength: Grade C).
If no bladder abnormalities or ulcers are found, then the distension may proceed and serve as a treatment. Studies report that one or two exposures to low-pressure, short-duration hydrodistension can result in clinically significant relief of bladder pain and does not decrease bladder capacity, even with multiple procedures. However, benefits must be balanced against the possibility of a (usually temporary) flare of symptoms after distention.
