Interstitial Cystitis/Bladder Pain Syndrome - CUA 2016 Flashcards
Definition de IC/BPS
An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than six weeks duration, in the absence of infection or other identifiable causes.
The corresponding French terminology is cystite interstitielle, cystalgie à urine claire, or cystalgie abacterienne.
Prévalence de IC/BPS
Current studies estimate that between 2.7 and 6.5% of American women have symptoms consistent with a diagnosis of IC/BPS.
Unfortunately, delay of diagnosis is common, with an average time of three to seven years from the time of presentation to the general practitioner to diagnosis by a specialist.
Analyse d’urine possible
A urine dipstick represents the minimum required laboratory test for IC/BPS. Glucose, leukocytes, hematuria, nitrites, and osmolality may be simply screened for. Absence of leuko- cytes does not rule out IC/BPS.
If signs of UTI are identified, a culture and sensitivity is required and possibly testing for Chlamydia trachomatis, Mycoplasma, Ureaplasma, Corynebacterium species, Candida species, and Mycoplasma tuberculosis if sterile pyuria persists.
Prévalence d’ulcère de Hunner
Hunner’s ulcers or lesions can be found with or without hydrodistension under anesthetic in approximately 16%.
Instilation de lidocaine
An anesthetic challenge test, such as an alkalized lidocaine test, instills 10‒20 mL of an anesthetic mixture (in this case, 200 mg lidocaine mixed with 8.4% sodium bicarbonate) into an empty bladder. This fluid is held for 10‒15 minutes and then drained by catheter.
To differentiate between the pain originating from urinary bladder from that of other pelvic organs, Taneja et al treated 22 women with pelvic pain with 20 mL of 2% intravesical lidocaine solution. Sixty-eight percent experienced a reduction of pain by 50% or greater.
Hydrodistention
The technique of diagnostic HD generally involves gravity filling of the bladder at 70‒100 cmH20 for a minimum of two minutes, performed under general or regional anesthetic.
While severely reduced anesthetic bladder capacities (<400 mL) do correlate with pain, more than 50% of patients with IC/BPS show capacities more than 800 mL.
Despite the initial adoption of the HD findings of glomerulations as a criteria for the diagnosis of IC/BPS by the National Institutes of Health (NIH), approximately eight percent with a diagnosis of IC/BPS do not show glomerulations.
As the literature is conflicting regarding its utility, HD for diagnostic purposes may be appropriate in certain situations. These may include: when a patient is unable to tolerate cystoscopy under local anesthetic and is having a general anesthetic; when a patient has failed other treatment options and HD to assess disease severity may contribute information to the diagnosis; and when assessing a patient for clinical trial eligibility.
BUD et IC/BPS
According to the NIDDK criteria, the finding of a capacity >350 mL, first sensation of having to void >150 mL, or the presence of DO are exclusionary for a diagnosis of classic IC.
However, it is recognized that approximately 15% of patients diagnosed with IC/BPS will demonstrate DO and, thus, the coexistence of urge incontinence or DO should not preclude a diagnosis of IC/BPS.
Overall, UDS studies are not recommended in the standard diagnostic evaluation of a patient suspected of having IC/BPS.
Changements des habitudes de vie
Based on best evidence principles, initial management should focus on conservative strategies. These include patient education, diet and lifestyle changes, and bladder training for all patients. Significant improvement in 45‒50% of patients may be expected with only advice and support, as demonstrated in two well-designed, randomized trials.
Based on survey studies, common food triggers include coffee, tea, citrus fruits, carbonated and alcoholic beverages, bananas, tomatoes, spicy foods, artificial sweeteners, vitamin C, and wheat products.
No standardized protocol exists, but common practice is to instruct patients to avoid all foods on the list for a period varying from one week to three months and then methodically re-introduce one item at a time, with a waiting period of three days to identify potential offenders.
Bladder training - efficacité
Timed voiding or scheduled voiding involves urinating at regular set intervals that disregard the normal urge to void. With the urge suppression strategy, patients are instructed to delay urination by gradually increasing the interval from when the urge is felt to when they actually void. Distraction (counting backwards) or relaxation (deep breathing) techniques may be used. The most appropriate protocol is not clear at this point.
The effectiveness of such behaviour modification program is supported by prospective data showing symptom improvement for 45‒88% of the cohorts.
Physiothérapie - efficacité
Evidence supporting this management option in IC/BPS is more robust, with RCTs and prospect- ive case series reporting moderate or marked improvement of symptoms in 50‒62% of patients and an additional 21% of patients having complete resolution of symptoms in one study.
Acupuncture - efficacité
Insertion of fine needles into specific points of the body appears to be an effective treatment to alleviate IC/BPS symptoms, according to a systematic review of 23 RCTs.
