ruptures following bladder distension. Ronstrom and Lai11 have recently published an atlas of HL which is useful in identifying the variations in appearance of HL. Fall et al.12 described BPS as a heterogenous syndrome comprising two main categories: ulcerative and nonulcerative. The term interstitial cystitis is now reserved for those patients who have mucosal (HLs) and histologic (evidence of inflammatory infiltrate on biopsy) changes at cystoscopy and hydrodistension and are thought to represent a distinct phenotype of BPS (Fig. 38.1).13
the interface between the bladder lumen and the interstitium which collectively contains the connective and muscular tissue, the vasculature and neural networks. It prevents urinary solutes, toxins, and bacteria from penetrating into the interstitium. It is postulated that dysfunction of the tight intercellular junctions allows these noxious agents to permeate into the interstitium, setting up the inflammatory and neural pathways that are proposed to drive the disease process.19,20
women with BPS compared to controls and correlated with bladder pain and urinary symptoms.36
when severe is described as pain. Urinary frequency is a manifestation of the actual act of voiding, but BPS patients have been known not to void because they realize that frequent voiding does not necessarily lead to relief of pain and urge sensations. From the standpoint of quantification of BPS symptoms, measurement of voiding frequency may be the best objective parameter.
TABLE 38.1 ESSIC Confusable Diseases (Excluding Male Pathology) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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History of previous urinary tract infections
Urologic/pelvic surgery
Triggers
Diet: Although no research links BPS symptoms to certain foods or drinks, some patients may notice worsening symptoms with ingestion of caffeinated beverages, carbonated drinks, alcohol, tomatoes, hot and spicy foods, chocolate, citrus juices and drinks, monosodium glutamate, and high-acid foods.
Hormonal: Some women note perimenstrual flares in BPS symptoms.52
Evidence of pelvic organ cross talk or systemic disease clusters: endometriosis, bowel symptoms (irritable bowel syndrome, inflammatory bowel disease), fibromyalgia, chronic fatigue syndrome, migraine, autoimmune diseases (Sjögren disease)
Psychological conditions: anxiety, depression
Suprapubic tenderness
Vulva—exclude vulval/vestibular disease, cotton swab test to assess and score sites of tenderness
Vagina—evidence of vaginismus, tenderness on palpation of the urethra or anterior vaginal wall/bladder base, evidence of levator ani spasm/trigger points suggestive of pelvic floor hypertonicity; exclude urethral diverticulum (suburethral mass)
infused at a pressure of 80 to 100 cm H2O (this distance above the bladder, i.e., gravity fill) into the bladder until filling into the drip chamber stops; this may require urethral occlusion as water may bypass the cystoscope around the urethra. During filling, the anesthetist may note patient tachycardia or increased respiratory rate indicative of pain. The bladder is distended for 2 to 5 minutes before all the irrigant is released from the bladder under direct vision. The volume of instilled fluid is measured and noted as the patient’s anesthetic bladder capacity. Glomerulations may be noted as petechial hemorrhages during bladder emptying and should be quantified as to the number of bladder quadrants in which they are observed (Fig. 38.3). The bladder is then refilled to 20% to 50% of bladder capacity to allow visualization of HLs (Fig. 38.4), appearing as fissures or cracks in the epithelium (these findings are often seen on first fill), and biopsies (both superficial and deep including detrusor muscle) taken if required. Although HLs are considered pathognomic of IC, the presence of glomerulations is not, occurring in up to 45% of normal subjects without symptoms of BPS at volumes higher than their usual functional bladder capacity. For example, 9 out of 20 asymptomatic women had glomerulations when having tubal ligation and cystoscopy with bladder fill volume of 950 mL.59 Conversely, glomerulations are often not found in subjects with symptomatic BPS, and therefore, absence of identifiable epithelial changes at cystoscopy does not exclude BPS.
TABLE 38.2 Interstitial Cystitis Symptoms Quantitation
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