What is the initial workup and treatment for bladder pain syndrome in men?

Workup and Treatment of Bladder Pain Syndrome in Men

The initial workup for bladder pain syndrome (BPS) in men should include a thorough history, physical examination, urinalysis, and assessment using the International Prostate Symptom Score (IPSS), followed by a multimodal treatment approach starting with behavioral modifications and progressing to oral medications, intravesical therapies, and procedures based on symptom response. 1

Diagnostic Workup

History and Physical Examination

• Document symptoms for at least 6 weeks with negative urine cultures
• Assess key symptoms:
  • Number of voids per day
  • Constant urge to void
  • Location, character, and severity of pain/pressure/discomfort
  • Ejaculatory pain (specific to men)
  • Dysuria
• Perform brief neurological examination to rule out neurologic conditions
• Evaluate for incomplete bladder emptying

Laboratory and Diagnostic Tests

• Urinalysis and urine culture (even with negative urinalysis to detect lower bacterial levels)
• Post-void residual (PVR) assessment
• Consider uroflowmetry

Specialized Testing

• Cystoscopy is indicated when:
  • Hunner lesions are suspected
  • Need to rule out other conditions (bladder cancer, stones, foreign bodies)
  • Note: Cystoscopy is the only reliable way to identify Hunner lesions 1
• Urodynamic testing is generally not recommended for routine diagnosis but may be useful if:
  • Outlet obstruction is suspected
  • Poor detrusor contractility is possible
  • Patient is refractory to initial therapies 1

Treatment Algorithm

First Line: Behavioral and Lifestyle Modifications

• Patient education about BPS as a chronic condition with symptom fluctuations
• Dietary modifications:
  • Elimination diet to identify trigger foods
  • Avoid common bladder irritants (coffee, citrus products)
• Fluid management:
  • Adjust concentration/volume of urine through hydration or restriction
• Stress management techniques
• Application of heat or cold over bladder/perineum
• Pelvic floor muscle relaxation
• Bladder training with urge suppression
• Avoidance of tight clothing and management of constipation 1

Second Line: Oral Medications

1. Amitriptyline (Evidence Strength: Grade B)

   • Start at low dose (10 mg) and titrate gradually to 75-100 mg if tolerated
   • Monitor for side effects: sedation, drowsiness, nausea 1

2. Cimetidine (Evidence Strength: Grade B)

   • Effective for pain, symptoms, and nocturia
   • Minimal adverse effects reported 1

3. Hydroxyzine (Evidence Strength: Grade C)

   • May be particularly effective in patients with systemic allergies
   • Side effects include sedation and weakness 1

4. Pentosan Polysulfate (PPS) (Evidence Strength: Grade B)

   • Only FDA-approved oral medication for BPS/IC
   • Dosage: 100 mg three times daily
   • Clinical trials showed 38% of patients had >50% improvement in bladder pain vs. 18% with placebo
   • Counsel patients about potential risk for macular damage and vision-related injuries 1, 2

Third Line: Intravesical Treatments

1. Dimethyl Sulfoxide (DMSO)

   • Administration: 50 mL instilled directly into bladder for 15 minutes
   • Repeat every two weeks until maximum relief is obtained
   • Consider lidocaine jelly to urethra prior to catheter insertion
   • For severe cases, initial treatments may require anesthesia 3

2. Heparin or Lidocaine instillations 1

Fourth Line: Procedures

1. Cystoscopy with Hydrodistension

   • Serves diagnostic and therapeutic purposes
   • Allows for disease "staging" by determining anatomic bladder capacity 1

2. Hunner Lesion Treatment

   • If Hunner lesions are present, perform fulguration (with laser or electrocautery) and/or injection of triamcinolone 1

3. Neurostimulation trial if other treatments fail 1

Fifth Line: Advanced Interventions

• Botulinum toxin A injections
• Cyclosporine A (for experienced providers only, requires monitoring)

Sixth Line: Surgical Options

• Reserved for severe, unremitting cases where quality of life is severely affected
• Only after all other treatment options have been exhausted 1

Special Considerations for Men

• Rule out prostate-related conditions that can mimic BPS symptoms
• Assess for outlet obstruction which may require different management
• Consider ejaculatory pain which is specific to male patients with BPS 1

Treatment Monitoring

• Evaluate patients 4-12 weeks after initiating treatment
• Use validated symptom scores (IPSS) to track progress
• Adjust therapy based on symptom response and side effects
• Prepare patients for the chronic nature of BPS, which typically involves symptom exacerbations and remissions 1

Pitfalls and Caveats

1. Avoid focusing solely on bladder-directed therapies without addressing systemic factors
2. Pain management alone is insufficient; must address underlying bladder symptoms
3. Due to the opioid crisis, use non-opioid alternatives preferentially for pain management
4. Monitor patients on PPS for vision changes due to potential macular damage
5. Recognize that multiple treatment trials may be necessary before achieving adequate symptom control
6. Surgical treatments (except for Hunner lesion fulguration) should only be considered after exhausting other options 1