My last few blog posts have been quite heavy and have entailed lots of research. They’re boring enough to read, I’m sure, but can you imagine writing them?! I hope you don’t mind, but I fancied something a bit lighter this month. I’ve been watching quite a lot of ‘Friends’ recently – I was a bit too young to appreciate it when it was first on TV in the nineties. I like the way all the episodes are titled ‘The One…’ so you can easily identify them. It occurred to me that there should be a similar system for pelvic pain conditions, or conditions that otherwise affect the genitourinary system. There are so many of them, often with very similar symptoms, and have you noticed that a lot of them seem to begin with the letter V? I don’t know about you, but I get very confused about them all and could do with a brief synopsis of each one to help me remember which is which!

If you already know which pelvic pain condition you have and aren’t interested in anyone else’s, you won’t need to read this ‘Friends’ themed blog – you can just go and watch an actual episode of it instead! Or, to put it in properly clinical language, if you have already received an official diagnosis which you believe to be correct, you need not concern yourself with any differential diagnosis. If, however, you have a pelvic pain condition that is as yet undiagnosed, it might help to know a little bit about each of the contenders.

Please note that I am not a doctor and nothing in this blog post is intended to constitute medical advice. Neither is it to be used as a diagnostic tool. The material is purely for your interest and entertainment. Please always consult with a qualified healthcare professional to obtain a proper diagnosis and before embarking on any kind of treatment strategy. 

Cystitis: the one where you feel like you need to wee frequently and urgently, even when you’ve just been, and it hurts, especially when you do actually wee. There might be blood in your urine and a normal urine test will show infection. Clears up quickly with antibiotics.

Interstitial cystitis: the one where you feel like you need to wee frequently and urgently, even when you’ve just been, and it hurts, especially when you do actually wee. There might be blood in your urine and a normal urine test will not show infection. Does not clear up quickly with antibiotics.

Painful bladder syndrome: the one that’s just another name for interstitial cystitis.

Overactive bladder: the one where you feel like you need to wee frequently and urgently, but it doesn’t hurt.

Bacterial prostatitis:  the one where you feel like you need to wee frequently and urgently, even when you’ve just been, and it hurts, especially when you do actually wee. It may also hurt in your testicles and up your bottom, so having a bowel movement may also be painful. You might experience urinary retention or need to strain to get started. There might be blood in your urine or semen. Ejaculation might be painful. A normal urine test will show infection and a prostate examination will reveal pain and inflammation. Clears up with antibiotics, although it might require a few courses if it is a chronic condition.

Non-bacterial prostatitis: the one where you feel like you need to wee frequently and urgently, even when you’ve just been, and it hurts, especially when you do actually wee. It may also hurt in your testicles and up your bottom, so having a bowel movement may also be painful. You might experience urinary retention or need to strain to get started. There might be blood in your urine or semen. Ejaculation might be painful. A normal urine test will not show infection, although a prostate examination will reveal pain and inflammation. Does not clear up quickly with antibiotics.

Trigonitis: the one that feels the same as cystitis or interstitial cystitis, except that it only affects the lower portion of the bladder. Upon cystoscopy, inflammation or cellular changes called nonkeratinising squamous metaplasia may be seen. Without cystoscopy, it is indistinguishable from cystitis or interstitial cystitis. Nonkeratinising squamous metaplasia occurs due to hormonal imbalances.

Dysuria: the one that’s just a posh word for painful urination. Dysuria is a symptom of things like cystitis rather than a condition in its own right.

Dyspareunia: the one that’s just a posh word for painful sex or penetration. Dyspareunia is a symptom of things like vulvodynia rather than a condition in its own right.

Vulvodynia: the one where you have unprovoked and unexplained vulval pain that might include burning, rawness, stinging and throbbing. It might hurt to have sex and, less often, it might itch. It might be generalised to the whole vulval area, or it might be localised to just one part.

*The vulva is the external female genital area – it includes the vaginal opening, but not the deeper vaginal canal. 

Vestibulodynia: the one where you have provoked and unexplained vestibular pain that occurs with a light touch. It might hurt to have sex, insert tampons, or wear underwear. There is usually no pain unless something is provoking it. The pain might spread to the general vulval area.

*The vestibule is the opening to the vagina. 

Vestibulitis:  the one that’s an out of date name for vestibulodynia. The –it is suffix implied inflammation, which is not always present, so the name was changed.

Vaginismus: the one where the muscles of the vagina involuntarily contract when penetration is attempted. This makes penetrative sex and perhaps the insertion of tampons painful or impossible. No visible genital abnormality will be present. Non-penetrative forms of sex might still be enjoyed. Might improve with touching exercises and relaxation techniques. Could be a symptom of other pelvic pain conditions, as it often (not always) develops as a self-protection mechanism in response to painful sexual encounters or fear.

