Guideline of guidelines: bladder pain syndrome

Abstract

There is disagreement between guidelines on the exact definition of BPS and the nomenclature to use to describe this condition. However, all agree that the diagnosis is dependent on the presence of pain, pressure, or discomfort, in addition to at least one urinary symptom, in the absence of other diseases that could cause pain. Exclusion of other pathology that could cause similar symptoms requires thorough evaluation, and is recommended in all guidelines. There is also disparity in the recommended diagnostic investigation of BPS, with hydrodistension and bladder biopsy either recommended, considered optional, or not recommended, by different guidelines. It is accepted that BPS can be diagnosed clinically, without invasive investigation, but cystoscopy and diagnostic hydrodistension aids sub-typing of patients and may help direct treatment strategies. Patients should be phenotyped in order to direct multimodal treatment (including behavioural, physical, emotional, and psychological therapy), and treatments should follow a stepwise approach starting with the most conservative. Although widely performed, hydrodistension as a therapeutic strategy has a limited evidence base and is unlikely to provide long-term resolution of symptoms CONCLUSION: There are multiple national and international guidelines for the diagnosis and management of BPS, and this review has highlighted the differences in nomenclature, definitions, and recommended diagnostic tests between guidelines. The overall evidence base for the majority of treatments for BPS/IC is of low-quality, and larger randomised trials are required to more accurately inform guideline recommendations and clinical management of this complex group of patients.

Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014

“…Chronic pelvic pain syndrome (CPPS) is one of the unresolved problems in urology. There are multiple recommendations for the management of CPPS, and the BJUI guideline of guidelines on bladder pain syndrome by Malde et al [1] summarizes differences in nomenclature, definitions and recommended diagnostic tests and treatments between major national and international guidelines. CPPS is defined according to the European Association of Urology as chronic or persistent pain perceived in structures related to the pelvis without proven infection or other obvious local pathology that may account for the pain, and it is often associated with negative cognitive, behavioural, sexual and emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction [2].…”

How can we improve the diagnosis and management of bladder pain syndrome? Part 2:ICI‐RS 2018

“…The treatments for BPS are suggested as serial treatments where the failure of one level of treatment leads to the next set of treatments being offered. 57 This produces an intrinsic problem in that different levels of treatment are applied to different groups or severities of disease. This means that oral treatments will be given to a different patient group form those who will be offered surgical treatments.…”

“…Sacral nerve modulation (SNM) is considered after patients have failed oral agents, bladder instillations, hydrodistension, laser to Hunner's ulcer, and often features as a fourth‐line treatment option in many of the BPS/IC guidelines . There appears to be a consensus in the guidelines that it should be tried before committing the patient to radical surgery.…”

“…Sacral nerve modulation (SNM) is considered after patients have failed oral agents, bladder instillations, hydrodistension, laser to Hunner's ulcer, and often F I G U R E 1 Intravesical treatment vs placebo: subjective cure features as a fourth-line treatment option in many of the BPS/IC guidelines. 57 There appears to be a consensus in the guidelines that it should be tried before committing the patient to radical surgery. A recent systematic review by Tutolo et al 58 , highlighted only one study eligible for consideration according to their methodological criteria indicating the evidence in this field was poor and could not give a strong level of recommendation for SNM in treating BPS/IC.…”

“…Surgery is reserved as a treatment of last resort when all other options have failed and is recommended takes place in high volume centers after full multidisciplinary team discussion. 57 Surgery includes a variety of reconstructive options including substitution cystoplasty and supra-or subtrigonal cystectomy, cystectomy, and continent diversion, or incontinent urinary diversion with or without cystectomy. In general, surgery should be reserved for the disease which is significant, bothersome to the patient and unresponsive to all other treatments.…”