jen graham 28/03/14. definitions epidemiology clinical assessment aetiology management
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Jen Graham 28/03/14
DefinitionsEpidemiologyClinical AssessmentAetiologyManagement
Poorly defined Initially defined in research settingPelvic Pain + Urinary storage
symptomsHeterogenous spectrum of disorders Inflammation is only present in a
small subset of patients IC vs PBS or BPS
Bladder Pain Syndrome (BPS) is the occurrence of persistent or recurrent pain perceived in the urinary bladder region accompanied by at least one other
symptom e.g. pain worsening with bladder filling, day-time and/or night time urinary frequency
In the absence of “confusable conditions” e.g. urinary tract infection
Mostly women (10:1 F:M)
No difference in race or ethnicity Genetic component may be present Age ≥18
Median age 42-45 at diagnosis
Associations: allergies, functional somatic syndromes - IBS,
fibromyalgia, CFS autoimmune - Sjogren’s syndrome, SLE depression
Variable due to inconsistent definitions
Difficult to diagnose and treatNo pathological criteria define the
disease
Large variation 0.06%-30% Mainly <1% in most populations
Made on the basis of: History Examination Urinalysis Cystoscopy with hydrodistension +/-
biopsy
Nature of the pain is key Pain/pressure discomfort perceived to be related
to bladder, increasing with increasing bladder content
Located suprapubically but may radiate to groins, vagina, rectum or scrotum
Relieved by voiding, but returns Aggravated by food or drink
Other LUTS – frequency, urgency, haematuria Urological diseases (incl. UTI)
- Previous pelvic operations- Previous pelvic radiation treatment
Other PMH e.g. Autoimmune disease
Abdomen / bladder Males:
DRE Females:
PV for pain mapping of vulval regiontenderness of urethra, trigone and
bladdersuperficial/ deep vaginal tendernesstenderness of pelvic floor (levator,
adductor)
Validated symptoms score
Can be helpful in monitoring response to treatment
MSUUrine cytologyEMU x3 (if sterile pyuria)ChlamydiaOther tests guided by history
e.g. Foreign travel
Under GA Fill to maximum capacity and distend
for 3 minutes at 80-100 cmH2O Empty and measure volume and look
for bleeding 2nd look only fill to 1-2/3 bladder
capacity Inspect bladder
Cystoscopy + biopsy may differentiate different subtypes
Development of glomerulations is a positive prognostic sign
Inflammation often leading to small capacity fibrotic bladders
Reddened mucosa Hunner’s Ulcers in 5-
10% Small vessels radiating
to central scar Scar ruptures at
bladder distension leading to waterfall-type bleeding
Likely to be multifactorial1. Urinary infections used to be thought to be initial insult
UTI/urgency more frequent during childhood in subsequent sufferers
2. Mast cells ? Causative or secondary Frequently associated with PBS/IC bladder, also present in non
IC bladders Active allergies exacerbate symptoms
3. Epithelial permeability Deficiencies in glycosaminoglycan (GAG) layer Exposes submucosal nerve endings to noxious urine
components 4. Neurogenic Inflammation
Abnormal sensory nerve activity 5. Autoimmunity6. Hormonal
IC / PBS not curable Try to make patient as self-reliant as
possible Manage expectations of patient Lots of potential treatments → lots of
potential treatment combos Spontaneous temporary remission can
be short lived and unrelated to therapy (up to 20% in placebo studies)
Behavioural Dietary Pharmacological Intravesical Surgical
Interstitial cystitis database study noted >180 treatment modalities for IC/PBS with poor results in the majority of cases
Behavioural bladder training in patients who predominately have
frequency / urgency with little pain Diet
no real affect in altering diet (little more than placebo), though there are many lists of foods to avoid
Intravaginal electrical stimulation effective in alleviating pain
Acupuncture conflicting evidence, may be beneficial not a recommended / evidenced based
therapy
Analgesics Often disappointing effect on visceral pain of
BPS Amitriptyline
Blocks h1 histaminergic receptors and decreases mast cell activity.
Decreases painful nociception by inhibition of reuptake of serotonin and noradrenaline
Cimetidine H2 receptor antagonist
Pentosan polysulphate sodium (Elmiron) Heparin analogue Thought to substitute defect in GAG layer
Given via intermittent catheterPentosan polysulphate
Glycoprotein replacing deficient GAG layerHyaluronic acid (Cystistat)Chondroitin sulphateDimethyl sulphoxide (DMSO)
Chemical solvent that penetrates cell membranes
Claimed to have analgesia, anti-inflammatory and muscle relaxant effects
HydrodistensionTransurethral resection of Hunner’s
ulcers Intratrigonal botox Neuromodulation
Denervation procedures Cystectomy/cystoplasty
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