Bladder Pain Syndrome (Interstitial Cystitis)
Bladder pain syndrome (BPS) or Interstitial cystitis is a complex, chronic condition characterised by pain perceived to be from the bladder area. The painful condition is usually associated with other bladder symptoms including a frequent and urgent need to urinate, often only passing small amounts. Classically (although not always the case) the pain (which is usually a burning sensation) occurs during bladder filling and is relieved as you pass urine. The pain tends to be cyclical in nature, with periods of relative stability followed by acute flare ups and then a return to baseline.
Painful bladder syndrome is often associated with other pelvic conditions like endometriosis, pelvic pain, fibromyalgia, overactive bladder and irritable bowel syndrome. The overlapping and at times non specific symptoms require a specialised approach to diagnosis and management of your individual symptoms.
As a subspecialist Urogynaecologist Dr Usama Shahid leads the bladder pain syndrome Wollongong service by providing compassionate, holistic assessment and an evidence based approach so you can reclaim your life from chronic pain.
The exact cause of bladder pain syndrome hasn't been completely understood. What we do understand is that the condition is a result of a dysfunction of the inner lining of the bladder wall. This layer of bladder lining is known as the glycosaminoglycan (GAG) layer. It functions as a largely impermeable barrier protecting the bladder wall from painful stimuli (like urine). Once not functioning properly (as is the case in painful bladder syndrome) the disrupted GAG layer allows irritants in the urine to pass through to the bladder wall triggering inflammation, nerve sensitisation and pelvic pain.
In response the bladder activates mast cells which release inflammatory mediators and initiate an autoimmune response. Overtime these pain signals can amplify in a process called central sensitisation resulting in long term pain.
Given the significant overlap of symptoms with other conditions, tagged with a relentless cycle of bladder pressure, pelvic pain, frequent urination and sporadic periods of temporary relief, bladder pain syndrome prevalence rates are very likely under reported. The following are some known risk factors:
There is no specific test to diagnose bladder pain syndrome. Instead it is a diagnosis of exclusion, whereby other conditions that could possibly explain symptoms are ruled out. This is done through:
Dr Shahid provides this assessment all in house in his Wollongong rooms.
There is no single treatment that works for all women with BPS, instead management is highly individualised based on your specific concerns, general health and personal goals of management. This requires a stepwise, multi-disciplinary approach with various treatments and although this takes some time it allows for a meaningful improvement in your day to day life.
Certain foods and drinks can irritate the inner lining of the bladder and trigger or worsen bladder symptoms. Through a process of trial and error (over 2-4 weeks) the following foods and drinks should be eliminated as much as possible:
Once the urge has settled, walk calmly to the toilet at your scheduled time or hold on a little longer if you can.
Pelvic floor dysfunction, particularly hypertonic pelvic floor muscles are common in women with BPS. While with pelvic organ prolapse and stress urinary incontinence the goal of physical therapy is to strengthen the pelvic floor, in BPS it is often a case of down regulating and relaxing the pelvic floor. This is done through:
Psychological stress or anxiety is a well established trigger for flare ups. Incorporating relaxation techniques to reduce stress can have a meaningful impact on symptom control and are used as an adjunct to other treatments. This can be achieved through:
In the absence of a known definite cause, the treatment options for the medical management of BPS vary but are all aimed at providing symptom relief. If needed referral to a pain specialist can be considered.
Simple pain relief medication like paracetamol and ibuprofen help block pain and will be discussed with you. Although easily available these medications do have side effects.
This medication is from a group called tricyclic antidepressants. It functions by reducing central sensitisation of the nerves around the bladder and can improve sleep. It is used at a much lower dose than for its other use in depression.
Amitriptylline can cause drowsiness and thus should be taken around 6pm, so the effects occur during night time when you are in bed.
These oral medications are less frequently used due to their limited efficacy in the evidence base of side effects. Namely hydroxyzine, cimetidine and pentosan polysulfate sodium (which is no longer available on the PBS).
It is common for patients with bladder pain syndrome to suffer from urinary urgency, frequency and incontinence. Mirabegron helps the bladder to relax and alleviate bladder symptoms.
This is administered as a weekly course of bladder instillations for 3 months. Followed by once monthly maintanence doses.
The procedure involves emptying the bladder of urine and inserting a combination of DMSO, heparin and local anaesthetic into the bladder. You then lie in various positions for a total of 30 minutes allowing it to spread across the bladder wall.
This procedure is used to exclude other conditions as part of diagnosis. Bladder hydrodistention is the process of filling the bladder up with sterile fluid under an anaesthetic. The stretching of the bladder wall has been described as a treatment for BPS but unfortunately only provides temporary relief.
