Interstitial Cystitis (IC)/Painful Bladder Syndrome(PBS)

Transcription

1 Interstitial Cystitis (IC)/Painful Bladder Syndrome(PBS) Ene G. George M.D., FACOG, FPMRS Kaiser Permanente Baldwin Park Division of Urogynecology Department of Obstetrics and Gynecology

2 PBS/IC I have no disclosures

3 Definition of PBS/IC A condition characterized by persistent urinary urgency, frequency, suprapubic / pelvic pain and dyspareunia, with profound effect on quality of life Occurs in absence of other pathology UTI Bladder Carcinoma Cystitis induced by radiation HSV Pain is often related to bladder filling Present for more than 6 weeks Associated with lower urinary tract dysfunction

4 Definition of PBS/IC The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) Very strict Criteria for diagnosis Actually designed for research purposes Most patients do not fulfill all diagnostic requirements Hence Painful bladder syndrome more inclusive

5 Definition of IC: NIDDK Inclusion criteria; Glomerulations on cystoscopic examination under Anesthesia or classic Hunner s ulcer and either: Pain associated with the bladder or urinary urgency

6 Definition of IC: NIDDK exclusion criteria Bladder capacity of greater than 350 cc on awake cystometry Absence of an intense urge to void with the bladder filled to 100 cc of gas or 150 cc of water during cystometry, using a fill rate of cc/min The demonstration of phasic involuntary bladder contractions on cystometry using the fill rate described above = OAB Duration of symptoms less than 9 months Absence of nocturia Symptoms relieved by antimicrobials, urinary antiseptics, anticholinergics, or antispasmodics A frequency of urination, while awake, of less than 8 times per day

7 Definition of IC: NIDDK exclusion criteria A diagnosis of bacterial cystitis or prostatitis within a 3-month period Bladder or ureteral calculi Active genital herpes Uterine, cervical, vaginal, or urethral cancer Urethral diverticulum Cyclophosphamide or any type of chemical cystitis Tuberculous cystitis Radiation cystitis Benign or malignant bladder tumors Vaginitis Age less than 18 years

8 Definition of PBS/IC Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology ICS (International continence society) 2002

9 Definition of IC/PBS An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary symptoms of more than six weeks duration in the absence of infection or other identifiable causes SUFU/ AUA SUFU: Society of Urodynamics, Female pelvic medicine & Urogenital reconstruction AUA: American Urological Association

10 PBS vs. IC: What s in a name? Different groupsà different names, which is best? No gold standard or agreed upon symptom complex Pain/bladder pressure/discomfort= hallmark Location: urethra, vulva, vagina, rectum Bladder irritants: specific foods/beverages Cystitis not all patients have inflammation Up to 20% of patients with PBS/IC have OAB Women > men 10:1 Up to 85% of women with CPP

11 Why Interstitial Cystitis? Implies: disease of interstitium à not necessarily true. Term first coined in Dr. Alexander Skene Destroyed the mucous membrane [of the bladder] partly or wholly and extended to the muscular parietes. Traditional Dx: by cystoscopy Reduced bladder capacity seen Hunner s ulcers Dr. Guy Hunner Fissuring of bladder seen Hunner s ulcer Ulcerative patches surrounded by mucosal congestion

12 Why Interstitial Cystitis? Diagnosis includes petechial, submucosal hemorrhages on cystoscopy after hydrodistention 1949, John R. Hand Glomerulations Walsh in 1978 Now clear bladder can be source of pain without these findings Confusing terminology

13 Proposed theories Infection Autoimmunity Inflammation Stress Genetics

14 Proposed theories Mast cells-probably central role but NOT primary pathogen. Mast cells à produce histamine à released into tissues à pain, hyperemia and fibrosis Permeability of the glycoaminoglycan (GAG) layer à toxins in the urine to leak through and damage underlying nerve and muscle tissues à trigger pain Antiproliferative Factor (APF) appears to block the normal growth of urothelial cells & may hinder healing process that follows any damage or irritation to bladder tissues All agree: Multifactorial

15 Pathogenesis of IC: Integrated Pathophysiology Bladder injury or insult è GAG defect Leakage of urinary contents into bladder wall Visceral organ hyperalgesia è Bladder pain Mast cell activation Pelvic pain/endometriosis Pelvic floor myalgia Vulvodynia Gastrointestinal - IBS Nervous system activated Urothelial Dysfunction & Neurotransmiter release Inflammatory reaction Chronic pain syndromes - Fibromyalgia Reflex Sympathetic Dystrophy (RSD) Chronic fatigue syndrome Migraine, Allergies C-Fiber afferent Nerve upregulation & Release of substance P

16 Diagnosis of PBS Careful history/physical: exclude other disorders UA and Urine culture Assessment: baseline voiding symptoms and pain level Interstitial Cystitis Symptoms Index (ICSI) PUF Questionnaire (Pelvic Pain and Urgency/Frequency Patient Symptom Scale) Visual analog pain scale Pain body maps K+sensitivity test: NOT specific or sensitive, no effect on clinical decision making, NOT recommended

