Guideline Update on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome

Diane K. Newman | July 05, 2022

The American Urological Association (AUA) released a guideline update on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome with 26 updated guideline statements on diagnosis and approach to management.  Evidence levels assigned included a strength rating of A (high), B (moderate), or C (low) but many recommendations were based on Clinical Principles and Expert Opinion when insufficient evidence existed.

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diane k newman

Diane K. Newman, DNP FAAN BCB-PMD is a Urologic Nurse Practitioner, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health. She is the author of several books. The most recent is as lead editor of the 1st edition of the SUNA Core Curriculum for Urologic Nursing and of Clinical Application of Urologic Catheters, Devices and Products.

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Patient Education Resources

Patient Education Tools for Pelvic Floor Muscle Excercises and Bladder Training
Download Controlling Your Bladder Urges With Bladder Training

CONTROLLING YOUR BLADDER URGES with BLADDER TRAINING is information about overactive bladder symptoms of urgency, frequency and urgency incontinence. This tool detail bladder training strategies including methods for controlling urinary urgency.

Download Habits That Can Affect Your Bladder

HABITS THAT CAN AFFECT YOUR BLADDER is information about foods and liquids that can irritate the bladder causing urgency, frequency and incontinence. The first page is a list of foods that are known to be bladder irritants, with a list of foods and liquids that contain caffeine. The second page lists other things that can cause bladder symptoms including herbs that have been shown to negatively impact the bladder and information on recommended daily intake of fluids and drinks.

Download Pelvic Floor Muscle Exercises

How to Do Pelvic Floor Muscle Exercises are instructions for performing pelvic muscle exercise. These are commonly referred to as “Kegels”. It details how to perform both quick and slow muscle contractions and provides tips for identifying the muscle, when to do them. These instructions are for men and women.

Download Doing the "Knack" to Stop Bladder Leaks

Doing the “Knack” to Stop Bladder Leaks reviews the strategy for stopping insentience, bladder leaks. Some refer to these as “stress strategy”. These instructions will assist a person in the use f the pelvic muscle at the time when urine leakage is most apt to occur.

Physician-Scientist Review Articles
State of the Evidence Review Articles
Pelvic Health
October 7, 2021
Overactive bladder (OAB) is a symptom complex of lower urinary tract symptoms of urgency, frequency with or without urinary incontinence. It is prevalent in both men and women (10.8% and 12.8% respectively). According to Irwin and colleagues (2006), women have a higher rate (13.1% vs 5.4%) of urinary incontinence (urgency, stress, or mixed), are more likely (19% vs 12%) to report frequency of more than eight times per day, and are more bothered by urinary frequency than men (66% vs 46%).

