Page 2 - Diagnosis and treatment of interstitial cystitis/bladder pain syndrome

iC/BPS guideline

This translates into approximately 3.3‒7.9 million women patients with IC/BPS void to relieve pain, whereas OAB
over the age of 18 years in the U.S. affected by symptoms of patients void for fear of incontinence. A good response to
IC/BPS. Of these women, however, only 9.7% report being antimuscarinics suggests OAB, however, be cautious that this
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diagnosed with IC/BPS. In addition, this study found that may confound the diagnosis, as the disorders may coexist.
women with the diagnosis of IC/BPS were significantly more Despite the absence of urinary infection (UTI) being a
likely to be uninsured, less likely to be married, and had prerequisite at the time of diagnosis, up to 50% of patients
more children than controls. Of patients with IC, 94% are will have a previous history of UTI. It is important to elicit a
White and the median age is 40 years. comprehensive medical history, including past pelvic surgery
Although the disease can affect both sexes, approximately or radiation, medications that can cause cystitis (nonsteroidal
90% are female. In addition, the condition is dramatically anti-inflammatory drugs, cyclophosphamide, and ketamine),
under-reported in men. There is significant overlap of symp- fibromyalgia, depression, sexual dysfunction, autoimmune
toms of IC/BPS to those of chronic prostatitis/chronic pelvic diseases, allergies, and other gynecological conditions (vul-
pain syndrome, with 17% of men found to have symptoms vodynia, endometriosis, dyspareunia). Not only is the past
of both complexes. 11 medical history important for diagnosis, but also because
many of these conditions may co-exist, further stressing the
Diagnosis of IC/BPS importance of multidisciplinary management. Table 1 sum-
marizes relevant diseases that may be confused with IC/BPS.

1. History (MANDATORY, all patients, Grade C, Level 4 evidence) 2. Physical examination (MANDATORY, all patients, Grade C, Level
4 evidence)
A thorough general medical history is of paramount
importance to identify typical diagnostic symptoms of IC/ The physical exam should include an abdominal and pelvic
BPS and other potential mimicking causative conditions. exam, with particular focus on looking for masses, blad-
Unfortunately, delay of diagnosis is common, with an aver- der distension, hernias, and tenderness. A musculoskeletal
age time of three to seven years from the time of presentation and focused neurological exam may also be contributory.
to the general practitioner to diagnosis by a specialist. 12,13 Although there is no physical finding specific to patients
The characteristic presentation of IC/BPS includes a with IC/BPS, suprapubic tenderness and bladder neck point
combination of pain, frequency, nocturia, and urgency. tenderness, in both men and women, is very often noted. In
The onset of symptoms may be gradual and/or with only a men, tenderness may be elicited by palpating the perineal
single voiding symptom; however, pelvic pain is the main area between the scrotum and anus; in women, palpating
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descriptor of IC/BPS. In early or milder IC/BPS, patients the anterior vaginal wall along the course of the urethra up
may not describe frank pain, but rather describe sensations to the bladder neck may elicit pain.
of “pressure,” “burning,” “sharp,” or “uncomfortable sensa- Peters et al demonstrated an association between IC/
tion of having to urinate.” Typically this sensation is felt in BPS and pelvic floor dysfunction in a study of 70 women,
the supra-pubic area, but it can be referred to areas located
in the pelvis, including the urethra, vagina, labia, inguinal Table 1. Summary of differential diagnoses
area, perineum, and/or lower abdomen or back. Disease How they can be excluded or diagnosed*
The location of pain, relation to bladder filling/emptying Endometriosis Pain worse during menses (vs. few days prior)
duration, and a description of the type of pain can all be History of radiation, nonsteroidal anti-
useful. Pain that occurs only during voiding is not consistent Non-infectious inflammatory drugs, cyclophosphamide, and/or
with IC/BPS, and vulvar disorders, which cause pain when cystitis ketamine use
urine makes contact with the vulva, should instead be con- Vulvar Pain occurs only during voiding, when
sidered. Symptoms of IC/BPS are generally worse a few days disorders urine contacts vulva, and/or painful sexual
prior to menses, in contrast to endometriosis, which is worse intercourse
during menses. Patients may describe “flares,” or periods Overactive Good response to anti-muscarinics, patient
voids to avoid incontinence (vs. to relieve pain);
of worsening symptoms, which may be triggered by stress, bladder no significant perceived bladder pain
intercourse, menses, or diet. Common triggers include cof- Worse with sitting, positional dependency
fee, alcohol, citrus fruits, tomatoes, carbonated beverages, Pudendal nerve suggests a neurogenic or musculoskeletal
and spicy foods. 15 entrapment process
The most common presenting symptom, however, is fre- Prostate- Pain during or after ejaculation, pain on
quency, estimated to be 92% of one population. 12,16 Urgency related pain prostate palpation
is also prevalent, however, cannot distinguish IC/BPS from Pelvic floor Trigger point, fascial or muscle pain or
overactive bladder (OAB). Typically, the difference is that disorders tenderness, spasm on palpation
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* IC/BPS may co-exist.
CUAJ • May-June 2016 • Volume 10, Issues 5-6 E137