Interstitial Cystitis / Bladder Pain Syndrome Flashcards
What should be done in the office the first time you see a patient with suspected interstitial cystitis / bladder pain syndrome?
- -History
- -Physical
- -Baseline voiding symptoms (with at least one day voiding log)
- -Pain levels
- -IF COMPLEX: Cystoscopy, urodynamics
The basic assessment should include a careful history, physical examination, and laboratory examination to rule in symptoms that characterize IC/BPS and rule out other confusable disorders.
Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.
ONLY IF COMPLEX: Cystoscopy and/or urodynamics should be considered as an aid to diagnosis only for complex presentations; these tests are not necessary for making the diagnosis in uncomplicated presentations.
What is the definition of IC/BPS?
“An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder , associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.”
Research Innovation Clinical Evidence (RICE) Bladder Pain Syndrome/IC (BPSIC) case definitions:
High Sensitivity definition:
- pain, pressure, or discomfort in the pelvic area
- daytime urinary frequency of 10+ or urgency due to pain, pressure, or discomfort (not fear of wetting)
High specificity definition:
- same criteria as high sensitivity but with:
- symptoms did not resolve after treatment with antibiotics
- no treatment
Exclusion criteria include conditions such as bladder cancer, spinal cord injury, pregnancy, and more.
Basic assessment for IC/BPS - Details
The clinical history should include questions about symptom duration.
IC is a chronic disorder and symptoms should be present for at least six weeks with documented negative urine cultures for infection.
The number of voids per day, sensation of constant urge to void, and the location, character and severity of pain, pressure or discomfort should be documented.
Dyspareunia, dysuria, ejaculatory pain in men and the relationship of pain to menstruation in women should also be noted.
The physical examination should include an abdominal and pelvic examination noting masses, tenderness, and presence of hernias. The pelvic examination should include palpation of the external genitalia, bladder base in females and urethra in both sexes focusing on areas of tenderness.
The pelvic floor muscles in both sexes should be palpated for locations of tenderness and trigger points. The pelvic support for the bladder, urethra, vagina, and rectum should be documented.
A focused evaluation to rule out vaginitis, urethritis, tender prostate, urethral diverticulum or other potential source of pain or infection is important.
A trial of antibiotic therapy is appropriate when infection is suspected; if symptoms resolve one might consider a course of antibiotic suppression to allow for full recovery.
A brief neurological exam to rule out an occult neurologic problem and an evaluation for incomplete bladder emptying to rule out occult retention should be done on all patients.
The basic laboratory examination includes a urinalysis and urine culture. If the patient reports a history of smoking and/or presents with unevaluated microhematuria, then cytology may be considered 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.
Treatment strategies for IC/BPS (state your general approach)
Treatment strategies should proceed using more conservative therapies first
Less conservative therapies employed if symptom control is inadequate for acceptable quality of life
Because of their irreversibility, surgical treatments (other than fulguration of Hunner’s lesions) are appropriate *only after other treatment alternatives have been exhausted,* or at anytime in the rare instance when an end-stage small, fibrotic bladder has been confirmed and the patient’s quality of life suggests a positive risk-benefit ratio for major surgery.
What should influence initial treatment type for IC/BPS?
Initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences; appropriate entry points into the treatment portion of the algorithm depend on these factors.
Multiple, simultaneous treatments may be considered if it is in the best interests of the patient; baseline symptom assessment and regular symptom level reassessment are essential to document efficacy of single and combined treatments.
When should ineffective treatments be stopped?
Ineffective treatments should be stopped once a clinically meaningful interval has elapsed.
The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches.
Pain management in IC/BPS
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.
What are first line treatments for interstitial cystitis / bladder pain syndrome?
Patient education / behavioral modification
– Patients should be educated about normal bladder function, what is known and not known about IC/ BPS, the benefits v. risks/burdens of the available treatment alternatives, the fact that no single treatment has been found effective for the majority of patients, and the fact that acceptable symptom control may require trials of multiple therapeutic options (including combination therapy) before it is achieved.
–Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible.
–Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations.
Second line treatment for IC/BPS - less invasive
Appropriate manual physical therapy techniques (e.g., maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately-trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided.
Multimodal pain management approaches (e.g., pharmacological, stress management, manual therapy if available) should be initiated.
Amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate may be administered as second-line oral medications (listed in alphabetical order; no hierarchy is implied).
Second line treatments for IC : more invasive
DMSO, heparin, or lidocaine may be administered as second-line intravesical treatments
What medications can be used as second line treatments for IC/BPS? Side effects?
