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Bladder Pain Syndrome (BPS) / Interstitial Cystitis (IC)

What is Bladder Pain Syndrome (BPS) / Interstitial Cystitis (IC)?

BPS/IC is a chronic, debilitating disease of the bladder that is characterised an unpleasant bladder sensation, of more than 6 weeks’ duration and in the absence of infection or other identifiable causes.

How common is it?

The incidence of BPS/IC is estimated at 8 to 1600 per 100 000. It affects men and women of all ages, cultures and socioeconomic backgrounds. It is more common in women and the male-to-female ratio is estimated to be about 1:10.

What are the causes?

Despite extensive research, the exact causes of BPS/IC are still unclear.

What are the symptoms?

Patients complain of frequent urination, sensation of constant urge to void and bladder pain. Chronic pain is an essential component of the syndrome and is described as worsening with bladder filling and is relieved by voiding. This pain is not only localised to the bladder, but can be felt throughout the pelvis (vagina, rectum, urethra, vulva).

How is it diagnosed?

BPS/IC is a diagnosis of exclusion; meaning that other causes of these symptoms such as infection, overactive bladder (OAB), cancer, radiation or other forms of cystitis must be ruled out first.

Assessment should include a careful history, physical examination and investigations. In the history, BPS/IC patients void to avoid or relieve pain, whereas OAB patients void to avoid incontinence. The number of voids per day, sensation of urge to void and characteristics (location, severity, character) of the pain should be documented. A bladder diary may be useful here.

A urine test is done to exclude a urinary tract infection. It can also be done to look for cancer cells, especially in those with increased risks (over 50 years old, smoking history).

Cystoscopy and urodynamics are considered as an aid to diagnosis, and are not necessary in uncomplicated cases.

Cystoscopy

  • A cystoscopy (inspection of the inside of the bladder with a tubelike camera) can be done to look for features of IC, such as bladder ulcers or small bleeding points seen after distension of the bladder with sterile fluid. These findings are helpful but not necessary when making a diagnosis of IC.

  • During the cystoscopy, a bladder biopsy can also be done to look for inflammatory cells in parts of the bladder wall.

  • This can also rule out other bladder pathology like a bladder tumour, stone, or a urethral diverticulum (small out-pouching in the tube that drains the bladder).

Urodynamics

  • Rule out other diagnoses like an overactive bladder (OAB) or a poorly compliant (stiff) bladder.

  • Can look for bladder outlet obstruction from failure to relax the pelvic floor during voiding.

What are the treatments?

First of all, it must be clear that there are no curative treatments; the treatments are aimed at alleviating the symptoms such that a patient can continue to have a reasonable quality of life. The patient should be counselled with regards to reasonable expectations for treatment outcomes. Treatment strategies should proceed from conservative ones to more invasive therapies. Some patients may benefit from a combination of treatments. Acceptable symptom control may also require trials of multiple therapeutic options.

Conservative approaches

  • Diet changes: avoid food that triggers symptoms (eg. spicy foods, alcohol, caffeine).

  • Altering the concentration or volume of urine, wither by fluid restriction or additional hydration.

  • Application of local heat or cold over the bladder, trigger points and areas of hypersensitivity

  • Strategies to manage flare-ups.

  • Pelvic floor muscle relaxation / avoid pelvic floor strengthening exercises.

  • Bladder retraining with urge suppression.

  • Manual physical therapy (trigger point release by physiotherapist).

Multimodal pain management

  • May involve medications, stress management or manual therapy.

  • A pain specialist is usually involved.

  • It is difficult to predict which pain medication is most effective; this may require a trial of different medications.

Oral medications

  • Tricyclics antidepressants

    • Some examples are amitriptyline, imipramine.

    • Side effects are fatigue, drowsiness, weight gain, dry mouth (a third of patients cannot tolerate this).

  • Sodium pentosan polysulfate (Elmiron)

    • Acts by repairing defects in the bladder mucosa.

    • A 3 to 6 month course is needed to demonstrate an effect.

    • At a dose of 100mg three times a day, it is well tolerated and has few side effects.

  • Cimetidine

    • Dose of 400mg twice a day.

    • Potential interaction with other medications.

Anitibiotics have no role in the management of BPS/IC in the absence of a proven urinary tract infection.

Bladder instillation therapy

A catheter is first inserted and the medication is then infused into the bladder for a period of about 15 – 20 minutes (depending on the drug). Multiple therapies are usually required. This route of administration provides high drug concentrations in the bladder and avoids systemic side effects. Long term remission is achievable in some patients, but most will relapse eventually and need more treatments. Some examples of these medications are dimethyl sulfoxide (DMSO) and Clorpactin. See bladder instillation therapy.

Surgical therapy

  • Cystoscopy with bladder distension and electrical cautery of bladder ulcers if present.

    • Some patients get relief of symptoms from this procedure, but most of the time, the effects will wear off.

  • Trial of sacral neuromodulation (bladder pacemaker)

    • A temporary stimulator is first inserted during the trial period; a permanent implant is then inserted if the patient demonstrates positive response.

    • The use of sacral neuromodulation in BPS/IC is not Medicare-approved.

    • It may relieve the symptoms of bladder urgency and frequent need to void, but not alleviate the pain.

    • Current data lacks long-term follow up, but this option may be suitable in some individuals.

  •  Anti spasm bladder injection

    • This is more commonly used in patients with an overactive bladder (OAB).

    • The data in BPS/IC is limited to observational studies. Please note this procedure is not approved by Medicare in Australia for this indication.

    • The effectiveness will decrease over time (about 9 months).

    • Side effects include infection, mild bleeding and inability to fully empty the bladder (patient may need to do intermittent self catheterization).

  • Urinary diversion with or without surgical removal of the bladder

    • The ureters (tubes draining the kidneys to the bladder) are reimplanted into a segment of bowel which is diverted to the abdominal skin surface as a stoma (opening). A bag is then placed over the stoma to catch the urine.

    • This option is often the last resort and can sometimes be very effective.

    • Patients must understand that pain relief is not guaranteed even if the bladder is removed.

Download American Urological Association (AUA) Treatment Algorithm for BPS/IC – PDF (193 Kb)