Page 5 - Diagnosis and treatment of interstitial cystitis/bladder pain syndrome

Cox et al.

To differentiate between the pain originating from urinary merulations in 45% of 20 normal women who consented
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bladder from that of other pelvic organs, Taneja et al treated to undergo HD at the time of tubal ligation.
22 women with pelvic pain with 20 mL of 2% intravesical As the literature is conflicting regarding its utility, HD for
lidocaine solution. Sixty-eight percent experienced a reduc- diagnostic purposes may be appropriate in certain situations.
tion of pain by 50% or greater. All non-responders were These may include: when a patient is unable to tolerate
subsequently diagnosed with non-bladder pathology causing cystoscopy under local anesthetic and is having a general
their pelvic pain. 47 anesthetic; when a patient has failed other treatment options
With no risk of symptom flare, the anesthetic bladder and HD to assess disease severity may contribute informa-
challenge may be considered when there is uncertainty as tion to the diagnosis; and when assessing a patient for clini-
to whether the pain is originating from the bladder. cal trial eligibility.

10. Hydrodistension (OPTIONAL, select patients, Grade C, Level 3 11. Urodynamics (UDS) (NOT RECOMMENDED in the routine evaluation
evidence) of IC/BPS, Grade C, Level 3 evidence)

Hydrodistension (HD) under general anesthetic allows for Filling cystometrogram (CMG) has been advocated by some
stratification of patients into those with more classic disease for the diagnosis of IC/BPS. 3,52 Certainly there is overlap
associated with ulcers and glomerulations from those with between the conditions of OAB-dry and symptoms of IC/
no obvious mucosal abnormalities. The technique of diag- BPS, and the finding of detrusor overactivity (DO) on filling
3
nostic HD generally involves gravity filling of the bladder at CMG may lead the clinician to initiate therapy with anti-
70‒100 cmH 0 for a minimum of two minutes, performed cholinergic agents.
2
under general or regional anesthetic. Maximum anesthetic According to the NIDDK criteria, the finding of a capacity
capacity is determined whereby the inflow backs up in the >350 mL, first sensation of having to void >150 mL, or the
drip chamber or leakage occurs per urethra despite com- presence of DO are exclusionary for a diagnosis of classic
3
pression against the cystoscope. While severely reduced IC. However, it is recognized that approximately 15% of
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anesthetic bladder capacities (<400 mL) do correlate with patients diagnosed with IC/BPS will demonstrate DO and,
pain, more than 50% of patients with IC/BPS show capaci- thus, the coexistence of urge incontinence or DO should not
33
ties more than 800 mL. preclude a diagnosis of IC/BPS. Other findings on UDS from
The presence of terminal hematuria upon draining the the IC database study were a reduced first sensation to void
infusion fluid and the appearance of petechial submuco- (mean 81 ± 64 mL) and maximum sensory capacity (mean
sal hemorrhages (glomerulations) has been suggested to be 198 ± 107 mL). While these UDS parameters do correlate
characteristic of IC/BPS and is one of the prerequisite find- well with frequency, nocturia, and urgency, they have not
ings in the NIDDK criteria. Glomerulation severity has also been well-correlated to global pain, cystoscopic findings
3
been graded.A possible relationship between glomerulations at HD (other than the presence of a Hunner’s lesions), or

and angiogenic growth factors has been found, suggesting results of therapeutic intervention.
that these growth factors may have an important role in the Bladder capacity may be assessed less invasively and
pathogenesis of IC/BPS. 48 more cost effectively by means of a frequency volume chart
Despite the initial adoption of the HD findings of glo- with self-measurement of voided volumes; this has been
merulations as a criteria for the diagnosis of IC/BPS by the shown to correlate with maximum cystometric capacity and
National Institutes of Health (NIH), approximately eight first sensation of having to void in patients with IC/BPS. 33,53 If
percent with a diagnosis of IC/BPS do not show glomerula- a cystoscopy under local anesthetic is planned, a functional
tions. 19,32 The severity of glomerulations was found to cor- bladder capacity and its relation to the patient’s pain can be
relate poorly with symptoms and with histological evidence assessed with patient awake.
of inflammation. In contrast, Lamale et al found a strong Pressure flow studies, with or without electromyography,
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correlation with pain and HD findings. Their series was may be useful in some situations where there are coexistent
50
small (12 patients), including perhaps more severe patients, voiding symptoms with suspicion of bladder outlet obstruc-
as evidenced by a mean anesthetic bladder capacity of 604 tion or voiding dysfunction due to high-tone pelvic floor
mL, but represented an untreated cohort where they postu- dysfunction.
lated there were no confounders of treatment allowing a true Overall, UDS studies are not recommended in the stan-
correlation to be identified. In another series of 84 patients, dard diagnostic evaluation of a patient suspected of having
cystoscopy with HD provided little useful information above IC/BPS.
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and beyond the history and physical examination findings.
Additionally, the specificity of glomerulations was brought
into question when Waxman et al found characteristic glo-

E140 CUAJ • May-June 2016 • Volume 10, Issues 5-6