Chronic pelvic pain Flashcards
(20 cards)
definition of CPPS
perceived pain in structures related to the pelvis in men and women, where is no proven local pathology or infection to account for the symptom
often associated with negative cognitive, behavioural and emotional consequences
aetiology of CPPS 4
multi factorial poorly understood low grade infection chemical irriation altered immunity neuromuscular disturbances
history
- Duration
- Impact on QOL
- Most bothersome symptoms
- Previous medical or surgical treatments for condition, or pelvic conditions
- Urinary bowel sexual menstruation symptoms
- Psychological well being and history
history
- Duration
- Impact on QOL
- Most bothersome symptoms
- Previous medical or surgical treatments for condition, or pelvic conditions
- Urinary bowel sexual menstruation symptoms
- Psychological well being and history
Parson’s test
• Parson’s test • Instilling potassium chloride into bladder via catheter • May yield pain or cystitis symptoms • Gauges permeability of the GAG layer poor sens and spec
UPOINT
- Another tool to classify patients who have an established diagnosis of CPPS/PPS
- Into clinically relevant phenotype that can guide therapy
- Urology
- Psychology
- Organ specific
- Infection
- Neurological
- Tender muscle
bladder pain syndrome
timing
number symptoms
examples symptoms 2
- No longer use IC, or painful bladder syndrome
- Presence of persistent or recurrent pain in urinary bladder region for more than 6 months with at least one other symptom
- Such as pain worsening during bladder filling and daytime and or night time urinary frequency
- No proven infection or other bladder pathology
theory of BPS
anti proliferative factor is produced by bladdder urothelium
potential mediator of BPS by increasing transmembrane permeability and decreasing heparing binding epidermal growth factor
what are glomerulations
pin point red marks, petehcial haemorrhages on bladder wall
what are Hunner’s ulcers
lesions which are circumscribed red area with small vessels radiating towards a central scar with attached fibrin deposit and central fragility
ESSIC classification of BPS based on cystoscopy hydrodistension and biopsy 4 x 4 table
- Subclassification according to results of cystoscopy with hydrodistension
- Biopsy – not done, normal, inconclusive positive (A-C)
- Cystoscopy – not done, normal, glomerulations, Hunner’s lesion (1-c)
- Numbers indicate grade of severity at cystoscopy
- Letters A,B or C represent biopsy findings
- X indicated not done for both
what counts as positive biopsy
histology showing inlammatory infiltrates and or detrusor mastocytosis and or granulation tissue and or intrafascicular fibrosis
management BPS 5
According to predominant symptoms and their impact on quality of life
Long and frank discussion
Emphasise benign condition
Explain lack of evidence in favour of any treatment
Goal should be symptom control rather than eradication
Management multimodal of an appropriate duration and incremental in nature
drugs used in BPS
Cornerstone of management
1. NSAID – 80% more likely to have favourable response than placebo
2. Antibiotics
3. Alpha blockers – meta analysis improvement in total symptoms, pain, voiding and QOL
NSAID can be replaced with muscle relaxant such as diazepam or baclofen or a TCA
EAU
Insufficient data on muscle relaxants
Pregabalin is not effective for PPS
EAU recommendations CPPS 7
Use quinolone or tetracyclines over a minimum of 6 weeks in treatment naive patients with duration of PPS less than one year
Offer high dose oral pentosane polysulphate
Amitriptyline effective for pain
Offer acupuncture
ESWL – probably effective over short term
Acupuncture
PTNS – probably effective
Neuromodulation: SNM may be effective
Pudendal nerve stimulation is superior to SNM for BPS
Psychological therapy – CBT may improve pain and QOL
surgical treatments EAU BPS
Intravesical lidocaine effective in short term
Insufficient data for bladder distension
Hydrodistension plus botox more effective then distension alone
SNM may be effective
Pudendal nerve stimulation is superior to SNM for BPS
Offer intravesical hyaluronic acid or chondroitin sulphate before more invasive measures
Offer submucosal bladder wall and trigonal injection of botox plus hydrodistension if intravesical therapies failed
RCOG guidelines
Bladder diary
Food diary may be useful to identify if specific foods cause flare up of symptoms
Rule out urological malignancy
Bladder biopsies and hydrodistension not recommended in diagnosis of BPS (also don’t use UDS)
Use validated symptom score
Use VAS to assess severity of pain in BPS
Dietary modification can be beneficial – avoidance of caffeine, alcohol and acidic food and drinks
Oral amitryptaline or cimetidine (unlicensed) may be considered when first line treatments failed
Other treatments intravesical: Lidocaine Hyaluronic acid (Cystistat) Botox Heparin Chondroitin sulphate
Further treatment options as part of MDT:
Fulguration treatment – Hunners ulcers do not respond to oral treatments and need surgical treatment.
PTNS or SNM
Oral cyclosporin A
Major surgery
NOT recommended
Oral hydroxyzine
Oral pentosan polysulfate – NICE recommended 2019
Long term antibiotics
elmiron mechanism
Pentosan polysulfate sodium is a semi-synthetic heparin-like substance that resembles glycosaminoglycans.
It is thought to work by binding to and repairing the glycosaminoglycan layer in the deficient mucous of the bladder
elmiron mechanism
Pentosan polysulfate sodium is a semi-synthetic heparin-like substance that resembles glycosaminoglycans.
It is thought to work by binding to and repairing the glycosaminoglycan layer in the deficient mucous of the bladder
DMSO
A 50 ml solution of 50% DMSO for intravesical instillation (Rimso-50) is licensed by the US Food and Drug Administration
Unlicensed in UK
dimethyl sulfoxide bladder instillation
A Cochrane review included the RCT described above and provided additional statistical analysis not available in the published study. This showed no statistically significant difference between DMSO and placebo for bladder capacity and pain
