Transcript Bladder Pain Syndrome (Interstitial Cystitis)

‫بسم اهلل‬
‫الرحمن‬
‫الرحیم‬
Pelvic Pain
What Is Pelvic Pain?
If you have pain below
your belly button and
above your legs, it counts
as pelvic pain. It can be
caused by a lot of things. It
may be a harmless sign
that you’re fertile, a
digestive disorder, or a red
flag that you need to go to
the hospital.
Appendicitis
If you have a sharp pain in
the lower right part of your
belly, are vomiting, and
have a fever, it could be
appendicitis. If you have
these symptoms, go to the
ER. An infected appendix
may need surgery. If it
bursts, it can spread the
infection inside your body.
This can cause serious
complications.
Irritable Bowel
Syndrome (IBS)
Do you have belly pain,
cramps, bloating, and
diarrhea or constipation
that keeps coming back?
Talk to your doctor to
figure out the problem. It
could be IBS, sometimes
called spastic colon.
Doctors aren’t sure what
causes it. Diet changes,
stress management, and
medications may help.
Mittelschmerz (Painful
Ovulation)
Ever feel a painful twinge
between periods? You may
be feeling your body
ovulate. When you do, the
ovary releases an egg along
with some fluid and blood.
It can cause irritation. This
feeling is
called mittelschmerz -German for "middle" and
"pain." That’s because it
happens midway through
your monthly cycle. The
pain may switch sides from
month to month. It isn't
harmful and usually goes
away in a few hours.
PMS and Menstrual Cramps
You can usually feel these cramps in
your lower belly or back. They
typically last 1 to 3 days. Why the
pain? Every month, your uterus
builds up a lining of tissue. That’s
where an embryo can implant and
grow. If you don't get pregnant, the
lining breaks down and is shed
during your period. When the uterus
tightens to push it out, you get a
cramp. Try a heating pad and overthe-counter pain relievers to ease
pain. Exercise and de-stressing can
help, too. You can also talk to your
doctor about PMS pain. Certain birth
control pills or antidepressants may
help.
Ectopic Pregnancy
This happens when an
embryo implants somewhere
outside of the uterus and
begins to grow. This usually
happens in the fallopian
tubes. Sharp pelvic pain or
cramps (particularly on one
side), vaginal bleeding,
nausea, and dizziness are
symptoms. Get medical help
right away. This is a lifethreatening emergency.
Sexually Transmitted
Diseases
Pelvic pain is a warning
sign of some STDs. Two of
the most common are
chlamydia and gonorrhea
(shown here through a
microscope). You often get
both at the same time.
They don't always cause
symptoms. But when they
do, you may have pain
when you pee, bleeding
between periods, and
abnormal vaginal
discharge. See your doctor.
It’s also important to get
partners checked and
treated, too, so you don’t
pass the infection back and
forth.
Pelvic Inflammatory Disease
This is a complication of sexually
transmitted diseases. It's the No. 1
preventable cause of infertility in
women. It can cause permanent
damage to the uterus, ovaries, and
fallopian tubes. Belly pain, fever,
abnormal vaginal discharge, and pain
during sex or urination can be
symptoms. Get it treated right away
to avoid damage. It is treated with
antibiotics. In severe cases, you may
need to be hospitalized. Get your
partner treated, too.
Ovarian Cysts
Ovaries release eggs when you
ovulate. Sometimes a follicle doesn't
open to release the egg. Or it recloses
after it does and swells with fluid.
This causes an ovarian cyst. They’re
usually harmless and go away on their
own. But they may cause pelvic pain,
pressure, swelling, and bloating. And
if a cyst bursts or twists, it can cause
sudden, severe pain, sending you to
the emergency room. Doctors can
spot them during a pelvic exam or
ultrasound.
Uterine Fibroids
These grow on or in the wall of the
uterus. While they’re sometimes
called fibroid tumors, they are not
cancerous. Fibroids are common in
women in their 30s and 40s. They
usually don’t cause problems. But
some women may have pressure in
the belly, low back pain, heavy
periods, painful sex, or trouble
getting pregnant. Talk with your
doctor if you need treatments to
shrink or remove them.
Endometriosis
In some women, the tissue that
lines the uterus grows outside of it.
It can happen on the ovaries,
fallopian tubes, bladder, intestines,
and other parts of the body. When
it's time for your period, these
clumps break down, but the tissue
has no way to leave the body. While
this is rarely dangerous, it can
cause pain and form scar tissue
that may make it tough to get
pregnant. There are several
treatment options. Pain
medications, birth control pills,
hormones to stop periods, surgery
with small incisions, and even a
hysterectomy (taking out your
uterus) are options.
Urinary Tract Infection
Do you have to pee often, or does it hurt
when you do? Or do you feel like your
bladder is full? It could be a UTI. This
happens when germs get into your urinary
tract. Treating it quickly can keep it from
it getting serious. But if it spreads to the
kidneys, it can cause serious damage.
Signs of a kidney infection include fever,
nausea, vomiting, and pain in one side of
the lower back.
Kidney Stones
These are globs of salt and minerals that
your body tries to get rid of in urine.
They can be as tiny as a grain of sand or
as large as a golf ball. And boy can they
hurt! Your urine may turn pink or red
from blood. See your doctor if you think
you have a kidney stone. Most will pass
out of your system on their own, but
some need treatment. Even if they can
pass on their own, your doctor can help
with pain medication and will tell you to
drink lots of water.
Interstitial Cystitis (IC)
This condition causes ongoing pain
and is related to inflammation of the
bladder (illustrated here). It’s most
common in women in their 30s and
40s. Doctors aren’t sure why it
happens. People with severe IC may
need to pee several times an hour.
You might also feel pressure above
the pubic area, pain when you
urinate, and pain during sex.
Although this can be a long-term
condition, there are ways to ease the
symptoms and avoid flares.
Pelvic Organ Prolapse
As you get older, this may happen. Your
bladder or uterus drops into a lower
position. It usually isn't a serious health
problem, but it can be uncomfortable. You
may feel pressure against the vaginal wall,
or your lower belly may feel full. It may
also give you an uncomfortable feeling in
the groin or lower back and make sex hurt.
Special exercises like Kegel’s or surgery
may help.
Pelvic Congestion Syndrome
We’ve all seen varicose veins in legs. (This is
a picture of one in the upper thigh.) They
can sometimes happen in the pelvis, too.
When blood backs up in veins, they become
swollen and painful. This is known as pelvic
congestion syndrome. It tends to hurt worse
when you sit or stand. Lying down may feel
better. It usually can be treated with
procedures using very small incisions.
Scar Tissue
If you've had surgery or an infection,
you could have ongoing pain from
this. Adhesions are a type of scar tissue
inside your body. They form between
organs or structures that aren’t meant
to be connected. Adhesions in your
belly can cause pain and other
problems, depending on where they
are. In some cases, you may need a
procedure or surgery to get rid of
them.
Vulvodynia
Does it hurt when you ride a bike or
have sex? If it burns, stings, or
throbs around the opening of your
vagina, it could be this. The feelings
can be ongoing or come and go.
Before you’re diagnosed with this,
your doctor will rule out other
causes. This isn’t caused by an
infection. Treatment options range
from medication to physical
therapy.
Chronic Pelvic Pain
If you have pain that lasts at least 6 months,
it’s considered chronic. It may be so bad it
messes with your sleep, career, or
relationships. See your doctor. Most of the
conditions we've covered get better with
treatment. Sometimes, even after a lot of
testing, the cause of pelvic pain remains a
mystery. But your doctor can still help you
find ways to feel better.
Prostatitis is the most common urologic
diagnosis in men younger than age 50
years and the third most common
urologic diagnosis in men older than age
50 years after benign prostatic
hyperplasia (BPH) and prostate cancer.
