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New perspectives in chronic bladder problems – Part 2

The 19th International Meeting of the European Association of Urology Nurses (EAUN18) held in Copenhagen last March attracted around 340 delegates from all over the world. The EAUN Scientific Committee (chaired by Corinne Tillier), had prepared a comprehensive programme with a wide range of topics relevant for urological nurses, such as benign urology, oncology, psychology, communication, quality of life, etc.

The EAUN Special Interest Group on Continence organised a one-hour session format with three (15-minute) talks followed by a discussion which was very well received. The first lecture, Painful bladder syndrome diagnosis or UTI – misdiagnosis?, was discussed in Part  1. This second article discusses the following lectures on Underactive bladder and the Misdiagnosis with UTI.

Dr. Veronique Phé from Paris (FR) discussed underactive bladder (UAB), a symptom suggestive of detrusor underactivity and usually characterised by prolonged urination time with or without a sensation of incomplete bladder emptying, usually with hesitancy, reduced sensation on filling, and a slow stream. For those with UAB, careful neurologic and urodynamic examinations are required for correct diagnosis. In managing UAB, the avoidance of upper tract damage, prevention of over distension, and reduction of residual urine are paramount. Conservative treatment can include timed voiding, double voiding, medication such as alpha-blockers, and intermittent self-catheterization. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5740034/

The third lecture took up differential diagnosis for Painful Bladder Syndrome and Interstitial Cystitis (PBS/IC) which remains just as difficult today even more than a century after it was first described. There are no specific pathognomonic findings with regards patient history, physical examination, laboratory, or cystoscopy findings. The exclusion of other clinical entities remains the foremost goal of the work-up and evaluation of patients suspected of this condition.

IC/PBS is diagnosed when the symptoms occur without evidence for other causes (Taylor, B. 2007). A full medical history and physical examination are essential. Urinalysis and urine culture are also vital to rule out urinary tract infections (UTI). A voiding/bladder diary is helpful in establishing baseline voiding frequency. Other tests include a pelvic examination, bladder biopsy, urine cytology, and very rare a potassium sensitivity test, and it turned out that nobody in the audience had used this test.

There are no specific radiographic, ultrasonographic, imaging findings specific for PBS/IC, unless when ruling out alternative diagnoses. Cross-sectional imaging, including magnetic resonance imaging (MRI), computed tomography (CT) scanning, and pelvic ultrasonography, may be performed when clinically indicated to evaluate for a suspected pelvic mass that is causing compression of the bladder or for an adjacent inflammatory process (e.g. diverticulitis). Cystography and voiding cystourethrography may be used to evaluate the bladder for other causes of lower urinary tract symptoms, such as intravesical masses, stones, bladder diverticula, urethral diverticula, urethral stricture, meatal stenosis and neurogenic or non-neurogenic voiding dysfunction (Rovner et al 2017).

Urodynamic Studies (UDS) are optional and not generally part of routine evaluation for PBS/IC. The findings maybe suggestive of an alternative diagnosis such as detrusor over-activity or pelvic floor dysfunction but there are no specific UDS findings. During UDS procedure on bladder filling, many patients do have increased sensation with decreased volume, however, pain with bladder filling that reproduces the patients’ PBS/IC symptoms is very supportive of a diagnosis of interstitial cystitis.

Cystoscopy can be described as the most important diagnostic tool for assessing a patient who may have PBS/IC. In general, this is performed while the patient is under anaesthesia in order to provide sufficient bladder distention to examine for co-existing urethral and bladder pathology (e.g., transitional cell carcinoma) and features of interstitial cystitis, such as Hunner Ulcers and glomerulations. During cystoscopy, bladder capacity can also be evaluated. The characteristics of Hunners ulcer are rarely seen to confirm the diagnosis (Rovner et al 2017). Diagnosis can be made based on cystoscopic findings, for patients with PBS/IC and can be classified as either Hunner-type/classic IC (HIC), presenting with a specific Hunner lesion, or non-Hunner-type IC (NHIC), presenting with no Hunner lesion, but posthydrodistension mucosal bleeding ( Maeda D et al Published: Nov 20, 2015). Diagnosis is still one of the exclusions as there are no defined indicators, no aetiology or pathophysiology available.

Profound consequences
Over time it is clinically recommended to see a specialist for on-going symptoms to rule out any possible differential conditions prior to diagnosing interstitial cystitis. The consequences of a diagnosis of PBS/IC are profound since it is a chronic condition without universally effective therapy. Ward-Smith in 2009 stated that there is an estimated 13 million individuals experiencing some type of incontinence and 85% of these are women! In general the symptoms of PBS/IC are characterised by urinary frequency, urgency, and/or pelvic pain and can affect the following types of conditions: infectious or inflammatory, gynaecologic, urologic, or neurologic.

There are also many complications which include reduced bladder capacity caused by stiffening of the bladder wall. Most importantly, it can reduce quality of life due to frequent urination and lack of sleep that affect daily activities, social/work events, etc. Another important aspect of PBS/IC is the effect it can have on personal relationships and sexual intimacy. Patients can be affected by psychological /emotional issues which can also impact on their sexual health, caused by the difficulty dealing with the side effects of chronic pain, and the lack of sleep associated with interstitial cystitis can lead to depression. It is imperative that each person has individualised treatment plans to include a physical examination, appropriate clinical tests, all done in a timely manner for their diagnosis to increase their knowledge and awareness of condition.

IC/PBS is a chronic, complex and poorly diagnosed condition. Pain is one of the primary symptoms, which affects mainly the females. Often times they have suffered for many years with misdiagnosis, and overuse of antibiotics. Many would have tried multiple unsuccessful treatments, maybe be labelled as challenging and difficult, hypochondriac, anxious or mad. But inevitably, all will have a reduced quality of life. For the future, a general consensus on definition, diagnosis and treatment would be of benefit.

References

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Eva Wallace, RN, National Rehabilitation Hospital, Dept. of Urology, Dunlaoighre Co Dublin (IE), ewallace116@gmail.com