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244 Challenging Concepts in Urological Surgery
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may be suitable scaffold materials for stem cells to ‘seed’ on, with proposed cells used in trials so
far mainly consisting of adipose- derived stem cells. However, much more research is required
before we will see biological derived slings entering clinical testing.
26
References
1. Karantanis E, Allen W, Stevermuer TL, et al. The repeatability of the 24- hour pad test. Int
Urogynecol J Pelvic Floor Dysfunct. 2005;16(1):63– 68.
2. Painter V, Karantanis E, Moore KH. Does patient activity level affect 24- hr pad test results in
stress- incontinent women? Neurourol Urodyn. 2012;31(1):143– 147.
3. Avery K, Donovan J, Peters TJ, et al. ICIQ: a brief and robust measure for evaluating the
symptoms and impact of urinary incontinence. Neurourol Urodyn. 2004;23(4):322– 330.
4. Vissers D, Neels H, Vermandel A, et al. The effect of non- surgical weight loss interventions
on urinary incontinence in overweight women: a systematic review and meta- analysis. Obes
Rev. 2014;15(7):610– 617.
5. Cody JD, Jacobs ML, Richardson K, et al. Oestrogen therapy for urinary incontinence in
post- menopausal women. Cochrane Database Syst Rev. 2012;10:CD001405.
6. Steinauer JE, Waetjen LE, Vittinghoff E, et al. Postmenopausal hormone therapy: does it
cause incontinence? Obstet Gynecol. 2005;106(5 Pt 1):940– 945.
7. Li J, Yang L, Pu C, et al. The role of duloxetine in stress urinary incontinence: a systematic
review and meta- analysis. Int Urol Nephrol. 2013;45(3):679– 686.
8. Burkhard F, Bosch J, Cruz F, et al. Urinary incontinence. European Association of Urology.
2019. https:// uroweb.org/ guideline/ urinary- incontinence/
9. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ
prolapse in women: management. NICE guideline [NG123]. April 2019. National Institute
for Health and Care Excellence. https:// www.nice.org.uk/ guidance/ NG123
10. Bo K, Kvarstein B, Nygaard I. Lower urinary tract symptoms and pelvic floor muscle exercise adherence after 15 years. Obstet Gynecol. 2005;105(5 Pt 1):999– 1005.
11. Dumoulin C, Hay- Smith EJC, Mac Habee- Seguin G. Pelvic floor muscle training versus no
treatment, or inactive control treatments, for urinary incontinence in women. Cochrane
Database Syst Rev. 2014;5:CD005654.
12. Agur W, Housami F, Drake M, et al. Could the National Institute for Health and Clinical
Excellence guidelines on urodynamics in urinary incontinence put some women at risk of a
bad outcome from stress incontinence surgery? BJU Int. 2009;103(5):635– 639.
13. Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before
stress- incontinence surgery. N Engl J Med. 2012;366(21):1987– 1997.
14. van Leijsen SAL, Kluivers KB, Mol BWJ, et al. Value of urodynamics before stress urinary
incontinence surgery: a randomized controlled trial. Obstet Gynecol. 2013;121(5):999– 1008.
15. Sokol ER, Karram MM, Dmochowski R. Efficacy and safety of polyacrylamide hydrogel for
the treatment of female stress incontinence: a randomized, prospective, multicenter North
American study. J Urol. 2014;192(3):843– 849.
16. Ford AA, Rogerson L, Cody JD, et al. Mid- urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev. 2017;7:CD006375.
17. Blaivas JG, Purohit RS, Benedon MS, et al. Safety considerations for synthetic sling surgery.
Nat Rev Urol. 2015;12(9):481– 509.
18. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356(21):2143– 2155.
19. Fusco F, Abdel- Fattah M, Chapple CR, et al. Updated systematic review and meta- analysis of
the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the
surgical treatment of female stress urinary incontinence. Eur Urol 2017;72(4):567– 591.
20. Albo ME, Litman HJ, Richter HE, et al. Treatment success of retropubic and transobturator
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mid urethral slings at 24 months. J Urol. 2012;188(6):2281– 2287.
21. Agur W, Riad M, Secco S, et al. Surgical treatment of recurrent stress urinary incontinence
in women: a systematic review and meta- analysis of randomised controlled trials. Eur Urol.
2013;64(2):323– 336.
