Induction Course for Patients

Induction course for IC/BPS is designed to empower and educate the patient to understand the condition and also team up as a partner in healthcare with the doctor. This course covers the following essential headings:

Introduction by Dr. Raman Tanwar

IC/BPS is a very difficult disease to diagnose as well as to treat. But the good part is that if it is diagnosed then treatment is easy and it is possible. So we usually suspect Interstitial Cystitis/BPS in those patients who present after a troublesome journey with various doctors with complaints of going to the washroom again and again, a vague kind of pain in the lower abdomen which sometimes even goes to the genital regions as well, along with a chronicity which does not get relieved with regular medications like antibiotics, pain killers and various other measures.
So usually what happens is that these patients keep going to different doctors and it starts from your general practitioners, who usually suspect that there’s a possibility of an infection and he will try and give you antibiotics for it. But it will eventually come to the fact that you will be taking multiple courses of antibiotics but ultimately the symptoms will not go away. There will be bothersome symptoms and there will be lot of trips to the washroom maybe even 30-40 times in a day. In the night also it becomes very difficult to sleep and usually because of the pressure of the pain we would like to go and pass urine again and again. These kind of features are suggestive of something more than infections or something more than any other disease and such kind of symptoms they point to what we call as Interstitial Cystitis/Bladder Pain Syndrome.
Usually the diagnosis itself takes a lot of time, so patients who present to us usually have 3-4 years prior treatment history, they have been taking a lot of medications various sorts, they must have even tried homeopathic medicines, ayurvedic medicines and they have completely lost faith in allopathic medicines as such. So usually what we do in this disease, will be told to you/guided to you through a series of experts in the following videos that will follow this initial introduction video. But just keep that in mind that this disease, even though it looks very scary, even though the diagnosis looks very difficult to make, it still has cure and there is still hope at the end of this tunnel. So let’s embark on this journey of IC/BPS and find out what this disease is and how we can find a cure to it.
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Clnical Diagnosis by Dr. Rajesh Taneja

Normally anybody who has a urinary symptom viz. Frequency, pain, burning sensation, it is expected that this person may be having an infection. So most of these patients who present to their initial doctors with burning sensation in the urinary passage or pain in the urinary passage or pain in the lower abdomen and frequent visits to the washroom, getting up 4-5times or even more at night, they’re treated as infections.

It is not wrong also, because majority of these patients who present with these symptoms for the first time, they would have urinary infection. So an empirical treatment with antibiotics is Good enough. But if within 2-3 days, the symptoms don’t resolve or they keep coming back again and again, it is very important that the very next episode the person presents with these symptoms, he/she should undergo a detailed urinary examination to exclude the infection.

So, if the infection is excluded, that is the time the clinicians must be alerted to a diagnosis which is different from infections, so the clinicians must understand that this patient is suffering from something, which is not an infection. The usual gynecologists or the surgeons who is looking after these patients would actually miss the diagnosis and they will keep treating them. As a result, when these patients have visited a lot of doctor’s lot of times, they get a combination of various antibiotics, various medications, and they build up a file of their medical records pertaining to this. So a patient who walks into my clinic who has interstitial cystitis perhaps walks in with a thick wad of consultation papers and investigations and with a very depressive look on their faces not only their but their caretakers, usually a spouse in this case and they are frustrated and do not believe that you are going to treat them. Somebody has suggested a urologist or somebody’s name and that is why to oblige that third person, they would come and visit you. They have by now being convinced that their treatment is either possible nor is their diagnosis.

They symptoms which are very typical of Bladder Pain Syndrome are that: a) You are waking up at night vey frequently to visit the washroom and when you wake up, it is the pain or burning sensation rather than a desire to pass urine when you’re going to the washroom. The patient is usually learnt that by going to the washroom and reducing the bladder volume or evacuating the bladder would reduce the symptoms. The symptoms are pain, burning or discomfort in the lower abdomen in the urinary passage.
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Investigations by Dr. Shivam Priyadarshi

Diagnosis of IC/BPS could be very challenging. Because there is no specific investigation which can clinch the diagnosis of IC/BPS. So basically the diagnosis is symptom based, so a patient who has frequent urgent voiding which is driven by pelvic or lower abdominal pain and which increases with the bladder filling and the patient gets relived after voiding that is very typical of IC/PBS. And by the symptoms only you can diagnose the problem that these symptoms can be mimicked by many other confusable disorders like urinary tract infection, then we have malignancy, bladder stone, gynecological disorders, so we need to exclude these confusable disorders to come at the diagnosis of the IC/BPS, so for excluding we need to investigate these patients.