Definition and Classification
Acute bacterial prostatitis
Acute bacterial prostatitis was diagnosed
when prostatic fluid was clinically
purulent, systemic signs of infectious
disease were present, and bacteria were
cultured from prostatic fluid.
Chronic bacterial prostatitis
Chronic bacterial prostatitis was
diagnosed when pathogenic
bacteria were recovered in significant
numbers from a purulent prostatic
fluid in the absence of a concomitant
UTI or significant systemic signs.
Nonbacterial prostatitis
Nonbacterial prostatitis was diagnosed
when significant numbers of bacteria
could not be cultured from prostatic
fluid but the fluid consistently revealed
microscopic purulence.
Prostatodynia
Prostatodynia was diagnosed in the
remaining
patients
who
had
persistent
pain
and
voiding
complaints as in the previous two
categories but who had no significant
bacteria or purulence in the prostatic
fluid.
There is no validated cutoff point for the
level of WBCs per high-power field that is
required to differentiate an inflammatory
from a noninflammatory CP/CPPS.
Although the suggested limits have ranged
from as low as 2 to as high as 20, the
consensus appears to favor 5 to 10
WBCs/hpf in EPS as the upper level of
normal.
cystoscopy is indicated in patients in whom the
history (e.g., hematuria), lower urinary tract
evaluation (e.g., VB1 urinalysis), or ancillary studies
(e.g., urodynamics) indicate the possibility of a
diagnosis other than CP/CPPS. In these patients,
occasionally lower urinary tract malignancy, stones,
urethral strictures, bladder neck abnormalities, and
so forth that can be surgically corrected are
discovered. Cystoscopy can probably be justified in
men refractory to standard therapy.
Transrectal ultrasonography can be
valuable in diagnosing medial prostatic
cysts in patients with prostatitislike
symptoms, diagnosing and draining
prostatic abscesses, or diagnosing
and draining obstructed seminal vesicles.
Treatment
Antibiotics
Most experts suggest therapy initially with
parenteral antibiotics (depending
on the seriousness of the infection) followed
by oral antibiotics with wide-spectrum
antimicrobial activity.
The most common drugs suggested for initial
therapy are a combination of penicillin (i.e.,
ampicillin) and an aminoglycoside (i.e., gentamicin),
second- or third-generation cephalosporins, or one
of the fluoroquinolones.
α-adrenergic blocker
The bladder neck and prostate are rich in a
receptors, and it is hypothesized that αadrenergic blockade may improve outflow
obstruction, improving urinary flow and
perhaps diminishing intraprostatic ductal
reflux.
Anti inflammatory
Nonsteroidal anti inflammatory drugs,
corticosteroids, and immunosuppressive
drugs theoretically should improve the
inflammatory parameters within the
prostate and possibly result in a reduction
of symptoms.
pentosan polysulfate
The results of a multicenter, randomized,
placebo-controlled trial that randomized 100
men to pentosan polysulfate, 900 mg/day
(three times the usual dose), or
placebo indicated this medication provided
modest benefit for some men with CPPS.
skeletal muscle relaxants
The use of α-blockers to relax smooth
muscle (see earlier discussion of αadrenergic blockers) and skeletal muscle
relaxants combined with adjuvant medical
and physical therapies has been
advocated and promoted.
Antiandrogens
Theoretically, antiandrogens (including 5α-reductase
inhibitors) could result in regression of prostatic
glandular tissue (inflammation is believed to begin at
the level of the ductal epithelium), improved voiding
parameters (especially in older patients with BPH and
prostatitis), and reduced intraprostatic ductal reflux.
Finasteride cannot be recommended as a monotherapy
except perhaps in men with associated BPH.
Others
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Phytotherapeutic Agents
Neuromodulator Therapy
Allopurinol
Prostatic Massage
Perineal or Pelvic Floor Massage
Pudendal Nerve Entrapment Therapy
Biofeedback
Acupuncture
Psychological Support
Minimally Invasive Therapies:
Balloon Dilatation
Transurethral Needle Ablation
Microwave Hyperthermia and Thermotherapy
 Bladder pain syndrome/interstitial cystitis (BPS/IC) is
a condition diagnosed on a clinical basis and
requiring a high index of suspicion on the part of the
clinician.
