Pain related to the bladder is common and can be complicated, but diagnosis doesn’t have to be. In this resource-packed talk, urogynecologist Caitlyn E. Painter, DO, explains how to categorize causes, what to understand about urine cultures and other tests, and the latest evidence on which treatments help patients. Get her experience-based guidance on selecting prophylactic antibiotics for UTI-prone women, an inside look at the urinary microbiome, and a better definition for bladder pain syndrome (formerly interstitial cystitis).
All right. So uh we will begin with everyone's favorite topic which is D. C. Area and what to do when it persists. It's frustrating for the primary care physician. It's frustrating for the specialists and certainly frustrating for the patient um and can have significant impacts for the quality of life. So I'm happy to be sharing this information with you today. Um I have no relevant financial disclosures. Um and as we had discussed in the beginning I am very open to questions I can't see you. So it always feels a little bit odd giving these virtual presentations. Um but hope has agreed to monitor the chat And I'm always happy to answer questions as we go and um really have this be tailored to your needs and create a dialogue about how I can help you. Um For the purpose of this talk will be going through really persistent to syria and some of the causes both infectious and non infectious and and some of the things that we can do about it and really what you can do as the primary care physician and how you can get someone started on the on the pathway to feeling better. Um for this presentation i the the the word women will be used. That's what's used in the studies. This is specifically for individuals born with female genitalia. Um And and this talk is not necessarily um tailored to the transgender individual. This talk is also not going to review some of the other gynecologic conditions. I may mention them but it's not going to go into depth or detail about how to treat let's say simple cystitis someone's first episode um or even um uh you know the specific treatment of vaginitis or stds but we will talk about you know making sure especially in your patient population you know having to roll those things out. Okay so what is this area? Um This is the definition that was given by the international continent society. Um And they've really done an excellent job of trying to standardize definitions and terminologies both for research but also for clinical practice so that we can know what we are talking about when we speak to each other. And I do. I really like this definition as it really presents. Thinking about the lower urinary tract is not just the bladder and the urethra but that things can be referring pain to that area. So it can broaden our differential when we're talking about the area. So it's a complaint of pain burning or other discomfort during voiding. The discomfort may be intrinsic to the lower urinary tract that is the bladder and the urethra or external or referred from another adjacent similarly innovative structure. They say lower ureter here but we have the uterus and bowel. Um And the male flashes. We'll talk about later. So moving forward we'll we'll talk briefly about infectious causes and what to do and and the definitions associated with those um for recurrent U. T. I. There are many different definitions that are out there. And I prefer the definition that was coined by the american urologic association and this is also accepted by several other different societies and it's helpful to have that same definition um Both for for research but also for giving someone a diagnosis. And that is when um patient has two episodes of acute bacterial cystitis within six months or three episodes within one year. And the prevalence is very difficult to predict. It depends on the age of patients that you're looking at, it depends on the study. Uh And this data isn't very good because this is often retrospective data and people have defined uh urinary tract infections in different ways and studies. So it may not be based off of urine culture. It may be based off of just patients they pick up antibiotics. Um And so it's very hard to actually get the prevalence of the UTA. Recurrent U. T. I. This specific study looked at 100 and 13 college aged women um and what they found was that 27% experienced at least one culture confirmed recurrence within the first six months after initial infection. So by by definition of above that that's 27% of women are are having recurrent U. T. I. S. And then of of those 2.7% had a second recurrence within the same six months. So this is something that you will be seeing in your in your clinic. Um so what can we do about it? Well first is how do we help patients get a diagnosis? Currently the standard is still a urine culture. Um And I wanted to to bring this up because we get into this cycle where you know maybe for the first U. T. I. You're going going off of the dipstick or you go off of patient symptoms. But then we really want to be making sure that we're treating them appropriately. Really making sure that it's actually truly an infection. So ordering a urine culture and for some of these patients that you know really they're constantly getting antibiotics. You know they're calling in after hours. Maybe not. You know even seeing a provider. Um And then they're just on these antibiotics. I will order a standing urine culture. So that way they can actually just go leave the sample. Um And then that will come back to me and I really try to tell them like let's hold off until we get the culture before giving you antibiotics and then you'll start to see the split where