Friday, September 25, 2009

Interstitial Cystitis can mimic other common female pelvic conditions

Interstitial Cystitis (IC) is a chronic pain syndrome of the bladder that is often now included within Painful Bladder Syndrome (PBS). IC is noted for symptoms of pelvic pain, urgency, frequency, nocturia in the absence of bacterial infection.
Some surveys show that it may be present in up to 2% of all women. The chronic nature of the symptoms can be debilitating and have a profound negative impact on quality of life.

What causes IC is not well understood, but it may be secondary to defective bladder lining that then allows acid/other toxins to permeate into the bladder wall and lead to pain. Pain nerves are stimulated but perhaps maintain an “on” state where pain is perceived in the absence of the bad stimulus.

After a bladder infection is cleared with antibiotics, the pain and symptoms resolve. In IC the nerves that send pain signals may continue to be active despite the fact that no toxin/bacteria are present any longer.

So what can common diagnoses can IC mimic? In other words, most or all of the following conditions are often diagnosed first, while IC becomes a diagnosis of exclusion once these common problems have been ruled out.

Recurrent UTIs- a simple culture can verify the presence of bacteria, but if recurrent UTIs really occur, a search for why bacteria persist or recurs must be sought after.

Endometriosis- this could lead to pelvic pain and bladder symptoms, as well as pain with sex. Pain with endometriosis will mimic the menstrual cycle and laparoscopy with a gynecologist can make the diagnosis.

Chronic Pelvic Pain- this is usually defined as pain for at least 6 months with unclear etiology. It can be from the back, buttocks, abdominal wall muscles, and the pain leads to functional impairment. Common causes are: adhesions, pelvic inflammatory disease, ovarian pain, radiation pain, and so on…)

Vulvodynia- this is pain emanating from the opening of the vagina in the absence of any clear pathology. The vulva and the bladder share nerve endings and are derived from similar structures in development and there is likely some crossover in perception of symptoms. Often IC and vulvodynia will be diagnosis together in about half of all IC cases.

Overactive Bladder (OAB)- This is a common constellation of symptoms of urgency, frequency, and urge incontinence, with or without nocturia. It does not involve chronic pain. Often, OAB can be managed with fluid/diet/caffeine control, and of more severe, medication.

Bladder cancer- This usually presents with blood in the urine. It’s higher risk in those over 50, or smokers. Gross blood in the urine should always be evaluated, but microscopic blood in this age and risk group should also be evaluated. Bladder cancer usually doesn’t cause pain, but can lead to OAB-type bladder symptoms.

Friday, September 18, 2009

Persistent Gential Arousal Disorder

Recently I saw a patient with an interesting and peculiar complaint: she felt constant clitoral arousal that lead to pressure that she could not relieve. It was leading to anxiety and disrupting her life and activities. Even after achieving orgasm from masturbation, she would still sense the clitoris to be stimulated.

It was fortuitous that I read about this condition about 3 months before I saw the patient in the office. It is a little known condition that was first described in 2001. It is a problem of genital arousal not sexual arousal. Patients will experience tingling, pressure, irritation, congestion, throbbing, pain or vaginal contractions. Only sometimes can sexual intercourse or masturbating alleviate the sensation. In a recent Dutch study, there appears to be a correlation between PGAD, overactive bladder and anxiety.

In my patient’s case, as is described for PGAD, the patient felt genital/clitoral arousal the entire day; it was unwanted and intrusive to her life; it was triggered by non-sexual activity (she had a UTI that preceded it); it lead to distress; it was not associated with a psychological condition. Because of the problem, her anxiety level is raised which leads to a vicious cycle of worsening the condition.

What are considered to be the triggers for PGAD?
Sexual stimulation
Masturbation
Stress
Anxiety
Loss
Menses

What can exacerbate the condition?
Pressure against the genitals
Visual arousal
Vibration (car, motor)
Stimulation by partner
Intercourse
PMS
Genitals becoming too hot
Riding a bicycle/horse

There is no specific treatment since the cause remains vague. Psychosocial support and defining the condition helps to create some knowledge that such a condition exists. Intercourse or orgasm may bring some temporary relief. Ice or topical anesthetics can help reduce swelling and sensation. Pelvic massage or stretching exercises may help. Mood stabilizing medication is empiric and may or may not help, especially if there is underlying anxiety or depression. Anxiety-reducing coping skills and activities can lead to distraction and may be useful.

Thus far, topical anesthetics have brought my patient some relief.

Tuesday, September 1, 2009

What Causes the First UTI a Woman Develops?

Like most women suspect, often the first UTI a woman will have is related to sexual activity. In bygone days, it was called “honeymoon cystitis”, referring to a bladder infection the developed after have sex on the honeymoon. Recently researchers in Florida characterized the presentation and risk factors of the first UTI women experience.

181 women who visited the university health clinic in Gainsville, Florida for their first UTI were observed and compared to controls. Urinary urgency and frequency were the two predominant presenting symptoms in these young women. The average age was 21 years. Sexual activity was the most important risk factor for their first UTI, with vaginal intercourse and number of sex partners within the prior two weeks. Interestingly, tampon use vs. pads during menstruation and direction of wiping was not strongly correlated to first UTI. (These are two hygiene practices I ask about in my female patients who have recurrent UTIs, though).

There was found a strong correlation to coffee and tea consumption, and a weak correlation to alcohol consumption. E coli was the most common bacteria isolated in cultures, followed by Ureaplasma. E coli happens to be the most common bacteria causing all UTIs.

The ultimate conclusion of the researchers was that certain lifestyle choices are the items that pose the risk for development of the first UTI.