22. Nikolopoulos KI, Betschart C, Doumouchtsis SK. The surgical management of recurrent stress urinary incontinence: a systematic review. Acta Obstet Gynecol Scand.
2015;94(6):568– 576.
23. Resus CR, Phe V, Dechartres A, et al. Performance and safety of the artificial urinary
sphincter (AMS800) for non- neurogenic women with urinary incontinence secondary to
intrinsic sphincter deficiency: a systematic review. Eur Urol Focus. 2020;6(2):327– 338.
24. Peyronnet B, O’Connor E, Khavari R, et al. AMS- 800 Artificial urinary sphincter in female patients with stress urinary incontinence: a systematic review. Neurourol Urodyn.
2018;38(Suppl 4):S28– S41.
25. Morling JR, McAllister DA, Agur W, et al. Adverse events after first, single, mesh and nonmesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in
Scotland, 1997- 2016: a population- based cohort study. Lancet 2017;389(10069):629– 640.
26. Chapple CR, Osman NI, Mangera A, et al. Application of tissue engineering to pelvic organ
prolapse and stress urinary incontinence. Low Urin Tract Symptoms. 2015;7(2):63– 70.
245Case 24 Stress urinary incontinence
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25
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CASE
Bladder pain syndrome/
interstitial cystitis
Altaf Mangera
Expert commentary Altaf Mangera
Case history
A 49- year- old female describes a pain in her lower abdomen leading her to void every
hour during the daytime and wake every 90 minutes at night to pass urine. She does
not have any voiding symptoms such as reduced flow, straining, intermittency, and
hesitancy. Her general practitioner referred her for assessment of her recurrent ‘urinary
tract infections’ (rUTIs). She has had multiple urinary dipstick assessments by her
general practitioner which sometimes show leucocytes and sometimes nitrites. Urine
culture has been positive on two occasions in the last 18 months with Escherichia
coli being grown by the laboratory. Other occasions mostly show no growth or mixed
growth. When symptoms are ‘bad’, she has severe urgency and is incontinent in pads.
Clinical tip Differentiating between overactive bladder syndrome, rUTI, and bladder
pain syndrome
The differential diagnoses for bladder pain syndrome (BPS)/ interstitial cystitis (IC) are shown in Box 25.1.
From a patient history, it can be difficult to differentiate between overactive bladder syndrome (OAB),
rUTI, or BPS/ IC. Urgency, the hallmark symptom of OAB, is described by the International Continence
Society as ‘a sudden compelling desire to void which is difficult to defer’. However, patients with BPS
and rUTI will also exhibit this symptom. The excluding factor for OAB is the presence of pain which
also accompanies BPS and rUTI. Typically, the pain in BPS was thought to occur with bladder filling and
relief with voiding and in rUTI the pain is with voiding also known as dysuria. Infective symptoms such
as a temperature, malaise, and offensive urine may point to rUTI but a good differentiating question
would be ‘Do antibiotics completely rid you of your symptoms?’ Having symptom- free periods when
antibiotics have taken effect and the presence of bacteria in the urine are strongly indicative of rUTI.
BPS has a more chronic course with intermittent ‘flare- ups’, although there are no strict criteria on how
long the symptoms need to go on for.
Box 25.1 Differential diagnoses for BPS/ IC
● Overactive bladder.
● Urinary tract infection.
● Drug induced cystitis (i.e. ketamine).
● Tuberculous cystitis.
● Radiation cystitis.
● Bladder or ureteric calculi.
● Bladder cancer.
● Vulvodynia.
● Prostatitis.
● Endometriosis.
● Bowel disorders.
● Genital herpes.
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The US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) defines criteria
for the research of BPS but these have been found to be too strict for everyday use. Therefore,
different guideline panels have provided different definitions of BPS which typically rely on history,
examination, cystoscopic findings, and exclusion of other conditions with overlapping symptoms. All
guidelines agree that a pressure, pain, or discomfort needs to be felt in the pelvis with at least one
other urinary symptom and other possible causes need to be excluded through thorough evaluation.1
Cystoscopic examination either with or without hydrodistension should be considered either to
exclude a competing pathology or to help subtyping of patients. Bladder capacity under anaesthetic
is an independent predictor of severity and bladder treatment success along with the presence
of Hunner’s lesions (cracks in the lining of the bladder) which are thought to represent a separate
subclassification.