you get the patients that truly have the current U. T. I. And then the patients that have this area that's not an infectious cause. I wanted to take a minute to talk a little bit about some new molecular methods and I'm not going to go into big detail but it's sort of the hot topic within um Euro gynecology or urology right now And and it's this multiplex PcR testing or NGS next generation sequencing for for urine pathogens and these remain understudied. Um and I don't you know in in my patient population I have I would say a few patients a week asking me for this testing. Um and it may be that this proves to be fruitful in the future but it remains understudied at this point. And there are no studies that are actually looking at outcome data. So there are studies looking at standard urine culture comparing it to the you know, urine PcR testing. And they find that the urine PcR testing is finding more more bacteria or even um Canada microorganisms than standard PcR testing. And it tends to find our standard culture. And the PcR testing tends to find things that don't really grow out very well on culture. The problem is we don't know what that means. So you know, if you get this testing, your patient may come to you with like 15 Pages report of like percentage of this percentage of that percentage of this and you don't know what it means clinically. You don't know if this actually has anything to do with their symptoms. And then it can do that slippery slope of. Now we end up over treating these patients are on you know long term antibiotics or or higher dose antibiotics or antifungal and we don't actually know if it's helping. Um And so so I this is kind of what I tell my patients like this may be the future. We may get there when we have more studies that are looking at, you know, what is the normal urine microbiome? Um And and that's something that is also a shift in thinking um there is evidence of a urinary microbiome. So we used to think that you're in with sterile and urine is is actually not sterile and this is really in its infancy scenes in being studied. And um very much a hot topic within my field is what is the urine microbiome? What is the difference between controls? You know why? Which of these organisms are actually beneficial and protective and which ones are truly pathogens and and how should we treat? And we just don't know yet. So I sort of tell people to, you know, let's hold on this and I don't want to go down that slippery slope where I'm getting you on antibiotics that you don't need and we're getting into that spiral where now we're in anti microbial resistance patterns. There is studies that show there is a difference between the urinary microbiome between controls of those with pain and those without pain. So I I think it's exciting that may help us in future research. Um and there are studies that show that lactobacillus within the urinary microbiome as well as an increased diversity. So a diversity of the microbiota is that maybe actually protective as the, you know, patients with pain tend to have less lactobacillus and tend to have less diversity in their microbiota. So when I talk about that too with patients I say well if we're giving you lots of antibiotics we may actually be decreasing the good bacteria that's in the urinary microbiome. Um And for the most part patients are okay with it. But these urine pcr testing stations can actually go online and buy themselves. Um And most insurance companies don't cover it. Um But I just wanted to take a minute to talk about it because I think you will as it's becoming more and more popular and as there's more and more ads out there on the internet I think you will be getting these questions as primary care providers as well. Okay so this is a picture of the eu a guideline and algorithm for recurrent urinary tract infections in women. And this is specifically for uncomplicated patients. Um complicated patients would be someone who has a congenital malformation. Someone who has a condition like multiple sclerosis where they have incomplete bladder emptying. Um And they're using a catheter or you do an exam and something doesn't quite feel right. Those are the people that you should feel very comfortable sending to to us to help you with. Um But but it's really the uncomplicated patients so their exam is normal they're healthy. They just keep getting these U. T. I. S. Um And and that you know I don't know if you can see my pointer here but but that's really this side here. So so once we get them started on antibiotics what can we do for prophylaxis? And the evidence uh the evidence is it's tricky here. Every time a new Cochrane review comes out it contradicts what the last one had said and it's a it's a mixed bag. So antibiotics are actually so so low dose antibiotics are actually the most effective especially in the younger patient population. Um when we're talking about post menopausal women and and I haven't really talked about that because that's not you know in general your your patient population vaginal estrogen is very important and very effective in preventing U. T. I. But um in younger patients where you're not worried about a lack of estrogen doing low dose antibiotics is actually very very effective. Um And you can decide whether or not they have a trigger. So in this younger patient population sex is a big trigger. Um A common thing that I see is a patient that says you know haven't been sexually active for a while and then I have a new partner and I did all the STD testing and it was all negative. But I keep like every time we have sex I get a U. T. I. Um and those are the patients that I typically will start them on a post coital antibiotic