Definition
A.Interstitial cystitis (IC) is a chronic condition that results in recurring discomfort or suprapubic pain, as well as pressure in the bladder and surrounding pelvic region related to bladder filling. IC is also commonly known as painful bladder syndrome (PBS). IC/PBS includes all cases of urinary pain with persistent urge to void or urinary frequency that cannot be attributed to other causes (i.e., infection, stones, or other pathology).
B.The persistent urge to void helps to distinguish the symptoms of IC/PBS from those of overactive bladder (OAB). IC/PBS affects quality of life related to social activities, lost work productivity, sleep deprivation because of urinary frequency, fatigue, and even depression.
C.The Society for Urodynamics and Female Urology (SUFU) has stated that the symptoms should last more than 6 weeks in order for therapy to begin.
D.IC/PBS patients void to avoid or relieve pain, whereas patients with OAB void to avoid incontinence.
Incidence
A.Actual prevalence is unknown because of the variability of diagnostic criteria. It is not uncommon for patients to experience a lag time of 5 to 7 years before diagnosis. It is estimated that in the United States, IC/PBS affects 3 to 8 million women and 1 to 4 million men. The symptom complex is the same for females and males.
Pathogenesis
A.The pathophysiology of IC/PBS remains unclear. It is not established whether IC/PBS is a localized condition just involving the bladder or whether it is a systemic disease that affects the bladder.
Predisposing Factors
A.In both genders, with a higher prevalence in females.
B.Mean age of diagnosis is 42 to 45 years.
C.Urinary tract infection (UTI).
D.Prostatitis.
E.Chronic yeast infections.
F.Posthysterectomy or other pelvic surgery.
G.Medications:
1.Calcium channel blockers.
2.Cardiac glycosides.
H.Other hypersensitivity conditions that coexist with IC:
1.Fibromyalgia.
2.Irritable bowel syndrome (IBS).
3.Chronic headaches.
4.Vulvodynia.
5.Sjögren’s syndrome.
Common Complaints
A.Mild discomfort to intense pain with bladder filling and/or emptying is the hallmark symptom. The pain is not limited to the bladder/suprapubic area but includes symptoms throughout the pelvic area, lower abdomen, and back.
B.Persistent urge to void.
C.Frequency.
D.Urgency.
E.Nocturia.
Other Signs and Symptoms
A.Combination of urgency and frequency.
B.Pressure.
C.Increase in symptoms during menstruation.
D.Pain during vaginal intercourse.
E.Low back pain with bladder filling.
Subjective Data
A.Review onset, frequency, duration, and severity of symptoms.
B.Evaluate if the pain of bladder filling is partially or completely relieved by voiding.
C.Does the patient void frequently in order to maintain a low bladder volume and avoid discomfort versus voiding frequently to avoid urge incontinence (OAB)?
D.Are there any OAB triggers (e.g., citrus, beer, coffee) that exacerbate symptoms?
E.Are symptoms increased after stress, exercise, intercourse, being seated for long periods of time, or during the menstrual cycle?
F.How much do the symptoms affect the patient’s quality of life (e.g., sleep disturbance, loss of work, avoiding activities)?
G.Does the patient have any other chronic pain syndromes such as IBS, chronic fatigue, dyspareunia, or fibromyalgia?
H.Review the patient’s surgical history and history of genitourinary (GU) cancers.
I.Has the patient had any GU trauma or falls onto the coccyx?
J.Review the patient’s history of UTIs, urinary retention, and urinary tract stones.
K.Review all medications, including over-the-counter (OTC) and herbal products.
L.Administer a pain/symptom evaluation tool at each visit:
1.The Pelvic Pain and Urgency/Frequency (PUF) Patient Symptom Scale is available at www.ichelp.org/wp-content/uploads/2015/06/PUF_Questionnaire.pdf.
2.The Interstitial Cystitis Symptoms Index (ICSI) is available at www.essic.eu/pdf/ICSIandICPI.pdf.
Physical Examination
A.Temperature (if indicated to rule out infection; fever is not associated with IC) and blood pressure (BP).
B.Inspect:
1.Note general appearance for signs of depression and discomfort before and during examination.
2.Inspect the male external genitalia for redness, edema, lesions, and discharge.
3.Inspect female genitalia for discharge, lesions, fissures; inspect cervix for cervicitis.
C.Auscultate:
1.Auscultate the heart and lungs.
2.Auscultate bowel sounds in all four quadrants.
D.Palpate:
1.Palpate back; note costovertebral angle (CVA) tenderness.
2.Palpate the abdomen for suprapubic tenderness, rebound masses, or pain.
3.Females: Perform bimanual exam to rule out other infections and pelvic inflammatory disease (PID; tenderness of the cervix, uterus, and adnexal should be absent).
During the pelvic examination, evaluate locations of tenderness and trigger points.
4.Males: Complete palpation of external genitalia, prostate, and rectal exam.
E.Percuss:
1.Percuss the bladder.
2.Percuss back for CVA tenderness.
F.Perform a limited neurological examination to rule out an occult problem.
Diagnostic Tests
A.Urinalysis with microscopy to exclude hematuria.
