What are the Common Causes of this Syndrome?
According to the American Urological Association’s guideline for painful bladder syndrome, or interstitial cystitis, the condition is defined by an unpleasant sensation perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes.
The exact cause of painful bladder syndrome or interstitial cystitis is unclear and not completely understood. However, several factors have been proposed that could contribute to the syndrome:
- Inflammation and mast cell activation: Inflammation can release chemicals that disrupt the integrity of the bladder’s epithelial surface leading to mast cell activation and ultimately giving rise to pain and voiding dysfunction.
- Tamm-Horsfall protein: A urinary protein that protects the urothelium from cytotoxic agents. A defect in Tamm-Horsfall protein can lead to the development of interstitial cystitis.
- Autoimmune mechanism: An autoimmune disorder may cause the immune system to attack the bladder mistakenly. CD8+, CD4+, and B lymphocytes, plasma cells, and immunoglobulins were found to bind to the epithelial surface of the bladder in patients with interstitial cystitis.
- Urothelial dysfunction: The bladder urothelium is lined by glycosaminoglycans that help to prevent adherence of uropathogens to the urothelium. In addition, it protects the urothelium by being impermeable to various toxic solutes in the urine. It is possible that a disruption in the glycosaminoglycans layer could lead to interstitial cystitis.
- Genetic disposition: It is reported that the prevalence of interstitial cystitis in adult first-degree relatives of patients with the condition is 17 times higher than in the normal population.
What are the Signs of the actual Syndrome?
The signs of painful bladder syndrome can vary between individuals and is usually characterised by painful bathroom trips. The symptoms can also be made worse with certain food or drinks such as citrus fruits, spicy food, alcoholic drinks, caffeinated drinks, carbonated drinks, and artificial sweeteners. These symptoms are:
- Pain, pressure, or discomfort in the pelvic area
- Pain in the vulva or vagina for women
- Pain in the scrotum, testicles, or penis for men
- Frequent urination or urgency to urinate
- Pain during sexual intercourse
What are the possible treatments?
Painful bladder syndrome treatment usually involves a combination of therapies starting with the more conservative approach first. Surgical procedures are considered after the other treatment options are found to be ineffective. The goal of the treatment for painful bladder syndrome is to maximise function and minimise pain and side effects. Possible painful bladder syndrome treatments here in singapore include:
1. First-line treatment (lifestyle modification):
- Stress management: Emotional stress can worsen the symptoms of painful bladder syndrome. Implementation of stress management strategies and coping mechanisms can help to reduce stress-induced symptom exacerbations.
- Self-care and behavioural modification: Avoiding certain food or drinks trigger such as citrus products and caffeinated drinks can help to reduce the irritability of the bladder. Fluid restriction can also help to alter the concentration and volume of urine.
2. Second-line treatment (medication and various therapies):
- Physical therapy techniques: Physical therapy involves appropriate exercises that can help to resolve pelvic, abdominal, and hip muscular trigger points. It can be especially helpful for patients with associated pelvic floor muscle spasms.
- Oral medications: Pentosan polysulfate sodium helps to reduce urothelial permeability and restore urothelial function. Amitriptyline, which is an antidepressant drug, can help to reduce painful nociception by inhibiting neural activation. Hydroxyzine is a histamine receptor antagonist that inhibits mast cell activation and can help to provide symptomatic relief.
- Intravesical treatment: Intravesical treatment involves the delivery of dimethyl sulfoxide – a water-soluble and anti-inflammatory chemical solvent, into the bladder directly by a catheter. Dimethyl sulfoxide has muscle-relaxing properties and may help to reduce pain and swelling.
3. Third-line treatment (minimally-invasive procedures):
- Cystoscopy with hydrodistension: Cystoscopy is a procedure done under anaesthesia to inspect for stones, tumours, and Hunner’s lesions. It is usually coupled with low-pressure hydrodistension which also helps to determine anatomic bladder capacity. Hydrodistension may provide therapeutic effects by reducing bladder pain.
- Treatment of Hunner’s lesions: A small number of patients diagnosed with painful bladder syndrome may present with Hunner’s lesions which can be identified under cystoscopy. Resection or fulguration of the Hunner’s lesions can help to improve the symptoms of painful bladder syndrome significantly.
4. Fourth-line treatment (minimally-invasive procedures):
- Intradetrusor neurotoxin injections: This procedure paralyses the bladder muscle to help relieve some of the pain. Although this procedure is not approved by the U.S. Food and Drug Administration for interstitial cystitis, it can be performed by physicians experienced with managing this condition with long-term care provided post-intervention.
- Neuromodulation: This procedure involves the implantation of a device that delivers mild electrical impulses to the nerves in the lower back. This may help to offer relief of chronic pain and manage urinary function.
5. Fifth-line treatment (medication):
- Cyclosporine A: Cyclosporine A is an immunosuppressive drug that suppresses the activation of T-cells and is commonly used in organ transplantation. There are studies that show long-term low dosage of cyclosporine A may help to provide symptomatic relief.
6. Sixth-line treatment (surgical intervention):
- Diversion with or without cystectomy: Urinary diversion is a surgical procedure that diverts the flow of urine to by-pass a diseased area in the urinary tract. There are many types of urinary diversions including bladder catheterisation, cystostomy, ureteral stent, urostomy, and continent urinary diversion.
- Substitution cystoplasty: Cystoplasty is a surgical procedure usually done in patients who lack detrusor compliance or adequate bladder capacity. It helps to make the bladder larger and may help to relieve nocturia and reduce frequency of urination.