Recommendations for the Diagnosis and Management of Bladder Pain Syndrome. Spanish Urological Association Consensus Document

Recommendations on the use of intravesical hyaluronic acid instillations in bladder pain syndrome

INTRODUCTION

Bladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet.

OBJECTIVE

To synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA. The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations.

RESULTS

There is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment).

CONCLUSIONS

Intravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles). Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up).

The effect of intravesical cocktail therapy combined with low-dose amitriptyline on primary bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

We compared the effectiveness of intravesical combination treatment and intravesical treatment plus low-dose amitriptyline in patients with primary bladder pain syndrome (PBPS).

METHODS

A total of 53 patients were included in the study. Demographic data, voiding frequency, nocturia, visual analog scale (VAS) scores, validated O'Leary-Sant IC Symptom Index (ICSI), and IC Problem Index (ICPI) scores and scores on the Short Form-36 (SF-36) questionnaire were collected from the patients at the beginning of the treatment, and at the 6th week and 6th month of the treatment. The patients were divided into two groups. Group 1 received intravesical treatment for 6 weeks. Group 2 received intravesical treatment plus amitriptyline at a dosage of 10 mg/day.

RESULTS

The frequencies of voiding and VAS scores were significantly improved in groups 1 and 2 at the 6th week compared with pretreatment (in group 1 p < 0.001, p < 0.001, and in group 2 p < 0.001, p < 0.001 respectively). The median ICSI and ICPI scores also significantly decreased in groups 1 and 2 (in group 1 p < 0.001, p < 0.001, and in group 2 p < 0.001, p < 0.001 respectively). Scores on the dimensions of the SF-36 questionnaire were significantly improved in both groups. There was no significant change in terms of VAS, nocturia, ICSI or ICPI scores when comparing the 6th week and 6th month results in groups 1 and 2 (all p > 0.05). Only role functioning/emotional achieved a significant improvement in group 2 (p = 0.007).

CONCLUSIONS

Intravesical combination therapies are effective in PBPS treatment. Adding low-dose amitriptyline to intravesical therapy in patients with PBPS improves emotional status.

Variations in bladder pain syndrome/interstitial cystitis (IC) definitions, pathogenesis, diagnostics and treatment: a systematic review and evaluation of national and international guidelines

INTRODUCTION AND HYPOTHESIS

Interstitial cystitis (IC) and bladder pain syndrome (BPS) are challenging and encompassing hypersensitivity disorders of the lower urinary tract. A variety of national and international guidelines have been published including guidance on nomenclature, definitions, etiopathology, diagnostics and treatment. A lack of universally established clinical guidance is apparent. The aim of this review is to evaluate key guidelines on this area of practice, identify variations, compare their recommendations and grade them using AGREE II.

METHODS

Literature searches were performed using the PUBMED and CINAHL database from January 1, 1983, to December 1, 2018, referring to the search strategy of AUA. Ten national and international guidelines were included into the analysis. We assessed the guidelines with the updated AGREE II.

RESULTS

Symptoms congruent in all guidelines are: pain, pressure, discomfort and frequency, urgency and nocturia. Urinalysis is a prerequisite for diagnostics, cystoscopy for most and urodynamics not part of the routine assessment. Treatment options are recommended stepwise. The highest level of evidence and consensus was identified for oral therapies. Nine guidelines had an overall quality score ≥ 50% and three scored ≥ 70% (AUA, GG, RCOG).

CONCLUSIONS

The guidelines are congruent in symptom reporting, quite congruent in diagnostics and vary to a high degree on treatment recommendations. The complexity of BPS and emerging evidence indicate the need for regular updating of the guidelines and a wider consensus.

Bladder pain syndrome: Prevalence and routine clinical practice in women attending functional urology and urodynamics units in Spain

INTRODUCTION AND OBJECTIVES

Bladder pain syndrome (BPS) is classified as a rare chronic debilitating disease and its diagnosis presents a challenge because its symptoms overlap with those associated with overactive bladder syndrome. The aim of the routine study was to estimate the prevalence of BPS and discover to study the profile of symptoms and clinical practice for patients attending functional urology and urodynamics units.

