Painful Bladder

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Painful Bladder Syndrome — Recognise, Exclude & Treat in Steps

Painful bladder syndrome (interstitial cystitis, bladder pain syndrome) is often missed or treated as repeated infection. This sheet gives how to recognise it, what to exclude, the stepwise treatments, and how to counsel.

🎯 AT A GLANCE — PAINFUL BLADDER SYNDROME

Painful bladder syndrome (bladder pain syndrome or interstitial cystitis) is suprapubic pain with urgency and frequency, with no proven infection or other cause

About 90% of cases are in women; symptoms develop and worsen over years

Pain gets worse as the bladder fills and eases after passing urine; frequency may reach 60 times a day

Flares with high-potassium foods, tobacco, alcohol, spicy food, stress, periods, ovulation and sex

It is a diagnosis of exclusion, made by history and examination, urinalysis, culture and a bladder diary

It often coexists with endometriosis and chronic pelvic pain

A cure is rare, but most women improve with several treatments given in steps

Exclude infection, blood in the urine and cancer first; then start with education, triggers and physiotherapy, and climb the ladder of treatments one step at a time.

🚨 DO NOT CALL IT BPS — INVESTIGATE FIRST IF…

There is blood in the urine — it excludes the diagnosis until bladder cancer and stones are ruled out

The urine culture is positive — treat the infection

Cystoscopy shows a Hunner ulcer — biopsy to exclude bladder cancer

Frequency and pain with sterile pus cells in the urine — think of genitourinary tuberculosis (from memory)

The bladder is not emptying, or she is not responding to treatment — urodynamics

She is severely distressed, or has suicidal thoughts — respond at once; chronic pain causes depression (from memory)

STEP 1 · RECOGNISE — history, exclusions and examination

🔍 WHAT SHE TELLS YOU

Pressure or pain above the pubic bone and in the pelvis, building as the bladder fills and easing when she passes urine

Frequency, urgency and passing small amounts; getting up at night

Flares with certain foods, drinks, tobacco, her period, stress or sex

Several UTI-like attacks with negative cultures (from memory)

Scarring of the bladder in time reduces its capacity, so the urgency and frequency worsen

🧐 WHAT ELSE IT MAY BE

Look-alike	Clue
Urinary tract infection	Positive culture; burning; fever; improves with antibiotics
Overactive bladder	Urgency and frequency without pain; the pain does not build with filling (from memory)
Bladder stone or cancer, including carcinoma in situ	Blood in the urine; smoking; cystoscopy and imaging (from memory)
Genitourinary tuberculosis	Sterile pyuria, frequency; common in India (from memory)
Pelvic inflammatory disease, endometriosis, diverticulitis	Other pelvic or bowel symptoms; examination and scan
Urethral diverticulum or vulval pain	Pain at the urethra; tender anterior vaginal wall; pain on touch of the vulva (from memory)

🩺 ASSESSMENT

Take a history and examine the abdomen, vagina and pelvic floor muscles

Send urinalysis and a urine culture to exclude infection; check for blood

Ask her to keep a bladder diary: times, volumes, pain and foods

Record a symptom score (GUPI, ICS or a pain scale) at the start and track response

Cystoscopy is not required in uncomplicated cases; do it if the diagnosis is unclear, if there is blood in the urine, or if she does not respond; it can show Hunner ulcers

Urodynamics is not routine; consider it for suspected obstruction or poor response

STEP 2 · TREAT — a ladder, one step at a time

🧭 FROM PAIN TO TREATMENT

🪜 THE LADDER OF TREATMENT

Step	Options	Notes
1. Education and self-care	Explain the condition; find triggers with a food diary; stop smoking; cut alcohol, spicy food and other triggers; reduce stress; join a support group	Drop a food only if it truly triggers her pain, and reintroduce it later (from memory)
1. Physiotherapy	Pelvic floor physiotherapy; manual therapy and trigger-point release	Kegel strengthening exercises are not recommended
2. Oral drugs	Amitriptyline 10 to 25 mg; an H2 blocker (ranitidine or cimetidine); hydroxyzine; paracetamol or NSAID for pain; an antimuscarinic or mirabegron if urgency is the main problem	No single drug is clearly best; amitriptyline is limited by drowsiness and a dry mouth
2. Pentosan polysulfate	Oral, hospital use	Needs a baseline eye examination and regular retinal checks because of the risk of macular damage; availability varies
3. Bladder instillations	DMSO; a mixture of heparin, lidocaine and pentosan; hyaluronic acid or lignocaine	For those who do not respond to oral drugs
4. Procedures	Cystoscopy with hydrodistension; resection of Hunner ulcers; sacral (S3) nerve stimulation	Botulinum toxin is another option (from memory)
5. Surgery	Cystectomy or urinary diversion	Only for unbearable pain that has not responded; outcomes are unpredictable

Avoid: repeated or long antibiotic courses when cultures are negative, oral steroids, and opioids. (from memory) Review her symptom score at each step before moving on.

STEP 3 · COUNSEL — what she needs to hear

🗣️ WHAT TO TELL HER

The pain is real and comes from the bladder, even though the urine is clean

It is not an infection and she cannot pass it to anyone (from memory)

It tends to come and go in flares; a cure is rare, but most women get better with treatment

Triggers differ from woman to woman: use the diary to find hers

Stress makes it worse; relaxation and counselling are part of the treatment

Emptying the bladder before sex, and using a lubricant, may help; talk about pain with sex (from memory)

Do not drink less water to avoid going: concentrated urine irritates the bladder (from memory)

⚠️ COMMON PITFALLS

Treating every episode as a UTI with antibiotics

Missing blood in the urine, a bladder tumour or tuberculosis

Teaching strengthening Kegel exercises, which may tighten already tense muscles

Starting pentosan without an eye check

Going too fast to surgery

Using opioids

Not asking about mood, sleep, sex and other pelvic pain

Memory Aid

FILL

Four steps for painful bladder syndrome.

F

Find the pattern — pain that builds as the bladder fills and eases after voiding

I

Infection, blood and cancer excluded — culture, urinalysis, cystoscopy if needed

L

Lifestyle first — triggers, stress, pelvic floor physiotherapy

L

Ladder of treatments — oral drugs, instillations, procedures, then surgery

Remember: believe her pain, exclude the dangerous causes, and treat in steps.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the South West London “Bladder Pain Pathway” (definition, diagnosis, self-management, amitriptyline 10 to 25 mg, H2 blockers, pentosan, instillations, referral) and the MSD Manual Professional “Interstitial Cystitis” (female predominance, symptoms, triggers, diagnosis, cystoscopy and Hunner ulcers, drug and procedure options, Kegel exercises, prognosis). I could not open the AUA guideline. Items marked “from memory” (look-alikes, tuberculosis, botulinum toxin, what to avoid, counselling) were not checked. Availability of pentosan, DMSO and instillations varies in India: follow local practice.