Amitriptyline (25 mg daily titrated over several weeks to 100 mg)
-Sedation, drowsiness, nausea
Cimetidine (200 TID, or 300 or 400 mg BID)
-No major adverse effects
Hydroxyzine (10 mg daily titrated to 50 mg daily)
-If the patient has allergies, try this!
Pentosan polysulfate (100 mg TID) --Low adverse effect profile
- risk of macular damage and vision-related injuries
- retinal pigmentary maculopathy
- ophthalmologic history and retinal exam before PPS
What second line medication should be used for IC/BPS if the patient has allergies?
Hydroxyzine (10 mg daily titrated to 50 mg daily)
What are third-line treatments for IC/BPS?
Cystoscopy under anesthesia with short-duration, low pressure hydrodistension maybe undertaken if first- and second-line treatments have not provided acceptable symptom control and quality of life or if the patient’s presenting symptoms suggest a more invasive approach is appropriate.
If Hunner’s lesions are present, then fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed.
What are fourth line treatments for IC/BPS?
Intradetrusor botulinum toxin A (BTX-A) may be administered if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach. Patients must be willing to accept the possibility that post-treatment intermittent self- catheterization may be necessary.
A trial of neurostimulation may be performed and, if successful, implantation of permanent neurostimulation devices may be undertaken if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach.
Fifth line treatment for IC/BPS
Cyclosporine A may be administered as an oral medication if other treatments have not provided adequate symptom control and quality of life or if the clinician and patient agree that symptoms require this approach.
Sixth-line treatments for IC/BPS
Major surgery (e.g., substitution cystoplasty, urinary diversion with or without cystectomy) may be undertaken in carefully selected patients for whom all other therapies have failed to provide adequate symptom control and quality of life.
Treatments that should NOT be offered
Treatments that should not be offered: The treatments below appear to lack efficacy and/or appear to be accompanied by unacceptable AE profiles.
- -Long-term oral antibiotic administration should not be offered.
- -Intravesical instillation of bacillus Calmette-Guerin (BCG) should not be offered outside of investigational study
settings. - -High-pressure, long-duration hydrodistension should not be offered.
- -Systemic (oral) long-term glucocorticoid administration should not be offered.
What are important history components to obtain for suspected IC/BPS?
Description of pain (filling vs. emptying)
Prior tx/efficacy with emphasis on abx
Agents that exacerbate (dietary/situational/stress)
Symptom duration (must be > 6 weeks)
Gross hematuria
Bowel sxs
Urinary incontinence
Frequency, urgency, other LUTS
Dyspareunia
Sexual dysfunction
Other conditions associated with IC/BPS?
fibromyalgia
IBS
chronic fatigue syndrome
Sjogren’s
Chronic headaches
Vulvodynia
Depression/Anxiety
Hx of abuse/trauma (sexual)
What are important parts of physical exam for IC/BPS? CPPS for male?
Pelvic exam (pelvic floor tenderness, bladder, trigger points, levator muscles, sidewall, prolapse, vaginitis, urethritis, diverticulum)
Abdominal exam
Complication of prior surgery
Brief Neuro exam (sensation, occult neuro dx)
Male: DRE, penis, testis, perineum, levators
What is ddx of chronic dysuria, “recurrent UTIs”, pelvic, pain improved with urination? Worsened by acidic foods?
IC/BPS
UTI
OAB
Bladder cancer
Endometriosis
Urethral Diverticulum
POP
Vulvodynia
Other pelvic cancers
Urolithiasis
STIs
Vaginitis (candida)
NGB (incomplete emptying, MS)
Men:
Urethral stricture dz
BOO
Prostatic infection/abscess
What are basic assessment in addition to H&P for IC/BPS? What adjunct functional or anatomic evaluation could be utilized when appropriate?
UA, CX, voiding diary, PVR
Standardized Questionnaires
Adjunct:
Cysto → ID Hunner’s lesions
UDS → r/o BOO, impaired compliance, DO
Imaging→ any additional concerns
What are first line treatments of IC/BPS?
Concurrent treatments possible
Patient education (algorithm, definitions)
Behavioral: fluid mgmt, dietary mgmt (reduce irritants/caffeine), quit smoking, bladder training, bowel management
Stress management
Pain management (NSAIDs)
What are second line treatments of IC/BPS?
Continued pain mgmt. PFPT (trigger points, lengthen muscle contractures, release painful scars) oral meds (cimetidine [H2], hydroxyzine [H1], amitriptyline, pentosan polysulfate [Elmiron]) intravesical therapies (lidocaine, heparin, bicarb, gent, DMSO)
MC a/e of 2nd line oral medications
Cimetidine: rare
Pentosan polysulfate (Elmiron): diarrhea, nausea, hair loss, HA, vision loss
Amitriptyline: sedation, nausea, drowsy (titrate)
Hydroxyzine: sedation, weakness
What are third line treatments of IC/BPS?
Continued pain management
Cysto with bx/tx of Hunner’s lesions (fulguration +/- triamcinolone)
Hydrodistention (low pressure 60-80 cm H2O) risk bladder rupture
What are fourth line treatments of IC/BPS?
Botox (UTI, hematuria, urinary retention)
SNM (lead migration, infection)
*neither FDA approved
What are fifth line treatments of IC/BPS?
Cyclosporine A
*Immunosuppression, nephrotox, not FDA
Continued Pain managment
What are sixth line treatments of IC/BPS?
Surgical reconstruction: diversion, augmentation
Risk failure to resolve pain, need CIC, general surgical risks
What tx are not advocated for IC/BPS?
Long term abx
BCG
Oral Glucocorticoids
Genitourinary Pain Index (GUPI)
Interstitial Cystitis Symptom Index (ICSI)
ICSI
- self-report instrument
- evaluates symptoms of IC/BPS
- frequency, urgency, pain, pressure
- profiles baseline
GUPI
- tool used to assess the intensity and location of pain in the GU system
IC/BPS may be defined clinically as “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than ___ , in the absence of ___ or other identifiable causes. The pain or discomfort usually mounts with ___ and is the factor that typically prompts urinary frequency.
IC/BPS may be defined clinically as “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes. The pain or discomfort usually mounts with bladder filling and is the factor that typically prompts urinary frequency. The diagnosis of IC/BPS is one of exclusion because there is no specific test or marker that is diagnostic
T/F Current epidemiology suggests approximately 3 million females and 2 million males in the USA with IC/BPS symptoms. A male to female ratio of 5:1 is cited, based upon clinical practice.
false
Current epidemiology suggests approximately 3 million females and 2 million males in the USA with IC/BPS symptoms. A female to male ratio of 5:1 is cited, based upon clinical practice.
Sexual dysfunction in female IC/BPS may have a profound effect upon their__ and ___, underscoring the importance of identifying and ultimately treating this problem when present.
Sexual dysfunction in female IC/BPS may have a profound effect upon their physical and mental QoL, underscoring the importance of identifying and ultimately treating this problem when present.
t/f Common overlapping functional disorders such as high-tone pelvic floor dysfunction, overactive bladder syndrome, vulvodynia, and IBS may necessitate a multidisciplinary approach to achieve symptom relief.
Common overlapping functional disorders such as high-tone pelvic floor dysfunction, overactive bladder syndrome, vulvodynia, and IBS may necessitate a multidisciplinary approach to achieve symptom relief.
two distinct pain phenotypes in the IC/BPS patient: those with pelvic pain only and those with ___ and ___,” the latter group representing over ___ of patients. This suggests that many patients have pain derived from the central nervous system.
d two distinct pain phenotypes in the IC/BPS patient: those with pelvic pain only and those with “pelvic pain and beyond,” the latter group representing over 75% of patients. This suggests that many patients have pain derived from the central nervous system.
The ___ is the pathognomonic finding for the “classical form” of IC and represents a minority of the IC/BPS population. Ls.
The Hunner lesion (formerly termed “Hunner ulcer”) is the pathognomonic finding for the “classical form” of IC and represents a minority of the IC/BPS population. HLs are easily identified during office cystoscopy, although bladder distention beyond functional capacity and other imaging strategies have been used to enhance identification. Mounting evidence suggests that BPS is indeed a syndrome and distinct from those patients presenting with HLs.
t/f
There are reliable differences in clinical presentation between IC/BPS patients with or without HLs
F
There are no reliable differences in clinical presentation between IC/BPS patients with or without HLs
Adult female first-degree relatives of patients with IC/BPS may have a prevalence of IC/BPS ___that found in the general population.
Adult female first-degree relatives of patients with IC/BPS may have a prevalence of IC/BPS 17 times that found in the general population.
Although ___ may be seen at any age, the clinician should be especially wary of the young patient who presents with a clinical picture of IC/BPS with or without visible inflammation of the bladder wall.
Although ketamine abuse may be seen at any age, the clinician should be especially wary of the young patient who presents with a clinical picture of IC/BPS with or without visible inflammation of the bladder wall.
