Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Interstitial Cystitis / Painful Bladder Syndrome
N30.10 – Interstitial cystitis (chronic) without hematuria
R30.9 – Painful micturition, unspecified
I. DEFINITION
Interstitial cystitis (IC) is a chronic, inflammatory, noninfectious disorder of the bladder with no associated histologic changes and affecting both men and women. IC is more common in women than in men. Of the 1 million Americans with IC, up to 90% are women, and 15% of those are of Jewish heritage.
II. ETIOLOGY
A. The exact pathogenesis and etiology of IC remain unclear; they are thought to be multifactorial.
1. Abnormal bladder epithelial permeability and inflammation, including fibrosis and discrete bleeding ulcers, perhaps due to abnormal diffusion of toxins from urine to the submucosa
2. Neurogenic abnormalities
3. Autoimmune disorders
4. Allergic reactions
5. Infectious etiologies
6. May present as part of a more visceral pain syndrome
B. Genetics: Researchers have found a higher-than-expected prevalence of IC among first-degree relatives of index IC cases.
III. HISTORY
A. What the patient may present with
1. Urinary urgency and urinary frequency; voiding as often as 15 times a day, sometimes every hour, including nocturia
2. Dyspareunia
3. Pressure, pain (can be worse during menstruation) and tenderness around bladder, pelvis, and perineum
B. Additional information to consider
1. Treatment of urinary tract infection (UTI) with no response to antibiotics
2. Pain worse with menses
3. Pain influenced by diet, medications, and supplements
4. Feelings of depression or anxiety; stress
5. Decreased quality of life
IV. PHYSICAL EXAMINATION
A. Thorough medical history
B. Pelvic exam essential to rule out pelvic inflammatory disease (PID), vaginitis, vaginosis, and/or sexually transmitted infection (STI)
C. Abdominal exam, tenderness, and/or palpable mass
D. Vital signs
INTERSTITIAL CYSTITIS/PAINFUL BLADDER SYNDROME 143
V. LABORATORY EXAMINATION
A. Urinalysis and culture
B. Urine cytology
C. Vaginal and cervical cultures
D. Bladder diagnosis. Potassium sensitivity test may be done in office as a minimally invasive procedure that involves the instillation of a potassium chloride solution into the bladder to determine the degree of the patient’s pain or urgency response.
E. Cystoscopy with biopsy
F. Patient assessment questionnaire
VI. DIFFERENTIAL DIAGNOSIS
A. Endometriosis
B. Irritable bowel syndrome
C. UTI
D. Vulvodynia
E. Nonbacterial prostatitis (males)
F. Fibromyalgia
G. Coexisting depression and anxiety
H. Bladder cancer
I. Kidney disorders
J. STIs
K. Neurologic or rheumatologic disorders
VII. TREATMENT
A. Bladder distention: Researchers are not sure why bladder distention helps, but some believe that it may increase capacity and interfere with pain signals transmitted by nerves in the bladder.
B. Bladder instillation (bladder wash or bath): The bladder is filled with a solution that is held an average of 10 to 15 minutes before being emptied.
C. Dimethyl sulfoxide (DMSO, RIMSO-50) treatments are given every week or two for 6 to 8 weeks and repeated as needed. Most people who respond to DMSO notice an improvement 3 to 4 weeks after the first 6- to 8-week cycle of treatment.
D. Oral drugs
1. Pentosan polysulfate sodium (Elmiron)—100 mg three times a day
2. Analgesic medications
3. Tricyclic antidepressants
4. Antihistamines
5. Antispasmodics
6. Anticholinergics
E. Transcutaneous electrical nerve simulation
F. Diet: There is no scientific evidence linking diet to interstitial cystitis/painful bladder syndrome (IC/PBS), but many health care
providers and patients find that the following may contribute to bladder irritation and inflammation.
1. Alcohol
2. Tomatoes
3. Spices
4. Chocolate
5. Caffeinated beverages
6. Citrus beverages and fruits
7. Highly acidic foods
8. Artificial sweeteners
G. Eliminate smoking: Many patients believe that smoking makes their symptoms worse.
H. Exercise: Gentle stretching exercises may help relieve IC/PBS symptoms.
I. Bladder training methods vary, but basically, patients void at designated times and use relaxation techniques and distractions to keep to the schedule.
J. Physical therapy and biofeedback
VIII. COMPLICATIONS
A. Missed diagnosis
B. Depression (rare cases), suicidal ideation
IX. CONSULTATION
A. Consult with a physician regarding the appropriate testing
B. Refer to a physician for appropriate testing
C. Refer to a urologist or IC specialist
X. FOLLOW-UP
A. 1 to 2 weeks after initial workup and evaluation
B. 4 to 6 weeks after starting any treatment
C. Initially as needed to adjust treatment measures and symptoms— may take months
D. Regular follow-up visits to monitor symptoms and progress
Websites: www.ichelp.org; www.ic-network.com; www.mayoclinic.com/health/ interstitial-cystitis/ds00497