Pudendal nerve entrapment: the one where you get burning, numbness, deep aching or electric shock type pains that are typically worse when sitting, but improve when lying down or standing. The pain may affect the perineum, genitals and general pelvic area. There may be urinary urgency and frequency, as well as constipation, painful sex and erectile dysfunction. Pudendal nerve entrapment is often misdiagnosed as interstitial cystitis. Chiropracty, osteopathy and pelvic physiotherapy might be helpful before more invasive options like nerve blocks are tried.

*I would be inclined to think that if there is perineal pain, pudendal nerve entrapment ought to be considered, especially if the bladder symptoms are sporadic or are not the main source of complaint. 

Persistent genital arousal disorder: the one where you feel like you need to orgasm all the time, but having orgasms does not relieve the sensation and might even make it worse. May be experienced in any part of the genitalia, as well as occasionally the nipples and anus. Some people experience spontaneous, uncontrollable, unwanted orgasms. May be experienced as tingling, burning, throbbing, rawness, a feeling of pelvic congestion and fullness, and pain. Often occurs with cystitis or interstitial cystitis. Is sometimes caused by pudendal nerve entrapment.

Pelvic floor dysfunction: the one where your pelvic floor muscles are either too relaxed or too tight (or a combination of both). The former may lead to incontinence, leakage, prolapses and pain. The latter may lead to constipation, difficulty passing urine and muscle spasms. Both may involve bladder pain, lower back pain and sexual pain. Pelvic floor dysfunction and interstitial cystitis are quite difficult to tell apart.

*I would be inclined to think that if oral supplements and medications have made no impact whatsoever on symptoms, that pelvic floor dysfunction rather than interstitial cystitis be the culprit. Pelvic physiotherapy might be helpful, along with relaxation techniques, stretching and targeted exercises. 

Lichen sclerosus: the one where you get itchy, thin, white patches of skin that can bleed easily and be painful. The genitals are often affected, which can make sex painful.

Lichen planus: the one where you need to look for white borders. The vulva will have red or pink patches, but there will be streaky white borders, pain and burning. The penis will have white or purple rings and may also be painful and burn. Itching is less common in lichen planus than in lichen sclerosus, but may still occur. Urination and sex may be painful. The mouth may be affected in a similar manner to the genitals. Elsewhere on the body, there may be itchy, purple-red, shiny bumps.

Genital thrush: the one with itching and white discharge. You might also get stinging, burning and soreness. Caused by an overgrowth of the yeast Candida albicans.

*Doctors won’t tell you this, but thrush is a sign that you have a candida overgrowth in your digestive tract as well. Google it and deal with it to avoid more and worse health issues later. 

Vulval dermatitis: the one where it’s probably an allergy or eczema that is occurring on the vulva. Is likely to itch and be sore. May be difficult for the layperson to tell apart from lichen sclerosus and lichen planus.

Sjogren’s syndrome: the one where you get dry mucous membranes, which may include the vagina. An autoimmune disease that often accompanies other autoimmune conditions. Eyes, mouth, skin and other organs may be affected.

Vaginal dryness: the one where you get a dry vagina, but your other mucous membranes are fine. A dry vagina may also feel sore, itchy and cause sex to be painful. May be a condition in its own right, or a symptom of other genitourinary conditions.

*Get your hormone levels checked. If the ones from your GP come back fine, consider salivary hormone testing or DUTCH testing for a more comprehensive evaluation. Get your thyroid hormones checked while you’re at it. If the ones from your GP come back fine, consider a more comprehensive set of private blood tests – see Thyroid UK for details.

Vaginal atrophy:  the one where your vagina becomes thin, dry and inflamed. Causes painful sex and urinary symptoms, including frequent urinary infections. Most common in post-menopausal women, is generally (although not exclusively) associated with getting old, but is by no means inevitable. Is often now referred to as Genitourinary Syndrome of Menopause (GSM).  

*Get your hormone levels checked. If the ones from your GP come back fine, consider salivary hormone testing or DUTCH testing for a more comprehensive evaluation. Read ‘Me and My Menopausal Vagina: Living with Vaginal Atrophy’ by Jane Lewis.

Okay, that’s all the things I can think of right now that might cause cystitisy type symptoms. This post turned out to require a lot more research than I anticipated and I’m not sure anyone will be any the wiser now – so many of the conditions are so similar, aren’t they?! If I was to use the ‘Friends’ system to classify this post I’d call it ‘The One That Wasn’t as Much Fun as I Thought’! If you’ve made it to the end, thank you for reading and I hope you’ve learned something – I know I have!

Tiny x

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