September 8, 2021
Summary
A 59 year old gentleman presented to the urology outpatient department, having been referred by his general practitioner (GP) with lower urinary tract symptoms (LUTS). On review of his medications, he was taking a calcium channel blocker for control of his mild hypertension. This was subsequently swapped and his symptoms improved and he was discharged from the urology clinic. It is shown in the literature that there is a clinically significant correlation between use of calcium channel blockers and worsening of LUTS.
Conference Coverage
Conference Highlights Written by Physician-Scientist
Presented by Patrick Campbell
This was a UK prospective study of the compliance at 12 months of the use of a vaginal device, the Uresta bladder support, for management of stress urinary incontinence (SUI). Interestingly, study recruitment was through advertisements on social media, running clubs, and gyms. Outcomes were assessed using the PUQ, ICIQ-FLUTS, UDI-6, IIQ-7, QUID, and PGI-I questionnaires.
Presented by Piotr Radziszewski
An incontinence absorbent product is changed several times per day, but changing too early leads to unutilized products being discarded, and changing too late implies a risk of urine leakages, as well as, risk of moisture-associated skin damage. Caregivers must check the product for saturation status many times a day, which can be a burdensome manual process. This presentation was on the TENA SmartCare Change Indicator
Presented by Lily Arya
This study reported on the results of an evidence-based digital platform that remotely delivers treatments including self-management strategies to female patients with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS). The aims were 1) to develop a conceptual framework for the self-management of IC/BPS, 2) to develop a digital platform that remotely delivers first- and second-line AUA treatments of IC/BPS, and 3) to test its feasibility in this population.
Presented by Ruth Maher
Proprioception is fundamental to motor learning, and sensorimotor afferents may facilitate changes in motor control. Neuromuscular electrical stimulation (NMES) is used clinically as an adjuvant intervention to facilitate pelvic floor muscle (PFM) contractions. Neural imaging shows that NMES contractions activate similar cortical and subcortical structures to volitional ones. Consequently, these NMES elicited contractions may enhance proprioception and PFM function.
Presented by Blayne Welk
Research suggests that OAB anticholinergic medications may lead to cognitive dysfunction and an increased risk of dementia, but few studies have evaluated the effect of these medications in those with pre-existing cognitive dysfunction and few have followed patients long term.  APOE-e4 allele is a genetic risk factor for Alzheimer's, and may lead to increased sensitivity to anticholinergic-mediated cognitive decline, but has not been evaluated in the context of OAB anticholinergics.
Presented by Frank Martens
This presentation reported on data from the initial 500 patients from 20 centers who reached one-year follow-up in the EAU Research Foundation prospective registry SATURN (Surgery for mAle incontinence with artificial Urinary sphincters and slings) which was established to assess the efficacy of male stress urinary incontinence (SUI) surgery in daily practice. SATURN’s overall goal is to analyze 1000 patients undergoing male SUI surgery with 10-year follow-up from 29 implanting centers in 9 European countries. The group has defined “cured” as the absence of pad use or only 1 security pad.
Presented by Madeline Moureau
Mind Over Matter: Healthy Bowels, Healthy Bladder is a small-group behavior change intervention for women aged 50 or older who want to prevent or improve urinary incontinence (UI) or anal incontinence (AI). This is a community-based program that consists of three 2-hour sessions delivered over one month and results of this in-person program have been previously and showed a 9-fold improvement in bladder symptoms and a 4-fold improvement in bowel symptoms compared to controls.
Presented by Laura Pedofsky
The perineometer, a balloon pressure-type type device, was first described by Dr. Arnold Kegel in the 1940s and since then has been used extensively to determine ‘the strength’ and ‘function’ of the pelvic floor muscles (PFMs). However, due to the design of these devices, the pressure changes reflect global pressure change within the vagina, making it impossible to discriminate between an increase in abdominal pressure and that induced by the PFMs.
Presented by Sarah Dean
This study aimed to develop a comprehensive training package for midwives and resources for pregnant women, to support the teaching of an antenatal pelvic floor muscle exercise (PFME). The presentation was on the feasibility of such training tested in a pilot randomized controlled trial. The study comprised four iterative phases of intervention development, including a stakeholder event and multiple patients and public involvement and engagement (PPIE) activities. The PPIE advisory group included women with young children, with meetings held in the community.
Presented by Suzanne Hagen
A parallel two-arm, superiority, multicentre randomized controlled trial study aim was to determine the effectiveness and cost-effectiveness of self-management of a vaginal pessary on prolapse-specific quality of life (at 18 months) for women with pelvic organ prolapse (POP) when compared to pessary clinic-based care. Inclusion criteria were women age ≥18 years, pessary use of any type/material (excluded: Shelf, Gellhorn, or Cube pessaries), and retention of a pessary for at least two weeks.
