During the AUA2023 plenary session, Dr Henry Lai led a panel discussion on “Case-based Discussion of Chronic Pelvic Pain” along with panelists Dr Elise De from Albany Medical Center, Dr Priyanka Gupta from the University of Michigan, and Dr Lindsey McKernan from Vanderbilt University Medical Center. The cases illustrated the take-home message that the treatment of interstitial cystitis (IC)/bladder pain syndrome (BPS) may be tailored based on specific patient phenotypes (Figure 1).

The first case, Maria, is a 60-year-old female with a 1-year history of bladder pain that is worsened with bladder filling. The pelvic pain is associated with a constant urge to urinate, urinary frequency, and dyspareunia. Urinalysis and urine culture are negative, and postvoid residual is 20 cc. Voiding diary reveals frequent, low-volume voided volumes. Examination is unremarkable.

The clinical presentation is consistent with IC/BPS, which is defined in the AUA Guideline as having “pain, pressure, or discomfort, perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks’ duration, in the absence of infection or other identifiable causes.”¹ IC/BPS is a diagnosis of exclusion. Confusable conditions that give rise to similar symptoms should be ruled out. Dr De presented a comprehensive list of differential diagnoses or confusable conditions to exclude (see Table).

Table. Differential Diagnosis of Interstitial Cystitis/Bladder Pain Syndrome

Per the updated AUA Guideline, men or women over the age of 50 years should consider cystoscopy to evaluate for Hunner lesions.¹ Maria underwent office cystoscopy, and was found to have Hunner lesions (Figure 2). She was treated with fulguration and triamcinolone injection into the Hunner lesions, and improved remarkably. IC patients with Hunner lesions on cystoscopy have a bladder-centric phenotype, and can be offered fulguration and/or triamcinolone injection that specifically targets their Hunner lesions (Figure 1).

The second case, Kysha, has similar clinical presentation except that she has no Hunner lesions on cystoscopy, and thus she has BPS instead of ulcerative IC. Her pelvic floor examination is remarkable for tenderness on palpation. Dr Gupta gave a presentation on the evaluation and management of high-tone pelvic floor dysfunction.

Up to 85% of IC/BPS patients have pelvic floor tenderness on pelvic examination. Standardized pelvic exam may be performed vaginally in women or transrectally in men as previously described (Figure 3).² Pelvic floor physical therapy is the gold standard and the backbone of any pelvic floor treatments.³ Additional treatment options include vaginal valium or amitriptyline suppository, neuromodulation, or injections into the pelvic floor muscle. Dr Gupta uses a curved nasal trumpet (7-inch spinal needle) which allows the needle to pass around the pubic bone. Injections are performed using a standard template immediately behind the pubic bone, at the level of the ischial spine, and at 1, 3, 5, 7, 9, and 11 o’clock to target the obturator internus and externus muscles and the iliococcygeus, pubococcygeus, and puborectalis muscles. At the 5 and 7 o’clock proximal locations a pudendal nerve block is performed. The injection solution contains 25 cc 0.5% bupivacaine mixed with 1 cc 40 mg triamcinolone. Two cc are injected at each location with 3 cc for the pudendal block. Injections may repeat every 6 to 8 weeks and can be done in the clinic or the operating room. Several studies have demonstrated efficacy in women with pelvic floor hypertonicity with tenderness, including intralevator injection of 100 to 300 U onabotulinum toxin A.^4,5 Patients with pelvic floor tenderness have a pelvic floor-centric phenotype and can be offered pelvic floor therapies that specifically target their pelvic floor (Figure 1).

The third case, Steve, is a 20-year-old male with bladder pain for 5 years. He is a graduate student, but because of his pain, he is disengaged and underperforming. He avoids relationships due to sexual pain and performance concerns. He is no longer active, and is depressed.

Dr McKernan discussed psychological approaches to manage chronic pelvic pain. Some patients may benefit from psychological referrals, such as those with red flags (eg, anxiety or depression affecting the ability to follow through with treatments, intense emotional response to symptoms, insomnia or nightmares, distress or avoidance, active trauma, or symptoms of posttraumatic stress disorder). It is important to approach with a multidisciplinary team (urology, psychology, psychiatry, physical therapy, pain management, etc). Steve was offered 20 sessions of cognitive behavioral therapy, which aimed to increase his pain coping skills, motivate him for treatment engagement and adherence, and address his depressive symptoms. Generally, patients with localized pain likely respond well to relaxation-based interventions, flare management, and having enhanced coping skills. Psychological intervention and a multidisciplinary approach may be most appropriate for patients with widespread pain or centralized presentation. Even when the pain intensity does not improve, secondary benefits may be realized in terms of improvement in quality of life, coping, and self-efficacy important to a person’s well-being.

In addition, Steve also has widespread pain when a body pain map is administrated (Figure 4). Dr De discussed that widespread pain points to a systemic pathology and that some patients may have small-fiber polyneuropathy.⁶ Dr Gupta emphasized the importance of multidisciplinary care in patients with widespread pain or systemic presentation. IC/BPS patients with widespread pain likely have centralized pain phenotype. They can be offered multidisciplinary treatments, medications that address their systemic pain such as amitriptyline or gabapentinoids, and/or psychosocial intervention such as cognitive behavioral therapy.

Figure 4. Widespread pain in interstitial cystitis/bladder pain syndrome, as mapped by Lai et al.⁸

In summary, the treatment of IC/BPS may be tailored based on specific patient phenotypes—bladder-centric vs pelvic floor-centric vs centralized pain phenotype (Figure 1).