Management of patients with interstitial cystitis or chronic pelvic pain of bladder origin: a consensus report

Pelvic pain in urogynecology. Part II: treatment options in patients with lower urinary tract symptoms

Therapeutic options for chronic pelvic pain in women offer only a limited symptom relief. Especially in the patient with lower urinary tract symptoms (LUTS), where overlap of pain, storage and voiding symptoms is common, data on the efficacy of treatment of pain are limited. We conducted a literature review to detect articles which pertained to female patients with LUTS and pelvic pain and we included articles which evaluated the efficacy of the treatment of pelvic pain. Forty-one articles were detected, which included nerve stimulation (sacral and pudendal), intravesical instillations and injections, oral pharmacological treatments, periurethral injections as well as physical and manual therapy as treatment options. Only five controlled trials were found, which did not show superiority of the active treatment versus placebo. Although some treatment options show promising results in the treatment of pelvic pain in patients with LUTS, more randomised controlled trials are needed to confirm these results.

Role of inflammation in bladder function and interstitial cystitis

Cystitis, or inflammation of the bladder, has a direct effect on bladder function. Interstitial cystitis is a syndrome characterized by urinary bladder pain and irritative symptoms of more than 6 months duration. It commonly occurs in young to middle-aged women with no known cause and in fact represents a diagnosis of exclusion. Many factors have been suggested, including chronic or subclinical infection, autoimmunity and genetic susceptibility, which could be responsible for initiating the inflammatory response. However, a central role of inflammation has been confirmed in the pathogenesis of interstitial cystitis. Patients with interstitial cystitis are usually managed with multimodal therapy to break the vicious cycle of chronic inflammation at every step. Patients who develop irreversible pathologies such as fibrosis are managed surgically, which is usually reserved for refractory cases.

Interstitial Cystitis: Minimal Diagnostic Criteria

Any article reporting on Interstitial Cystitis (IC) will list numerous investigations. This paper presents a review of the minimum investigations needed and their significance for the initial evaluation and diagnosis of patients with Interstitial Cystitis. To optimize patient's early diagnosis and disease monitoring, a comprehensive algorithm for the diagnosis of IC has been proposed. The paper defines interstitial cystitis (IC) as a disease of the urinary bladder diagnosed by at least one of the following 3 requirements: 1) endoscopic criteria (cystoscopy findings); 2) pathologic criteria of bladder biopsy; and 3) clinical criteria including pain and lower urinary tract symptoms evaluation. Furthermore, the exclusion of confusable diseases is mandatory in all cases. These are recommendations, mostly based on expert opinions and literature review. Where possible, a level of recommendation was developed according to a 3–grade scale: mandatory (grade 1), recommended (grade 2), and optional (grade 3). By using a stepwise approach and an evidence-based thought process, the diagnosis of IC is made easier and reliable.

Diagnostic options for early identification and management of interstitial cystitis/painful bladder syndrome

AIMS

The aims of this article were to discuss options for diagnosing interstitial cystitis (IC), to compare approaches and to encourage early diagnosis of this disorder in the primary care setting.

METHODS

Experts discussed the tools available to diagnose IC and the advantages and disadvantages of each approach. Treatment options, both pharmacological and non-pharmacological, were also discussed. The importance of patient follow-up was emphasised.

RESULTS

Diagnostic options for IC include a thorough history and physical examination, laboratory evaluations, symptom screening tools, cystoscopy with hydrodistention, bladder biopsy, potassium sensitivity testing, intravesical anaesthetic challenges, urodynamics and urinary markers. Treatment options include oral and intravesical medications, dietary modification and physical therapy. Patient follow-up can be an opportunity to educate and empower patients to participate in their treatment.

DISCUSSION

A thorough patient history, physical examination and laboratory evaluations are keys to the diagnosis of IC. Optional diagnostic approaches may help increase physician confidence in prescribing therapy for this disorder. Multimodal therapy with an emphasis on patient education can help ensure success in treating IC.

CONCLUSION

Understanding the options available to diagnose IC may result in earlier identification and treatment for some patients.

Interstitial cystitis/painful bladder syndrome: appropriate diagnosis and management

Interstitial cystitis/painful bladder syndrome (IC/PBS) is characterized by urinary frequency, urgency, and pelvic pain in the absence of any other identifiable pathology. Initial identification of IC/PBS is challenging, as patients may have a range of symptoms that overlap with other disorders, including urinary tract infection (UTI). These patients may be treated empirically with antibiotics; however, many patients with such symptoms are actually culture negative and are later diagnosed with IC/PBS. This review describes the importance of recognizing the symptom overlap between IC/PBS and UTI and focuses on approaches to the diagnosis and management of IC/PBS. Physicians can improve patient care by considering IC/PBS early in the differential diagnosis.

Interstitial cystitis/painful bladder syndrome as a cause of sexual pain in women: a diagnosis to consider

INTRODUCTION

Sexual pain, or dyspareunia, is a common symptom among women. Dyspareunia presents in many ways, and arises from a range of causes. Interstitial cystitis/painful bladder syndrome (IC/PBS) is one potential cause that may frequently be overlooked by clinicians. Interstitial cystitis is increasingly recognized as more common than was once thought. However, it can be difficult to identify, as the symptoms of IC/PBS (urinary urgency and frequency, dyspareunia, nocturia, and pelvic pain) overlap with other urogynecologic conditions.

AIM

This article will review the association between dyspareunia and IC/PBS, and will provide an approach to the diagnosis and treatment of IC/PBS in women with sexual pain.

METHODS AND MAIN OUTCOME MEASURES

Review of the medical literature and expert medical opinion.

RESULTS

Many women with IC/PBS experience dyspareunia, often in conjunction with chronic pelvic pain. When IC/PBS is suspected, there are simple measures to aid in the diagnosis of this condition, and treatments are readily available.

CONCLUSIONS

When a woman presents with the symptoms of urinary urgency and frequency, dyspareunia, nocturia, and/or pelvic pain, IC/PBS should be part of the diagnostic evaluation.

The management of interstitial cystitis: an update

Treating interstitial cystitis (IC) is one of the greatest challenges facing physicians and other health care providers who manage patients with this condition. The symptoms of urinary frequency and urgency, dysuria, and chronic pelvic pain characterize IC, but it is the debilitating pelvic pain associated with IC that is most difficult to control. The pathophysiology of IC pain is poorly understood, but is thought to be a complex entity including nociceptive, visceral, and neuropathic components. There are currently no universally effective therapies available. Oral treatments, however, are frequently used, including nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentin, and pentosan polysulfate, all of which have shown varying degrees of efficacy. Recognition that IC pain is multifactorial, and probably has a neuropathic component, has led to the use of some of these agents, previously prescribed for other neurologic conditions associated with chronic pain. Intravesical and surgical options are also available, which expands the armamentarium for those who treat pain secondary to IC. Treating IC requires managing all of the symptoms of this disease. This review aims to cover standard and novel treatment options, while concentrating on the management of pain.