 Simply put, it should be considered in the
differential diagnosis of the patient presenting
with chronic pelvic pain that is often exacerbated
by bladder filling and associated with urinary
frequency.
 National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK) Diagnostic Criteria for
Interstitial Cystitis
• Duration of symptoms less than 9 months
• Absence of nocturia
• Symptoms relieved by antimicrobial agents, urinary
antiseptic agents, anticholinergic agents, or antispasmodic
agents
• A frequency of urination while awake of less than 8 times
per day
• A diagnosis of bacterial cystitis or prostatitis within a 3month period
• Bladder or ureteral calculi
• Active genital herpes
Prevalence
 range from 1.2 per 100,000
 population and 4.5 per 100,000 females in Japan ,
to a questionnaire-based study that suggests a
figure in American women of 20,000 per 100,000
 All domains of female sexual function including
sexually related distress, desire, and orgasm
frequency can be affected
DIAGNOSIS
 It has now morphed largely into a diagnosis of
chronic pain, pressure, or discomfort associated
with the bladder, usually accompanied by urinary
frequency in the absence of any identifiable cause
 Diagnostic approaches vary widely, and general
agreement on a diagnostic algorithm remains a
future goal
 A presumptive diagnosis can be made merely by
ruling out known causes of frequency, pain, and
urgency in a patient with compatible chronic
symptoms
 Often this will involve a complete history, physical
examination, appropriate cultures, and local
cystoscopy.
The gold standard in defining
BPS/IC for research purposes
has been the NIDDK criteria.
Treatment Options
A) Conservative Therapy
B) Interventions:
1. Oral pharmacologic agents
2. Intravesical therapy
3. Surgical therapies
Conservative Therapies
If the patients symptoms are tolerable and do
not significantly impact quality of life, a
policy of withholding treatment is
reasonable.
 Behavioral and physical therapy:
 Biofeedback
 pelvic floor rehabilitation
 bladder training programs (progressively increasing
the voiding interval over the course of weeks to
months)
 Stress reduction, exercise, warm tub baths
 They are excellent initial interventions and have been
used by some authors with some success.
 The urinary frequency and urgency components
seem to respond better to these interventions than
the pelvic pain component.
Dietary Therapy
 Dietary restrictions are unsupported by any
literature (Campbell) , but EAU guideline stated
that consider diet avoidance of triggering
substances (GR C).
 Many patients do find their symptoms are
adversely affected by specific foods and would do
well to avoid them.
 Often this includes caffeine, alcohol, artificial
sweeteners, hot pepper, and beverages that might
acidify the urine such as cranberry juice.
Medical Treatment
Amitriptyline
 (EAU) Amitriptyline is effective for pain and related
symptoms of BPS (LE 1b)
 Mechanism: blockade of acetylcholine receptors,
inhibition of serotonin and noradrenalin reuptake, and
blockade of histamine H1 receptors. It is also an anxiolytic
agent.
 Median preferred dose is 50 mg in a range of 25 to 150
mg/day. The speed of onset of effect is 1 to 7 days.
 Drowsiness is a limiting factor with amitriptyline, and thus,
nortriptyline is sometimes considered instead.
Pentosan Polysulphate Sodium
 Oral PPS is effective for pain and related symptoms of BPS (LE 1a)
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and could be offered oral pentosanpolysulphate sodium for the
treatment of BPS (GR A).
It is thought to repair defects in the GAG layer.
Subjective improvement of pain, urgency, frequency, but not
nocturia, has been reported.
PPS had a more favorable effect in BPS with lesion than in non-lesion
disease.
Approved dosage is 100mg TDS.
At 32 weeks, about half the patients responded. So
a 3- to 6-month treatment trial is generally required to see
symptom improvement.
