Alex Digesu Department of Urogynaecology

St Mary’s Hospital, London

  CPS is a common and poorly defined condition

 A constellation of syndromes with a complex natural history, unclear etiology and poor response to therapy.

 It is managed best with a multidisciplinary approach, requiring good integration and knowledge of multiple organ systems.

 Inconsistency in the duration, definitions and classification of pelvic pain that are used arbitrarily

International working groups: -  ESSIC -  ICS -  IUGA -  AUA -  EAU -  IASP -  IPPS

  Cystoscopy: - Rigid cystoscope - Infusion height ~ 80 cm from symphysis pubis - Max capacity (till fluid dribbling stops) - Pre-distension observations (oedema, hyperemia, cracks,

scars, white spot…) - Distension maintained for 3 mins - Second filling ~ 1/3 or 2/3 bladder capacity

  Glomerulations (bleeding with hydrodistension): Grade 0 = normal mucosa Grade I = petechiae in at least two quadrants Grade II = large submucosal bleeding (ecchymosis) Grade III = diffuse global mucosal bleeding Grade IV = mucosal disruption, with or without bleeding/oedema

  Hunner’s lesion  A 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 bladder distension, with petechial oozing of blood from the lesion.

 Biopsies: - 3x full thickness including muscle @ half bladder capacity - From lateral walls and dome plus lesional areas fixed in formalin - Detrusor mastocytosis = > 28 mast cells/mm2

A 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.

 ‘‘Interstitial Cystitis’’ (IC) has different meanings in different centers

 European Society for the Study of Interstitial Cystitis (ESSIC) has worked to create a consensus on definitions, diagnosis, classification to overcome the lack of international agreement on IC.

  Definitions, diagnostic criteria and disease classification discussed in 4 meetings and extended e-mail correspondence.

  It was agreed to name the disease bladder pain syndrome (BPS).

 This name is in line with nomenclature recommended by the EAU and International Association for the Study of Pain classification (IASP)

 BPS would be diagnosed on the basis of -  Bladder pressure/discomfort accompanied by at least

one urinary symptom (ie.urgency, frequency). -  CPP (>6 mo)

  Cystoscopy and hydrodistension are prerequisite  Positive signs of BPS are (2-3 or C): - Glomerulations grade 2–3 or Hunner’s lesions or both - inflammatory infiltrates and/or granulation tissue and/or

detrusor mastocytosis and/or intrafascicular fibrosis

  No specific definition or classification but follow the taxonomy of the International Association for the Study of Pain (IASP) and EAU

 Bladder Pain Syndrome (BPS) replaced PBS and IC.

 BPS: “a chronic (>6 months) pelvic pain, pressure, or discomfort related to the bladder accompanied by at least one other urinary symptom such as persistent urge to void or frequency. Confusable diseases as the cause of the symptoms must be excluded”.

 Further classification of BPS might be performed according to cystoscopy with hydrodistension and bladder biopsies.

 Cognitive, behavioral, emotional, and sexual symptoms should be addressed.

  IC/BPS Unpleasant sensation (pain, pressure, discomfort) perceived to

be related to the urinary bladder, associated with LUTS of > 6 wks in the absence of infection or other identifiable causes (SUFU)

  Chronic prostatitis/CPPS = NIH type III prostatitis (no demonstrable infection)

- Pain is the primary defining characteristic - Perineum, suprapubic, testicle, tip of penis - Exacerbated with urination/ejaculation - LUTS (incomplete bladder emptying, frequency, urgency) often

associated

  Both conditions can occur together

  The basic assessment should include a careful history, physical examination and laboratory examination to document symptoms and signs that characterize IC/BPS and exclude other disorders commonly associated with IC/BPS in the differential diagnosis.

  Cystoscopy and/or urodynamics should be considered when the diagnosis is in doubt; these tests are not necessary for making the diagnosis in uncomplicated presentations.

- The only consistent cystoscopic finding that leads to a diagnosis of IC/BPS is one or more Hunner lesions or ulcerations

- Glomerulations (pinpoint petechial hemorrhages) may be detected in other conditions (ie. Endometriosis, cancer, radiation, asymptomatic patients, exposure to chemotherapeutic drugs)

  CPP: chronic or persistent pain perceived in structures related to the pelvis of either men or women. It is often associated with negative cognitive, behavioral, sexual and emotional consequences as well as with symptoms suggestive of blader, bowel, sexual, pelvic floor or gynecological dysfunction.

  Pain must have been continuous or recurrent for at least 6 months.

  CPP can also be subdivided/classified in:

1.  Specific disease-associated pelvic pain related to a well defined pathology (ie. Infection, cancer, inflammation)

2. Chronic pelvic pain syndrome (CPPS) in the absence of proven infection, inflammation or other obvious pathology’’.

3.  If pain localised to a single organ the end-organ term will be used (BPS, rectal pain syndrome)

4.  If multiple organs involved the term will be regional/multisystemic pain syndrome or CPPS.

SCHEME FOR CODING CHRONIC PAIN DIAGNOSES Digits and letters (S=spinal; R=radicular; C=combined)   AXIS I : Region

  AXIS II: Systems

  AXIS III: Temporal characteristics of pain

SCHEME FOR CODING CHRONIC PAIN DIAGNOSES

  AXIS IV : Patient’s statement of intensity

  AXIS V: Etiology

  ICS: the working party is finalising the current draft of the CPP Standardisation of Terminology document, but there is no own ICS Definition, Terminology or Classification system yet. ICS work is based on the EAU and IASP Classification.

  IUGA: no classification

  IASP has just released a revised taxonomy which is now online via the home page http://www.iasp-pain.org/AM/Template.cfm?Section=Classification_of_Chronic_Pain&Template=/CM/ContentDisplay.cfm&ContentID=16280 (GROUP XXIII: CHRONIC PELVIC PAIN SYNDROMES)

  EAU Guidelines: http://www.uroweb.org/guidelines/online-guidelines/