Painful Bladder Syndrome

What is painful bladder syndrome (PBS)?

Painful bladder syndrome is a condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region. The pain can range from mild discomfort, pressure or tenderness too intense pain in the bladder and pelvic area. It is a chronic, debilitating syndrome and people respond variably to treatment. There is no cure but patients can experience long periods of remission.

Who has PBS?

Painful bladder syndrome (PBS) is common affecting around 3-5% of the population. Nine out of ten sufferers are women. It can develop at any age but the most common onset is around the age of 40 years.

What causes PBS?

The cause is unknown. Most likely there are different causes for the same symptoms in different people. This helps explain why people respond differently to treatment.

Some of the possible causes include:

  • A leaky bladder lining. The theory is, there is a defect in part of the inner lining of the bladder, the so-called glycosaminoglycans (GAG) layer, that allows urine to irritate and inflame the bladder.
  • Excessive histamine release. Symptoms may be caused by an allergic reaction leading to the release of histamines from cells (known as mast cells) in the bladder wall. The histamines cause swelling and inflammation of the bladder lining.
  • Autoimmune response. The body’s immune system may attack the bladder.
  • Toxic urine. There may be an agent in the urine of sufferers which inflames the bladder.
  • Medication induced. The use of non-steroidal anti-inflammatory drugs (NSAIDS) has been linked to painful bladder syndrome especially tiaprofenic acid (Surgam).
  • Infection. An as yet undiscovered viral or bacterial infection.
  • Neurological. A nerve problem, making your bladder feel pain from things that usually don’t hurt.
  • Musculoskeletal. Cramping of pelvic floor muscles.

What are the symptoms of PBS

Common symptoms of PBS include:

  • The main symptom is pain when the bladder is full, with a feeling of some relief on voiding, or emptying, the bladder. Pain may be felt in the pelvis, abdomen and in the vagina. Pain may be worse with bladder filling, voiding or during sexual intercourse. Men may feel pain in their prostate, scrotum or penis.
  • Having to urinate frequently, including overnight, is a classic sign of IC. People with the condition may urinate 40 or 50 times in 24 hours in most severe cases compared to the usual seven or eight.
  • Urgency is the sudden desire to void that is difficult to defer. It can occur even immediately after urinating. It is usually not associated with urinary leakage or a fear of leakage. Some describe a constant desire to pass urine.

How is PBS diagnosed?

There is no conclusive test to prove the diagnosis of PBS. Instead investigations rule out other conditions, such as overactive bladder, endometriosis, infection, and cancer which may cause similar symptoms.

Common investigations include:

  • Urine analysis. This often needs to be repeated. It is also not unusual that sometimes it identifies and infection and other times, does not.
  • Renal tract ultrasound or a CT scan to exclude pathology which may irritate the bladder.
  • Bladder diary. Allows quantitative assessment of the number of times you urinate and the volumes you pass each time.
  • Urodynamic. This test looks at the normal function of the bladder by measuring its response to filling (with sterile fluid) and emptying when you urinate.
  • Cystoscopy. Telescope inspection of the bladder. Sometimes a biopsy is required.

What are the treatment options?

There are many treatment options and a range may be tried before a patient achieves remission. These treatments are usually offered in a step-by-step process to see what works for each individual.

Treatment options include:

  • Lifestyle changes. Regulation of fluid intake. Avoidance of drinks containing sugar, caffeine and alcohol. Avoidance of certain food items known to make symptoms worse in many patients. These include tomatoes, citrus fruits, bananas, chocolate, cheese, mayonnaise, nuts, onions, raisins, sour cream, yoghurt, and spicy foods. Patient support groups are often a good source of information about bothersome foods. Not everyone will be affected the same way so remember whats works for some may not work for others.
  • Medication. There are many pharmaceutical agents that can provide relief. The most common first line agent is amitriptyline. Other agents include oxybutynin, solifenacin, ranitidine, and gabapentin. Elmiron, a drug specifically approved for PBS restores the GAG layer of the lining of the bladder wall to protect it from irritants in the urine which cause inflammation. It is not on the PBS and can be difficult to locate.
  • Hydro-distension. Filling of the bladder (with saline) under anaesthetic. This can relieve symptoms in about half of patients.
  • Intravesical agents. Agents can be instilled in the bladder either at the time of cystoscopy or as an outpatient with the use of a catheter. Sometimes weekly sessions are required. Weeks or even months of relief may follow. Commonly used agents include DMSO, Heparin, Steroids and iAluril.
  • Sacral neuromodulation. Electrodes are implanted in the lower back which block nerves that transmit pain from the bladder.
  • Surgery. When all else fails, and particularly when bladder volume is decreasing, surgery can be considered. Types of surgery include urinary diversion (ileal conduit). This operation allows urine to by-pass the bladder and be collected in a bag on the outside of the abdominal wall. Despite the body image issues created by this option, many patients value the freedom it gives them because they do not have pain and do not need to worry about proximity to a toilet. Bladder augmentation. The bladder is reconstructed with a segment of the bowel. This expands the capacity of the bladder but pain may persist.


  • Painful bladder syndrome is term given when pain or discomfort in the bladder area leads to a desire to void.
  • It is important to exclude any concerning conditions before commencing treatment.
  • There are many treatment options.
  • Response to treatment is variable and it is not common to have to try a number of treatments before identify which one works for each person.