B.Urine culture and sensitivity may be ordered even with a negative urinalysis to evaluate low levels of bacteria.
C.Postvoid residual (PVR) volume by straight catheter or ultrasound.
D.Urodynamic testing is not currently considered to have a role in the diagnosis of IC/PBS; however, urodynamic testing should be used for complex presentations.
E.Cystoscopy is usually reserved for gross or microscopic hematuria.
F.Hydrodistension is not required for diagnosis or treatment.
G.Bladder biopsy is not required for diagnosis; however, it is used for exclusion of other disorders.
H.The potassium sensitivity test is not recommended for routine use since results are nonspecific for IC/PBS.
Differential Diagnoses
A.IC.
B.UTI.
C.IBS.
D.Females:
1.Endometriosis.
2.Vulvodynia.
E.Males:
1.Chronic prostatitis (CP).
2.Benign prostatic hypertrophy (BPH).
Plan
A.General interventions:
1.Behavioral modifications are recommended. Restrict fluids to 64 ounces/d, divided into 16 ounces per meal and 8 ounces between meals.
2.Progressive timed voiding on a 2- to 3-hour schedule. If the patient is unable to hold urine for this interval, progressively increase urine storage time between voids by 15 minutes per week until the goal of a 2- to 3-hour interval is reached.
3.Kegel exercises should be avoided with IC.
4.Psychosocial support is an integral part of chronic pain disorders.
B.Patient teaching:
1.Educate about normal bladder function, the benefits versus risks/burdens of the available treatment alternatives, and the fact that no single treatment has been found to be effective for the majority of patients.
2.Several foods have been identified as bladder irritants, including foods rich in potassium. Patients may try to eliminate foods/drinks and reintroduce them one at a time to identify any items that make their symptoms worse. Examples:
a.Alcohol.
b.Tomatoes.
c.Spices/spicy foods.
d.Chocolate.
e.Caffeinated beverages.
f.Coffee.
g.Artificial sweeteners.
h.Citrus: Lemons, limes, and oranges (including citrus-flavored beverages).
i.Cranberry/cranberry juice.
C.Pharmacological therapies:
1.Pentosan polysulfate sodium (Elmiron) is the only oral medication approved by the FDA for the treatment of IC.
a.Dosage: 100 mg orally three times daily.
b.Patients should be evaluated at 3 months and may be continued an additional 3 months if there has been no improvement and if there are no therapy-limiting side effects.
c.The risks and benefits of continued use beyond 6 months in patients who have not responded is unknown.
2.Amitriptyline (Elavil) is used in the treatment of other pain syndromes, including IC. May utilize a self-titration dose of 25 mg orally every night and increase in increments of 25 mg every week to a maximum dose of 100 mg orally per day.
3.Cimetidine 400 mg twice daily.
4.Hydroxyzine hydrochloride (Vistaril, Atarax) 25 to 75 mg orally at bedtime.
5.Uro-blue medications for short-term bladder spasms.
6.NSAIDs for pain control.
7.Medications may be instituted for treating any comorbid depression.
8.Treat any comorbid infections and conditions (e.g., UTIs, STIs, inflammatory bowel disease, or endometriosis).
9.Bladder instillation:
a.Intravesical dimethyl sulfoxide (DMSO; Rimso-50) is the only drug approved by the Food and Drug Administration (FDA) for bladder instillation.
b.Heparin instillation.
c.Lidocaine instillation.
d.Bladder cocktail
combination of sodium bicarbonate, heparin, lidocaine, and/or triamcinolone. There are various formulas/combinations.
10.Cyclosporine A has been utilized when other treatments have not provided adequate relief or control of symptoms and quality of life. The American Urological Association (AUA) guidelines consider cyclosporine as the fifth-line treatment option.
D.Intradetrusor botulinum toxin A (BTX-A) therapy may require posttreatment intermittent self-catheterization.
E.Laser or electrocautery if Hunner’s ulcers are present.
F.Surgical options are available if all other therapies have failed.
G.Some alternative treatments such as guided imagery and acupuncture have shown some success but have not been studied.
H.Therapies that are not recommended/should not be offered include the following:
1.Long-term antibiotics.
2.High-pressure, long-duration hydrodistension.
3.Systemic steroids.
4.Intravesical resiniferatoxin (ultrapotent capsaicin analogue).
5.Intravesical Bacillus Calmette–Guerin (BCG).
6.Potassium sensitivity test is not recommended for routine use. It is a nonspecific and painful test.
Follow-Up
A.The IC/BPS diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches.
B.Ineffective treatments should be stopped once a clinically meaningful interval has elapsed.
C.Allodynia, the perception of nonnoxious stimuli such as touch being noxious or painful, may be present; therefore, an adequate pelvic examination may not be possible. Consider empiric treatment and have the patient return for a pelvic examination to finish the evaluation.
D.Have the patient keep a 1-day bladder diary prior to visits to evaluate a pattern of low urine volume frequency characteristic of IC/PBS.
E.As with all medications, start at the lowest dose and titrate/increase doses if there is an improvement in symptoms.
Consultation/Referral