Expert comment Combination of diagnoses
Despite the individualized definitions of OAB, BPS, and rUTI, it can be difficult to tell them apart and
some patients may present with a combination of problems. There is no reason why a patient with
BPS may not have a UTI periodically and one would even argue it occurs more frequently than in
those without BPS. An open mind is required when taking a history and the individual symptoms and
their bother should be recorded. Other frequently encountered diagnoses in patients with BPS include
inflammatory bowel disease, systemic lupus erythematosus, allergies to medications, irritable bowel
syndrome, sensitive skin, and fibromyalgia.
The patient is perimenopausal and does not have any bowel or gynaecological
problems. She does suffer from anxiety and has also been told she has chronic fatigue
syndrome which leads to a lot of tiredness.
2
3
Clinical tip Clinical assessment
Stress has been studied as a risk factor for BPS and flare- ups can occur during periods of heightened
stress.4 It is postulated that sympathetic dominance plays a role in inducing a hyperalgesic state.5
Visceral hypersensitivity or more central hypersensitization are potential aetiological mechanisms and
should be sought out in the history. Thus, careful assessment of the gynaecological, sexual, and bowel
function needs to be undertaken. Exacerbating and relieving factors should be sought along with
relationship to periods and food/ drink. Pelvic floor muscle examination and trigger points need to be
examined and, in men, prostate examination, paying particular attention to areas of tenderness, needs
to be undertaken.
Learning point Investigations
As the urologist providing the specialist opinion, a urinary dipstick and midstream specimen
of urine would be recommended to exclude a UTI and request a cystoscopy if red cells are
present. Sterile pyuria may prompt the need to send samples to exclude tuberculosis and sexually
transmitted infections.
A frequency volume chart is useful to show small functional bladder volumes and urinary frequency.
The diagnosis of a specific bladder pain pathology is less likely if functional bladder volumes exceed
350 mL and with a frequency of fewer than eight/ day. These were considered exclusions on the
NIDDK criteria. A more objective measure of symptoms can be obtained with a visual analogue scale
assessing pain severity or the use of a validated quality- of- life scoring tool such as the O’Leary– Sant
Interstitial Cystitis Symptom Index (ICSI) and Problem index (ICPI).
The place of cystoscopy in the assessment of BPS is much debated. If there are any concerns picked
up on the history or dipstick assessment then there should be no delay in obtaining the investigation
which is generally done with a flexible cystoscope under local anaesthetic. On the other hand,
a hydrodistension procedure with the opportunity to take a biopsy under a general anaesthetic
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would be more useful diagnostically and also has a potential therapeutic role. The timing of the
hydrodistension procedure would follow after conservative measures have failed to improve the
symptoms.
Clinical tip Performing a hydrodistension
It is important to standardize one’s hydrodistension procedure. It is the author’s practice to perform the
procedure under general anaesthetic. The cystoscope should be inserted into the bladder and the water
pressure set to 100 cm. A cystoscopy is undertaken looking for any urethral or bladder abnormalities
including Hunner’s lesions. The bladder is then filled until it reaches its capacity at 100 cmH2O pressure.
The cystoscopic inflow tap is left open so if any fluid leaks out around the cystoscope it can continue
to fill. In women who have very weak sphincteric resistance, the urethra can be compressed against
the cystoscope (if this is not done then the bladder may not fill as it all leaks around the cystoscope
giving a false impression of a small- capacity bladder). The hydrodistension is held for 3 minutes. The
anaesthetist is asked to report any changes in blood pressure or pulse which indicate a positive painful
response under anaesthetic. After 3 minutes, the water inflow to the cystoscope is switched off and
the bladder emptied into a measuring jug. The bladder capacity under anaesthetic with 100 cmH2O
pressure is recorded in the notes. The bladder is refilled and any glomerulations and their locations
noted. Hunner’s lesions may become more apparent after hydrodistension and are described as a
circumscript, reddened mucosal area with small vessels radiating towards a central scar, with a fibrin
deposit or coagulum attached to this area. This site ruptures with increasing bladder distension, with
petechial oozing of blood from the lesion and the mucosal margins in a waterfall manner. A biopsy
should only be taken after the hydrodistension and not before.
