Painful Bladder Syndrome

The episode begins with Dr. Fitzgerald describing her pathway into urogynecology, including training with MIGS physicians. This allowed her to make the connection between many young, reproductive-aged women with painful urination who also have endometriosis. She then goes into how to define IC, which can be difficult. Officially, it is bothersome urinary symptoms lasting more than 6 weeks without other identifiable causes. It is almost always a diagnosis of exclusion after negative urine cultures and other tests. Cystoscopy is no longer needed for diagnosis as it is often normal. However, the best understood phenotype of IC is bladder-centric IC, and these have Hunter lesions seen with cystoscopy. This type responds very well to fulguration, Kenalog, or steroid injections with 85% of patients experiencing improvement.

Dr. Fitzgerald further discusses treatments for IC. Behavior modification is essential, and she advises that patients avoid alcohol, coffee, tea, soda, spicy things, acidic things, and any other dietary triggers. She is also doing trials of giving patients an “IC bundle” which includes neurogenic medications like amitriptyline or gabapentin, vaginal estrogen, scheduled Pyridium, Hiprex, and aloe vera tablets. For some patients, she offers bladder instillations (comprised of heparin, lidocaine, bicarbonate, kenalog, +/- gentamicin), pelvic floor injections of bupivacaine and kenalog, and pelvic floor PT.

Next, Dr. Fitzgerald discusses the basic science research she has done that connects pain pathways throughout the pelvis. Chronic pelvic inflammatory disorders cross-talk through central sensitization. The lumbosacral plexus nerve roots receive pain signals from the bladder, colon, and other pelvic organs, explaining the relationship between IBS, endometriosis, and IC. The pathways are well understood, but we don’t yet know how to reverse central sensitization.

Finally, Dr. Fitzgerald ends by describing the multidisciplinary clinic for endometriosis at Pittsburgh: MIGS, urogynecologists, pelvic floor PT, and behavioral health teams all work together to care for these complex patients holistically. She stresses the importance of teamwork and great administrators who have made this happen. She finishes by discussing how researching more about mast cells, especially through COVID patients, can help us learn more about these chronic inflammatory disorders of the pelvis.