Bladder pain syndrome (BPS) is a common chronic pelvic pain condition that affects an estimated 7.9 million women in the United States.1
Although the nomenclature for BPS remains controversial, the American Urological Association defines BPS/interstitial cystitis as "an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than duration of six weeks, in the absence of infection or other identifiable causes. 1
Patients may present to several different doctors and describe "flares of worsening symptoms caused by stress, sexual intercourse, menstruation, or diet.
Bladder pain syndrome is incompletely understood and includes a spectrum of overlapping pain conditions rather than a distinct urothelial abnormality.
| Proposed etiologies include injury to the glycosaminoglycan layer of the bladder with resulting neurogenic inflammation , autoimmune abnormality, epithelial dysfunction, and infectious agents, as well as peripheral sensitization, central sensitization, or both, described as increased sensitivity to nociceptive stimuli.1 |
Symptom presentation can be variable, suggesting that BPS is a multifactorial disease with overlapping etiologies driven by complex pelvic neural circuits.
Definitive diagnostic criteria and research measures that correlate with treatment outcomes are lacking. This complexity causes significant diagnostic delay and misdiagnosis and often requires coordinated treatment from multiple subspecialists.
Other conditions that can mimic BPS should be excluded, including endometriosis, urinary tract infections, and pelvic inflammatory disease.
The characteristics and duration of pain and exacerbating and mitigating factors, such as dietary triggers, bladder filling and emptying, bowel habits, sexual intercourse, and menstruation, should be recorded. Physical or sexual abuse should also be evaluated.
The history should include details about the use of medications that can cause cystitis (such as nonsteroidal anti-inflammatory drugs, cyclophosphamide, and ketamine), prior pelvic surgery, sexually transmitted infections, malignancies, and conditions associated with BPS (such as irritable bowel syndrome, vulvodynia, endometriosis, fibromyalgia, chronic fatigue syndrome and autoimmune diseases).
Physical exam
The physical examination should include abdominal and pelvic examinations. A musculoskeletal examination should be completed to evaluate lumbar, pelvic girdle, and hip contributions to pain, along with a focused neurological examination of the lower extremities.
Pelvic floor myofascial pain and dysfunction (PFMP) have been found in up to 85% of patients with BPS.2 Therefore, a pelvic floor muscular examination should be performed as an additional component of the pelvic, vaginal, and/or examination. rectal (depending on comorbid symptoms) in dorsal lithotomy position.
The examination should include gloved palpation of the levator ani muscles, assessing tenderness, tight bands, and trigger points, as well as baseline muscle tone, voluntary and involuntary contraction, and relaxation.
Complementary exams
Basic laboratory tests should include a urinalysis and urine culture.
Urodynamic testing should be reserved for women in whom relevant neurological disease is suspected.
Cystoscopy and bladder biopsy are expected to have normal findings in most patients with BPS and are not necessary for diagnosis.
In general, cystoscopy can be reserved for evaluation of hematuria and for women with a significant history of smoking, personal or family history of genitourinary malignancies, or failure of conservative therapies.
Hunner lesions, erythematous inflammatory lesions of the mucosa that often have vessels radiating toward the center, are notable on cystoscopy in 11% to 16% of patients with BPS and are associated with more severe bladder symptoms. 4 Terminal hematuria, glomerulations, and petechial bladder hemorrhages found by cystoscopy are neither sensitive nor specific for BPS.
Specialists may consider a bladder anesthetic challenge with dilute lidocaine instillation to help with diagnosis and future treatment if a patient improves symptoms after instillation.1,4
Potassium sensitivity testing is expensive, painful, and inaccurate and is therefore not recommended.1
Summary
In summary, BPS can be diagnosed in patients with bladder/suprapubic pain and voiding symptoms lasting more than 6 weeks if infection and structural genitourinary pathology are excluded.
Comprehensive guidelines advocate a gradual approach to treatment that balances the benefits and adverse effects of chosen therapies.1
Patients should be educated about the chronicity of the disease, the goals of symptom management, and the noninfectious origin of the symptoms.
Antibiotics are not indicated without a documented microbial target.
Additionally, self-care techniques that emphasize stress management and behavior modifications are key first-line treatments. This includes avoidance of bladder irritants (e.g., acidic foods, coffee/tea, carbonation, alcohol) and individualized triggers based on symptoms.
Patients should be encouraged to assess their hydration level, bladder volume, and voiding frequency to improve symptoms.
A bowel regimen focused on treating constipation related to irritable bowel syndrome may also be helpful. Studies have shown that up to 45% of patients have improvement with behavior modification alone. Due to the complex etiology and comorbid conditions often associated with BPS, a multidisciplinary approach is recommended.
Inclusion of behavioral health professionals for psychiatric comorbidities and stress management is paramount. In women with opioid dependence, treatment should be coordinated with a pain center team.
Pelvic floor physical therapy ( PFPT) is recommended for women with myofascial abnormalities.
In a multicenter randomized clinical trial comparing PFPT with global therapeutic massage for women with BPS, 59% vs. 26% showed moderate to marked improvement.5 Although it is still unclear whether associated PFMP precedes BPS symptoms or develops in response to BPS. The treatment option has little risk and demonstrated success.
Additional adjunctive treatment options can be incorporated early into the treatment algorithm with minimal risk of complications. Acupuncture is associated with improving symptoms for other pain conditions, and preliminary research suggests it has benefits for BPS. If conservative treatment is unsuccessful, other therapies may be added or substituted, including referral to a center . with experience in the multidisciplinary management of chronic pelvic pain.
Oral agents including amitriptyline, cimetidine, hydroxyzine, and pentosan polysulfate may benefit a subset of patients, but have adverse effects4 including fatigue, dry mouth, and, specifically with pentosan polysulfate, pigmentary maculopathy. Furthermore, studies comparing oral agents are lacking.
Lidocaine, heparin, and dimethyl sulfoxide instillations may be beneficial, although no specific treatment combination has been shown to be more effective than others.
For 11% to 16% of patients with Hunner lesions, fulguration or intralesional steroid injections should be considered1,4. Furthermore, evidence suggests the effectiveness of intradetrusor botulinum injections for patients with refractory symptoms4,7. Emerging evidence for pelvic floor botulinum injections for PFMP is also promising.4 Major surgery involving cystectomy or diversion is rarely indicated.
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