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BLADDER PAIN SYNDROME (BPS)


Semir A. S. Al Samarrai

Introduction

Interstitial cystitis (IC) describes a chronic, distressing bladder condition (2)

The so called ulcer, which is a typical cystoscopic finding in 10-50% of IC patients, was decribed by Amy Hunner at the beginning of the last century (3, 4).

Subsequent research (5,7) has shown that IC encompassed a heterogeneous spectrum of disorders; with different endoscopic and histopathological presentations, with inflammation an important feature in only a subset of patients.

To embrace all patients suffering from bladder pain, the term Painful Bladder Syndrome (PBS) or BPS have suggested as more accurate when referring to pain in the bladder region, while assuming IC with Hunner’s lesion as a specific type of chronic inflammation of the bladder (8, 9).

Diagnosis

Bladder pain syndrome should be diagnosed on the basis of pain, pressure or discomfort associated with the urinary bladder, accompanied by at least one other symotoms, such as daytime and /or night time increase urinary frequency, the exclusion of confusable diseases as the cause of symptoms, and if indicated, cystoscopy with hydrodistension and biopsy (9).

Reports of the prevalence of BPS have varicel greatly, along with the diagnosis criteria and populations studied. Recent report generally showed higher figures than earlier ones, ranging from 0.06% to 30% (10, 11, 12, 13, 14, 15, 16, 17, 18, 19).

There is a female predominance of about 10:1 (4, 71, 81, 82). Evidence that BPS may have a genetic component has been presented in several studies, but may contribute to less than one third of total variation in susceptibility for BPS, with the remainder being environmental (20, 21, 22, 23).

Medical treatment

1) Analgesics:

Pain is often a dominant symptom, therefore, many patients try commonly used analgesics at some stages of the disease. However, pain relief is disappointing because the visceral pain experienced in BPS responds poorly to analgesic drugs.

Short-term opoids may be indicated for breakthrough or exacerbated pain and periodic flare-ups. Long-term opoids may be considered after all other available therapeutic options have been excluded (24).

2) Corticosteroids:

Reports an outcome with corticosteroid therapy have been both promising (25) and discouraging (26). Soucy et al (27) have suggested a trial of Prednisone ((25mg daily for 1-2 months, afterwards reduced to the minimum required for symptom relief)) in patients with severe ulcerative BPS.

3) Antiallergics:

Mast cells may play a role in BPS. Histamine is one of the substances released by mast cells. Histamine receptor antagonist have been to block the H1 (28) as well as the H2(29) receptor subtypes, with variable results. The tricyclic antidepressant (Amitriptyline) has alleviated symptoms in BPS, probably via mechanisms such as blockade of acetylcholine receptors, inhibition of recaptake of released Serotonin and noradrenalin, and blockade of histamine H1 receptors.

4) Pentosan-Poly-Sulphate-Sodium has been evaluated in double-blind, placebo-controlled studies. This agent positive effect by the BPS is thought to substitute for a defect in the GAG layer. Subjective improvement of pain, urgency, frequency, but not nocturia, has been reported in patients taking the drug compared to placebo (30, 31).

5) Antibiotics have a limited role in the treatment of BPS. Antibiotics alone or in combination may be associated with decreased symptoms in some patients, but do not represent a major advance in therapy for BPS (32).

6) Immunosuppressants (such as Azathioprine, Cyclosporine and methotrexat were initially evaluated in open studies with good effect on pain, but a limited effect on urgency and frequency (23,24). Men recent studies of Cyclosporin A have reported promising results, daily voiding maximal bladder capacity and voided volume was significantly improved after one year of treatment (35).

7) Ouercetin: is a bioflavonoid that maybe effective in male pelvic pain syndrome (36).

Intravesical Treatment

Intravesical application of medications establishes high concentration at the target, with few systemic side effects.

Hyaluronic acid: is a natural proteoglycan aimed at repairing defects in the urothelial gluosaminoglycan (GAG) layer. A response rate of 56% at week 4 and 71% at week 7 was reported in patients treated with hyaluvonic acid. (37).

Chondroitin-sulphate: Intravesical Chondroitin-sulphate (38), demonstrated beneficial effect in patients with a positive potassium stimulation test.

Bacillus Calmette Guerin (BCG)

The Turberculosis BCG vaccine is used for immunomodalatory properties in the Transvesical treatment of superficial bladder carcinoma, but because of the low response rate of 18% for BCG in BPS patients, the argument against routine use of BCG for BPS has been substanciated (39).

Interventional Treatments

a) Bladder distension is a common treatment for BPS scientific justification is scarce. 

b) Tranurethral Resection (TUR), coagulation and laser. Endourological ablation of blade tissue aims to eliminate urothelial, mostly Hunner lesions (21).

Transurethral application of the (Nd-YAG) Laser is suggested as an alternative to TUR for endogenic treatment in BPS (40).

Controlled studies are still lacking Endorological resection is not applicable to non-ulcer BPS.

c) Botulinum toxin (BTX-A) may have an antinoceptive effect on bladder afferent pathways, producing both sympathomatic and urodynamic improvements (41). Trigonal-only injection seem effective and long-lasting because of 87% of patients reported improvement after 3 month follow-up period in a study by Pinto et al. (42).

d) Neuromodulation:

Sacral Nerve Stimulation (SNS) or Pudendal Nerve Stimulation (PNS) (43).

Sacral neuromodulation showed adequate improvement for the symptoms of refractory BPS Reoperation rate was 25% (44).

Non-pharmacological treatments

1) Behavioural bladder training techniques are attractive for BPS patients with predominant symptoms of frequency/urgency but hardly any pains (45).

2) Diet. In analysis of the Interstitial Cystitis Data Base (ICDB) cohort study special diets were among the five most commonly used therapies (46). Bade et al. (47) have found that BPS patients consume significantly fewer calories, less fat and coffee, but more fiber. Scientific data on a rationale for such diets are unavailable. The concentration of some metabolity and amino acids appears to be changed in BPS (48).

Overall, dietary management is a common-self care strategy in BPS and after a cost-effective therapeutic approach.

Comprehensive instructions on how to identify individual trigger foods are given in the IC-Network. Patient Handbook. However, scientific data are limited and dietary restriction alone does not produce complete symptomatic relief.

3) Acupuncture: In non-curable and agonising diseases like BPS, desperate patients often try complementary medicines, such as acupuncture. However, scientific evidence for such treatments is often poor, with contradictory results from few low evidence reports on acupuncture, with any effects appearing to be limited and temporary. (49).

4) Hypnosis: is a therapeutic adjunct in the management of cancer, surgical disease and chronic pain. Although used in urological patients (50, 51), there are no scientific data on its effect on BPS symptoms.

5) Physiotherapy: General body exercises may be beneficial in some BPS patients(52)

Surgical treatment

When all efforts fail to relieve disabling symptom, surgical removal of the diseased bladder is the ultimate option (53, 54, 55, 56).

Three major techniques of bladder resection are common

  • Supratrigonal (i.e. trigone-sparing) Cystectomy
  • Subtrigonal Cystectomy
  • Radical Cystectomy including excision of the urethra
All techniques require substitution of these exercised bladder tissue, mostly patient with bowel segments.

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Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae