Chronic suprapubic pain

Specialty: Nephrology and urology.

• persistent anterior pelvic pain
• chronic suprapubic discomfort

Why it occurs

• Interstitial cystitis / Painful bladder syndrome (suprapubic pain of more than 6 months of evolution that progressively worsens with filling of the bladder and is relieved with urination, in the absence of proven urinary infection)
• Chronic radiation cystitis or actinic cystitis (late complication of pelvic radiotherapy for gynecological, prostatic or rectal tumors with bladder obliterans endarteritis, wall fibrosis and ongoing pain)
• Iliohypogastric nerve neuropathy (due to injury or entrapment after previous pelvic surgeries, cesarean sections or laparoscopies)
• Chronic pelvic pain syndrome associated with hypertonia of the pelvic floor (muscle spasm of the levator ani that causes pain referred to the suprapubic region)

Initial workup

High resolution kidney-bladder ultrasound with high frequency transducer; urinalysis with repeated negative urine cultures; urine cytology in three isolated samples to rule out transitional cell carcinoma of the bladder; cystoscopy with bladder hydrodistension under anesthesia (to evaluate the presence of Hunner's ulcers or glomerulations typical of interstitial cystitis).

Standard management

• Pentosan polysulfate sodium — 100 mg orally every 8 hours; restores the damaged glycosaminoglycan - GAG - layer of the bladder mucosa in interstitial cystitis, requiring 3 to 6 months to evaluate response; monitor coagulation tests
• Amitriptyline — 10-25 mg orally at night, modulator of chronic pain of neuropathic and visceral origin
• Antihistamines such as Hydroxyzine (25 mg daily at night to reduce the degranulation of bladder mast cells involved in the pathophysiology of interstitial cystitis).