Hunners Ulcers

Overview

A Hunner's ulcer is a raw, red, inflamed patch on the inside wall of the bladder. Doctors also call it a Hunner lesion. It is found in some people who have bladder pain syndrome, also called interstitial cystitis. That is a long-term condition that causes pain in and around the bladder, plus a strong and frequent need to pass urine. A Hunner's ulcer is not cancer, it is not an infection you can pass to anyone, and it is not a sexually transmitted infection. It is a patch of damaged, sore bladder lining that can bleed and cause pain.

No. Hunner's ulcers are uncommon. They are found in only a small share of people who have bladder pain syndrome. Most people with bladder pain do not have ulcers.

Most people diagnosed are women in their 40s to 60s, but men and younger adults can have them too. They are rare in children. Anyone with long-standing bladder pain can be checked for them.

Symptoms

Common symptoms

• Pain in the lower belly, pelvis, or urethra (the tube you pass urine through).
• A sudden, strong urge to pass urine, often many times a day and at night.
• Pain that gets worse as the bladder fills and eases soon after passing urine.
• A burning or stinging feeling when you pass urine.
• Blood in the urine. Sometimes it is too small to see and only shows on a urine test.
• A feeling of pressure or heaviness in the pelvis.
• Pain during or after sex.
• Waking several times at night to pass urine.
• Passing only small amounts of urine each time.

Symptoms in children

• Hunner's ulcers are very rare in children, but bladder pain syndrome can occur.
• A child may complain of tummy or pelvic ache rather than using the word 'bladder'.
• Needing the toilet very often, bedwetting, or holding on because it hurts to go.
• Repeated 'urine infections' where tests keep coming back clear.
• See a doctor if a child has ongoing bladder pain, blood in the urine, or problems passing urine.

Symptoms in older adults

• Symptoms are sometimes mistaken for overactive bladder, repeated urine infections, or changes after menopause.
• Blood in the urine should always be checked, because other causes are more common in older adults.
• Other conditions can cause similar symptoms, so tests are needed to rule them out.
• Bladder pain can affect sleep, balance, and confidence in getting to the toilet in time, so it is worth raising with your doctor.

Causes

Main causes

• The exact cause is not known. Experts think several things may play a part.
• The bladder has a thin protective lining. If that lining is damaged, irritants in urine can reach the sensitive tissue underneath and cause pain and inflammation.
• Long-term inflammation in the bladder wall can lead to raw patches where the lining has worn away. These are the ulcers.
• Nerve changes in the bladder may make it over-sensitive, so normal filling feels painful.
• The immune system and certain cells in the bladder wall may be involved in keeping the inflammation going.

Risk factors

• Having bladder pain syndrome (interstitial cystitis).
• Being a woman, especially in midlife.
• Having other long-term pain conditions, such as fibromyalgia or irritable bowel syndrome.
• Having an autoimmune condition, where the body's defence system attacks its own tissues.
• Previous bladder surgery or repeated bladder problems. This link is not certain.
• Stress and certain foods can make symptoms worse, but they are triggers, not the cause.

When to see a doctor

See a doctor urgently if:

• You see blood in your urine.
• You have a fever with pain in your back or side.
• You cannot pass urine.
• You have severe pain that is not controlled at home.

Book a routine appointment if:

• Bladder or pelvic pain that has lasted more than a few weeks.
• Needing to pass urine very often, or waking at night to go.
• A burning feeling when you pass urine and urine tests show no infection.
• Pain during sex that started with your bladder symptoms.
• Symptoms that keep coming back after treatment.

Diagnosis

Your doctor will start by asking about your symptoms and how they affect your day. They will check your urine to look for infection and other problems, and may ask you to keep a bladder diary for a few days. If bladder pain continues and other causes are ruled out, you will usually be referred to a bladder specialist, called a urologist. The key test is a cystoscopy. A thin, flexible tube with a tiny camera is passed into the bladder through the urethra. To see ulcers clearly, the bladder is gently stretched with fluid first. This is called hydrodistension and is usually done under a general or spinal anaesthetic, so you will not feel it. A small sample of tissue, called a biopsy, may be taken to check the cause of any redness and to rule out other conditions.

Tests that may be done

• Urine dipstick test, to look for blood, infection, or other signs.
• Urine culture, to check for bacteria.
• A bladder diary, recording what and when you drink and how often you pass urine.
• Cystoscopy with hydrodistension, to look directly at the bladder lining.
• Biopsy of any abnormal area, checked in a laboratory.
• Ultrasound scan or other imaging, to look at the kidneys and bladder and rule out other problems.
• Bladder pressure tests, called urodynamics, in some cases.

What to expect at your appointment

The cystoscopy usually takes about 15 to 30 minutes and is often done as a day case, so you can go home the same day. You may have some soreness, and your urine may look pink for a day or two. Drink plenty of water afterwards. Your specialist will explain what was seen and whether any treatment was done at the same time. Results from a biopsy can take a week or two, so you may need a follow-up appointment or phone call.

Treatment

There is no single cure for Hunner's ulcers, but there are many ways to reduce pain and help the bladder work better. Treatment is usually built up in steps. You and your specialist will choose what suits your symptoms, your health, and what you would like to try. Some treatments help straight away; others take weeks to show a difference. It can take time to find the right combination, so try to keep talking with your care team about what is and is not helping.

