Managing Interstitial Cystitis/Bladder Pain Syndrome in Older Adults - Beyond the Abstract

While interstitial cystitis/bladder pain syndrome (IC/BPS) has previously been thought to be a disease of young women, recent studies indicate that IC/BPS occurs across all age groups; with one study reporting 38% of patients with IC/BPS being diagnosed at an age greater than 60 years.1 Older patients with IC/BPS may present with different symptoms than their younger counterparts including nocturia, urinary incontinence, and Hunner’s lesions. Consequent to the reported link between antimuscarinic drug use in the elderly and dementia,2 as well as new concern of a novel maculopathy associated with chronic exposure to pentosan polysulfate,3 urologists are becoming increasingly aware of the importance of understanding side effect profiles and medication interactions when prescribing medication for chronic conditions such as IC/BPS. This is especially important when selecting pharmacologic treatments for frail, older adults with extensive medication lists.


It goes without saying that non-pharmacologic treatments should remain first-line in the treatment of IC/BPS, especially when considering those who may be frail and older in age. One of the most important, though time-consuming, elements of a treatment plan for IC/BPS is patient education. This should involve relevant family members or caregivers when indicated. Patient education should be specific to IC/BPS, but may also include a discussion of how existing medical comorbidities or their treatments contribute to symptomatology.

In accordance with the American Urological Association (AUA) guidelines, when first-line treatments including patient education, behavioral modifications, stress management, and physical therapy are insufficient, it is appropriate to escalate to pharmacotherapy or procedural treatment options.4 While there are many different approaches to selecting treatment for IC/BPS, the pendulum is swinging towards the use of a multimodal, phenotype-directed approach rather than a sequential tiered treatment strategy.5-6 Therefore, our review organizes pharmacologic treatments based on clinical phenotypes and symptomatology including urinary symptoms, inflammatory or allergic symptoms, neuropathic pain, ulcers, and tenderness of muscles, with a focus on special considerations for the treatment of older adults with IC/BPS.7

It is worth noting that since patients with a diagnosis of IC/BPS at an older age were more likely to have Hunner’s lesions than the younger cohort (39.8-42% versus 12%)1, our practice is to initiate a trial of behavioral modification and symptom-targeted pharmacologic therapy, and if symptoms do not improve, proceed with early cystoscopy.

While caution should be exercised in the use of pharmacologic agents in the treatment of IC/BPS in older adults, the addition of medications is reasonable and offers patients the potential for improved quality of life. Clinicians should be open with patients that treatment of IC/BPS centers around improving quality of life while avoiding adverse events, and that as of yet, no cure exists. When a question regarding medication interactions or side effect profiles arises, clinicians are encouraged to collaborate with pharmacists or primary care physicians to safely provide treatment.

Written by: Alyssa Gracely, MD, and Anne Pelletier Cameron, MD, Department of Urology, University of Michigan, Ann Arbor, Michigan

References:

  1. Rais‐Bahrami, Soroush, Justin I. Friedlander, Amin S. Herati, Mostafa A. Sadek, Marina Ruzimovsky, and Robert M. Moldwin. "Symptom profile variability of interstitial cystitis/painful bladder syndrome by age." BJU international 109, no. 9 (2012): 1356-1359.
  2. Gray, Shelly L., Melissa L. Anderson, Sascha Dublin, Joseph T. Hanlon, Rebecca Hubbard, Rod Walker, Onchee Yu, Paul K. Crane, and Eric B. Larson. "Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study." JAMA internal medicine 175, no. 3 (2015): 401-407.
  3. Pearce, William A., Rui Chen, and Nieraj Jain. "Pigmentary maculopathy associated with chronic exposure to pentosan polysulfate sodium." Ophthalmology 125, no. 11 (2018): 1793-1802.
  4. Hanno, Philip M., Deborah Erickson, Robert Moldwin, and Martha M. Faraday. "Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment." The Journal of urology 193, no. 5 (2015): 1545-1553.
  5. Clemens, J. Quentin, Chris Mullins, A. Lenore Ackerman, Tamara Bavendam, Adrie van Bokhoven, Benjamin M. Ellingson, Steven E. Harte et al. "Urologic chronic pelvic pain syndrome: insights from the MAPP Research Network." Nature Reviews Urology 16, no. 3 (2019): 187-200.
  6. Crane, Alice, Jessica Lloyd, and Daniel A. Shoskes. "Improving the utility of clinical phenotyping in interstitial cystitis/painful bladder syndrome: from UPOINT to INPUT." The Canadian journal of urology 25, no. 2 (2018): 9250-9254.
  7. Gracely, Alyssa, and Anne P. Cameron. "Managing Interstitial Cystitis/Bladder Pain Syndrome in Older Adults." Drugs & Aging (2020): 1-16.
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