prophylaxis and they do really really well um in some patients who they can't really identify the trigger. Um we do talk about a course of antibiotics. So 6 to 12 month course of continuous prophylactic antibiotics. Um and that's really a discussion with the patient. So and and in the studies that have been done it seems that continuous prophylactic antibiotics and postcoital antibiotics. Antibiotic perplexes seem to be similar in their efficacy. Um Now I just said we don't want in the previous slide we don't want to go down that slippery slope of giving people too many antibiotics when they don't need it. Um So what are some of the non antibiotic prophylaxis things that we can offer patients and get them started on. So um going back to other things that we can try. Um De manos is sugar a policy aka right Actually that has actually some evidence. It depends on the study that that you read. But the newer evidence is actually showing that the demon knows can be effective in preventing U. T. I. S. And it's specifically for bacteria that have the little flag ela because it prevents the adhesion. And so um the main bacteria that has that is E. Coli which is the number one cause of of U. T. I. S. And that um the demands prevents the adhesion of the L. A. To the Urethra helium and you want to make sure that patients are getting enough. So the studies look at 1 to 2 g a day. Um And then if you look at most commercial preparations, they're usually around um 500 mg. So I often tell people patients that depending on what they buy they need to take 2 to 4 of those a day. Um And it's been it's very well tolerated. Um You know for people that you're worried about blood sugar for diabetes, it does not increase um their blood sugars. Um And so that is often something that I will start people on. Um for the other things that are available, Cranberry is has not shown to be effective. Um And so I tell people you know especially like cranberry juice uh that you know it needs to be that without sugar and the active component in cranberry that's actually preventing the infection is pro anthocyanins or packs. Um And if you look at the concentration of the cranberry, the pro anthocyanins are fractionally much more pro anthocyanins and other things like chocolate and coffee. So uh so cranberries sort of something of the past. I don't typically recommend it if you're buying capsules. Another thing that's tricky is that the concentration of the cranberry is very very different within the different concentrations. And so I believe that is why we're getting such mixed data and which mixed results. Um The last Cochrane review that showed that there was no evidence to support the use of cranberry methamphetamine is something that really doesn't have a lot of studies on it. And a lot of data um and this is used to acidified i the urine. The tricky part about methane amine is that it's actually converted to formaldehyde in the bladder. Um And there's no long term studies on it. So we actually have no idea what happens when you convert uh you make formaldehyde in the patient's bladder. Um And so formaldehyde is a known carcinogen. So I'm I'm pretty cautious especially in the young patient to get them on methamphetamine when we don't actually know what it's gonna do to the long term. You're you're a helium. And it's actually not that effective. The other thing about meth ketamine is that it can be tricky for patients in that you actually need to stop it when you're taking antibiotics for an infection because it can make the antibiotics less effective within the bladder itself because of the acidification. And and it depends on the antibiotics but one of the ones that it really doesn't work with is sulfa antibiotics. So back drum. Um And so that's a very common one that's prescribed. So so I tend to avoid my cinnamon as well. And I would love probiotics to work. That sounds great. I would love probiotics to be the answer. And yet it is not. There's there's good studies that show that probiotics don't do anything. So hopefully as as um my colleagues are researching the urinary microbiome. And we learn more about that than we can to tailor uh different non antibiotic treatments to help with our current U. T. I. So currently I realized to de manos and considering post quota antibiotic especially for the younger patient population. I this is just from up to date and I just wanted to throw this up there because I think this is something easy for you to look up um to look at antibiotics and dozing to figure out what you want to start somebody on. Um And and this is I agree with this chart within up to date. I typically will start people on nitro foreign twin or macro bit if they can tolerate it. Um It's very well tolerated in general. Um And the it's the reason why I like it is that it it doesn't have high resistance patterns. Um And certainly when we get people with multi drug resistant organisms there can be some resistance to nitro friend to inter macro bid. Um But in general um most bacteria are susceptible to it. The caveat being that nitro Frenchman is bacteria static not bacteria sidle. So if someone has um you know pretty significant infection where you're worried about pilot nephritis it's not something that you would use. And then this is probably not something that you're thinking about in your patient population but in some of my elderly populations you want to make sure that they have good kidney function. So it doesn't work if they're G. F. R. Is less than 60. So I don't think that you're really worried about that as much. The second one is Bactrim. I actually try not to use that because especially with E. Coli and especially in this area and looking at