Management of Bladder Pain Syndrome (BPS): A Practical Guide

Bladder pain syndrome (BPS) is a prevalent and pervasive disease. The physical and psychological sequelae can be very burdensome for the patient, and the condition represents a real challenge for the clinician as well. With no simple pathognomonic test, finding harmony in navigating patient care can be demanding. Diagnosis and management rely upon a multidisciplinary and holistic approach. Treatment options include conservative measures and pharmacotherapies as well as bladder instillation therapies. Ultimately, surgery may be offered but only in cases of refractory disease. This article offers a pragmatic guide for clinicians managing this challenging disease.

Small Fiber Polyneuropathy May Be a Nexus Between Autonomic Nervous System Dysregulation and Pain in Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a highly heterogeneous chronic and debilitating condition which effects millions of women and men in the United States. While primarily defined by urinary symptoms and pain perceived to be emanating from the bladder, IC/BPS patients frequently have co-occurring conditions and symptoms, many of which affect diverse body systems related to autonomic nervous system function. The impact on the autonomic system appears to stem from increased sympathetic innervation of the urinary tract, along with increased systemic sympathetic tone and decreased parasympathetic tone. Concurrent with these findings is evidence for destruction of peripheral sympathetic innervation to the sweat glands which may relate to small fiber polyneuropathy. It is unknown to what degree the wider alterations in autonomic function are also related to destruction/alterations in the small fibers carrying autonomic innervation. This potential nexus is an important point of investigation to better understand the unclarified pathophysiology of interstitial cystitis/bladder pain syndrome, the numerous co-occurring symptoms and syndromes, and for the identification of novel targeted therapeutic strategies.

Assessing the Efficacy of Superior Hypogastric Nerve Block as a Possible Treatment Option for Bladder Pain Syndrome

Introduction: Chronic pelvic pain (CPP), and its subtype of interstitial cystitis/bladder pain syndrome (IC/BPS) can be debilitating and difficult conditions to treat. A new treatment modality being explored is the superior hypogastric (plexus) nerve block (SHPB). While previously indicated to relieve conditions related to chronic abdominal and pelvic pain, there is a paucity of evidence for use in IC/BPS patients. We aim to explore the efficacy of SHPB therapy in this population. Methods: This is a retrospective, single institution study including patients with IC/BPS or CPP who underwent SHPB during a 7-year span. Parameters analyzed include number of treatments, percentage of pain improvement after treatment, and multiple demographic and disease variables. Results: A total of 30 patients (26 CPP; 4 IC/BPS) were included in the study and 80% completed pain scores after their first injection (n=24). Fourteen patients had >50% pain improvement (58.3%), 10 had >70% improvement (41.7%) and 5 patients had 100% improvement (20.8%) after their first injection. Greater pain improvement was seen in the multiple vs. single injection group (52.3% vs. 20.8%, p=0.013). There was no significant difference in pain improvement between CPP and IC/BPS groups (42.2% vs. 50.0%, p= 0.630). Conclusion: SHPB may be useful as an alternative therapy for IC/BPS patients who have failed previous treatment options. Additional high-powered studies are needed to validate the safety and efficacy of SHPB in this population.

Pelvic Floor Myofascial Pain Might Influence Treatment Outcome of Interstitial Cystitis/bladder Pain Syndrome

IntroductionIn patients with interstitial cystitis or bladder pain syndrome (IC/BPS), 85% were found to have pelvic floor myofascial pain (PFMP) and hypertonicity (PFH). However, they are not typically trained to consider or assess PFMP as a contributing factor to patients’ IC/BPS symptoms. This study aimed to explore the relationship between PFMP and treatment outcomes in women with IC/BPS.MethodsPatients with IC/BPS who received any type of treatment were prospectively enrolled. They underwent vaginal digital examination at baseline. PFMP severity was quantified on the visual analog scale (VAS). Subject assessment items included O’Leary-Sant symptom score (OSS), Global Response Assessment (GRA), and Beck’s anxiety inventory. Object assessment items included bladder computed tomography (CT), urodynamic parameters, maximum bladder capacity, and grade of glomerulation.ResultsA total of 65 women with IC/BPS (mean age, 57.1 ± 11.3 years) were enrolled in the study. Patients with more severe PFMP had significantly higher rate of dyspareunia (p = .031); more comorbidities (p = .010); higher number of PFMP sites (p < .001); and higher OSS (p = .012). PFMP severity was not significantly correlated with bladder conditions, whether subjective or objective. Moreover, PFMP severity (VAS) was significantly negatively associated with GRA score.ConclusionPFMP might affect the subjective results of IC/BPS treatment but not the bladder condition. Therefore, in the future treatment of patients with IC/BPS, digital vaginal examinations of pelvic floor muscles should be performed and focused more on the PFM-related conditions, and necessary PFM treatments, such as the vaginal pelvic floor muscle message, should be scheduled.

Urinary Biomarkers in Interstitial Cystitis/Bladder Pain Syndrome and Its Impact on Therapeutic Outcome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is defined as a chronic bladder disorder with suprapubic pain (pelvic pain) and pressure and/or discomfort related to bladder filling accompanied by lower urinary tract symptoms, such as urinary frequency and urgency without urinary tract infection (UTI) lasting for at least 6 weeks. IC/BPS presents significant bladder pain and frequency urgency symptoms with unknown etiology, and it is without a widely accepted standard in diagnosis. Patients’ pathological features through cystoscopy and histologic features of bladder biopsy determine the presence or absence of Hunner lesions. IC/PBS is categorized into Hunner (ulcerative) type IC/BPS (HIC/BPS) or non-Hunner (nonulcerative) type IC/BPS (NHIC/BPS). The pathophysiology of IC/BPS is composed of multiple possible factors, such as chronic inflammation, autoimmune disorders, neurogenic hyperactivity, urothelial defects, abnormal angiogenesis, oxidative stress, and exogenous urine substances, which play a crucial role in the pathophysiology of IC/BPS. Abnormal expressions of several urine and serum specimens, including growth factor, methylhistamine, glycoprotein, chemokine and cytokines, might be useful as biomarkers for IC/BPS diagnosis. Further studies to identify the key molecules in IC/BPS will help to improve the efficacy of treatment and identify biomarkers of the disease. In this review, we discuss the potential medical therapy and assessment of therapeutic outcome with urinary biomarkers for IC/BPS.