Learning point Intravesical instillations
Intravesical instillation of potassium chloride, as a diagnostic test for BPS, can be painful and has
poor specificity for BPS and therefore is not widely performed.6 It was postulated that an abnormal
glycosaminoglycan layer allowed potassium ions to cross the epithelium leading to pain. However,
this does not help in the diagnosis due to poor specificity and does not predict improvement with
intravesical therapies designed to reline the glycosaminoglycan layer.7 Similarly, the use of intravesical
anaesthetic to localize the pain to the bladder and exclude an extravesical cause has been evaluated.8
After instillation, if the pain improves or disappears then theoretically the bladder is implicated as
the source of the pain. The test has not gained widespread acceptance due to the lack of robust data
regarding its sensitivity and specificity.
249Case 25 Bladder pain syndrome/interstitial cystitis
Expert comment
Urodynamics
Urodynamics does not have a
routine role in the assessment of
BPS but may be utilized where
there is ambiguity in the description
of pain which may be described
as a pressure to void by some
patients. A detrusor overactive
contraction may be responsible
for such a sensation. Also, if
voiding dysfunction is suspected,
such as with a raised post- void
residual, then urodynamics may be
indicated.
Learning point Oral medications
The next line would be oral medications. Patients with central or organ- specific sensitization may
benefit from amitriptyline or gabapentin. Pentosan polysulphate may be beneficial in some patients;
however, a recent placebo- controlled randomized controlled trial (RCT) failed to show a significant
difference to placebo.9 Similarly, hydroxyzine has not shown significant benefit in a pilot RCT
either.10 Oral cyclosporine A was found to have a greater clinical response compared to pentosan
polysulphate in one trial though with a higher side effect profile.11 It requires close blood pressure
and serum drug concentration monitoring, and has the potential for serious adverse events (e.g.
nephrotoxicity and immunosuppression) and would thus not be used unless symptoms were severe.
Analgesic medication such as amitriptyline and gabapentin are also used by pain specialists in patients
with a neuropathic- sounding pain possibly from a previous insult or surgical scarring. Amitriptyline
has been found to be effective at reducing symptom scores in two RCTs when given at a dose >50 mg
and is a recommended treatment for BPS/ IC.
mechanism for BPS/ IC. Two trials have not shown a clear benefit of L- arginine in improving
12,13
Gabapentin has not been studied in an RCT.
Expert comment
Patient education
Patient education is the most
important aspect of BPS
management. From the outset,
patients should be told it is likely to
be a chronic condition with flareups and - downs. Setting realistic
expectations of improvements
in quality of life are important.
The optimal management should
be multimodal and include
behavioural, physical, and
psychological techniques, and
management should proceed in a
step- wise manner, starting with the
most conservative.
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Learning point Behavioural
techniques
Behavioural techniques such as
timed voiding, fluid modification,
and bladder training are
recommended as first line. Diet
modification is recommended,
that is, reducing acidic beverages,
spicy foods, and alcohol which
have been reported to exacerbate
symptoms in up to 90% of
patients with BPS. Physiotherapy
is also recommended, especially
for patients with pelvic floor
dysfunction, and phenotypedirected multimodal management
approaches (including stress
management and psychotherapy)
are suggested as first- line
management options.
Learning point Acupuncture
Acupuncture is recommended by
the East Asian, Royal College of
Obstetricians and Gynaecologists,
and Canadian Urological
Association guidelines as a noninvasive option for motivated
patients, and trigger- point
injections with local anaesthetic are
given a grade D recommendation
by the Canadian Urological
Association guideline panel as an
option for patients with pelvic floor
trigger- point pain.
Expert comment Bladder
hydrodistension
Bladder hydrodistension and
transurethral fulguration of
Hunner’s lesions are considered
third- line options for the
treatment of BPS after failure
of the second- line therapies
described above. Several case series
have demonstrated long- term
therapeutic benefit.
23
symptom and pain scores.
14,15
Sildenafil has been compared to placebo in a RCT of 48 women.16
After 3 months it led to a >50% improvement in symptom scores and urodynamic parameters but
not on the visual analogue scale scores.
Sequential antibiotic rotation has also been assessed in a small randomized study and only showed
benefit in a small number of patients with many side effects.17 There is also a risk of developing
antibiotic resistance and so should not be utilized in patients.
Learning point Intravesical therapies
Intravesical instillations of hyaluronic acid have shown efficacy in patients with BPS/ IC.
