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Date issued: August 2021 

Review date: August 2023

Ref: A-414 v2

PDF:  Bladder pain syndrome interstitial cystitis final August 2021 v2.pdf [pdf] 304KB

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

Bladder Pain Syndrome also known as Interstitial Cystitis is the presence of pelvic pain deemed to be related to the urinary bladder, accompanied by other urinary tract symptoms such as frequency and nocturia, with the exclusion of any other diseases of the lower urinary tract. 

The precise cause of the condition is unknown. Possible causes include any injury to the bladder including childbirth, bladder catheters, bladder infection etc. BPS/IC is therefore a diagnosis of exclusion (diagnosed only when all other causes of the symptoms have been ruled out).

How common is BPS/IC?

Because BPS/IC is a diagnosis of exclusion, the incidence of the condition is difficult to determine. Diagnosis depends on the country of origin and the criteria used for diagnosis. Diagnosis is usually based on patient report of symptoms: occasionally cystoscopy or urodynamic tests may be performed. Although the condition can affect both sexes, it is more common in women with 90% of sufferers being female.

Symptoms include:

• Pelvic pain: this is the most common symptom of BPS/IC. Pain is typically described as involving the lower abdomen, pelvis, urethra or vagina. Many patients experience pain when the bladder is full, and this pain is typically relieved on emptying the bladder. For this reason, a lot of patients prevent their bladder from becoming too full by frequent emptying in order to avoid the pain of a full bladder. Hence patients often report urinary frequency.

• Frequency (passing urine more than 8 times per day): frequency associated with BPS/IC is different to the frequency associated with the overactive bladder syndrome where patients empty their bladders in order to prevent leaking urine.

• Urgency: this is the sudden urgent need to pass urine. This symptom is less common in BPS/IC than other lower urinary tract problems such as bacterial cystitis or overactive bladder.

• Nocturia: waking to pass urine more than once or twice at night. This is a behavioural symptom and is done, once again, in an attempt to prevent the bladder becoming too full causing pain.

How is it diagnosed?

Diagnosis is usually by a process of elimination of other clinical syndromes or diseases which may mimic the condition such as urinary tract infections or overactive bladder. Diagnosis is therefore reliant on patient history. You may occasionally be given a bladder diary to complete. This may be supplemented with Urodynamic testing (this is a test of bladder function performed in the outpatients) and cystoscopy (inspection of the bladder while it is fully distended, usually performed under a short general anaesthetic).

Possible Trigger Foods for IC/PBS Sufferers

Certain foods are known to irritate the bladder, and as such, can worsen your bladder symptoms. These include:

Avoid chocolate, which is also high in caffeine.

Avoid spicy or acidic foods which are common bladder irritants.

To identify culprits, eliminate one type of food every 2 to 3 weeks to see if your symptoms improve.

Foods, which are considered safe and don’t irritate the bladder include:

Water, milk, soups and diluted fruit juices are non-irritable. 

Your body needs about 2 litres of fluid per day.

Avoid constipation with a healthy intake of fruit and vegetable.

Associated medical conditions

BPS is commonly associated with other medical conditions. These include depression, vulvodynia (this means vulval pain), irritable bowel syndrome and fibromyalgia. It is important to mention these conditions if present to your doctor.

By definition, BPS is a diagnosis of exclusion. Therefore, the presence of urinary tract infections (UTI) precludes the diagnosis. However, it is possible to have BPS and develop a UTI, which may exacerbate your BPS symptoms. In such situations, the UTI should be treated promptly, with repeat urinary cultures to confirm resolution of infection.

Treatment

Complementary

Tips for a healthy bladder

• Smoking cessation: cigarette smoking and nicotine are immediate bladder irritants.

• Protect yourself from UTIs: drink plenty of water.  If you drink too little, this can lead to concentrated urine and constipation which can irritate the bladder.

• Always empty your bladder before and after intercourse. 

• Avoid constipation: try including more fruit, vegetables and wholemeal (fibre) in your diet. If your bowel is full, it can worsen your bladder problems.

• Keep a healthy weight to reduce the pressure on the bladder.

  • Bladder training: bladder control can be improved by having a strict routine for going to the toilet. Avoid going to the toilet “just in case” as over time, too little fluid can make your bladder feel full even when it isn’t.

  • Dietary modification: using the pictorial charts above, you have a better idea of foods and drinks which can irritate your bladder. Try avoiding these and substitute for those foods which don’t irritate the bladder. Instead of diet drinks, dilute a third of a glass of pure fruit juice topped up with water.

Cystoscopy and hydrodistension

While cystoscopy and bladder distension is used for diagnosis, it can also be used for the management of BPS. Bladder distention may be done awake but is usually done under general anaesthesia. You may notice some relief for several months.

Oral medication

• Oral antibiotics: This group of medication is not usually recommended for management of BPS as less than 5% of affected patients have bacteriuria (bacteria in the urine).  

• Analgesics: Non-steroidal anti-inflammatory drugs are very effective in managing the pain associated with BPS.

• Cimetidine: this antacid, commonly used for management of stomach ulcers, is shown to be effective in 60-70% of patients with BPS. It is not licensed to treat BPS/IC and so is only prescribed by specialists.

• Amitriptyline: This is a type of anti-depressant medication, which at low doses causes bladder relaxation, while its analgesic effects are noticed with higher dose regimes.  Studies have shown that whether used alone or in combination with other medications, amitriptyline is an effective management strategy for patients with BPS. Side effects include nausea, blurred vision, skin rash, and constipation or diarrhoea.

• Elmiron: this medication is effective in treating the pain and discomfort of the condition, by restoring the damaged barrier layer inside the bladder.

• Others: Anticholinergics (bladder relaxants) are useful for the irritative symptoms of BPS, such as frequency, urgency and nocturia. Your doctor will discuss these with you.

Intravesical

One of the most common theories regarding the cause behind BPS is a defect in the protective barrier layer inside the bladder. As a result, urine penetrates this normally impermeable barrier and cause irritation of the underlying muscles and nerves. The acidity of the urine causes pain. Therefore, intravesical therapies, which aim to strengthen this barrier layer, are commonly used in the management of BPS.

Your bladder is catheterised, and drugs are instilled into the bladder. In addition to barrier replacement therapies, other drugs can also be instilled into the bladder such as local anaesthetics and anti-inflammatory medication. These have the direct effect of numbing the pain of BPS. These therapies can be given alone or in combination. Your consultant will talk to you about which is best suited for you.

Percutaneous tibial nerve stimulation (PTNS)

PTNS involves inserting a fine needle near the ankle to stimulate the posterior tibial nerve. This nerve contains fibres from the same spinal segments as the nerves to the bladder. Stimulation typically last for 30 minutes and is performed by nurses in the gynaecology clinics. Weekly sessions for an average of 12 weeks are required. PTNS is shown to alleviate the symptoms of urgency and frequency commonly associated with BPS, thus improving overall quality of life for patients. However, as this treatment is not licensed for BPS/IC, its use needs to be discussed with your clinician.

Surgery

Surgical management is typically a last resort for those patients who are refractory to other treatments. Options include urinary diversion and cystectomy (this is major life changing surgery which involves removal of the bladder).  

Useful contacts for support and advice:

Bladder and Bowel foundation

www.bladderandbowelfoundation.org

Tel. 0845 345 0165

 

Cystitis and Overactive Bladder Foundation

www.cobfoundation.org

 

International Urogynecological Association interstitial cystitis website

www.yourpelvicfloor.org/media/Interstitial_Cystitis.pdf