Bladder injections are a surgical management option for the treatment of bladder pain syndrome. This procedure directly targets inflammatory changes in the bladder wall by visualising them with a camera (cystoscope) and injecting a combination of specific antibiotics (gentamicin which cant be taken orally), steroids and pain relief. .
The injections work by decreasing inflammation and pain and directly administering antibiotics to the bladder. Most people will need to procedure repeated if their symptoms start becoming frequent again (down the track), which the average duration between injections of 12 months.
The is done under a general anaesthetic as a day procedure (no overnight hospital admission required) and is quick (takes 15 minutes to perform).
A cystoscope (camera) procedure (through which the injections are administered) also excludes other pathology which could be causingsymptoms (like a bladder cancer, bladder stones, cystitis or mesh exposure into the bladder from previous surgery).
Bladder injections are overall a safe and well tolerated procedure. There are some potential side effects that are important to understand:
Bladder injections are done as a day surgery (no overnight hospital admission is required). The procedure itself takes 15 minutes and you are monitored in recovery for 2 hours following the procedure and go home the same day.
Over the next few days it is normal to experience a mild discomfort, slight burning sensation when passing urine or small amounts of blood in your urine. This is normal and settles quickly. The pain is adequately managed with simple analgesia in paracetamol and ibuprofen, if you are able to take it. If your pain is worsening, please call the post-operative phone number or consult your doctor.
Most women return to their normal daily activities the same day or the following day
Tips for success:
You will be contacted by our team and have your post-operative appointment booked in 4-6 weeks time. We will review your symptoms and confirm that you are emptying your bladder well with an ultrasound. We will ensure that you are closely followed up.
Sacral neuromodulation (SNM) is a surgical treatment option for the management of bladder pain syndrome (where conservative and medical treatments have failed to provide adequate symptom relief).
The procedure works through a permanent implantable pulse generator placed under your skin in the upper buttock (under a general anaesthetic). The pulse generator device is very small (about the size of a 20 cent coin) and not noticeable in your day to day activities. The implantable pulse generator releases gentle sacral nerve stimulation signals which act like a bladder pacemaker to control your bladder function. These electrical pulses are distributed through a soft wire facilitating sacral nerve stimulation. These electrical pulses aim to modulate the signals (which become erratic in BPS) between the brain, sacral nerve and the bladder.
SNM has great long term success rates with 90% of patients reporting significant improvements in their symptoms and general quality of life.
Sacral neuromodulation is done as a 2 step procedure:
How long does the permanent implantable pulse generator work for?
Is the implantable pulse generator safe for MRI scans and airport security scanners?
Contra-indications: with certain conditions it is not possible to get a permanent SNM. These include
SNM is a well established and safe procedure. With that in mind, there are some potential risks and complications that are important to understand. These include:
After the stage 1 (trial period) insertion you are usually admitted to hospital overnight. Once discharged you will be required to keep a bladder diary for 2 weeks.
The procedure is usually well tolerated and you are given pain relief to keep you comfortable.
Tips for success:
If the trial period is successful (defined as a 50% reduction in urinary urgency, frequency, voids at night and incontinence episodes) then stage 2 (permanent implantation) will proceed. This is done as a day case and no hospital overnight admission is required.
You are then closely followed up to ensure all the settings are working as desired to given you the best relief of your symptoms.
A diagnosis of bladder pain syndrome can feel overwhelming and the journey to find effective and lasting symptom control can be frustrating. If you have been living with chronic bladder pain, discomfort and unexplained bladder symptoms, subspecialist assessment may provide the answers and the relief you are looking for.
Dr Usama Shahid is a consultant subspecialist Urogynaecologist based in Wollongong full time. He offers a compassionate and evidence based approach to your individual care. Allowing you to effectively manage your symptoms and reclaim your life.
Not necessarily. Management options involve doing watching and waiting (and observing progress), conservative (or non surgical options) and then surgical options. Dr Shahid will discuss all available options for your prolapse as an individualised experience. The decision to proceed with any management is always your choice.
Yes, referrals are required in order for you to obtain Medicare rebates. Please see your GP and mention you want a referral to see Dr Usama Shahid or otherwise contact our rooms and we will guide you to known GP’s for referrals.
Anytime you are bothered by your symptoms and they are affecting your quality of life. All options for management will be openly discussed with you. There are treatments available.
Pelvic floor health is personal, and Dr Shahid understands that. He is committed to making every patient feel at ease. Your first consultation is an opportunity to discuss your symptoms in a confidential, supportive environment. Dr Shahid will take a history, perform an examination to assess your pelvic floor and if needed do further tests like urodynamics and ultrasound before having a robust discussion about options available to you. Thus allowing you to make an informed decision about your care.
