The urinary bladder is a hollow, muscular and distensible organ that stores urine excreted by the kidneys. Urine enters the bladder through the ureters and escapes through the urethra. The bladder is present in the lower abdomen in the pelvic region. Pain in the bladder can result from inflammation, infection, damage or injury to the bladder. The symptoms vary with each condition. They may be constant or variable and may get better or worse with movement. Bladder pain may be sharp, dull, piercing, burning or throbbing and ranging in intensity from mild to severe. There are several causes for bladder pain, of which the three most common causes are interstitial cystitis, urinary tract infection, and bladder cancer. Bladder pain can also be caused by chronic underlying diseases such as endometriosis and bowel disorders. Malignant tumors can also cause bladder pain along with pain with urination, abdominal pain, and bloody urine. Scarring of the bladder or damage to the surrounding structures like urethra, may also contribute to bladder pain. If the urethra is constricted then urine may remain in the bladder leading to pain and infection. Immediate medical care should be sought if bladder pain is associated with high fever, difficulty in urinating, blood in urine, severe abdominal pain or persistent bladder pain.
Pathophysiology of Bladder Pain
Interstitial cystitis or the painful bladder syndrome is a mixed syndrome, which is characterized by bladder pain with frequency of urination as well as nocturia. Findings have revealed various pathophysiological mechanisms like of the epithelium, activated mast cells, neurogenic inflammation, occult infection. Urothelium and urothelial cells in the human bladder play an important role in the normal defense mechanism. Thinning of the bladder epithelium is the most common finding in patients with this syndrome suggesting a change in regulation of urothelial homeostasis. Urine from patients suffering from IC/PBS has shown to reduce urothelial proliferation through antiproliferative factor (APF). Urine samples of patients with IC/PBS showed significant increase in APF, decrease in heparin-binding epidermal growth factor (HB-EGF) and increased levels of EGF. APF from the urothelial cells regulates expression of other cytokines, upregulation of HB-EGF and downregulation of EGF along with improved permeability in cell culture. These abnormalities in cytokine were also related to increase in purinergic signaling, which transmits increased bladder sensation. The epithelial damage is followed by other histopathologic findings in the bladder wall. The afferent and efferent nerves in the suburothelial interstitial cellular network may induce a local inflammatory process, which incorporates the transmission of signals from the urothelium to the detrusor muscles in the bladder wall. Examination of relationship between chronic inflammation and urothelial dysfunction like urothelial apoptosis, expression of junctional protein and inflammatory reactions in the suburothelium might explain this theory.
Etiology and Risk Factors of Bladder Pain
Bladder pain is caused due to multiple factors including infection, disease or injury to the bladder. Involvement of other parts of the body also causes bladder pain like cancers, endometriosis or bowel disorders. All these conditions lead to bladder damage causing bladder pain.
Urinary Disorders Causing Bladder Pain Are As Follows:
- Interstitial cystitis.
- Benign or malignant tumors.
- Congenital abnormality.
- Kidney infection.
- Urethral stricture.
- Urinary tract infection.
- Other causes of bladder pain are bowel disorders, endometriosis, and cancers of the bladder and its surrounding organs.
Signs and Symptoms of Bladder Pain
Bladder Pain May Be Accompanied By Other Symptoms Such As:
- Hematuria (blood in urine).
- Frequent urination.
- Cloudy urine.
- Difficulty in urinating.
- Urine retention.
- Foul-smelling urine.
- Pain or burning micturition.
- Urgent need to urinate.
- Pain or cramping in the abdomen.
- Fever and chills.
- Lower back, groin, or side pain.
- Night sweats.
- Redness, warmth or swelling.
Serious Symptoms Indicating A Life-Threatening Condition Are:
- High fever (higher than 101 degrees Fahrenheit).
- Inability to void.
- Continued vomiting.
- Acute abdominal pain.
- Persistent bladder pain.
Treatment for Bladder Pain
Pentosan polysulfate sodium (Elmiron) is the only FDA-approved oral drug for treating interstitial cystitis, but this medication doesn’t work for everyone and takes a long time to show any effect. Other medications include antihistamine hydroxyzine (Vistaril, Atarax), tricyclic antidepressants such as amitriptyline (Elavil). Seizure medicines such as gabapentin (Neurontin) and topiramate (Topamax). Immunosuppressant medications such as cyclosporine and azathioprine. For mild bladder pain, over-the-counter pain medications such as aspirin, ibuprofen, or acetaminophen may be helpful. Antibiotics are prescribed for bladder infection or UTI. Patient is also advised to drink plenty of fluids to flush out bacteria from the urinary tract. Treatment for bladder cancer includes surgery to remove the tumor, chemotherapy and intravesical therapy. In advanced cancer stage, surgery is done to remove a part of the bladder or the entire bladder (radical cystectomy). Combination of chemotherapy and radiation is done in patients who cannot have surgery due to other ailments.
Other Treatments Which Are Helpful Are :
- Bladder instillation.
- Bladder distention.
- Nerve stimulation.
- Bladder retraining.
- Pelvic floor exercises.
- Stress management.
If all these treatments aren’t working and still there is persistent bladder pain then the doctor may recommend surgery as a last resort.
Investigations for Bladder Pain
- For diagnosis of interstitial cystitis: Urine sample and cystoscopy are done.
- An ultrasound or CT scan of the pelvis may also be done to rule out other conditions.
- Urinary tract infections are diagnosed by taking a urine sample and testing it for bacteria.
- Investigations to diagnose bladder cancer: Cytoscopy with biopsy, CT scan, MRI scan, urinalysis, urine culture, and the urine cytology are done.