um resistance patterns there's high equal i in the bay area has a high resistance to Bactrim. Um And also Bactrim is uh something that's very good for Mersa. And so I don't want to create more bacterial resistance. So I actually try pretty hard to stay away from Backstrom if I can. Um And I will often use uh election or Catholics for for postcoital postal axis. Um The fossil Myson is really nice. Um I tend to uh leave that for a little bit later because again there's not that much anti microbial resistance to fossil Myson. Um And so I tend to use that as like my secret gun when people have developed resistance to other antibiotics and you know I sort of reserve and save the fossil medicine. Um It's a little bit tricky because because it's a packet a three g packet of powder that you have to put into a cup and then the patients will use it like once a week. And so it's a little bit harder to remember. Okay so moving on to other infectious causes of death syria I just with your patient population. I just figured that you know I would bring this up and and you're probably already doing this as you know just for any of these patients, making sure that you're getting STD testing specifically in this area, gonorrhea has significantly gone up. So that's a this is a nice picture of the gonorrhea diplomat guy. Um But classically gonorrhea, chlamydia, herpes and trichomoniasis can all create a your arthritis. Um And then for for vaginal itis, some vaginal tv doesn't really typically cause it's a Dc area, but anything that that um you know infectious in the vagina can certainly lead to a feeling of d syria. Um And so just making sure you're you're checking these things off and again this is a little, you know, that would be another talk of of how to treat those things. Um I wanted to pause right here and talk about another common question and and and uh controversial topic in which is the testing for mycoplasma and your real plasma. So these are not tested for in routine urine cultures, you would need to do a specific test for these. Um And I really try to avoid doing this as well well. And that's because michael plasma and plasma are common genital urinary colonizers. They are basically a normal part of the vaginal microbiome in a sexually active person. Um And so if you look at, you know different studies will say oh if i if you should be getting a urethral swab for micro plasma urea plasma, but in more recent studies if you do that, it's the detection is not actually associated with irritated voiding symptoms or or dis syria. And so it's one of those things or yes, we found syria plasma and mycoplasma. We think we know that it's sexually transmitted but it's actually what we're finding more and more now is just a normal part of the urinary microbiome. I will have I will have patients that have you know, gotten tested and then they say, okay well I want to be tested again and because I have symptoms, you know, they did a course of doxycycline or leave boxes in and they say well I want to be tested again. Um And then in the times when I have done that often times negative and they're like what my symptoms never went away and that's what you know the new studies are showing is that you know, your replacement micro micro micro plasma actually not associated with these serious symptoms, it's just a confound er that we happen to be finding. Alright, so, moving out of um infectious causes to non infectious causes. So I feel like this is uh sort of the main lecturer and figuring out, you know, interstitial cystitis in and bladder pain syndrome. So these are the patients that you get that they constantly say I have a U. T. I. You you actually are doing the testing. They're getting your and they have negative urine cultures or they are the patients that have had 5 to 7 to have, you know, 20 quid versus of antibiotics and they're like, I'm still not better, I'm still not better. Um And this is sort of, this truly is a syndrome. So it really just incorporates a lot of different things and and and as pain syndromes go, uh it's very complex and difficult to parse out where where people really are and who's really falling into this category. And it's really a diagnosis of exclusion. So, so the current definition of um I see BPS, or we're really moving away from interstitial cystitis to the terminology bladder pain syndrome is an unpleasant sensation or pain pressure or discomfort perceived to be related to the urinary bladder associated with urinary tract symptoms of more than six weeks duration in the absence of infection or other identical identifiable causes. Um And this definition is important because it's only six weeks. So we can give people this diagnosis a lot sooner. You know, if you think about the other diagnosis in my field, which is chronic pelvic pain, that's six months. So six weeks versus six months. Um and then it doesn't actually need to be coming from the bladder, but it's perceived to be related to the, to the bladder. So what do people feel? Well they feel dysphoria? They feel urinary urgency and frequency. It's very common. Another thing in my field that, that I deal with is overactive bladder and if I could draw a Venn diagram, there's the, I see patients and the overactive bladder patients and a lot of patients where the two circles overlap. Um And then bladder pain. So the traditional thought was that they need to have pain with bladder filling that was relieved with voiding. Um And that is a little bit too too sensitive and too specific. And it leaves out a certain subset of population so it just has to be any sort of unpleasant sensation in the bladder doesn't necessarily need to be with feeling alone. Um And and a lot of times