What is painful bladder syndrome?

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

Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC) is a chronic condition characterized by an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms lasting more than six weeks, in the absence of infection or other identifiable causes. 1

Definition and Clinical Presentation

• PBS/IC is part of a broader bladder symptom complex that includes patients with bladder, urethral, and/or pelvic pain, lower urinary tract symptoms, and sterile urine cultures 1
• The condition is defined by symptoms lasting at least six weeks, which allows for earlier treatment initiation compared to definitions requiring longer symptom durations 1
• Pain (including sensations of pressure and discomfort) is the hallmark symptom, typically perceived in the suprapubic region but may extend throughout the pelvis and to extragenital locations 1
• Many patients describe their symptoms as "pressure" rather than pain, making it important to use broad descriptors when evaluating patients 1
• Pain typically worsens with bladder filling and improves with urination, and may be exacerbated by specific foods or drinks 1

Associated Symptoms

• Urinary frequency is almost universal (92% of patients) but is not specific to PBS/IC 1
• Urinary urgency is extremely common (84% of patients) but differs qualitatively from overactive bladder urgency 1
• PBS/IC patients typically void to avoid or relieve pain, whereas overactive bladder patients void to avoid incontinence 1
• PBS/IC patients may experience a more constant urge to void rather than the sudden compelling urge characteristic of overactive bladder 1
• The condition often coexists with other conditions such as allergies, endometriosis, fibromyalgia, irritable bowel syndrome, and panic syndrome 2

Diagnostic Approach

• Diagnosis requires careful history, physical examination, and laboratory testing to document symptoms and exclude other disorders 1
• Basic laboratory testing should include urinalysis and urine culture to rule out infection 1
• Cystoscopy should be performed in patients for whom Hunner lesions are suspected, as this is the only reliable way to diagnose their presence 1
• There are no agreed-upon urodynamic criteria diagnostic for PBS/IC, and urodynamics are not recommended for routine clinical use 1
• The condition is often misdiagnosed or diagnosis is delayed due to the wide spectrum of symptoms and physical exam findings 1

PBS/IC in Men vs. Chronic Prostatitis

• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) shares similar clinical characteristics with PBS/IC 1
• CP/CPPS is characterized by pain in the perineum, suprapubic region, testicles, or tip of the penis, often exacerbated by urination or ejaculation 1
• The diagnosis of PBS/IC should be strongly considered in men with pain, pressure, or discomfort perceived to be related to the bladder and associated with urinary frequency, nocturia, or an urgent desire to void 1
• Some men may meet criteria for both conditions, and treatment approaches can include therapies for both PBS/IC and CP/CPPS 1

Subtypes and Phenotypes

• PBS/IC can be divided into two main phenotypes: hypersensitive bladder (without lesions) and interstitial cystitis with parietal lesions (characterized by Hunner lesions) 3
• The pathophysiology likely differs between these entities, involving multiple factors such as inflammation, autoimmunity, infection, urothelial barrier dysfunction, and pelvic or central sensitization 3
• Early identification of Hunner lesions is important as most patients with these lesions will respond to targeted treatment 1

Treatment Approaches

• Treatment should be multimodal and targeted to the symptoms that patients find most bothersome 4
• Conservative treatment, including patient education, behavioral modification, dietary advice, stress relief, and physical therapy is essential initial management 4
• Oral medications such as amitriptyline, pentosan polysulfate, and hydroxyzine have variable results, with better outcomes when used in combination 2
• Pentosan polysulfate sodium (Elmiron) is FDA-approved for the relief of bladder pain or discomfort associated with interstitial cystitis 5
• Intravesical treatments include dimethyl sulfoxide (DMSO), BCG, pentosan polysulfate, oxybutynin, and alkalinization of urine pH, with BCG and oxybutynin showing the most promising evidence 6
• For patients with Hunner lesions, fulguration or resection can be performed during cystoscopy 4
• Neuromodulation and botulinum toxin A injections may be considered for refractory cases 4
• Radical surgery should be reserved for severe, unremitting cases that have not responded to other interventions 4

Common Pitfalls to Avoid

• Using research or clinical trial definitions in clinical practice, which can lead to misdiagnosis or delays in treatment 1
• Treating with antibiotics when no infection is present, which can lead to antibiotic resistance and disruption of protective flora 7
• Failing to address concurrent bowel dysfunction, which can exacerbate bladder symptoms 7
• Neglecting to rule out more serious conditions like bladder cancer in patients with risk factors 7
• Delaying diagnosis and treatment, which can affect outcomes and lead to the development of hyperalgesia/allodynia 2