MATERIAL AND METHODS

An epidemiological study in which 37 functional urology and urodynamics units in Spain participated. The prevalence was studied in both sexes. Clinical practice was evaluated for 319 women with BPS (new diagnosis or under review). Clinical and sociodemographic data were collected retrospectively. The results were studied of urine tests, cystoscopy, biopsy, physical examination, bladder diary, and those of the four available questionnaires: Patient Perception of Bladder Condition; Bladder Pain/Interstitial Cystitis Symptom Score; EuroQoL-5 Dimensions-5L and Patient Global Impression of Severity.

RESULTS

Five point four percent (503) of the patients who attended these units (9,312) had a diagnosis of BPS (90% [453] females). The tests that were performed most according to the clinical history and anamnesis were: urine test, bladder ultrasound and cystoscopy. The most common symptoms/comorbidities were: pain in the bladder region, increased urinary frequency, nocturia, anxiety and depression. Diagnostic assessment determined pain on hydrodistension (86.9%), positive biopsy (59.2%), myofascial pelvic pain (28.4%), urological phenotype (97.8%), and increased urinary frequency (88.7%). The questionnaires reflected how much the quality of life of these patients was affected.

CONCLUSIONS

The prevalence of BPS in functional urology and urodynamics units in Spain is low. No homogeneity was observed in terms of diagnosis between the different participating centres. Therefore, a common methodology is required for the management of patients with BPS in these units, with tools specific to this disorder.

Recent advances in imaging and understanding interstitial cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating condition associated with intense pelvic pain and bladder storage symptoms. Since diagnosis is difficult, prevalence estimates vary with the methodology used. There is also a lack of proven imaging tools and biomarkers to assist in differentiation of IC/BPS from other urinary disorders (overactive bladder, vulvodynia, endometriosis, and prostatitis). Current uncertainty regarding the etiology and pathology of IC/BPS ultimately impacts its timely and successful treatment, as well as hampers future drug development. This review will cover recent developments in imaging methods, such as magnetic resonance imaging, that advance the understanding of IC/BPS and guide drug development.

Hydrodistension plus Onabotulinumtoxin A in bladder pain syndrome refractory to conservative treatments

INTRODUCTION

For bladder pain syndrome (BPS) refractory to conservative treatment, the European guidelines consider bladder hydrodistention (HD) under anaesthesia and the injection of Onabotulinumtoxin A (OnabotA) jointly. The objective of this study was to assess our experience in implementing this technique.

MATERIAL AND METHODS

A prospective study of 25 patients with BPS who underwent HD plus a submucosal injection of 100 U of OnabotA in trigone. The Hunner lesions were treated endoscopically using resection or electrocoagulation. Thirty-eight procedures were performed (25 first interventions and 13 reoperations). To study the clinical change, we evaluated the subjective improvement (Treatment Benefit Scale [TBS] and Patient Global Impression of Change [PGIC] scales), the visual analogue scale (VAS) for pain, the Bladder Pain/Interstitial Cystitis Symptom Score (BPIC-SS) questionnaire and the voiding diary for 3 days. For the data analysis, we employed the Wilcoxon, Kruskal-Wallis, Kaplan-Meier and log-rank tests.

RESULTS

We observed subjective improvement in 21 patients (84%), which was significant in 47% of these patients, moderate in 41.2% and slight in 11.8%. Four patients did not improve. A post-treatment reduction in the pain VAS (from 7.1 to 1.8 points; P=.001), in daytime (from 11.8 to 7.5; P=.012) and night-time (from 5.9 to 3.6; P=.003) voiding frequency and in the BPIC-SS (from 27.9 to 11.2 points; P=.042). The degree of improvement was not related to age, the presence of bladder lesions or the treatment of relapses. The median duration of improvement was 7 months (95% CI 5.69-8.31), although this duration was somewhat longer for the patients younger than 65 years. Mild complications occurred in 23.7% of the cases.

CONCLUSIONS

The joint implementation of HD plus OnabotA is a valid therapeutic option in refractory BPS, which provides good clinical results and maintains its effectiveness in retreatments.