18,19
In
a study of 110 women, hyaluronic acid and chondroitin sulphate instillations were superior
to DMSO in reducing pain intensity, and other endpoints such as quality- of- life scores were
improved in both groups from baseline.20 Pentosan polysulphate or lidocaine instillations have
also been suggested to be useful in treating patients with BPS/ IC in small studies.
21,22
Therefore,
the European Association of Urology guidelines have recommended these intravesical therapies in
patients with BPS/ IC.
Learning point Other therapies
Botulinum toxin has shown mixed results in multiple RCTs and pooling of these data does suggest
some overall benefit in improving symptoms cores, maximum cystometric capacity, and urinary
frequency with an increase in post- void residue.24 Similarly, sacral neuromodulation has shown
benefit in patients with pelvic pain and in some with BPS/ IC in improving pain and voiding
symptoms.
25
As with a lot of functional problems, radical surgery often forms a last resort and therefore the patients
who go down this route tend to be the worst affected by their problems. A substitution cystoplasty
either with a supratrigonal or subtrigonal cystoplasty is offered to those with exceptionally bad
symptoms often demonstrated to have poor bladder capacity at hydrodistension under general
anaesthetic. The alternative is a urinary diversion. In those undergoing a diversion without cystectomy,
a cystectomy is required in 50% and therefore is recommended to be undertaken in the first instance.
Patients must be warned that despite a total cystectomy, bladder pain may still persist. The literature
contains mostly small series of patients having undergone surgery for BPS/ IC with decent success rates
26,27
reported.
Future directions Biomarkers
It is most likely that a number of different pathophysiological mechanisms and aetiological factors
are responsible for BPS/ IC and, as such, lumping together all patients with similar symptoms into
one large category does not do the problem justice. Therefore, more work needs to be done in
phenotyping and categorizing patients’ symptoms, investigations, and test results. Further tests need
to be developed to differentiate if the condition is inflammatory, diet related, related to loss of bladder
lining, owing to neurosensitization (either central or peripheral), or as a result of other causes. With a
better understanding of the underlying processes and biomarkers, better more targeted therapies can
be developed.
A number of possible biomarkers have been studied to date including nerve growth factor which can
induce bladder nociceptive responses, the proinflammatory cytokine tumour necrosis factor, and tolllike receptors, which play a role in the innate immune system. In addition, purinergic mechanisms may
also contribute to the bladder dysfunction in BPS/ IC as the P2X3 purinoceptor can drive sensitization
of bladder afferents in response to ATP release from the urothelium. Thus, P2X3 antagonists have been
proposed to reduce BPS/ IC symptoms. These approaches are still in their infancy and with further
research and development may be able to help patients with BPS/ IC.
Expert comment Pathophysiology of bladder pain syndrome
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The urothelial layer of the bladder was once thought of as being inert and impermeable. However, it
is now recognized to receive, amplify, and transmit information about the extracellular environment
either directly or through the lamina propria underneath (which contains interstitial cells) to the
central nervous system.28 Therefore, changes in the mucosal lining of the bladder may permit urine
or toxic substances to pass to the deeper layers, irritating the underlying neurons leading to the
symptoms commonly described.
In patients with pain symptoms of other organs, a central visceral hypersensitivity has been suggested which
may involve dorsal horn neurons within the spinal cord leading to sensitization which may continue long
after resolution of inflammation or pelvic insult. Alternatively, in those with widespread pain or associated
fibromyalgia, functional magnetic resonance imaging shows functional connectivity involving sensorimotor
and insular cortices, suggesting abnormal brain neuronal connectivity as a cause for the pain.
29
A final word from the expert
It is important to place the patient at the centre of the consultation when assessing if they
have BPS/ IC. It is imperative to rule out other differential diagnoses. If other aetiologies are
excluded and conservative measures fail to improve symptoms, then a cystodistension is
useful both diagnostically and also may have therapeutic benefits. The bladder capacity is a
good guide of the level of treatment indicated and a stepwise approach should be employed.
It is important to educate your patient that most commonly this is a poorly understood lifelong condition which needs managing and there is no quick- fix cure, although some patients
do find long- term relief after certain interventions. Ultimately, we must try to do the best for
each patient’s quality of life and individualized management is necessary.
251Case 25 Bladder pain syndrome/interstitial cystitis
References
1. Malde S, Palmisani S, Al- Kaisy A, Sahai A. Guideline of guidelines: bladder pain syndrome.
BJU Int. 2018;122(5):729– 743.