these patients are avoiding a lot to try to help relieve the pain. Okay so the prevalence is very very difficult to estimate. But in some of the more um the more recent studies the thought is that it's about 2.7 to 6.5% of women us age women 18 or older will have this diagnosis of I. C. B. P. S. And they actually think this is an underestimate because on average it takes about two years for women to get an actual diagnosis of bladder pain syndrome. So they're experiencing these symptoms are going through the rounds of antibiotics, they're trying to rule out all of those things and it takes about two years to actually get this diagnosis. Um And if you think about those percentages that's in the U. S. That's 3.3 to 7.9 William million US women that's a lot of women. Um There it's tricky to figure out where these these patients fall because patients will have different symptoms. Um And there's a there's a significant heterogeneity and the symptoms. And so there's been an initiative within the NIH with the map network was recently I guess it was in the early two thousand's to specifically look at pelvic team. Um and to look at how can we look at pain phenotype? So the not the studies on bladder pain syndrome are are lacking in a few different ways. One is that because of the heterogeneity of the patient population, the change the changes in the definitions as well as not really knowing the path of physiology of it. The treatments are not all that great either. And so this is what the NIH is really trying to work on and trying to figure out can we actually phenotype these patients? So are there people that are more urgency and frequency related? Are their patients that are more allergic component related? Are their patients that are more immune related. And that's where the current researches on on painful bladder syndrome. Because the hope is that if we can actually phenotype these patients into pain categories and we can tailor the treatment to them a little bit better and find them a treatment that's going to work faster right now. It's really just a trial by error. You tried this that didn't work. You tried this, it didn't work. You tried this, it didn't work and you just kind of move down the algorithm rather than saying, oh you have these specific clinical constellation of findings. What can we do to really target that for you to get these patients feeling better faster. Um We do know that there is a separate separate process. And really, really we think it's an autoimmune condition where patients actually have ulcers and and patients with all sort of I see is uh what I have picture here, they have a different disease process. Their symptoms are more severe. Um They're often having blood in their urine, bleeding in their urine. Um and they have pretty significant urgency and frequency because their bladder is not very compliant. So they can't hold that much. Um and those are the patients that do need a system copy and they're treated a little bit differently. So those would be the patients that kind of get bumped up to a sub specialist. And I think that's the challenge of trying to figure out well, you know, who should I send to you and and who can I start? And I would say you could start, everyone will talk about some of the first behavioral modifications, but when they're having persistent blood in their urine, when they're really debilitated by their their pain. And that's when I would say send them off to the sub specialist sooner rather than later. So we can decide, yes. No. Do they need a cyst ask api um and the whole reason for doing this is Sascha P is to try to see if we can see these ulcers because these ulcers, this can be treated in a very specific way. Um I do not offer all of my patients of Tosca. P. So um there and and it's not necessary for the diagnosis of painful bladder syndrome. Um it would be necessary to exclude a hunter's ulcer but it's a painful procedure. Um and if you don't see these hunters ulcers, it there's there's other things called variolation which is really just an increase in in the vascular charity of the bladder that is not sensitive or specific. So there's plenty of patients with painful bladder syndrome that have completely normal cyst ask api findings and there's plenty of patients that I do a system for for whatever reason. And I'm like, oh look they have increased, you know, glamour relations in their bladder but they have no pay. So that's why I do not. The system api is not, you know, in in the definite diagnosis of I see. Um however, you know, I I think it's very reasonable for um the primary care physician to say, you know, this patient is really, really worried. Uh this doesn't seem like, you know, someone who is gonna respond to some of these things to go ahead and refer them and then we can consider whether or not whether or not they need a Sista Ska P. So again, I wanted to give you a nice algorithm. I feel like it's nice to have these algorithms, this is like from the eu A as well um for you to kind of say okay, where do I think this patient falls? Um and what can I do to help? So I would say the bottom side of this algorithm is is more for the Euro gynecologist or urologist. And then the top side is really something that I want to empower you to start. Um And so that's this real box here. So the behavioral and non pharmacological treatments, they actually work great. I make all of my patients do this because for all of the treatments that we have for painful bladder syndrome, behavioral modifications actually work some of the best. Um And then I do think you could try some of the oral medications um and the oral medications is plus or minus, you know, treatment for painful