Presented by Kenneth M. Peters
URO-902 is an intradetrusor injection investigational gene therapy for overactive bladder (OAB). It consists of a plasmid vector that expresses the α subunit of the large-conductance Ca2+-activated K+ channel in the detrusor to reduce bladder hypercontractility. This presentation reported on results from a 12-week interim analysis of a 48-week multicenter, randomized, double-blind, placebo-controlled, dose-escalation phase 2a trial assessing the safety and efficacy.
Presented by Towe Wadensten
Delivering behavioral interventions, specifically pelvic floor muscle training (PFMT), via a mobile app has exploded over the past few years. The Tät®II,  a popular mobile app includes PFMT, bladder training, psycho-education, lifestyle advice, an exercise log, reminders, reinforcement messages, and tailored advice. In a 15-week randomized controlled trial (RCT), this app was shown to be effective for the self-management of urgency urinary incontinence (UUI), and mixed urinary incontinence (MUI).
Presented by Claire S. Burton, Amy Zhang, Alayne Markland, Ekene Enemchukwu
(UroToday.com) Evidence-based treatments are available for overactive bladder (OAB) with published guidelines and treatment pathways created for clinicians to optimize treatment and provide a clinical framework for diagnosis and treatment. The impact of these efforts remains unclear and medical treatment pathways are poorly understood.
Presented by Madeline J. Epsten, Jennifer Ferraro, Fareesa Khan, Cynthia Brincat, Kristin M. Jacobs
(UroToday.com) The effects of the COVID-19 pandemic and telemedicine on urinary tract infection (UTI) treatment are largely unknown. This study evaluated the impact of COVID-19 and telemedicine on empiric UTI treatment in women, hypothesizing that increased use of telemedicine during the pandemic would increase the rate of empiric UTI treatment.
Presented by Grant Gruenspan, Jian Wang, Laureen Hachem, Michael Fehlings, Paul Yoo
(UroToday.com) Peripheral nerve stimulation techniques are emerging as an effective alternative to existing therapies for overactive bladder (OAB). As a novel approach, saphenous nerve (SAFN) stimulation is being investigated as a method of electrically modulating bladder function. Published work showed that SAFN stimulation in urethane-anesthetized rats
Presented by Natalia Hernandez, Lia Miceli, Julie N. Stewart, Ricardo R. Gonzalez, Rose Khavari
(UroToday.com) The AUA guidelines recommend oral anticholinergics/antimuscarinics and beta-3 adrenergic agonists as second line therapy. There is increasing understanding that oral anticholinergics/antimuscarinics may have been negative cognitive effects and one of the beta-3 adrenergic agonists (mirabegron) may negatively affect the blood pressure in older adults.
Presented by Zhenyue Huang, Rosen Jeong, Edwin Lee, Heng Ruan, Tal Meir Cohen, Jason Kim
(UroToday.com) The rising presence of social media has offered a wide array of publicly available medical information for women suffering from recurrent urinary tract infections (rUTIs). This study sought to investigate the quality of information for UTI on YouTube.
Presented by Anjali Kapur, MD, Tal Cohen, MD, Colin Dabrowski, MD, Rebecca Andersen, MD, Kuemin Hwang, BS, Edwin Lee, BS, Heng Ruan, BA, Steven Weissbart, MD, Jason Kim, MD
(UroToday.com) Third-line therapies, including intradetrusor onabotulinumtoxinA (Botox), percutaneous tibial nerve stimulation (PTNS), and sacral neuromodulation (SNM), are indicated for patients with overactive bladder (OAB) who are refractory to first- and second-line therapies. This study sought to investigate specific reasons for patient preference of each third-line OAB therapy.
Presented by Juliann Chavez, Jacqueline Chavez, Ethan Fan, Alana Christie, Philippe Zimmern
(UroToday.com) D-mannose is a bioactive monosaccharide frequently recommended by clinicians to prevent recurrent urinary tract infections (rUTIs) in women. It is unknown if this protective effect against RUTIs results from urinary pH changes. This study analyzed the effect of D-mannose on urinary pH.
Presented by Parker Kenee, Alana Christie, Philippe Zimmern
(UroToday.com) In women with antibiotic-recalcitrant recurrent urinary tract infections (RUTI), electrofulguration (EF) to destroy of areas of chronic cystitis can provide durable cure or improvement. However, some women will fail while others will experience some UTI recurrences over time and are interested in non-antibiotic therapies to combat these UTI episodes.
Presented by Zara Khan, Parker R.M. Kenee, Shanee Abouzaglo, Jennifer Foster, Jordan McCoy, Naeemul Hassan, PhD, Philippe E. Zimmern, MD, Rena D. Malik, MD
(UroToday.com) The aim of this qualitative study was to qualitatively analyze rUTI discourse on the website Reddit and identify areas that healthcare professionals may better address to improve care for women with rUTI. The authors queried public subreddits r/TwoXChromosomes, r/Askwomen, r/WomensHealth, and r/CUTI for combinations of the search terms “recurrent” or “chronic”
Presented by Michael Peng, Paul Yoo, Anne Agur
(UroToday.com) Saphenous nerve (SAFN) stimulation is an emerging treatment for overactive bladder (OAB) syndrome, but precise knowledge of the subcutaneous distribution of nerve branches is lacking. This study volumetrically documented and modeled in 3D the course of branches of the SAFN relative to bony/soft tissue landmarks.
Presented by Meghana Reddy, Philippe Zimmern
