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Bladder Pain Syndrome (Interstitial Cystitis)

This is a new guideline from RCOG on Bladder Pain Syndrome, which used to be called Interstitial Cystitis, among other things. As this is a new guideline and it is a common problem (affecting up to 6% of people), I will summarise the bits relevant to us.

Definition

This is a chronic pain syndrome and a diagnosis of exclusion. It's management should therefore be similar to that for other chronic pain syndromes.

The official definition is:

"Pain, pressure or discomfort, in the pelvis/bladder, associated with urinary symptoms (frequency, urgency, nocturia, bladder filling pain), lasting at least 6w with no identifiable cause."

Symptoms

The symptoms are as per the definition. The pain may be described in various ways, from burning to pressure. It is most commonly felt in the bladder, urethra or vagina.

Exacerbating factors may include sex, stress, constrictive clothing, spicy foods, acidic foods and drinks and coffee.

Initial consultation

This is about evaluating the condition and excluding other causes. It is worth noting that patients with chronic pain who rate their initial consultation well, have better outcomes - so no pressure then... Once fairly certain of the diagnosis, explain that it is a chronic condition, with fluctuating symptom severity.

  • Assess patient's ideas re cause
  • Exacerbating factors as above
  • Other conditions that may be associated (IBS, vulvodynia, endometriosis, fibromyalgia, CFS, SLE, Sjogrens).
  • Physical or sexual abuse (can be associated with pelvic pain).

A full examination should be done, including abdo, speculum and bimanual exam.

Initial investigations

  • Bladder diary
  • Food diary (looking for exacerbating factors)
  • Dipstix (if positive white cells, send for culture. If sterile pyuria, test for ureaplasma and chlamydia).
  • Malignancy - if there is any suspicion of this then obviously refer accordingly

Initial GP management

  • Dietary modification - avoid alcohol, caffeine, acidic foods and acidic drinks.
  • Stress management may be recommended (been shown to benefit lots of patients).
  • Exercise - regular exercise has been shown to benefit lots of patients.
  • Analgesia - simple only.
  • Acupuncture - there is limited evidence from one small trial that it may be beneficial.
  • Support groups.
  • Amitriptyline. They do advise that this should be specialist only, but I guess it is relevant for us to know this as patients may be on it already or have other indications for it.
  • Psychological support. This should be considered if it is impacting on the patients life, or if the patient requests it. It is listed under specialist treatments, but I guess we could offer it too, given the waiting lists.

Specialist management

  • Oral treatments - they may try cimetidine too.
  • Intravesical treatments - there are lots of options here.
  • Physiotherapy - may be tried.
  • Nerve stimulation, cystoscopy with lesion ablation or hydrodilation may be tried among other things.

I’m a freelance GP locum in Winchester & Southampton.

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