Painful bladder syndrome and cystitis

Question 1

What is differential diagnosis for chronic pelvic pain?

Answer 1

Gynecological, urological, nephrolithiasis, painful bladder syndrome, bowel/IBS, MSK, supratentorial.

differential for painful bladder syndrome: UTI, OAB, urolithiasis, bladder lesions (polyp/tumor), urethritis.

Question 2

What are the causes/diagnosis of painful bladder syndrome?

Answer 2

etiology unknown - defects allow irritants to enter bladder wall. Clinical diagnosis.
- Unexplained bladder pain >6 weeks, incr discomfort w/ bladder filling and relief w/ voiding (pts void frequently to avoid pain from bladder filling), absence of infection or other cause (r/o with UA, UCX, PVR).
- have flares alternating w/ periods of relief. co-occurs w/ pelvic pain, other pain syndromes (fibromyalgia or IBS).
1/3 of pts w/ CPP may have painful bladder syndrome.

Ddx: UCx, PVR (normal is <100). cystoscopy NOT required for diagnosis.
- Classic findings on cysto: hunner’s ulcers (highly specific, only in 5-10% pts), glomerulations (petechiae) - nonspecific. If refractory to medical management, can fulgurate.

Question 3

What is the treatment for painful bladder syndrome?

Answer 3

• behavior modification
• avoid triggering foods: Artificial sugars, Caffeine, alcohol, spicy foods.
• 12wk trial of PFPT.
  Tx: amitriptyline=1st line. gabapentin/Pregabalin. - - Pentosan polysulfate=FDA approved (incr risk macular eye disease so need detailed ophthalmology exam and retinal exams q6mo). Anti-histamines if IC and allergies together.
• If refractory, can do bladder hydrodistension (DMSO dimethyl sulfoxide bladder instillation for flares), botox, sacral nerve modulation. .

Question 4

What is differential diagnosis for recurrent dysuria after intercourse?

Answer 4

recurrent postcoital bacteriuria/UTI
Lubrication deficit with tissue trauma
Allergy to contraceptive product
Underlying UTI

Question 4

What is recurrent cystitis?

Answer 4

> 2 infections in 6 mo or >3 in 12 mo

Workup: assess for anatomic abnormalities, upper tract (renal US, CT/MRI), lower tract (cysto).

Manage by treating underlying issue (glycemic control, tx of underlying infection), proper duration of abx and pt compliance, selection of abx not affecting fecal flora (predispose to yeast), STI testing, incr fluid intake, consider post-coital void.

IF nothing helps, try single dose abx after each act of coitis (50-100mg macrobid, Bactrim, cephalexin).
- if not coitus related: antibiotic suppression w/ daily Bactrim or macrobid x6mo, behavior modification, consider estrogen, probiotics.

Question 5

How do you manage hematuria that persists after infection treated?

Answer 5

eval for kidney stones, bladder polyp, bladder cancer.

consider underlying factor predisposing to recurrent infection:
- diabetes, spermicide, infected stone, inflammatory condition of lower genital tract (urethritis, BV, candida, STI), genetic component.

-possible resistant organism.

Question 6

What is postpartum urinary retention?

Answer 6

2/2 injury to pudendal nerve during birth process.

Overt PUR: absence of spontaneous urinartion within 6 hours of SVD or 6 hrs post removal of foley after CD.
- tx=intermittent catheterization

Covert PUR: PVR>150cc after spontaneous void. can have pudendal nerve dysfunction for up to 2-3mo PP.
- tx=intermittent catheterization q4-6 hrs or when pt has urge to void. continue until PVR <150cc.

differential: bladder atony, bladder pain 2/2 intrapartum injury, obstructive effect of hematoma, urethral spasm.

Question 7

What antibiotics should you give for empiric treatment for UTI?

Answer 7

Most likely organism is E. coli
- Antibiotics could be Nitrofurantoin (Macrobid) x 5d or Bactrim (Trimethoprim-sulfamethoxazole)