bladder syndrome. Any, any one thing that we have is around 50% effective. So better than placebo but not fantastic. Um Just before I go and I do want to mention the this thing PPS is uh the name for it is El moron. Um and I I typically don't prescribe that anymore. Um and I would I would caution you to be careful in prescribing that because there is um very real and significant data that there is a side effect um of retinopathy that can actually lead to blindness. Um And it's rare but it is definitely been proven in studies now. So usually when I am offering that to patients, they are like well I would rather deal with bladder pain than go blind. Um And the problem is we cannot predict what will happen to and once it happens we can't reverse it. So if I do have patients that are already on it and they're well controlled then I do make them get a dilated eye exam every single year. Um So I wanted to move on and and make sure that I'm saving time to to talk about other questions. But to review some of the behavioral and non pharmacologic treatments that that you can start to offer and give you some some resources that you can actually print for patients. So the first is looking at the I. C. Diet or removing bladder triggers um and doing a bladder diary. And I think in these pain patients where they're just like come in with this list of complaints. I say, you know what let's let's figure out what's going on here is the diary. Go home. Really look at this, Look at your life, what's making this source, what's making this better And then come back to me with this diary. Um And and it's so simple and yet so effective. This is an example of a specific food and intake voiding diary. That specific for pain. So it's looking at the symptoms that patients had. Um and this was taken off the website that I gave um here, which is I the I. C association when we look at bothersome food and drinks, I tell patients, you know, not all of these will fit for you, but some of them will and they're all the good things in life. So coffee, tea, alcohol, spicy food, tomatoes, uh fruit juices, artificial sweeteners, um and I don't, and the other thing that I tell patients is like, once you find your trigger, if you're feeling okay, you could always try to have a glass of wine and see how you do. And then if it just steps you over the edge, then maybe wine is not going to be something that works for you. But if you're in the middle of a flare and you're currently triggered, then this is when you need to back off of those things that are classic era tints to the euro thallium of the bladder. And some patients, and this is where you get to that phenotype ng against some patients who truly have triggers and they can tell you right away what the triggers are. Some patients don't really know. And then you start talking to them and they're like, well, I take I drank 15 cups of coffee a day and you're like, well, what happens if you take out 10 of those and they're like, oh, I feel better. Um So, so that's where the voiding diary comes in and then some patients are, like, I've tried the whole, I see diet, I basically drink water and eat toast and I don't feel better. Um and so I don't tell them they necessarily need to be restrictive. And then on the icy web site there is um guides to how to do an elimination diet. So basically not taking everything out at the same time, doing one thing at a time, you know, giving it a week or two to see the difference in their symptoms. So they can actually figure out what their true triggers are. Um, and this can be really empowering for patients and give them some control over what's going on and also allow them to see, you know, what truly are there, are there triggers, uh, coffee, red wine, and uh, and I would say like the tomatoes, the tomato sauces, tomatoes tend to be the biggest ones that I see. Um uh so you will have patients that won't want to give up their coffee. I don't want to give up my morning coffee, but it's just what they're um willing to live with and then for the multimodal pain management that was in that box, the evidence for here is really lacking. Um, but essentially what the american urologic association has said and their most recent update on the evidence is that there's no evidence for this, but it may be helpful and there's really no harm in trying these things. And so what can you do to help patients in the middle of their trigger to make them, you know, in the middle of their flair, right? Um I guess one thing that I didn't say is it's very common for for painful bladder syndrome patients to have flares. So they're they're doing great for you know, 2 to 3 months and all of a sudden they have this flare and they're miserable for about two weeks and then it starts to get better and they just kind of go up and down and up and down. Um And so how do we get them through their flares? So um so Pirate Pirate Dean um or Pirate or as oh um is something that I really really like to use because you can use it as needed. Um and you know, I just want them. It's gonna turn your p right orange. It's pretty cheap, You can get it over the counter and it's safe to take. Um And there is some studies actually looking in in in rat models that have looked at, well why does this work for the bladder? And it does something to the a parent delta fibers in the bladder to decrease pain sensations. So it tends to work pretty well for some patients. Um I try, you know, a set of medicine and and said can be helpful um hot baths, you know, putting a hot path on the lower abdomen. These are things that um you know, help some patients, you know, kind of get them through their flair without, you know, adding any increased risk. I'm