Bladder Pain Syndrome / Interstitial Cystitis

Bladder pain syndrome (BPS) is a condition characterised by the sensation of pain or discomfort around the suprapubic region for at least 6 weeks in the absence of urinary tract symptoms. Other concurrent symptoms are urinary frequency and urgency, painful intercourse and sometimes burning sensation in urethra.

Patients with interstitial cystitis (IC) would have similar symptoms as BPS but also have abnormal findings during cystoscopy such as pinpoint bleeding in the bladder following short term bladder distention or presence of Hunner’s ulcers.

The symptoms of BPS/IC can vary in individuals and the treatment is usually based on the severity of the symptoms.

The exact cause is unknown but various hypothesis have been suggested:

• Defective bladder lining causing bladder wall irritation from urine toxins (leaky bladder)

• Increased histamine production in the bladder as a result of inflammation process

• Repeated bladder lining injury e.g. recurrent bladder infections, chemotherapy

• Autoimmune response when antibodies are made that act against a part of the body e.g. rheumatoid arthritis, systemic lupus erythematosus.

The diagnosis of BPS is made based on your clinical symptoms. There is no one specific test to check for BPS. A urine test is commonly performed to exclude evidence of urinary tract infection. Vaginal swabs may be performed to rule out evidence of sexually transmitted infections. You may require a cystoscopy with short term bladder distension to exclude pinpoint bleeding or Hunner’s ulcers. Concurrent bladder biopsy may be performed at your doctor’s discretion. This procedure may provide short term relief of bladder pain in some cases.

Most of the treatments offered are aimed at relieving symptoms and some may require more than one treatment and multidisciplinary team input including physiotherapist, acute or chronic pain team service, clinical psychologist and possibly a sexual counsellor if required.

Conservative therapy:

• Dietary modifications – avoiding triggers such as caffeine, alcohol, fizzy drinks, spicy food

• Stress management – relaxation therapy or hypotherapy has been found beneficial in some people

• Medications – vary from simple analgesia to nerve stabilising agents such as amitriptyline (Endep), pregabalin (Lyrica) or gabapentin.

• Physical therapy – treatments with a physiotherapist include bladder retraining, biodfeedback, pelvic floor muscle relaxation and massage due to hypertonic pelvic floor muscle and myofascial therapy

Advanced therapy:

• Bladder instillation - During this treatment, a short plastic catheter will be inserted into your bladder to fill your bladder with medications. The options of bladder instillation include:

A cocktail of medications such as heparin, local anaesthetic agents, steroids, dimethyl sulfoxide (DMSO). Side effects of DMSO use include garlic-like odour, bladder discomfort during instillation and possible urinary tract infection

Hyaluronic acid/chondroitin sulfate (iAluril) – replenishes defective bladder lining. More tolerable than DMSO with minimal side effects.

• Initial treatment regime: Weekly instillation for the first month, fortnightly on the second month and once a month on the third month.

• Maintenance treatment: Once a month depending on symptoms

• Cystoscopy hydrodistension as described above ± treatment of Hunner’s ulcer if present

• Botox injections into the bladder – considered as fourth line treatment option for management of bladder pain with concurrent overactive bladder symptoms

Please discuss with Dr Yong directly for further advice on management of BPS/IC

https://www.yourpelvicfloor.org/leaflets/

http://www.painful-bladder.org/IPBFwho_are_we.html