ESSIC 2008 Annual Meeting Rome

Transcription

1 Bladder Pain Syndrome Developing a History Protocol Normal Bladder Function Depends on Suzy, Arul, Andrei, Arvind Integrity of the macroscopic and microscopic anatomy of the bladder Central nervous system Peripheral nervous system Bladder function is simple Storage Voiding PMC Small Capacity? Abnormal Detrusor Activity PAIN BPS S2-4 in cauda equina Pelvic & pudendal ns BPS/IC Pathogenesis of IC/BPS NIDDK Criteria and ESSIC Criteria Essentially Bladder pain Urgency Frequency Infection Inflammation Mast cell activation Urothelial dysfunction/gag-layer defects Autoimmune mechanisms Nitric Oxide Metabolism Neurobiology Toxic agents Hypoxia Complex pathogenic interactions History protocol S. Elneil et al 1

2 Diagnosis of IC/PBS History Examination Urine Analysis Cystoscopy and hydrodistention and biopsy Additional tests: O Leary-Sant Symptom Score, KCl test, Nature of Pain Objectives of the History Urological symptoms and Procedures Urgency of micturition Frequency of micturition Nocturia Hunner s/hydrodistention/glomerulations/hydrodistention y Ongoing QoL questionnaires Baseline 6, 12, 18, 24 month Medication Standard IC/BPS medication (e.g. oral pentosanpolysulfate, amitriptyline or hydroxyzine or bladder / instillation of DMSO, heparin or Ldc) Narcotics Typical Patient History Focus on medical, neurological, genitourinary history (Pain Details) Review voiding patterns/fluid intake Voiding diary Review medications (R x and non-r x ) Explore symptoms (duration, most bothersome, frequency, precipitants) Assess mental status and mobility Background History Infrequent Voiders Poor Stream Straining to Void Incomplete emptying Urinary frequency Recurrent UTI-like symptoms Hx of Childhood Abnormalities of Urinary Tract Site Radiation Pain Details Worst Presenting Symptom is PAIN! Gets worse with the following Certain food or drink Tight clothing Riding in the car Certain exercises Emotional stress Exacerbations in urinary symptoms during bladder filling Intensity and Duration (<I month, 1-6 month, >6 month) Mild Moderate Severe Bladder filling Just before, or during your period, or use of tampons During or after vaginal intercourse, touching the area Gets better with the following With urination During, immediately after, or more than half an hour after micturition After your period History protocol S. Elneil et al 2

3 Further History Urinary frequency and Nocturia Point/ Draw the site of most pain Haematuria (especially terminal) Duration of other symptoms Role of proven UTI Any radiation? If so, where? Any element of CPPS QoL SF-36 QoL Assessment Tool General Health Activities Physical wellbeing Healthiness Depression The Traffic Light System! A way forward? PAIN LOCUS OF CONTROL QUESTIONNAIRE Codes 0-4 (Very True, True, Untrue, Very Untrue) GREEN ZONE 1 My pain will often go away if I let myself relax physically 2 I can sometimes reduce pain by imagining the pain is really a pleasant stimulation 3 Only I can help myself with the pain 4 I can make my pain decrease if I concentrate on pain-free parts of my body 5 My pain level will go down if I remain passive and don t respond to it 6 Sometimes I can reduce my pain by not paying attention to it 7 I can reduce pain if I imagine a situation in which I have been pain free in the past 8 I am responsible for how the pain affects me 9 My pain will get better if I think of pleasant thoughts 10 Just slowing down and regulating my breathing pattern often helps my pain 11 I can make pain go away by believing it will go away 12 My pain will decrease if I think of things going on around me 13 My pain professionals can help with my pain 14 I need the help of others to control my pain 7 15 I need my medication to control my pain 16 Medication helps me control my pain 17 My pain is out of control 18 No matter what I do, I cannot seem to have an effect on my pain 19 My pain just comes and goes, regardless of what I do or think My pain will often go away if I let myself relax physically I can sometimes reduce pain by imagining the pain is really a pleasant stimulation Only I can help myself with the pain I can make my pain decrease if I concentrate on pain-free parts of my body My pain level will go down if I remain passive and don t respond to it Sometimes I can reduce my pain by not paying attention to it I can reduce pain if I imagine a situation in which I have been pain free in the past I am responsible for how the pain affects me My pain will get better if I think of pleasant thoughts Just slowing down and regulating my breathing pattern often helps my pain I can make pain go away by believing it will go away My pain will decrease if I think of things going on around me 20 Being in pain is never my choice History protocol S. Elneil et al 3

4 YELLOW (AMBER) ZONE RED ZONE My pain professionals can help with my pain I need the help of others to control my pain I need my medication to control my pain Medication helps me control my pain My pain is out of control No matter what I do, I cannot seem to have an effect on my pain My pain just comes and goes, regardless of what I do or think Being in pain is never my choice Aims Traffic Light System To rule out confusable causes To clarify the predominant symptom Urgency Symptoms To prepare the road for alleviation of symptoms Frequency Symptoms To provide a holistic approach to therapy Psychology Pain Multi-disciplinary Approach in History, Examination &Therapy Management Neurology ESSIC History Proforma? Small Capacity Idetrusor Dysfucntion PAIN BPS Physiotherapy CBT Urology or Urogynaecology History protocol S. Elneil et al 4

5 Signs Examination General, Abdominal, Pelvic Vulval and Vaginal Examination Urethral Examination Appearance, Position, Tenderness General Neurological Examination Physical Examination General examination Oedema, Neurological abnormalities, Mobility, Cognition, Dexterity Abdominal examination Pelvic and rectal exam in women Examination of back and lower limbs Observe urine loss with cough ESSIC Recommendations Examination Pain in abduction of hips or limitation of ROM Areas of hyperaesthesia in lower abdomen Vulval erythema or hyperalgesia on cotton swab test to each quadrant of vestibule Palpate bladder base, pelvic muscles for tenderness and reproducibility of symptoms Cervical excitation or pelvic masses Investigations MSU FREQUENCY/VOLUME CHART UROFLOWMETRY CYSTOMETRY SPECIALIST INVESTIGATIONS UPP USS Sphincter Volume EMG Radiology Endoscopy ESSIC Recommendations Investigations Normal Flow rate 3 day urinary diary O Leary Sant pain/bother scale Urine culture Urodynamics Stable Bladder (FDV <150ml) (Capacity <350ml) Modified K+ Test Qura [5ml/s/div] 10 s /div Double fill cystoscopy and hydrodistension History protocol S. Elneil et al 5

6 Intermittent Voiding Frequency Volume Chart ABDOMINAL STRAINING Time hr:min P, ND SD UR? Leak? +, ++, +++ Urine Passed (mls) Residual Urine? (mls) New Pad? Tabs? Qura [5ml/s/div] 9.3 ml/s Vura [100ml/div] 10 s /div VB MF VE Urgency Urgency is the complaint of a sudden compelling desire to pass urine which is difficult to defer ICS Standardization 2002 Urgency Bladder Diary Definitions A Strong desire (SD) to pass urine is a call of nature that cannot be ignored and interrupts routine activities (e.g. reading a book, watching television). It may or may not come on suddenly, but going to the toilet CANNOT be postponed - you have to stop your activities and make your way to the toilet but you have several minutes (approx. 5) to prepare yourself to pass urine. You might have an accident if you wait any longer than this. Pathological different from extreme desire to void which is the far ending of the filling spectrum An Urgent desire (UD) is a call of nature which is very strong and comes on suddenly. You HAVE to get to the toilet as QUICKLY AS POSSIBLE - i.e. in less than 1 minute (as if it were an emergency) to avoid an accident. The urge is so strong that it can be difficult for you to control your bladder. You may leak on the way or whilst transferring if you do not get to a toilet within a minute or two PROPOSED PATHWAY IN UK PATIENT GP Lifestyle, Fluid and Behavioural Management (?Trial of Medication for 4 months) Laboratory Investigations MSU MC+S, Cytology Fastidious Organisms COMMUNITY CARE PATHYWAY Voiding Diaries, PVR, Physiotherapy HOSPITAL SPECIALIST [MDT in Chronic Pelvic Pain Syndromes] K+ Test: Modified or not Cold Water Test Cystoscopy + Bladder Biopsy History protocol S. Elneil et al 6

7 Definition Chronic Pelvic Pain Non-malignant pain perceived as pain in the pelvis in either men or women Chronic Pelvic Pain Syndrome (CPPS) The occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction Acknowledgements The Uro-Neurology Team No infection or other obvious pathology (ICS 2002) History protocol S. Elneil et al 7