In May 2022, the American Urological Association released the long awaited update of their guidelines for the diagnosis and treatment of IC/BPS. The guidelines provide an evidence based “best practice” approach for urologists and patients as they seek to treat IC/BPS symptoms. Developed originally in 2011 and revised in 2014, the 2022 guidelines provide new, groundbreaking changes that will help patients find the best treatments to help their unique case of IC/BPS. Here are the major changes: 

IC/BPS is no longer considered to be a bladder disease. 

It is now recognized as a chronic pain syndrome.

IC/BPS is a diverse, varied patient population with three identifiable subtypes.

This is the first time that the AUA has acknowledged distinct patient groups each with different treatment priorities. 

  • BLADDER CENTRIC – These patients have clear bladder wall dysfunction, as demonstrated by the presence of Hunner’s lesions, a small badder capacity and/or pain that improves with local anesthetics (i.e. a lidocaine instillation). This group could include patients with estrogen atrophy and/or chemical irritation of the bladder wall. Patients with Hunner’s lesions should receive lesion specific treatments (fulguration, steroid therapy).
  • PELVIC FLOOR – These patients have tight, sensitive pelvic floor muscles. Their immediate treatment goal is to restore normal muscle tone, resolve painful trigger points in the pelvis and ease tight, constricted tissue. All patients with tight pelvic floor muscles should be referred to a pelvic floor physical therapist.
  • CHRONIC OVERLAPPING PAIN CONDITIONS / WIDE SPREAD PAIN – These patients have one or more pain conditions beyond the bladder (IBS, fibromyalgia, vulvodynia, TMJ, etc.), suggesting that their central nervous system is involved. They have signs of central sensitization, anxiety, depression and/or, a history of trauma or abuse. (Research has identified that these patients are in a constant state of “fight or flight”, also known as a central nervous system maladaption, and benefit from mind-body medicine techniques.)(Note from Jill – The three subtypes listed above are not widely different from the suggested five subtypes system created by Dr. Christopher Payne that we have used for several years. AUA has combined Hunner’s lesions & bladder wall driven into one subtype yet make the very clear distinction that lesions must be treated differently than bladder wall patients. AUA makes no mention of pudendal neuralgia which, we think, is a mistake. Many IC’ers have positional symptoms, areas of numbness, pins and needles and/or PGAD which suggest that pelvic floor muscles have become so tight that they are squeezing nerves. All in all, this is a very good development.)

Diagnosis

  • A diagnosis of IC/BPS requires a careful history, physical examination and lab tests. Symptoms of urinary frequency, urgency, pressure and/or pain should be present for at least six weeks. IC should be suspected in patients who have pain as the bladder fills with urine that is relieved by urination or who report increased symptoms with certain foods (i.e. coffee, tea, soda, citrus, etc.).
  • Physicians should actively work to exclude other disorders, such as UTI. Are there masses, areas of tenderness or hernias? Are the pelvic floor muscles tight, tender or do they have trigger points? Is there visible or microscopic blood in the urine? Bladder cancer should be ruled out in patients with tobacco exposure. Patients with very low urinary frequency or high bladder capacity should prompt a diligent search for an alternative diagnosis. (AUA makes no mention of embedded infection playing a role in IC nor do they mention research which has identified fungal or viral infection.)
  • A one day voiding diary should be obtained from the patient to establish baseline values for frequency, urine volume and pain that can be used to determine if future treatments are helping.
  • An in-office cystoscopy and/or urodynamics should be considered in complex cases or if the diagnosis is in doubt. Cystoscopy may identify bladder cancer, bladder stones, urethral diverticula and/or if any foreign bodies (vaginal mesh) are present. 
  • Glomerulations (petechial hemorrhages) are no longer considered specific to IC as they are seen in other conditions as well as some normal, healthy bladders. 
  • If Hunner’s lesions are suspected, particularly in patients over the age of 50, an office cystoscopy should be performed unless the patients to prefer to have this done under anesthesia. If lesions are found, the AUA recommends that treatment be performed under general anesthesia. The AUA recommends that physicians use a low pressure (60 to 80 cm water) with a short duration (under 10 minutes) to reduce the risk of bladder rupture and trauma. High pressure, long duration procedures are no longer recommended.

Treatment Approach

  • No single treatment works over time for the majority of patients. Treatment should be tailored to the specific symptoms (phenotype/subtype) of each patient. 
  • AUA has abandoned the six step treatment protocol which allowed patients and providers to rate the potential risks of treatment in a logical, intuitive scale. The 2022 guidelines rely on physicians to discuss the risks and benefits of each treatment. The key question? Do urologists have the time to have this in-depth conversation with their patients? 
  • If a patient is not responding to multiple treatments, the diagnosis of IC/BPS should be reconsidered. If bladder therapies are not effective and/or a patient is getting worse rather than better, the AUA strongly recommends reconsidering the diagnosis. Was something missed? Is another condition present that could be producing pelvic and/or urinary symptoms, such as: endometriosis, fibroid tumors, pelvic congestion syndrome, tarlov cyst, pudendal neuralgia or coccyx injury?

Pain Care

  • Pain management should be an integral part of IC/BPS treatment and pain levels should be assessed at every appointment. Multimodal therapy is encouraged, including medications, stress management and manual therapy. Complex patients may be referred to a pain management professional