incredibly, incredibly cautious and pretty much never prescribed narcotics for these indications. Um They don't tend to help. And then it just leads to another whole host of issues. There are nutraceuticals and um it's I I do well I will sometimes talk about them with patients and I say just like any supplement, they're not really well studied. Um There's two that I've listed here, calcium, uh glycerol phosphate, which the name is is relief. Uh There is actually a pretty decent study on that one and that's uh specific the way that I describe it to patients is uh it's like tons for the bladder. So if you know that you have a specific trigger like coffee or pizza or something like that, then you can take this uh you know, when or after you've had one of these things that can and it can be relieving. Um There there was only one study that it that was actually randomized and it was a small study, but it did show um About 60% improvement in symptoms. So, um I in my patients that have tried it, it's been a plus or minus. It's um pretty cheap and uh and you know, no significant side effects. So i if they have a specific trigger, I always say it's worth a try. Uh and then this is the second one with all of these different things in it. Um The I know I'm not supposed to be using trade names but it's a it's called system approach check. Um And the whole idea of this is that these um uh components are designed to coat the lining of the bladder. So one of the theories of pain and painful bladder syndrome is that the the gag layer, the second layer, the protective layer of the bladder has broken down. And so like instead of leaky gut it's leaky bladder. And so there's exposed pain sensors because there is a breakdown in the protective layer of the bladder and this is designed to to coach that. Um And there I cannot recommend a study on that, but but it is another option and when I counsel patients on it, I say just there there is not a lot of evidence to support or or refute the use of this. Um But it's it's interstitial cystitis and painful bladder syndrome is tricky and we don't have a lot of good treatment for it. So I do offer it. Um And then I definitely spend a significant portion of my time talking about the brain bladder connection. And I often say this is where Western medicine failed us and that we don't we are not able to always understand the way in which the our anxiety are mental health, the stressors of our life are impacting our bladder and people feel it in different ways and a lot of young women feel it in their pelvis and their bladder. Um And so there's a significant um component of anxiety related to some of these these bladder symptoms. There's a high rate of psychosocial comorbidities in patients with painful bladder syndrome. And it's hard to know like is it, do they have really bad depression and anxiety because they've been living in pain and they haven't been able to get help or is the depression and anxiety making it worse? And it's and I don't think we can actually tease that out. Um And it's prob probably a combination of both um and a cycle and cyclical. So the anxiety gets worse. They get to they start to flare a little bit and then that'll make their anxiety a little bit worse. Um There is some newer studies looking at, you know, our women with painful bladder syndrome um traumatized and there was, you know, a small pilot study that did show that there was some provisional criteria for PTSD and these patients, um and specifically they were looking at adverse childhood experiences and assault. And they did see that association and that's mirrored in the literature for chronic pelvic pain in general. Um So trying to treat some of the stress and anxiety is important and UCSF used to have during the the the pandemic. We have an integrated medicine center here called the Osher center. They were giving free mindfulness webinars which was which was great but I think that that has gone by the wayside now. Um But I imagine that UC Berkeley there are options for yoga or meditation or mindfulness. Um And and even if it's not um not necessarily helping the bladder itself, it can help the anxiety that goes along with it. And also give give these um patients um tools to help with some of the catastrophizing that comes along with it, where they just like can't stop thinking about their bladder to give them a way to kind of escape that cycle where they are not leaving the house because of their bladder. They're not doing anything because of their bladder and give them coping mechanisms really. Um And they were starting to study that as well. Um There was a study that looked at, you know um a specific, I think it was an eight week mindfulness based stress reduction program and it did show benefits in some of the validated questionnaires that look at bladder pain syndrome. So I definitely address this with the patients and when you talk to them about it, they'll say it's completely related to my anxiety or they'll say I feel the pain in my bladder but I really actually think it's all in my head. Um and you know, I validate them, it's not all in your head, you are feeling it in your bladder and there is a connection between your mental health and your bladder pain. Um And just to feel just hearing that I think can be helpful for these patients. Uh and then this one is my official pelvic pain. I could give an entire other grand rounds on this but I wanted to put it in here. Um my national public pain is very very very common in in in women um and in women with pain disorders. Um and specifically we have found that like 70-80% of patients with a diagnosis of painful bladder syndrome will have my own national trigger points on