Interstitial cystitis/bladder pain syndrome (IC/BPS) is a likely underdiagnosed chronic pain syndrome consisting of pelvic pain lasting longer than 6 weeks plus lower urinary tract symptoms in the absence of infection or other identifiable cause. It is more common after 40 years of age. The etiology is unclear, but some patients have inflammatory findings in the bladder known as Hunner lesions. Due to its variable presentation, there is no standardized evaluation for diagnosis of IC/BPS. The history should include pain and urinary symptoms; associated comorbid disorders, including autoimmune and mental health conditions; and symptoms suggestive of other causes (eg, infection). Cystoscopy is not required but should be considered for patients with refractory symptoms and when Hunner lesions are suspected, such as in those older than 50 years or with comorbid autoimmune disorders and/or bladder-centric presentation (eg, predominance of urgency, frequency, low urine volumes). Treatment is often multimodal, including behavior modifications, stress management, and nonpharmacologic therapy (eg, pelvic floor physical therapy). Oral pharmacotherapy can be considered, but no guidelines exist on preferred agents. Referral for procedural treatments can also be considered for refractory cases. Patients should understand that no treatments are definitively successful, and recurrences and flare-ups often occur.
Case 4. DO is a 39-year-old patient who reports more than 1 year of intermittent pain in her pelvis along with urinary urgency and frequency. She has visited emergency departments and urgent care facilities several times but has never been diagnosed with a urinary tract infection. She is frustrated and wants to know how to stop these symptoms.
Background
Interstitial cystitis/bladder pain syndrome (IC/BPS) is defined as chronic pelvic pain lasting longer than 6 weeks, along with lower urinary tract symptoms (frequency, urgency, hesitancy) in the absence of infection or other identifiable cause.1 Symptoms can worsen gradually over time or may manifest in acute flare-ups, occasionally without identifiable triggers. Symptoms are typically bothersome and disrupt quality of life, and can negatively affect social and psychological well-being. No unifying cause has been identified, but several associated pathologies have been proposed. IC/BPS management requires a multimodal and often multidisciplinary approach.
Epidemiology
IC/BPS most often occurs after 40 years of age,2–4 but the actual prevalence is uncertain due to variability in diagnosis. Women are at least four times more likely to experience IC/BPS than men, based on one study using self-reported questionnaires and another based on physician diagnosis and medical billing.1,5 Other studies using validated case definitions found that differences in prevalence by sex were less pronounced, at 6.53% in women and 4.2% in men.2,3
Some conditions unrelated to the bladder can be associated with IC/BPS, but the significance is unclear. Among these are environmental allergies, skin hypersensitivities, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, and anxiety.6,7 There also appears to be a link between the Hunner lesion disease subtype of IC/BPS and autoimmune conditions such as inflammatory bowel disease, rheumatoid arthritis, and systemic lupus erythematosus.7–10
Pathophysiology
Several factors, both inside and outside the bladder, are thought to contribute to the development of IC/BPS. They include chronic inflammation and stress, mast cell activation, dysregulated pain response, pelvic floor dysfunction, urothelial disruption, and autoimmune processes (Table 1).11–21
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