2. Messing E, Pauk D, Schaeffer A, et al. Associations among cystoscopic findings and symptoms and physical examination findings in women enrolled in the Interstitial Cystitis Data
Base (ICDB) Study. Urology. 1997;49(5A Suppl):81– 85.
3. Alagiri M, Chottiner S, Ratner V, Slade D, Hanno PM. Interstitial cystitis: unexplained associations with other chronic disease and pain syndromes. Urology. 1997;49(5A Suppl):52– 57.
4. Pierce AN, Christianson JA. Stress and chronic pelvic pain. Prog Mol Biol Transl Sci.
2015;131:509– 535.
5. Williams DP, Chelimsky G, McCabe NP, et al. Effects of chronic pelvic pain on heart rate
variability in women. J Urol. 2015;194(5):1289– 1294.
6. Hanno P. Is the potassium sensitivity test a valid and useful test for the diagnosis of interstitial cystitis? Against. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):428– 429.
7. Sairanen J, Tammela TL, Leppilahti M, Onali M, Forsell T, Ruutu M. Potassium sensitivity
test (PST) as a measurement of treatment efficacy of painful bladder syndrome/ interstitial cystitis: a prospective study with cyclosporine A and pentosan polysulfate sodium.
Neurourol Urodyn. 2007;26(2):267– 270.
8. Taneja R. Intravesical lignocaine in the diagnosis of bladder pain syndrome. Int Urogynecol
J. 2010;21(3):321– 324.
9. Nickel JC, Herschorn S, Whitmore KE, et al. Pentosan polysulfate sodium for treatment of
interstitial cystitis/ bladder pain syndrome: insights from a randomized, double- blind, placebo controlled study. J Urol. 2015;193(3):857– 862.
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10. Sant GR, Propert KJ, Hanno PM, et al. A pilot clinical trial of oral pentosan polysulfate and
oral hydroxyzine in patients with interstitial cystitis. J Urol. 2003;170(3):810– 815.
11. Sairanen J, Tammela TL, Leppilahti M, et al. Cyclosporine A and pentosan polysulfate
sodium for the treatment of interstitial cystitis: a randomized comparative study. J Urol.
2005;174(6):2235– 2238.
12. Foster HE Jr, Hanno PM, Nickel JC, et al. Effect of amitriptyline on symptoms in treatment naive
patients with interstitial cystitis/ painful bladder syndrome. J Urol. 2010;183(5):1853– 1858.
13. van Ophoven A, Pokupic S, Heinecke A, Hertle L. A prospective, randomized, placebo controlled, double- blind study of amitriptyline for the treatment of interstitial cystitis. J Urol.
2004;172(2):533– 536.
14. Cartledge JJ, Davies AM, Eardley I. A randomized double- blind placebo- controlled crossover trial of the efficacy of L- arginine in the treatment of interstitial cystitis. BJU Int.
2000;85(4):421– 426.
15. Korting GE, Smith SD, Wheeler MA, Weiss RM, Foster HE Jr. A randomized double- blind
trial of oral L- arginine for treatment of interstitial cystitis. J Urol. 1999;161(2):558– 565.
16. Chen H, Wang F, Chen W, et al. Efficacy of daily low- dose sildenafil for treating interstitial
cystitis: results of a randomized, double- blind, placebo- controlled trial— treatment of interstitial cystitis/ painful bladder syndrome with low- dose sildenafil. Urology. 2014;84(1):51– 56.
17. Warren JW, Horne LM, Hebel JR, Marvel RP, Keay SK, Chai TC. Pilot study of sequential
oral antibiotics for the treatment of interstitial cystitis. J Urol. 2000;163(6):1685– 1688.
18. Kallestrup EB, Jorgensen SS, Nordling J, Hald T. Treatment of interstitial cystitis with
Cystistat: a hyaluronic acid product. Scand J Urol Nephrol. 2005;39(2):143– 147.
19. Nordling J, Jorgensen S, Kallestrup E. Cystistat for the treatment of interstitial cystitis: a 3year follow- up study. Urology. 2001;57(6 Suppl 1):123.