(UroToday.com) Intravesical antimicrobials (IVA) can provide a localized modality of treatment for uncomplicated recurrent urinary tract infections (rUTIs). This was a systematic review on the efficacy of IVA in the management of rUTIs. The review included articles from inception to April 2021, utilizing the Cochrane and PRISMA standards with the following databases:
Presented by Raveen Syan, Jennifer Miles-Thomas, Diane K. Newman, Nitya Abraham, Keely Madaj, Krystal Anson Spenta, Amin Boroujerdi, Zhanying Bai, Lei Luo, Ekene Enemchukwu
(UroToday.com) Only 10% of patients with OAB progress to third line options (onabotulinumtoxinA [onabotA] and neuromodulation). Reasons include a lack of understanding of options, fear of side effects, or desire to avoid invasive treatments. Using a navigator, defined as a healthcare professional focused on patient-centered care),
Presented by Alixandra Ryan, Hayden Hill, MD, Anastasia Couvaras, MD, Colin Goudelocke, MD
(UroToday.com) Current guidelines recommend antibiotic treatment, and in some cases, antibiotic prophylaxis. The possible adverse effects, cost, and increased bacterial resistance to prophylactic antibiotics have led to the study of alternative prevention, such as cranberry, probiotics, and D-mannose. D-mannose is a monosaccharide isomer of glucose rapidly absorbed when given orally and
Presented by Elisabeth Sebesta, Stephanie Gleicher, Melissa Kaufman, Roger Dmochowski, W. Stuart Reynolds
(UroToday.com) This study sought to assess the proportion of patients who sought out medical care and received treatment for bladder symptoms, in addition to any predictive factors for doing so. A sample of 3,396 adults was recruited electronically to complete a questionnaire on clinical and demographic information, social needs, and urinary symptoms (LURN SI-10, ICIQ-UI SF, and PPBC).
Presented by Blayne Welk, Holly Fisher, Thomas Chadwick, Chris Harding
(UroToday.com) This study was a secondary analysis of community dwelling participants to assess the relative reduction in UTIs among people with different neurologic diseases and intermittent catheter use and to determine if UTIs impacted renal function. Analyzed were those individuals who participated in a 12-month randomized trial (AnTIC, a multicentered
Presented by Blayne Welk, Sara Lenherr, Yasir Santiago-Lastra, Melanie Goodman Keiser, Holly Norman, Christopher Elliott
(UroToday.com) This study compares UTI incidence and severity among intermittent catheter (IC) users with neurogenic (NLUTD) and non-neurogenic diagnoses. Analysis of health insurance claims data from the IBM MarketScan Database (commercial Preferred-Provider Organization and Medicare supplemental claims) between January 1, 2015 – December 31, 2019
Presented by Sirpi Nackeeran
The study’s aim was to show how frailty affects perioperative complications in women undergoing pelvic organ prolapse (POP) surgery. They sought to determine (1) the role of frailty on postoperative complications and (2) the association of racial and socioeconomic differences between frailty and postoperative complications among women undergoing apical prolapse repair.
Presented by Duane Hickling, MD
Dr. Duane Hickling presented the evidence behind many common urinary tract infections (UTI) treatments: water, methenamine salts, D-Mannose, and lactobacillus. He noted that UTIs are common as 20% of college-aged women had at least one culture-confirmed UTI recurrence within 6 months.
Presented by A Lenore Ackerman, MD Ph.D.
A urinary tract infection (UTI) is defined as microbial infiltration of the normally sterile urinary tract. But there are no accepted definitions of UTI-associated symptoms, cut-offs for culture result, or definitively accepted uropathogens that can guide clinicians in the objective management of a UTI.
Presented by Eric Rovner, MD
Dr Rovner moderated a symposium on Bulkamid, a periurethral injection which was approved by the FDA in 2020 for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) or in women who have SUI or stress predominant mixed urinary incontinence (UI).
Dr Tamara Bavendam was given the SUFU Lifetime Achievement award in recognition of an outstanding career in urology.  She had previously received SUFU’s Distinguished Service award. In accepting the reward, Dr. Bavendam reflected on what she termed “my unusual career”.
Presented by Jeffrey P. Weiss, MD
Miami, FL (UroToday.com) Dr. Jeffrey Weiss provided an update of the management of nocturia. Patients are oftentimes asked to fill out a 24-hour voiding diary but compliance in completing them is sometimes very difficult to obtain.
Presented by Harris Emilio Foster, MD
Miami, FL (UroToday.com) Dr. Foster leads the audience through the AUA BPH Guidelines briefly emphasizing the new changes /updates that will be seen in the new updated BPH guidelines.
Presented by Alison P Downey, MD
Philadelphia, PA (UroToday.com) Dr. Chapple from Royal Hallamshire Hospital, Sheffield, and his colleagues presented their experience and outcome of surgical intervention in the management of bladder pain syndrome in a tertiary center.
Presented by Mikel Gray, Ph.D., RN
Philadelphia, PA (UroToday.com) Mikel Gray, Ph.D., RN provided an overview of urodynamic procedures, which were defined as a set of tests created to estimate storage and evacuation of urine from the lower urinary tract (LUT).
Presented by Shannon Novosad, MD, MPH
Philadelphia, PA (UroToday.com) Shannon Novosad, MD, medical officer at the Centers for Disease Control and Prevention (CDC) has opened Educational Course on Clinical Directions in Continence care by providing an overview
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