Condition Interstitial Cystitis

Overview

WHAT IS INTERSTITIAL CYSTITIS (IC)?

Also known as painful bladder syndrome (PBS), interstitial cystitis is defined as chronic bladder pain without identifiable causes. It can coexist with other conditions, such as fibromyalgia and irritable bowel syndrome.

HOW COMMON IS INTERSTITIAL CYSTITIS?

It is five times more common in women than in men and affects about three to six percent of women in the United States. Many patients experience disruption of home and work life, and 50 percent are unable to work full time.

WHAT CAUSES INTERSTITIAL CYSTITIS?

There is little known about the cause of interstitial cystitis/painful bladder syndrome. Most patients cannot identify the event that triggered this condition. Certain foods such as caffeine, alcohol, citrus fruits, tomatoes, and spicy foods may worsen the symptoms.

HOW IS IC RELATED TO OTHER CHRONIC PAIN CONDITIONS?

IC is often associated with other chronic pain conditions such as irritable bowel syndrome and fibromyalgia. It is sometimes difficult to make a diagnosis of IC, because other conditions share similar symptoms such as pelvic pain and pain with intercourse.

Symptoms

Symptoms include persistent, unpleasant sensations in the bladder: discomfort with bladder filling, bladder pressure, and bladder spasms. The severity of symptoms can range from mild pressure to severe, debilitating pain. Additional symptoms include urinary frequency, urgency, and frequent urination at night. Seventy-five percent of patients with interstitial cystitis experience pain with intercourse.

CAN IC CAUSE SEXUAL DYSFUNCTION?

Sexual concerns are common in women with IC. In one study, 90 percent of women with IC reported low sex drive, difficulty with arousal, bladder pain during sex, and urge to urinate during sex.

Diagnosis

The goal of a diagnosis is to identify the characteristic features of IC and to exclude other conditions. Diagnosis involves a detailed history of symptoms and associated conditions, a physical exam, and urine testing. IC does not have any characteristic findings on imaging studies. Cystoscopy may sometimes be helpful to exclude other conditions and in patients who do not respond to initial therapy.

WHAT IS CYSTOSCOPY?

Under anesthesia, a camera is inserted into the bladder, and the bladder is distended with sterile water (hydrodistention). This procedure allows the doctor to examine the inside of the bladder and perform a biopsy, if necessary. Cystoscopy is often performed with laparoscopy in patients with pelvic pain.

IS CYSTOSCOPY NECESSARY FOR DIAGNOSIS OF IC?

Cystoscopy is not required to make the diagnosis of IC. It is typically performed if other conditions are suspected or if the patient does not respond to first- and second-line therapy (see below). IC is associated with several abnormal findings on cystoscopy. Normal cystoscopy, however, does not exclude the diagnosis of IC.

WHAT ABNORMAL FINDINGS ON CYSTOSCOPY ARE ASSOCIATED WITH IC?

Abnormal Cytoscopy Results

Abnormal Cytoscopy Results

 

Abnormal findings on cystoscopy are helpful to support the diagnosis of IC. These findings include reddened lesions (Hunner lesions) and small red spots on the lining of the bladder.

Treatment

Interstitial Cystitis is a chronic pain syndrome, and there is no treatment that is curative. There is no consensus on appropriate treatment of IC because the cause of this condition is unknown, the symptoms vary across patients, and there is not enough scientific evidence on the safety and effectiveness of treatments. No treatment is consistently providing relief for all patients. The goal of IC management is to provide relief of symptoms, in order to achieve an adequate quality of life.

ARE THERE MORE TREATMENT OPTIONS?

There are many treatment options for IC, but none are proven to be helpful in all patients. Therapies vary by the risk of adverse reactions and the invasiveness of the treatment. In general, the least invasive therapy is chosen as a first-line therapy. If the symptoms persist, this therapy is discontinued and another therapy is started. If the symptoms are severe, it may be necessary to proceed rapidly to more aggressive therapies.