Anti-Histamins
 Hydroxyzine: No significant response was found in an
NIDDK placebo-controlled trial. It has limited
efficacy in BPS (LE 3).
 Cimetidine:
 (Campbell) Uncontrolled studies show improvement of
symptoms in two thirds of patients taking it in divided
doses totaling 600 mg. Cimetidine is a common treatment
in the United Kingdom, where over a third of patients
reported having used it.
 (EAU) Limited data exist on effectiveness of
cimetidine in BPS (LE 2b) and it can be considered as
a valid oral option before invasive treatments (GR B)
Antibiotics
 Antibiotics have no role in BPS due to the lack of
evidence (EAU).
 There is no evidence to suggest that antibiotics have a
place in the therapy for BPS in the absence of a
culture-documented infection.
 Nevertheless, it would not be unreasonable to treat
patients with one empirical course of antibiotic
(Doxy is recommended) if they have never been
on an antibiotic for their urinary symptoms
(Campbell).
Immunosuppressants
 Cyclosporin A: might be used in BPS but adverse
effects are significant and should be carefully
considered (GR B).
 Initial evaluation of cyclosporin A and methotrexate
showed good analgesic effect but limited efficacy for
urgency and frequency.
 Azathioprine treatment has resulted in disappearance of
pain and urinary frequency.
 In an aborted multicenter randomized placebo-controlled
NIDDK trial, mycophenolate mofetil (Cellcept 1 to 2
g/day in divided doses) failed to show efficacy in the
treatment of symptoms of refractory BPS/IC.
Analgesics
 Urologists should preferably use analgesics in
collaboration with pain clinics.
 The long-term, appropriate use of pain
medications forms an integral part of the
treatment of a chronic pain condition such as IC.
 Many non-opioid analgesics including acetaminophen
and the NSAIDs and even antispasmodic agents have a
place in therapy along with agents designed to
specifically treat the disorder itself.
Others
 Corticosteroids are not recommended in the
management of patients with BPS because of a lack of
evidence (GR C).
 Gabapentin might be considered for oral treatment of
BPS (GR C).
 Prostaglandins (e.g. misoprostol): are not
recommended. Insufficient data on BPS, adverse effects are
considerable (GR C).
 Duloxetine: inhibits both serotonin and noradrenaline
reuptake. Duloxetin shows no efficacy, and tolerability
is poor (LE 2b)
 L-Arginine: The body of evidence does not support the
use of L-arginine for the relief of symptoms of IC.
 Nifedipine. inhibits smooth muscle contraction and cellmediated immunity. In one pilot study, with use of 30 mg
daily within 4 months, 50% of patients showed at least a
50% decrease in symptom scores and 3 of the 5 were
asymptomatic. No further studies have been reported.
 Montelukast: In a pilot study, with 10 mg of montelukast
daily for 3 months, frequency, nocturia, and pain improved
dramatically in 80% of the patients.
 Tanezumab is a humanised monoclonal antibody that
specifically inhibits nerve growth factor (NGF). It should
only be used in clinical trials.
Intravesical treatment
 Intravesical drugs are administered due to poor oral
bioavailability establishing high drug concentrations
at the target, with few systemic side-effects.
 Disadvantages include the need for intermittent
catheterization, which can be painful in BPS patients,
cost, and risk of infection.
Oxybutynin
 Intravesical oxybutynin combined with bladder
training improves functional bladder capacity,
volume at first sensation, and cystometric
bladder capacity.
 However, the effect on pain has not been
reported.
Bladder Hydrodistention
 Following diagnostic hydrodistention, therapeutic
hydrodistention may be performed.
 This is usually performed at 80-100 cm water for 810 minutes.
 Although bladder hydrodistension is a common
treatment for BPS, the scientific justification is scarce.
It can be a part of the diagnostic evaluation, but has a
limited therapeutic role.
 Bladder distension should only be used as
diagnostic (LE 3) and is is not recommended as a
treatment of BPS (GR C).
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