Urine Good Hands: Evaluation and Management of Bladder Pain in Urogynecology

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This presentation by Dr. Jocelyn J. Fitzgerald reviews the evaluation and management of bladder and pelvic pain, focusing particularly on Female Bladder Pain Syndrome (FBPS)/Interstitial Cystitis (IC). The case discussed involves a 26-year-old woman with persistent urinary urgency, bladder pressure, and discomfort, unresponsive to antibiotics, with negative recent urine cultures. She is on continuous oral contraceptives (OCPs) and has symptoms worsened by intercourse.<br /><br />The differential diagnosis includes urinary tract infection (UTI), sexually transmitted infections, bladder dietary sensitivities, stones, Skene’s gland pathology, malignancy, hormone effects/genitourinary syndrome of menopause (GSM), endometriosis, radiation cystitis, and FBPS. FBPS is defined by the American Urological Association (AUA) as bladder-related pain or discomfort with lower urinary tract symptoms for over six weeks without infection.<br /><br />Key points highlight the multifactorial nature of IC/PBS involving neuroimmune, infectious, musculoskeletal, and urothelial factors. Endometriosis is strongly associated with FBPS, often involving visceral hypersensitization, hormonal influences, microbiome changes, and inflammation.<br /><br />Management follows AUA guidelines emphasizing multimodal approaches: addressing inflammation and endothelial dysfunction, neuromodulation, mast cell stabilization, and symptom validation. Treatments include diet modification (identifying triggers), pharmacologic neuromodulators (amitriptyline, gabapentin), vaginal estrogen to improve urothelial health, bladder instillations (lidocaine/bicarbonate/heparin), pelvic floor physical therapy (PFPT), and mental health support. Monotherapies are rarely effective; integrated care improves adherence and outcomes.<br /><br />Emerging therapies under research include monoclonal antibodies, novel intravesical drug delivery systems, biomarker-driven diagnosis, and novel neuromodulators.<br /><br />Takeaways stress ruling out endometriosis in young patients with IC symptoms, providing multimodal care, early referral, and focusing on pelvic floor physical therapy and behavioral interventions to optimize outcomes in genitourinary pain.

Keywords

Female Bladder Pain Syndrome

Interstitial Cystitis

Bladder Pain

Pelvic Pain

Urinary Urgency

Endometriosis

Pelvic Floor Physical Therapy

Neuromodulation

Bladder Instillations

Multimodal Management