Receiver Operating Characteristic Curves Of Symptom Scores In The Diagnosis Of Interstitial Cystitis/Painful Bladder Syndrome

Main Category: Urology / Nephrology
Article Date: 15 Sep 2008 - 3:00 PDT

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UroToday.com - As one of several commonly diagnosed conditions associated with chronic pelvic pain, interstitial cystitis (IC), which is now also called painful bladder syndrome, presents a difficult problem for those of us who must treat these patients. The issues surrounding IC start with the actual definition of the diagnosis itself, and continue on to include the vexing co-morbidities and even the name of the condition.

One of the biggest problems facing IC clinicians and researchers is how to accurately define the condition. Several systems have been in use for some time, and there have been recent revisions. In this paper, we take a highly patient-centered point of view: IC is that condition which causes bladder pain, is a problem for the patient, gets better after alkalinized lidocaine instillation, and responds to hydrodistension (60 seconds under 80cm water pressure with general anesthesia). If this seems like a checklist approach, it is, and we use it as our diagnostic algorithm in the management of IC. Each part was developed based on the literature and our own experience.

Firstly, most clinicians will agree that IC is by definition a disorder of bladder pain, and moreover this must be sufficient pain to be a problem for the patient. In this manner the definition of IC becomes similar to the definition of dysmenorrhea. Obviously, concurrent infection or other problems must be ruled out or addressed. Since the majority of our patients have multiple diagnoses associated with their chronic pelvic pain, we use alkalinized lidocaine bladder instillation to more accurately identify pain localized to the bladder. Patients that have no pain relief, or are too uncooperative to hold the lidocaine in their bladder for long enough to notice an effect, are excluded from having the potential diagnosis of IC. If a patient reports any significant (which we generally leave up to the patient themselves to define) pain improvement, then we offer hydrodistension. This reassures us that the bladder is one of the main organs involved in pain generation.

We perform cystoscopy with hydrodistension only under general anesthesia. Our thinking is that to adequately stretch out the bladder muscle, the patient must be fully anesthetized. Epidural anesthesia could also probably be used. Two applications lasting 60 seconds each under 80 cm (measured) of water pressure is the published protocol we have adopted, and this has worked well for us. At the conclusion of the second distension, we fully drain the bladder and instill alkalinized lidocaine. This has significantly decreased our after hours calls for post-hydrodistension pain management.

Providing an adequate stretching of the bladder muscle is a component of our overall conceptualization of chronic pelvic pain. In this model, deep brain structures, such as the anterior cingulate cortex, become involved with the initiation and maintenance of peripheral tonic muscle contractions, which are perceived as pain. The muscles involved may be the bladder wall, bowel wall, pelvic floor, abdominal wall, or uterus. Therapies targeting muscles, such as physical therapy, trigger point injection with anesthetic or botulinum toxin, and laparoscopy (which acts as a distension of the abdominal wall) have all proven effective. One of the reasons patients have a relapsing course is that the muscle treatments cannot address the central process, which is driven by deep brain structures. Why these patient's brains develop this problem may be due to hereditary factors or personal predisposition, or can be initiated through traumatic experiences. The ultimate cause and most effective treatment for chronic pelvic pain is an ongoing area of research.

Finally, the question of nomenclature for this process has been debated extensively over the recent years. One problem with both naming and diagnosis is that IC seems to be a heterogeneous process, and it is difficult to adequately address all patients with a single system. Older patients with ulcerative disease are likely distinct from younger patients with non-ulcer disease. Similarly, the rare patient with IC alone is likely different from the patient with concurrent endometriosis, IBS, pelvic floor tension myalgia, and vulvodynia. It may also be necessary to include patients with primarily irritative symptoms rather than pain as their primary complaint. In addition, a definition or nomenclature must still account for patients who are narcotic addicted, while still not excluding them from the possibility of having 'real' disease. Ultimately, we expect that the current process of trial and error in the definition will continue until a useful diagnostic definition is developed.

To be useful, the next generation of IC definition must be able to guide treatment and predict prognosis. Our current approach allows us to select patients for one treatment regimen, hydrodistension, that have a good prognosis for symptom improvement with that particular approach. Future refinements of the diagnostic definition of IC should also be developed with such clinically applicable standards clearly in mind. The challenges inherent in the diagnosis and management of these patients are some of the reasons we developed a chronic pelvic pain referral center, and why we continue to be interested in future research in this area.

Written by Bradford W. Fenton, MD, PhD, FACOG, as part of Beyond the Abstract on Urotoday.com.

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