Bladder Pain

You may know all about cystitis. If so, you probably mean bacterial cystitis, which is the medical word for a bladder infection (urine infection). The word ‘cystitis’ really only means an irritated bladder. It does not say what caused the irritation.

Women and men with pelvic pain often have another type of bladder irritation called either Interstitial cystitis (IC) or Painful Bladder Syndrome (PBS). This type of cystitis is different from a urine infection. There is irritation of the bladder wall but no infection. It is one of several pelvic pains you can’t see at a laparoscopy or on an ultrasound scan.

If you have bladder troubles and pain on most days, then it is quite possible that you have PBS. Sometimes it is the bladder which causes most of the pain. Painful bladder syndrome is common in women with endometriosis. Men with Painful Bladder Syndrome are sometimes told that they have prostatitis, when the pain is coming from the bladder rather than the prostate.

The exact cause of Painful Bladder Syndrome is unknown and there may be more than one type. This may explain why no particular treatment suits everyone, and why you may need to try more than one treatment to find one that suits you.

The common symptoms include:

• Frequency (Needing to go to the toilet a lot)
• Nocturia (Needing to get up to the toilet at night)
• Urgency (Needing to rush to the toilet and finding it difficult to ‘hold on’)
• Pain Which gets worse as the bladder fills, and improves once the bladder empties
• Pain with intercourse in women Especially in positions that put pressure on the front wall of the vagina (near the bladder)

Many people with a painful bladder describe having ‘frequent urine infections’. Sometimes there is a bladder infection, but often it is a flare of their painful bladder that feels like a urine infection. If urine is sent to a laboratory during a flare, it may sometimes show blood but doesn’t show infection.

A urine test with your doctor to check for infection or other problems is a good idea.  They can also check for a chlamydia infection of the urethra if a sexually transmitted infection is possible.

Make sure you are drinking enough (but not too much) fluid each day. For most people, this will be around one and a half, to two litres of mostly water daily. If you drink a lot more than this, that may be part of the problem.

If you still have problems, think about whether any of the foods or drinks below trigger your bladder problems. Use the ‘bladder flare’ treatment described below if your pain flares up, and try a bladder medication such as amitriptyline from your doctor.

Stress and getting run-down are triggers for many people’s bladder pain. Managing stress, getting plenty of sleep, regular exercise and relaxation are all very important.

There are many foods that can make bladder pain worse, but most people only have problems with some of these. They include:
Foods high in acid such as citrus fruit, cranberries, strawberries, vitamin C, some herbal or green teas or tomatoes. A plain mint/chamomile tea or just water is best

Foods that stimulate nerves such as caffeine, chocolate or cola drinks

Foods high in sodium or potassium such as bananas

Artificial Sweeteners including aspartamine etc

Fizzy drinks (including mineral water). Diet cola drinks are probably the worst as they contain acid, caffeine and artificial sweeteners. Cigarettes can also affect the bladder.

• Medications are really useful but you may need to try a few different ones with your doctor to find the right one for you:
  • Low dose amitriptyline from your doctor. This is a good first choice as it helps frequency, urgency, pain and the number of times you pass urine at night. It can also sleep, bloating and headaches. A dose starting at 5mg taken around 3 hours before bed and increasing slowly to between 5 and 25mg daily suits around half those who try it. Sleepiness in the mornings usually wears off in a week or so, but start with a small dose. It needs to be taken every day, not just when you have the pain.
  • If amitriptyline makes you feel too sleepy, then you can try tolterodine 1-2mg daily, oxybutinin 5-15mg daily or solifenacin 5-10mg daily.
  • Hydroxyzine 10-50mg at night is often helpful but not available in Australia. This is an anti-histamine so especially useful for women with allergies.
  • Pentosan polysulphate sodium (Elmiron^®) 100mg three times daily. This is the only medication specifically used for painful bladder syndrome. It helps about half those who take it but is expensive and may take up to six months to work.
  • Pregabalin (Lyrica^®) is medication for nerve pain (neuropathic pain) which may help bladder pain in some people. It needs to be taken every day.

If simple treatments don’t help, your doctor may suggest seeing a urologist, gynaecologist or pain specialist for further tests or treatments.

Depending on your particular symptoms, these tests might include:

• An ultrasound of your bladder and pelvis
• A Cystoscopy which allows your doctor to see inside the bladder
• Urodynamics which investigates how the bladder functions when it fills and empties. This is usually only necessary if simple treatments haven’t worked for you or you have other bladder problems as well as pain.
• An MRI scan. This is only necessary when looking for rare types of pain such as a urethral diverticulum (pocket in the urethra).

Blood tests are not usually necessary.

How is a cystoscopy done and what can it show?

At a cystoscopy, a small telescope is inserted through the urethra (opening where urine comes out) up into the bladder. A cystoscopy can show some types of pain, such as stones or growths, but may still be normal in Painful Bladder Syndrome.

A cystoscopy can be done while you are awake, or asleep under general anaesthesia.

If done while you are awake, it is called a flexible cystoscopy. Your doctor will use a local anaesthetic gel to numb the urethra.

If done while you are asleep, it is called a rigid cystoscopy. In this situation the cystoscopy may be combined with a bladder stretch procedure (hydrodistension) or with a small sample of the bladder wall removed (biopsy). It can also show how much urine your bladder can hold. This may be less than usual in people with Bladder Pain Syndrome. Sometimes a cystoscopy done while you are asleep shows small bleeding points in the wall of the bladder called glomerulations, or ulcers in the bladder wall.

What if the cystoscopy is normal?

This can happen. It doesn’t mean that your pain is not real. There are many pains that can’t be seen. Bladder pain is diagnosed on your symptoms, not what his found at a cystoscopy. You will have the same chance of responding to treatments as anyone else with pain.

Depending on your particular symptoms, your doctor may recommend:

• Less common medications for bladder pain
• Cystoscopy and hydrodistension (bladder stretch) under anaesthesia with diathermy (cautery) of any ulcers found
• Pelvic Physiotherapy. This is particularly useful where there is spasm or tensing of the muscles around the bladder, making the bladder pain worse. This can happen without you realising the muscles are tight. There is information on the management of pelvic muscle pain on other pages on this site.
• A bladder installation (intravesical treatment). Soothing medicine is inserted into the inflamed painful bladder through a small catheter inserted through the urethra into the bladder. This can be done in the doctor’s office or treatment centre. If you find it helpful, you doctor may teach you how to do this at home. A common plan for installation might include installation once a week for 6 weeks, with top-up treatments when your problems return.
• Other treatments depending on your personal situation

Over time, your bladder pain may change and need different treatments. You can expect that there will be times when the pain is easier to manage than others. It may even go away altogether for months or years at a time – then come back at a time when you are stressed or run-down. Treatments are always improving and evolving. Even if a particular treatment hasn’t worked for you in the past, there may be newer treatments that suit you well.

It is important to work together with your doctors to find the treatments that suit you best.