What are BPS and Interstitial Cystitis?
Bladder pain syndrome (BPS) is a chronic bladder condition in Singapore characterised by pain and pressure in the bladder area. This pain is often unexplained by other infections or causes and lasts over six weeks. The condition is accompanied by symptoms such as the urgency to void, frequency of urination, and nocturia.
Interstitial cystitis (which is rather similar to BPS and can be a cause for BPS) may be associated with other chronic conditions such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome.
What are the symptoms of BPS?
The symptoms of BPS vary between individuals, and it can range from mild to severe. It is mainly characterised by the feeling of pain and pressure below the navel as the bladder fills and results in painful bathroom trips. Some may even feel pain in the urethra, lower abdomen, lower back, and pelvic area. The symptoms can be made worse by certain food or drinks and even stress.
Common symptoms:
- Pain in the pelvis and lower back
- Pain in the vulva or vagina for women
- Pain in the scrotum, testicles, or penis for men
- Frequent urination
- Urgency to urinate
- Pain during sexual intercourse
Common food triggers:
- Citrus fruits
- Spicy food
- Alcoholic drinks
- Caffeinated drinks
- Carbonated drinks
- Artificial sweetener
What causes BPS and IC?
The exact cause of BPS is uncertain. In most cases, the bladder is found to be normal whereas for IC, the bladder can be inflamed, ulcerated, scarred, or stiff. As such, researchers postulated several theories that may help to explain the damage to the bladder lining leading to the manifestation of the condition.
Factors that may contribute to interstitial cystitis (IC):
- 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 — It is 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 the normal population.
What can I expect during my first consultation?
During the first consultation, you will be asked a series of questions about your symptoms and medical history in order to get a better understanding of your condition.
A physical exam and lab tests will also be carried out to help rule out other conditions such as urinary tract infection.
How is Interstitial Cystitis diagnosed?
There is no medical test that makes a definitive diagnosis. Generally, the diagnosis is based on symptoms and exclusion of other conditions with similar symptoms. They include urinary tract infections, bladder cancer, sexually transmitted diseases, endometriosis, inflamed prostate, chronic pelvic pain syndrome, and kidney stones. Some of these assessments are:
- Clinical presentation and history — The O’Leary-Sant Interstitial Cystitis Symptom Index is useful to gather comprehensive information on the symptoms.
- Physical examination — The examination may include pelvic and digital rectal exams. They can help to detect pelvic floor spasms, rectal spasms, and suprapubic tenderness.
- Laboratory testing — Urinalysis and urine culture are conducted to exclude any bladder abnormalities and bacterial infections. One of the tests may include an intravesical potassium sensitivity test which is based on the theory that abnormally permeable urothelium allows diffusion of potassium into the bladder wall.
- Bladder and urethra biopsy — The procedure involves taking a small piece of tissue for closer examination. Although not routinely performed, it may be helpful to exclude diagnoses such as carcinoma-in-situ.
- Cystoscopy — It uses a thin telescope to observe the inside of the bladder and urethra to look for any ulcers, tumours, or bladder stones. Direct visualisation of the urothelium can also help to document bladder inflammation. Biopsies can be taken during the cystoscopy.
- Hydrodistension — This procedure is done under anaesthesia where the bladder is filled with fluid to evaluate maximum bladder capacity and to treat the pain symptom as well by enlarging the capacity.
How can you tell the difference between UTI and IC?
Urine culture test results will be negative in those with interstitial cystitis, whereas those who suffer from a urinary tract infection would test positive.
When should I visit a doctor?
You should see a urologist if you are experiencing any of the symptoms of a UTI. If you have a high fever, flank or back pain, or nausea, it is important that you seek medical treatment as soon as possible, as these are signs of a more serious kidney infection.
Can BPS and IC be cured?
There is currently no cure for interstitial cystitis, but several treatments are available to manage the symptoms. Response to treatment varies between individuals.
For some, symptoms may gradually improve and disappear completely while some may need to continue with treatment indefinitely. There are also some who do not respond to any treatment but, with adequate pain management, can improve their quality of life tremendously.
Similarly, after ruling out IC and other causes, BPS can be treated symptomatically.
How is Interstitial Cystitis treated in Singapore?
The main goal of treatment is to find the most effective combination of therapies that can provide long-term symptom relief. Treatment strategies usually proceed with a more conservative approach first before moving on to surgical procedures when all the other alternatives have been exhausted. Some of these are:
Behavioural interventions
- Effective stress management — Emotional stress can worsen symptoms. Implementation of stress management strategies and coping mechanisms can help to reduce stress-induced symptom exacerbations.
- Dietary restriction — Avoiding certain food or drink triggers such as citrus products and caffeinated drinks can help reduce the bladder’s irritability. Fluid restriction can also help to alter the concentration and volume of urine.
- Bladder training — Training the bladder to hold more urine by delaying bathroom trips can effectively suppress urges.
Medications
- Pentosan polysulfate sodium — This medication helps to reduce urothelial permeability and restore urothelial function.
- Amitriptyline — an antidepressant that can help reduce painful nociception by inhibiting neural activation.
- Antihistamines — Hydroxyzine is a histamine receptor antagonist that inhibits mast cell activation. It can help to provide symptomatic relief.
Intravesical treatment
- Dimethyl sulfoxide — It is a water-soluble and anti-inflammatory chemical solvent that is delivered directly to the bladder by a catheter. It has muscle-relaxing properties and may help to reduce pain and swelling.
- Hyaluronic acid —- This restored the natural covering of the bladder walls and prevent further insults and hopefully, inflammation.
Adjunctive therapy
- Physical therapy — Appropriate exercises can help to resolve pelvic, abdominal, and hip muscular trigger points. It can be especially helpful for patients with associated pelvic floor muscle spasms.
Procedures
- Cystoscopy — a procedure done under anaesthesia to assess the presence of stones, tumours, and Hunner’s lesions. The causes are then treated appropriately. It is usually coupled with low-pressure hydrodistension, which helps determine anatomic bladder capacity.
- Neuromodulation — This procedure involves the implantation of a device or using a needle to deliver mild electrical impulses to the nerves to change how they work. It may help to improve symptoms.
- Neurotoxin injections — This procedure paralyses the bladder muscle to help relieve some of the pain.
- Major surgeries — Substitution cystoplasty and urinary diversion may be undertaken when the alternative treatment options have been exhausted and are inadequate in controlling the symptoms. Urinary diversion may be able to help in relieving frequency of urination and nocturia.
Summary
Interstitial cystitis and BPS can cause major disruptions to social life and lead to several complications. As the urinary symptoms are similar, it can be commonly confused with urinary tract infection, and this is why it’s paramount to consult your doctor if symptoms persist.