So the two most important test are urine routine examination and the urine culture sensitivity, because urinary tract infection is the most important differential diagnosis of IC/BPS. So once you have done a urine routine examination and if you find that there is micro hematuria or if the patient is a chronic smoker, then we need to do urine psychology also in these patients and if the history of physical examination suggests we might do some special cultures like fungal culture, crimidal culture, a prosthetic fluid culture, a vaginal swab culture etc. so these are the basic test which we need to do.

We need to also do an imaging study because some of the disorders can be missed on history, physical examination and a simple urine routine examination, so an ultra sonography of the lower abdomen would help us to pick the bladder and the pelvic pathology and later we may do some advanced imaging study if that suggests. A urodynamic study could be done in these patients though not mandatory in patients who have obstructive urinary symptoms or poor destructive contractility or with overactive bladder a cystoscopy could be done. Though not necessary in all patients of BPS but this will help not only to rule out some of these confusable disorders like bladder stone, BPH, Malignancy, etc, but it will also help to support the diagnosis because the stigmata of IC/BPS in the form of glomerulations or hunner lesion can be picked on cystoscopy and the cystoscopy also could be therapeutic in the form that we do hydro distension or fulgurate the hunners lesion that will be helped by cystoscopy.

So these are the basic investigations. There is a lot of research going on to find out a validated marker by the urine based or a blood based marker which can actually clinch the diagnosis of IC/BPS and also help in the treatment progress, so one of that such promising marker is anti proliferative factor in urine which is a protein which is detected in patients with Interstitial Cystitis.  So if this becomes a reality and comes in clinical practice than we can truly cleans the diagnosis by measuring this factor. There are other research going on in other factors also but this is probably the most promising one.
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Treatment by Dr. Sanjay Pandey

Interstitial cystitis/Bladder Pain Syndrome is a disease which affects the bladder and the pelvic organs and makes you run again and again to the toilet because you can’t control urine, just because of filling of the bladder gives you a lot of pain. It is important that you meet your urologist and get this problem sorted out in time, because it could plague you for years together and there are changes which are progressive.

It is important that the bladder which is the seat of the disease is looked at carefully by a urologist, looked at bladder capacity, to look at there are no bladder disease of Interstitial Cystitis where you have got the Hunner’s Lesion and Bleeding Points, which are Hallmarks of the disease.

If a urologist is involved in evaluating and treating, he will take this subject forward to higher level of doing a cystoscopy and possibly would start you on those medications which could help you heal your bladder. Your bladder is going through a change where the inner lining of the bladder is not healing. It is undergoing a denudation and not getting replenished. Permeability of the bladder has increased and as a result of which the bladder requires a treatment.  The bladder in that situation will be able to control urine and there will be no pain while you are passing urine and you can control for longer periods of time which would never do in the past.

BPS/IC is a disease which at this point in time has to be taken to highest levels, by agreeing to this kind of set of treatments where medical management, cystoscopy, follow ups very closely and preventing flare ups is required.

The treatment of BPS/IC would be greatly dependent between you and your doctor, in terms of quality of life and improving to very high levels, for which he starts medical management with oral tablets, intravesicle management where cystoscopically he can do hydro-distention or distend the bladder to such levels which gives you relief from the discomfort that you have whenever you fill your bladder. He would also give you sometimes Botulinum Toxin inside the bladder to decrease the sensitivity of the pain findings and would decrease the bladder contraction. In other words, you will be able to hold the bladder without the pain that you have regularly.