exam. Um And so this is where a public for physical therapist, a good one is worth their weight in gold. I love our public for physical therapist here at UCSF. They're happy to see your patients. Um and they really really really help these patients not only are they working on the um you know doing actually internal work to release these these tight muscles and and triggered areas, but they're also teaching home exercises that these patients can do at home. Sometimes you know here at UCSF they do some zoom visit. There are many actually private practice public for PTS. In the East Bay. Um The one thing that I would say about private practice PTS is they don't always accept insurance which can be and challenging. So they you know, they'll send a super bill and it can just get really really expensive. Um I do know at alta Bates uh they do have a public for P. T. That are a public for pt group that does accept insurance. Um And uh and they'll often do breathing and relaxation exercises um and essentially a little bit of meditation to help these patients. Um And so I would say the majority of my patients with painful bladder syndrome are getting into public for P. T. At some point. Um And it's really unclear right? Is it is it the bladder pain that then caused a reaction in the muscles to tighten? You know that's what our body does to pay and we tighten up. Um Or is it that the tightness of the pelvic floor muscles is what's causing the bladder pain because you know you're kind of guy squeezing on those tiny little nerves that are going to the side of the bladder and the urethra there. I mean the urethra is essentially encased in pelvic floor muscles and it's and it's really it's really unclear and I don't think it matters because in in any pain syndrome it's usually multifactorial and people are going to get better if we treat all of the components that are leading to their their pain syndrome. So if you can find a public for physical therapist that you like and you refer to, they are worth their weight in gold. There's so many uh urologic and gynecologic conditions that can be treated with this and it's you know it's invasive in the fact that it's um often internal work. Um But it's it's there's really no no downside to it. Alright. And then I just wanted to end with this slide here. This was taken from the the chronic pelvic pain. Um The I. P. P. S. This is taken from their uh their site and I really like it because I talk about pain in the pelvis. You cannot it's very very hard and complex and all of these things go together. You know I can't tell you how many I see patients I have say oh is this related to my fibromyalgia and fibromyalgia sort of catch all for pain. They often have migraines. One of the one of the treatments, you know once they get to me that I can offer is actually Botox injections into the bladder. Um And then I find out that they're already getting Botox for their chronic migraines. And so we're kind of spacing it out with that. Um The it's it's the bladder bowel often go together. So you know I'm having them, see my g I colleagues for for the irritable irritable bowel while they're seeing me for their bladder. And often if the bowel gets worse than the bladder gets worse and and that has to a lot of that has to do with central processing again a whole other talk I could give on pain. Um But you know there's as as we get more pain inputs into the pelvis, it leads to, you know, the the gate theory in the pelvis you need less of a stimulus to start to feel pain. And so for these patients that are already sensitized and have the central sensitization it can take very little to kind of put them over the edge and to be into a flare. So if the if your patient is presenting with the, you know, the classic I see patient where I have a U. T. I have a U. T. I. And negative culture, negative culture, negative culture or antibiotic antibiotic antibiotic and not getting better. I do think it is very reasonable for a primary care provider to say, you know, I think this is painful bladder syndrome and these are the things that we can start you with and if you're not feeling better then we can go ahead and refer you to a specialist to see, to see if there's anything else that they can do. Um and I know especially with my colleagues here at UCSF that deal with a lot of endometriosis patients. Um Oftentimes getting that diagnosis can be very validating for these patients that are kind of living in pain and not really, you know, feeling a little bit lost or like it's all in their head. Um and then they can think about what they need to do to be feeling better. Um And then this last slide here is just some resources for you that are free on the internet. So the uh the au a both of those guidelines of algorithms that I gave you both on their current U. T. I. As well as on interstitial society, painful bladder syndrome are available. Um So you know you can access it from your computer or you can print it out and put it above your desk. Um And and the I. C. Help dot org is a site that I give patients when I do think that they have. I see and and give them resources that gives them a community. So there's a blog on there um as well as helping them to to think about steps of treatment. And then the last one here is just the center they do have. I'm sure you probably have a set Berkeley as well. Um But different classes, mindfulness classes, yoga classes, things like that that you can um join on to. Um And then I think I stayed within time. Hopefully there's a few more minutes for questions here. I'm happy to answer any questions. And then if there's further questions, you're welcome to email them to me. I'm happy to answer those as well