Women with Painful Bladder Syndrome (PBS) complain of urinary urgency, frequency, and bladder pain. Symptoms can range from mild, patients complain of frequency and pain with a full bladder, to severe (frequency of multiple times an hour and severe bladder pain). Patients are commonly misdiagnosed for months to years as having bladder infections. However, urine cultures do not show bacterial growth. The causes of PBS have been are poorly understood. Patients with Chronic bladder infections often have a history of pelvic surgery, autoimmune disorders such a rheumatoid arthritis, other types of neuropathic pain syndromes such as Fibromyalgia Rheumatica.
PBS can be categorized into 3 types: chronic cystitis or interstitial cystitis, muscular dysfunction of the pelvic floor, and neuropathic pain. Once the type of PBS has been identified, tailored treatment to that condition is offered.
There are many treatments for PBS, none of which are a “magic bullet”. If chronic cystitis or bladder inflammation is the main cause of PBS then your physician will offer treatments to reduce this inflammation and restore the normal bladder lining. A common treatment is bladder instillations, whereby a “cocktail” of medicine (DMSO, heparin, lidocaine, bicarbonate, steroid) in instilled into the bladder on a weekly basis for typically 6 weeks. Maintenance treatment may also be offered to control symptoms. Cystoscopy and hydrodistension or stretching of the bladder may also be offered. This procedure allows the physician to look into the bladder to rule out cancer, and stretch the bladder to improve volume, as well as treating ulcers associated with chronic inflammation. The hydrodistension has also been shown to incite bladder injury which produces natural excretion of epithelial growth factors that promote healing of the bladder lining.
Oral medication to treat PBS can also be effective. Bladder analgesics, such as Pyridium or Uribel, are used to lessen pain. Nerve stabilizers such as Gabapentin (Neurontin), Lyrica, Nortriptyline, Amitriptyline, are also used to treat the nerve pain that can cause PBS. Side effects of these medications are sedation. Therefore, this class of medication is often slowly titrated from very low doses to higher doses over several weeks Elmiron is another medication is used to restore the bladder lining that is often “leaky” or compromised in cases of chronic inflammation causing BPS. This medication requires 6 months of regular usage to restore the bladder lining. Side effects include hair loss and blood count effects. Patients should be monitored regularly by their physician while taking Elmiron. It is our practice at Washington Urology and Urogynecology to avoid narcotic usage in patient with PBS.
Bladder Botox chemodenervation has been used treat the bladder overactivity of BPS but it may not improve pain. This an office procedure that involves injection of Botox A ( a neuromuscular paralytic) that paralyzes the bladder muscle where injected and allows the bladder to hold more volume and be less spastic.
Sacral Neuromodulation (SNM): This treatment is used to treat the urgency and frequency component of PBS, but is not as effective in treating pain. The sacral nerve is stimulated by a low amplitude pulse simulation via an electrical lead placed in the operating room under a light anesthetic. This lead is worn for a one week trial. If the patient had a significant improvement in symptoms they move to the second stage of the procedure, whereby the lead placed during the first procedure is connected to a permanent battery placed beneath the skin in the buttock, below the hip bones and above the sit bones. The battery will need to be changed every 3-5 years. SNM is a durable and effective treatment for overactive bladder symptoms. SNM is typically covered by most insurers.
Pelvic Floor Physical Therapy: Most patients with bladder pain have tenderness and tension in their pelvic floor. Pelvic floor physical therapy (PFPT) is designed to release the tension in the pelvic floor muscles (kegel muscles) that cause much of the pelvic and bladder pain. The PFPT are specialized in treating pain. The sessions are once a week for 6-8 weeks. PFPT is the one treatment that has consistently shown in pelvic pain patients to improve symptoms.