10 Tips For Managing IC / PBS From Professor Curtis Nickel

Key Messages

  • Interstitial cystitis ( IC) or Painful Bladder Syndrome (PBS)  is a complex condition, for which monotherapies are generally unsuccessful
  • A biopsychosocial approach to assessment, looking outside the pelvis, is recommended
  • A multidisciplinary team approach to treatment is essential

Interstitial cystitis / painful bladder syndrome (IC/PBS) is a complex condition, and often difficult to treat.  Professor Curtis Nickel, urologist and pelvic pain guru from Canada, was a key note speaker at the recent USANZ conference, and shared ‘10 Tips For Managing IC/PBS’.  His overwhelming message, loud and clear, was that IC/PBS is a multi-factorial condition, and a multidisciplinary treatment approach is essential.

Pelvic pain and urinary symptoms, commonly urgency and frequency, are the most usual symptoms of IC/PBS. There is no general consensus about the etiology of this disease, and treatment is often ineffective.  A recent systematic review investigated contemporary management of IC/PBS including behavioural, dietary, interventional, pharmacologic, and surgical therapies, and came to no clear conclusion1.  

Professor Curtis Nickel, a urologist and researcher from Canada, is pioneering the understanding and treatment of chronic pelvic pain internationally, and has a particular interest in IC/PBS and male chronic pelvic pain syndrome.  His recent keynote address at the USANZ Conference 2017 was fascinating.  He discussed 10 tips for managing patients with IC/PBS, which we would like to share with you.

1.    You Cannot Cure IC/PBS

Prof Nickel discussed the importance of reconceptualising our approach to IC/PBS.  Rather than searching for a single cure for this condition, we need to manage it by approaching it with a biopsychosocial framework for assessment, and a multidisciplinary treatment program.

2.    Set Realistic Goals

He recommended using patient related outcomes, not necessarily related to pain, frequency or urgency.  He commonly measures lifestyle, sleep, wellbeing, work, and social (including sexual function).

3.    Examine The Patient

Prof Nickel highlighted the importance of doing a thorough physical examination, including the pelvic floor muscles to check for tenderness or overactivity.

4.    Look Beyond The Pelvis

An interesting (but not surprising) point he discussed is the overlap of IC/PBS with other pain conditions.  He stressed that we need look beyond the pelvis, and ask the patient about widespread pain. For example, in patients diagnosed with IC/BPS:

  • 38.5% also had IBS
  • 18.9% fibromyalgia
  • 47.7% low back pain
  • 28% migraines
  • 14% TMJ disorders

5.    Phenotype The Patient (using UPOINT classification)

Prof Nickel and Dr Daniel Shoskes have developed the UPOINT classification, a 6-point clinical phenotyping system for patients with IC/PBS or chronic pelvic pain2.  The 6 UPOINT domains are Urinary, Psychosocial, Organ-Specific, Infection, Neurologic/Systemic, and Tenderness.  For each positive domain, specific treatment is offered.  For example, if the patient exhibits ‘Tenderness’ of the pelvic floor muscles, referral to pelvic floor physiotherapy is recommended. At WMHP we find the domain of neurologic / systemic and centralised chronic pain responds very well to pain science education.

For more information on the UPOINT system, visit http://www.upointmd.com/

6.    Most Important Management Principles

The most important management principles from Professor Nickel’s perspective are:

  • Education: explaining to patients our understanding of IC/PBS, that we don’t know what causes it, but they’re not crazy, and we can help them
  • Diet: if they have bladder hypensisitivity (non-hunners ulcers) then he recommends eliminating common irritants from the diet, such as caffeine, nuts, chocolate, and acidic fruit juices
  • Exercise and exercises: general exercise such as daily walking, and specific exercises such as pelvic floor muscle relaxation exercises and yoga.

7.    Identify And Manage Maladaptive Coping

There is often a huge psychosocial component of IC/PBS, and if this isn’t identified and addressed, treatment progress will often be slow.  He recommends screening for pain catastrophisation and maladaptive coping behaviors, and refer to a psychologist with an interest in chronic pain if these behaviours are identified.  

We have a few psychologists that we commonly work with for our chronic pain patients – please don’t hesitate to get in touch with us if you would like their details. 

8.    Sequential Monotherapy Is A Recipe For Failure

It is continually shown in research that monotherapy for chronic pain conditions doesn’t work.  Prof Nickel recommends a biopsychosocial multi-disciplinary treatment approach for far superior results.

9.    Develop A Personalised Phenotype Specific Treatment Plan

Prof Nickel and his team have recently published outcomes from their tertiary pain clinic in Canada, reporting almost 50% of their IC/PBS patients experienced clinically significant improvement, regardless of the complexity or severity of their condition3. They use a phenotype-directed model of care, using the UPOINT system to classify their patients, then have a multidisciplinary team consisting of a urologist, pelvic floor physiotherapist, psychologist and possibly Pain Specialist.

Their main treatment approach is:

  • Treat the patient: education, diet, exercise
  • Treat the bladder: medication, intravesical treatments, surgery
  • Treat the other identified pain generators: vagina, pelvic floor, bowel, fibromyalgia
  • Treat the “mind”

10.    Manage Expectations Of The Patient And Physician

Prof Nickel’s final point was to set realistic expectations for yourself and your patients.  He commonly aims for amelioration of symptoms, increase in daily activity, and improvement in quality of life.
 

References

1 Giannantoni, A., Bini, V., Dmochowski, R., Hanno, P., Nickel, J. C., Proietti, S., & Wyndaele, J. (2012). Contemporary Management of the Painful Bladder: A Systematic Review. European Urology, 61, 29-53.
2 Shoskes, D. A., Nickel, J. C., Dolinga, R., & Prots, D. (2009). Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology, 73(3), 538-542; discussion 542-533.
3 Nickel, J. C., Irvine-Bond, K., Jianbo, L., Shoskes, D. (2014). Phenotype-directed Management of Interstitial Cystitis/Bladder Pain Syndrome. Urology, 84(1), 175-179.