17 Cystoscopy Cysto/Urodynamics: only if dx is in doubt or if complicated case

18 Diagnosis of IC Must have: Glomerulations OR Hunner s Ulcers on Cystoscopic examination and either: Pain associated with bladder or urinary urgency Hydrodistention: Under anesthesia Over distend bladder cm H20 water pressure under direct visualization for 1-5 minutes

19 Hunners Ulcer-Diagnostic Glomerulations-NOT diagnostic (seen in other conditions). Must see in 3 quadrants Biopsy? No clear guidelines Cystoscopy findings

20 These exclude IC/PBS as the diagnosis: Bladder Capacity >350cc(12oz) on awake cystoscopy (-) intense urge to void if bladder filled >150cc during UDS at rate cc/min Symptoms <6 weeks (9-6 months in some literature) Symptoms improve- ABX/Antichol/Antispasmodics (-) nocturia Frequency <8 times/day Renal/bladder Calculi Active HSV Vaginitis

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22 1st line Treatments Education always Dietary/behavioral modification OTC pain medication Stress Management / Meditation nt e m age n a sm s e r St

23 1st line Treatments Fluid management-increase or decrease Localized heat-bladder or perineum Meditation Bowel regimen

24 1 st line Treatments The IC Diet Very restrictive diet; NO caffeine, EtOH, citrus, tomatoes, chocolate, cranberry, sugar, tea, carbonation.. No objective/subjective basis for this 45% of pts improve with behavioral changes alone IC diet-avoid known bladder irritants (Foster et al-j Urol 2010)

25 COMPLEMENTARY THERAPIES Prelief ; over-the-counter food acid reducer CystoProtek ; Anti-inflammatory properties may help reduce bladder damage and pain & replenish the damaged GAG protective layer in the bladder Aloe Vera ; powerful anti-inflammatory and pain reliever. In addition, the active ingredients in the aloe plant are glycoaminoglycans

26 Appropriate Physical Therapy Trigger points Scar release Avoid Kegel s! 2 nd line Treatments May need to add Pharmacologic agents Pentosan polysulfate (Elmiron) Amitryptyline Cimetidine Hydroxyzine Bladder instillation of medications for pain and inflammation

27 Pentosan Polysulfate (Elmiron) Heparin analogue in PO form Chemically similar to GAG layer of bladder 100mg TID 3-6% of drug excreted in urine Overall improvement rate is low 25-50% Adverse side effects: alopecia, nausea, bleeding problems Benefit may not be seen for 3-6 months

28 Amitriptyline Most common medication used for IC/PBS Tricyclic Antidepresant: central & peripheral activity Blocks: active transport in pre-synaptic nerve endings responsible for Norepinephrine and Serotonin re-uptake Sedative effect (partly anti-histamine effect) Multiple studies >55% of treated pts improve 10mgà titrate 100mg Avoid: cardiac issues (conduction, arrhythmia)

29 Bladder instillations Dimethyl sulfoxide- DMSO or (Rimso-50) -wood pulp product. Only drug approved by the FDA for bladder instillation. Reduce inflammation and block pain. May also prevent muscle contractions that cause pain, frequency, and urgency. Treatments given Q 1-2 weeks for 6 to 8 weeks and repeated as needed. Garlic smell and taste.

30 Bladder instillations Heparin/Local Anesthetic Cocktail Heparin Chemically similar to GAG layer, (-) inflammation, (-) fibroblasts, No systemic absorption Lidocaine or Marcaine Sodium Bicarb Solumedrol +/- Series of treatments Q 1-2 weeks for 6-8 weeks Response rate varies % Safe/minimal side effects

31 3 rd Line Treatments Cystoscopy /Hydrodistention/Urethral Dilation Under anesthesia only Low pressure cm H2O If other treatments fail Short duration 2-5 mins Rule out other pathology (stones, tumors) Distention à Hunner s lesions à pain relief in some fulgurate if seen

32 4 th Line Treatments Neuromodulation; Thought to interrupt signals from the brain that trigger pain, urgency, and frequency in people with IC/BPS Not FDA approved for IC/PBS Pain management

33 5 th Line Treatments Intravesical Botox The most potent naturally occurring neurotoxin known. Blocks presynaptic-release of acetylcholine (Ach) from the nerve terminal. Causes flaccid paralysis of smooth and skeletal muscle. Cyclosporin A Immunosuppressant Pain management

34 6 th Line Treatments Augmentation Cystoplasty Cystectomy with urinary diversion

35 Treatment of PBS/IC Do Not offer: Long term ABX High pressure/prolonged hydrodistention Long term systemic steroids Bladder instillations with bacillus Calmette-Guerin (BCG) or Resiniferatoxin

36 Conclusion Many theories, main cause still unclear Not all treatments work for all patients Multiple treatment options can be offered simultaneously Always consider Dx in w/u for chronic pelvic pain

37 Patient resources Interstitial Cystitis Association Internet: Interstitial cystitis network Internet: American Chronic Pain Association Internet: American Urological Association Foundation Internet: International Association for the Study of Pain Internet: