Chronic Bladder Pain Syndrome

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Initial Assessment

The initial assessment includes:

  • Symptoms and associated disorders
  • Relevant past history, medical problems, surgery, trauma, hospitalizations
  • Assessment of emotional and psychological status as well as of lifestyle habits
  • Focused physical examination
  • Frequency/volume chart – daily bladder dairy (3 days)
  • Urinalysis and urine culture
  • Urine cytology

Urinalysis, urine culture and urine cytology

Urinalysis, urine culture and urine cytology tests are useful to exclude pathological changes: haematuria (red blood cells in the urine), proteinuria (protein detected in the urine), pyuria (white cells present in the urine) etc, to exclude patients with recurrent UTI, and abnormal urinary cytology. In case of pathologic findings the evaluation with appropriate imaging and endoscopic procedures is required.


Secondary Assessment

In more complicated cases, if the diagnosis is in doubt and if clinically indicated, or if the initial oral therapy fails, further evaluation is required.

The following invasive tests are considered:

  • Cystoscopy with bladder distention, possible bladder biopsy under general anesthesia
  • Characteristic cystoscopy findings include glomerulations (petechial hemorrhages), mucosal ulcerations of varying intensity, scars, and small bladder capacity. Ulcerations and small bladder capacity are indicators of the severity of the diseases. Problems may arise in differentiating malignancy from cystitis, therefore biopsy may be required. Hydrodistantion of the bladder during cystoscopy may result in improvement of symptoms.
  • Urodynamics
  • Urodynamics is a test that looks at how well the bladder, sphincters and urethra are storing and releasing urine. This is a useful test for patients who present with complaints, such as urgency and incontinence. Urodynamics are useful for initial assessment and to monitor treatment outcomes objectively in patients with urodynamic abnormalities.
  • Pelvic Imaging (Ultrasound, CT, MRI, etc, see below)
  • Many patients presenting with bladder pain and urinary symptoms do not require imaging.

    The imaging features of cystitis are nonspecific. On imaging only, one form of cystitis cannot be differentiated from another. Bladder tumors may cause mucosal and wall changes that are similar to the changes seen in cystitis, and vice versa. When imaging indicated, ultrasound is the best option.

    Ultrasound (US)
    Ultrasonography is a useful test to provide evaluation of the bladder and bladder wall thickness. It is an accurate method for measurements of bladder capacity, post void residual (PVR) and prostate assessment. US can be used to exclude bladder outlet obstruction and bladder calculi. It is good method in following dilated structures and provides excellent anatomical details at any plane. US also identify other pelvic organs, localise and characterise cystic, solid or complex lesions. The kidneys and ureters could be assessed to exclude associated pathology. Transabdominal US is painless, noninvasive, with no radiation exposure and does not involve contrast material. This method is without side effects and is low cost.
    Intravenous Urography ( IVU ) – contrast-enhanced study
    IVU provides similar information to ultrasound. This method is good at showing structural abnormalities of the bladder, ureters and kidneys. IVU also can assess the renal function, ureteric reflux and show hydroureteronephrosis.
    Computed tomography (CT)
    Computed tomography makes pelvic regional anatomy available in the axial and coronal plane with good resolution. CT scans demonstrates bladder calcifications, bladder diverticula, colovesical fistula, perivesical abscess. Blood vessels and masses can be assessed with intravenous contrast.
    Magnetic resonance imaging (MRI)
    MRI is a useful test to provide assessment of focal or diffuse thickening of the bladder wall in patients with cystitis. This imaging method is best for complicated forms of cystitis such as sinuses or fistula formations.

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