Self-care at home

• Keep a bladder diary for a week or two so you can spot patterns and triggers.
• Try cutting out one possible trigger food or drink at a time for two to three weeks, then see if it helps.
• Drink enough water through the day, but sip steadily rather than drinking a lot at once.
• Use a heat pack on your lower belly or back when pain flares.
• Wear loose, comfortable clothing around your waist.
• Learn to relax your pelvic floor muscles with slow breathing. A pelvic floor physiotherapist can teach you how.
• Avoid holding urine for long periods when you can.
• Treat constipation early, as a full bowel presses on the bladder.
• Build rest into your week and pace activities, rather than doing everything on a good day.

Medical treatments

Doctors may offer treatments in steps, depending on how much your symptoms affect you. Options include medicines taken by mouth that calm nerve pain or reduce inflammation in the bladder. Other treatments are placed directly into the bladder through a thin tube, called bladder instillations. These work by coating, soothing, or calming the bladder lining. Stretching the bladder with fluid under anaesthetic can also ease symptoms for a while in some people. If ulcers are seen during cystoscopy, the specialist may treat them by destroying the sore patches with heat, a laser, or a small electric current. This is called fulguration. Sometimes a medicine is injected into the ulcer area at the same time. Other approaches include nerve stimulation therapy and physiotherapy for the pelvic floor. Your specialist will explain the benefits and possible side effects of each option, and you can decide together what to try.

When is surgery considered?

Surgery is rarely needed. It is only considered when symptoms are severe and other treatments have not helped over time. Options include operations to make the bladder larger, or, in a small number of cases, removing the bladder and creating another way for urine to leave the body. These are major operations with real risks, so they are only offered after careful discussion with a specialist team.

Living with this condition

Living with bladder pain can take planning. Many people find it helps to know where the toilets are before they go out, to carry spare underwear and pads, and to build short breaks into the day. Travel, work, and social plans can all be adapted rather than given up. Tell people you trust about your condition so they understand when you need to stop or find a toilet. Good days and bad days are normal, and pacing yourself can make the bad days shorter.

Lifestyle tips

• Keep a simple record of flares so you can spot what sets them off.
• Cut back on smoking. Smoking can irritate the bladder and harms overall health.
• Find ways to manage stress, such as breathing exercises, gentle yoga, or talking things through.
• Keep active in a way that suits you. Gentle, regular movement often helps pain and mood.
• Protect your sleep. If you are waking often at night, mention it to your doctor.
• Avoid very tight waistbands, and choose clothes that feel comfortable.
• Ask your doctor about a referral to a pelvic floor physiotherapist.
• Consider talking to a counsellor or psychologist who works with long-term pain.

Diet and exercise

There is no single 'bladder diet' that works for everyone, and food is not the cause of Hunner's ulcers. Some people notice that drinks containing caffeine, fizzy drinks, citrus fruits and juices, tomatoes, spicy food, alcohol, and artificial sweeteners make symptoms worse. If you want to test this, remove one item at a time for two to three weeks and note any change, then put it back. Do not cut out lots of foods at once, as it becomes hard to know what helped. Drink water steadily through the day, and aim for urine that is pale yellow. For exercise, walking, swimming, cycling on a comfortable seat, and gentle stretching or yoga are good choices. Start slowly and build up. If exercise makes pain worse, tell your doctor or physiotherapist.

Mental health and emotional wellbeing

Long-term pain and the constant need to find a toilet can affect mood, sleep, relationships, work, and confidence. It is very common to feel anxious, low, frustrated, or isolated. These feelings are understandable and are not a sign of weakness. Tell your doctor how you are feeling, because support is available, such as talking therapies or pain-management programmes. If you ever feel unable to cope or have thoughts of harming yourself, please reach out for help straight away. Contact your local emergency number or a crisis support service in your country, or speak to a doctor or nurse you trust. You do not have to manage alone.

Prevention

There is no proven way to prevent Hunner's ulcers from forming, and no one is to blame for having them. What you can do is look after your bladder health and manage bladder pain syndrome as well as possible. Avoiding your own trigger foods, keeping bowels regular, staying hydrated, not smoking, and managing stress may help reduce how often symptoms flare. If you have bladder pain that keeps coming back, getting it checked early means any problems can be found and treated sooner.

Screening programmes

There is no general screening programme for Hunner's ulcers. If you have bladder pain syndrome, your specialist may suggest a cystoscopy to check the bladder lining, especially if you have blood in your urine or symptoms that are hard to control. Anyone with blood in their urine should have it checked, whatever their age.

Complications

If left untreated

• Pain can become worse and harder to manage over time.
• Scarring can make the bladder stiffer and smaller, so it holds less urine.
• You may need to pass urine very often, which disturbs sleep and daily life.
• Ongoing pain and broken sleep can lead to tiredness, low mood, and anxiety.
• Blood in the urine should always be checked, even though Hunner's ulcers themselves are not cancer.
• In rare cases, long-term bladder scarring can affect how the kidneys drain, so regular follow-up matters.

Long-term outlook

The outlook varies from person to person, and many people do get better with treatment. Some find their symptoms settle for long periods, while others need ongoing care. Ulcers can come back after treatment, but they can usually be treated again. Newer treatments and better understanding of bladder pain mean there is more help available now than ever before. Working closely with a specialist team, and looking after sleep, mood, and daily routines, gives the best chance of a good quality of life.

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