The surgical treatment of this disease is a lot dependent on the stage of your disease, wherein sometimes the bladder can actually go down in your capacity. If the bladder goes down below capacity where it cannot be treated, the last treatment could be probably generating a new bladder or creating a new bladder where you could store that amount of Urine which could make you socially continent and could keep you pain free.

An important aspect of IC/BPS is also Pelvic Floor muscle spasm/Pelvic floor dysfunction which could lead to discomfort while passing urine, and possibly not being able to pass urine the way you would normally pass even being a young patient, and therefore a lot of treatment is required here to relieve the pelvic spasm, to relieve the pelvic floor of the contractions which is not helping your urine to come out. We aim to get your urine flow well by decreasing the spasm and could have helped with you with Sacral Neuromodulation, which is very important in a high level treatment, it could be possible that we could give you electrical stimulation of specific nerves in specific segments in the pelvic floor which could be in the male and female pelvis which is a very complex structure.
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Pain Management by Dr. Navita Purohit

Pain Management is an integral part of the management of IC/BPS patients. Because of the pain the main presenting feature or a symptom u can say when they come to urologist or a gynecologist. And the diagnosis is always delayed because of that because they are always into a hierarchy of investigations and then the diagnosis is delayed. So once the diagnosis has been established the pain management at every tear of the management of whatever the urologist is doing whether it is instillation whether it is cystoscopies or whatever they are doing the management of the pain is an integral part.
How we can start to begin with when the patients come we have to know what is the intensity of the pain we ask the patients history and the clinical examinations is very important based on that the management is based. So if the intensity of the pain is high it means all severe, it means that patients says that it is on the score of 10. If it is more than 7 or 6 so it’s a moderate to severe kind of thing and ask the character of the pain depending on that we give them the medication.
Along with the medications we always look for any pelvic floor muscle spasm, pelvic floor dysfunction. We also see for any myofacial bands and if we find anything which adds to the pain of the patient, then we always prescribe them. We then send those patients to physical therapist for relaxation of the pelvic floor. Very important thing is that that we always write on the prescription, being a doctor and whose so ever it is when we write pelvic floor muscle exercises it undoubtedly or default it means it is contraction. So which is always contraindicated. We have to write on our prescription along with the medications, pelvic floor relaxation exercises so the therapist understands that he doesn’t have to give the pelvic floor strengthening exercises because that increases the spasm and we are increasing the pain, so that will get the patient relived of the spasm.
With that there are some physical modalities which can be used. the most important and the most commonly used, you can write on your prescription TENS which is TRANS ELECTRICAL NEURAL STIMULATION, so with that again the pain is relived along with the overall medications. When with the first history examination we also have to ask about the stress in the life of the patient because when the pain becomes chronic it becomes a disease in itself. And that causes a lot to the mental psyche of the patients so we have to deal with that also. When we ask them, any kind of stress increases the pain they always say yes. And there is always a past history of any stress.
There are some intervention minimally invasive intervention injection procedures which can be offered to the patient in terms of myofacial blocks that is releasing the muscle spasm by giving them local muscle injection that can be blind or that can be ultrasound guided depends on your skill. Than we can also offer them nerve blocks like if they have a typical type of a perennial pain radiating to the vagina or to the anus we can go for a pudendal nerve block and when it is a generalized pain because we know that it starts with bladder but it involves the pelvis, so we can go for sympathetic blocks which is again ultrasound guided.
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Dietary Restrictions by Dr. Amita Jain

If we talk about the diet for bladder pain syndrome patients, there is nothing as specific, but it has been seen usually those food items which are bladder irritants like acidic food, Citrus fruits, pineapple, apple, and caffeine in any form like – too much of tea or coffee or caffeinated drinks  or sour things like old curd, vinegar, artificial sweetness, all these things may cause bladder irritation and may aggravate the symptoms or pain of BPS, but usually we ask our patients to identify food items by their own, whatever they think that is aggravating their pain they can stop all those things at once and then once they are relived they should start any food item one by one if they have recurrence of symptoms that means that food item is not suiting for them and then they can take care while taking these kind of food items.
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We hope that his course has been informative and has empowered you to get more insight into the condition. If you have any queries please feel free to write into us.
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