20. Cervigni M, Sommariva M, Tenaglia R, et al. A randomized, open- label, multicenter study
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dimethyl sulfoxide in women with bladder pain syndrome/ interstitial cystitis. Neurourol
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21. Daha LK, Lazar D, Simak R, Pfluger H. The effects of intravesical pentosanpolysulfate treatment on the symptoms of patients with bladder pain syndrome/ interstitial cystitis: preliminary results. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(7):987– 990.
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23. Niimi A, Nomiya A, Yamada Y, et al. Hydrodistension with or without fulguration of hunner
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Urodyn. 2016;35(8):965– 969.
24. Wang J, Wang Q, Wu Q, Chen Y, Wu P. Intravesical botulinum toxin A injections for
bladder pain syndrome/ interstitial cystitis: a systematic review and meta- analysis of controlled studies. Med Sci Monit. 2016;22:3257– 3267.
25. Mahran A, Baaklini G, Hassani D, et al. Sacral neuromodulation treating chronic
pelvic pain: a meta- analysis and systematic review of the literature. Int Urogynecol J.
2019;30(7):1023– 1035.
26. Mateu AL, Gutierrez RC, Mayordomo FO, Martinez B, V, Palou RJ, Errando SC. Long- term
follow- up after cystectomy for bladder pain syndrome: pain status, sexual function and
quality of life. World J Urol. 2019;37(8):1597– 1603.
27. Kim HJ, Lee JS, Cho WJ, et al. Efficacy and safety of augmentation ileocystoplasty combined with supratrigonal cystectomy for the treatment of refractory bladder pain syndrome/
interstitial cystitis with Hunner’s lesion. Int J Urol. 2014;21(Suppl 1):69– 73.
28. Birder L, Andersson KE. Urothelial signaling. Physiol Rev. 2013;93(2):653– 680.
29. Kutch JJ, Ichesco E, Hampson JP, et al. Brain signature and functional impact of centralized
pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network
study. Pain. 2017;158(10):1979– 1991.
26
https://t.me/med1917
CASE
Female urinary retention
Pravisha Ravindra
Expert commentary Nikesh Thiruchelvam
Case history
A 23- year- old woman presented to the emergency department with lower abdominal discomfort and inability to pass urine for the preceding 24 hours. She has
no associated bowel symptoms or symptoms to suggest a urinary tract infection.
She had a past medical history of anxiety and polycystic ovary syndrome. Past
surgical history included a diagnostic laparoscopy for pelvic pain 18 months previously. Drug history consisted of sertraline 10 mg once daily and the combined
oral contraceptive pill. Observations on arrival into the department were unremarkable apart from a mild tachycardia of 105 beats per minute. Routine bloods
were sent; white cell count was marginally raised at 11.5 × 109/ L but all others
were normal. Bladder scan was performed and showed >999 mL in the bladder. As
such, a urethral catheter was inserted and a residual volume of 1.2 L was drained.
The patient was then discharged and a trial without catheter was arranged in the
community.
Learning point Voiding reflex
Learning point Definition and epidemiology
Urinary retention (UR) is defined by the International Continence Society as the complaint of the
inability to pass urine despite persistent effort.1 There are many causes of UR in a woman, although
the condition itself is relatively uncommon when compared to men.
One Danish study cited an incidence of acute urinary retention (AUR) in women as 7 per 100,000
population.2 The prevalence of the chronic condition is difficult to quantify as it generally requires
a bladder scan to confirm the diagnosis. In a group of female patients presenting with lower urinary
tract symptoms, 5% were found to have a post- void residual of >150 mL.3 There is no consensus
on the post- void residual threshold that defines UR with the American Urological Association
guidelines specifying 300 mL.
4
For normal voiding to take place,
the voiding reflex is initiated in
the pontine micturition centre.
The hypogastric nerve relaxes the
external urethral sphincter and the
pudendal nerve relaxes the pelvic
floor. Voiding then results when
the detrusor muscle contracts
under parasympathetic control.
Disruption at any point along this
pathway can result in incomplete
emptying.
Learning point Causes of UR
The aetiology is diverse and its presentation can be classified into acute (transient) or chronic
(recurrent). Commonly, the key differentiating factor between the two types is the presence of pain.
Pain is commonly associated with AUR; however, there are special occasions in which AUR can be
painless such as spinal cord compression or post anaesthetic (Table 26.1). The pathophysiology
of the condition is twofold, consisting of reduced or absent bladder contractility or bladder outlet
obstruction (or a combination of the two).
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