WHAT ARE THE DIFFERENT TREATMENT OPTIONS FOR THE ACUTE PAIN EPISODE (FLARE UP) OF IC?

The American Urologic Association has issued specific guidelines for treatment of IC. Pain medications: used for short-term relief for flares of bladder pain. These include over-the-counter medications (Tylenol, Motrin) and narcotic medications (Percocet, Vicodin). Urinary analgesic (Azo): this medication targets the bladder to relieve pain and can be purchased over the counter. Transdermal analgesics: patches that contain narcotic pain medication. Referral to a specialist in pain management is necessary if long-term pain medication is needed. Lidocaine bladder instillations: this procedure is done in the office. The doctor inserts a catheter into the bladder to instill numbing solution as a therapy for patients with an acute episode of severe bladder pain. Potential side effects include: bladder infection, pain with urination, and increase in bladder pain.

WHAT IS THE FIRST-LINE THERAPY FOR IC?

Initial therapy of IC is focused on self-care and the change in behavior to control the symptoms of IC. Such strategies include:

  • Application of local heat or cold over the bladder or perineum
  • Avoiding irritant food or beverages such as caffeine, alcohol, artificial sweeteners, hot peppers
  • Fluid and voiding: Patients who experience worsening of symptoms with concentrated urine should increase fluid intake. Others experience pain with bladder filling and may find that fluid restriction provides some relief.

WHAT IS THE SECOND-LINE THERAPY FOR IC?

Second-line therapy may be time-consuming and usually requires a referral to a specialist.

  • Physical therapy: This may be helpful for patients who experience pelvic floor muscle tenderness upon examination. Pelvic floor physical therapy includes treatment of the tender points. Pelvic floor physical therapists in the US can be found through the American Physical Therapy Association.
  • Oral medications:
    • Elavil can be used as an initial treatment. This drug is most effective at higher doses but may not be well-tolerated due to side effects.
    • Elmiron is reasonable for patients for whom Elavil is not effective or causes bothersome side effects. Elmiron is the only drug that has been approved by the FDA for treatment of IC.
  • Other medications: antihistamines.

WHAT IS THE THIRD-LINE THERAPY FOR IC?

Third-line therapy is performed in the operating room under sedation.

  • Bladder hydrodistention: Sterile water is used to distend the bladder. Some patients can experience temporary relief from their symptoms (for up to six months).
  • DMSO instillation: The bladder is filled with a special solution weekly for six weeks, then every two weeks for three to 12 months.

WHAT IS THE FOURTH-LINE THERAPY FOR IC?

  • InterStim: Implantable device that transmits electrical pulse to the sacral nerve located in the lower back. This device has been approved by the FDA for the treatment of urinary urgency and frequency, but not for the treatment of IC.

WHAT IS THE FIFTH-LINE THERAPY FOR IC?

There is little evidence to suggest that this therapy is effective. This therapy should only be administered by experienced professionals.

  • Bladder Botox: This treatment may cause urinary retention. It is not approved by the FDA for treatment of IC. Symptom relief lasts up to six months.
  • Restasis: This is an oral medication. It has limited use due to potential adverse side effects such as kidney toxicity, elevated blood pressure, immunosuppression, hair growth, muscle pain, and others.

WHAT IS THE SIXTH-LINE THERAPY FOR IC?

This is a surgical procedure and the treatment of last resort. It is reserved for patients whose symptoms significantly affect their quality of life, in whom all other therapies have failed, and for patients who are willing to accept the potential complications and lifestyle changes.

  • Urinary diversion: The bladder is removed and the ureters are attached to a new urine reservoir that is created from a bowel segment. In order to empty the new bladder, the patient will have to insert a catheter through an opening in the abdominal wall every four to six hours. This procedure will reliably relieve symptoms of frequency but pelvic pain may persist.

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