____ is secreted by bladder epithelial cells, inhibits bladder epithelial cell proliferation, and is used as a marker of the disease. It may be the primary cause of syndrome in some patients. Urine ___ appears to have the highest sensitivity and specificity of the markers studied for this disease.
Antiproliferative factor (APF) is secreted by bladder epithelial cells, inhibits bladder epithelial cell proliferation, and is used as a marker of the disease. It may be the primary cause of syndrome in some patients. Urine APF appears to have the highest sensitivity and specificity of the markers studied for this disease.
Current studies suggest that the etiology of IC/BPS symptoms may vary. Local processes such as “__, ___ and ___ may produce symptoms for some patients; however, the presence of co-morbid widespread pain syndromes, regional pain syndromes, and immune-mediated pain in the majority of patients suggest that more global pathologies may also be responsible
Current studies suggest that the etiology of IC/BPS symptoms may vary. Local processes such as “leaky epithelium,” mast cell activation, and neurogenic inflammation may produce symptoms for some patients; however, the presence of co-morbid widespread pain syndromes, regional pain syndromes, and immune-mediated pain in the majority of patients suggest that more global pathologies may also be responsible
___ among pelvic structures, that is, bowel and bladder, may contribute to chronic pain syndromes because this may result in alteration in function of adjacent pelvic organs.
Cross-sensitization among pelvic structures, that is, bowel and bladder, may contribute to chronic pain syndromes because this may result in alteration in function of adjacent pelvic organs.
Bladder compliance in patients with IC is ___; however, capacity is often _ and pain/discomfort is reproduced with filling.
Bladder compliance in patients with IC is normal; however, capacity is often reduced and pain/discomfort is reproduced with filling.
initial treatment of BPS.
Patient education, dietary manipulation, nonprescription analgesics, and pelvic floor relaxation sensation techniques
__ (an oral agent) and __(an intravesical agent) are the only two FDA-approved medications for the treatment of IC/BPS symptoms.
Pentosan polysulfate sodium (an oral agent) and dimethylsulfoxide (an intravesical agent) are the only two FDA-approved medications for the treatment of IC/BPS symptoms.
__, a tricyclic antidepressant, is not FDA approved for the treatment of IC/BPS. Nevertheless, it remains a staple of oral treatment given its antihistaminic properties, its ability to promote sleep, and reduce neuropathic (central and peripheral) pain
Amitriptyline, a tricyclic antidepressant, is not FDA approved for the treatment of IC/BPS. Nevertheless, it remains a staple of oral treatment given its antihistaminic properties, its ability to promote sleep, and reduce neuropathic (central and peripheral) pain
___ and ___ injection of botulinum toxin A are currently considered as fourth-line treatment strategies. Although urinary retention is a relatively rare event with BTX-A, caution should be exercised when considering its use in the patient with obstructive voiding symptoms
Sacral neuromodulation and intradetrusor injection of botulinum toxin A are currently considered as fourth-line treatment strategies. Although urinary retention is a relatively rare event with BTX-A, caution should be exercised when considering its use in the patient with obstructive voiding symptoms
Over 50% of IC patients were initially diagnosed with a ____
UTI
OAB symptoms unresponsive to anti-cholinergic medications is pathognomic of ____
IC
With ____, urgency is associated with fear of leakage
OAB
With ___, urgency is associated with pain
IC
IC/BPS Definition
An unpleasant sensation (pain, pressure / discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms >___ duration in the absence of infection or other identifiable causes
6 weeks
1st line therapy for IC
Behaviorial modifications & stress reduction
2nd line IC therapy + medications
pelvic floor physical therapy avoid pelvic floor strengthening exercises (i.e. Kegels)
Amitriptyline 25-50 mg qHS, cimetidine, hydroxyzine 10-25mg qHS, or pentosan polysulfate
2nd line IC therapy with intravesical agents
DMSO, heparin, or lidocaine
3rd line IC therapy with cystoscopic interventions
Hydrodistension, fulguration/steroid injection of Hunner’s lesions
4th line IC therapy with devices & injections
Neuromodulation OR Botox injections
Last line IC therapy with medication or surgery
Cyclosporine A, bladder diversion
Only oral treatment approved by the US FDA for the relief of bladder pain or discomfort associated with interstitial cystitis
pentosan polysulfate
Intravesical agent with adverse effect of Garlic-like taste/odor on breath/skin
DMSO
Interstim Indications
Urgency/frequency unresponsive to medical therapy
Urge incontinence
Retention not caused by obstruction
Fecal incontinence
NOT IC or PELVIC PAIN
Reflexes at S3
Toe extension & anal bellows
