The American Urology Association has finally released this month the long-awaited new clinical guidelines for Interstitial Cystitis/bladder pain syndrome! These new guidelines may be the most comprehensive clinical care article on IC written to date.
Included in the AUA clinical guidelines is new insight into diagnostic testing and a new six stage IC treatment algorithm that can be used by patients or physicians when considering treatment and pain management plans.
AUA DEFINITION OF INTERSTITIAL CYSTITIS
The definition for IC/BPS the AUA decided to use for their new guidelines was the definition first established by the Society for Urodynamics and Female Urology:
“An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.”
IS IC MORE THAN A BLADDER DISEASE?
The answer to that is still unknown. IC could be a primary bladder disorder in some patients and yet, for others, may have occurred as the result of another medical condition.
Citing several studies which explored the related conditions found in IC patients, the authors explored several theories, one of which is “IC/BPS is a member of a family of hypersensitivity disorders which affects the bladder and other somatic/visceral organs, and has many overlapping symptoms and pathophysiology.”
In the AUA guideline, pain is the hallmark symptom of IC/BPS, particularly pain with bladder filling. Pain can also occur in the vagina, uretha, vulva, rectum and/or throughout the pelvis. Urinary frequency is found in approx. 92% of IC/BPS patients.
Urgency is an often debated symptom because it is the primary symptom of overactive bladder, a condition often confused with IC. Yet, the authors make a critical distinction. Patients with IC experience urgency and then rush to the restroom to avoid or reduce pain whereas patients with overactive bladder experience urgency and rush to the restroom to avoid having an accident.
The AUA suggests that physicians complete a thorough history and physical examination of the patient. Symptoms should be present for at least 6 weeks (with no infection) for a diagnosis to be made. A physical examination of the pelvis should be conducted for both men and women and “the pelvic floor should be palpated for locations of tenderness and trigger points.”
Several conditions should be ruled out: bladder infection, bladder stones, vaginitis, prostatitis & bladder cancer.
“In general, additional tests should be undertaken only if the findings will alter the treatment approach.”
HYDRODISTENTIONS NO LONGER THE STANDARD
Cystoscopy and urodynamics, for example, are to be considered if a diagnosis of IC is not clear. The authors do note that cystoscopy helps to rule out other conditions which can mimic IC symptoms, such as bladder cancer or stones.
The presence of Hunner’s ulcers on the bladder wall will lead to a diagnosis of IC however the finding of glomerulations on the bladder wall during hydrodistention with cystoscopy is often vague, variable and consistent with other bladder conditions, thus the panel suggests that “hydrodistention is not necessary for routine clinical use to establish a diagnosis of IC/BPS.” Hunner’s ulcers are described in an acute phase “as an inflamed, friable, denuded area” or in a more chronic phase “blanched, non-bleeding area.”
Pain management can include the use of various medications, physical therapy and/or the relaxation of tense, painful muscles, biofeedback and a wide variety of other options. The guidelines encourage physicians to refer patients to other pain specialists if they are unable to provide an effective pain management strategy.
“Pain management should be continually assessed for effectiveness because of its importance to quality of life. If pain management is inadequate, then consideration should be given to a multidisciplinary approach and the patient referred appropriately.”
The panel suggests that the following treatments should not be offered due to the lack of effectiveness found in studies and/or the risk of serious adverse events. In these cases, the risk appears to outweigh the potential benefits.
- Long-term oral antibiotics
- Intravesical Bacillus Calmette Guerin (BCG)
- Intravesical Resiniferatoxin (RTX)
- High pressure, long duration hydrodistentions
- Systemic glucocorticoids