Interstitial cystitis

Also known as bladder pain syndrome.

A chronic pain pelvic pain condition that affects an estimated 7.9 million women in the US.

Bladder disease associated with urinary frequency occurring as often as every ten minutes.

Associated with pain in the bladder or in the pelvis.

Defined as an unpleasant sensation of pain, pressure, discomfort that is perceived to be related to the urinary bladder, and is associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.

Patient described flares of worsening symptoms that are triggered by stress, intercourse, menses, or diet.

Etiology unknown, but proposed mechanisms include: autoimmune, neurologic allergic and genetic in origin.

Surface glycosaminoglycans layer is damaged urine chemicals leak into the bladder tissues with resultant pain, inflammation and secondary symptomotolgy.

A multifactorial disease with an overlapping etiologies driven by complex pelvic neural circuitry.

Definitive diagnostic criteria are lacking.

Treatment with pentose polysulfate sodium (Elmiron) and other agents that can be placed into the bladder to rebuild damaged urothelium.

Two genes FZD8 (10p11.2) and PAND (13q22-q32)) are associated with the process.

Patients with the most advanced process have large thin areas of bladder referred to as Hunner’s ulcers.

Hunner’s ulcers present in about 5-10% of patients.

Many patients have no identifiable lesions on cystoscopy.

Many patients complain only of urethral burning.

Some patients complain of pain throughout the pelvis on voiding.

Some patients experience pelvic floor tightness and dysfunction.

Not related to bacteria infection and antibiotics do not improve symptoms.

A chronic process that affects approximately 1 million people in the U.S.

Most affected are women, and can affect children and men.

Patients may experience fluctuating symptoms and periods of remission.

Flares may be precipitated by menstruation, seasonal allergies, stress and sexual activity.

Patients may urinate up to 60 times per day and experience pain in the suprapubic area, vagina and anus and pain with intercourse in women and the scrotum and anus and with ejaculation in men.

Most patients experience pain and urinary frequency.

Characteristics and duration of pain and exacerbating and mitigating factors, such as dietary triggers, bladder filling and emptying, bowel habits, intercourse, and menstruation are noted.

History includes details of medications that can cause cystitis such as nonsteroidal anti-inflammatory drugs, cyclophosphamide, and ketamine, previous pelvic surgery, sexually transmitted infections, malignancies and, associated conditions such as IBS, vulvodynia, endometriosis, fibromyalgia, chronic fatigue syndrome, and autoimmune disease.

Has a high prevalence of fibromyalgia (FM), chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), allergy, asthma, vulvodynia, chronic pelvic pain, endometriosis depression, headache, tension headaches, temperomandibular disorder, sicca syndrome, panic disorder and anxiety.

These non-bladder syndromes have many similarities to IC syndrome: prominent pain, overrepresentation in women, normal local histologic findings, nondiagnostic laboratory tests, chronicity, and of unknown etiology.

Diagnoses to be excluded include: endometriosis, UTIs, and pelvic inflammatory disease.

The bladder pain syndrome can be diagnosed in patients with bladder/suprapubic pain and voiding symptoms lasting more than six weeks if infection and structural genitourinary pathology are excluded.

Because of these similarities, FM, CFS, temporomandibular disorder, chronic pelvic pain, migraine and IBS are referred to as the functional somatic syndromes (FSSs).

Laboratory testing includes: a urinalysis, urine culture, urodynamic testing in women with relevant neurologic disease,.

Cystoscopy is normal in the majority of patients with bladder pain syndrome and is unnecessary.

Physical examination includes a musculoskeletal assessment for lumber, pelvic, girdle, and hip contributions to pain, along with lower extremity neurologic examination.

Pelvic floor myofascial pain and dysfunction has been found in up to 85% of patients with bladder pain syndrome.

A pelvic floor muscle examination should be performed as an additional component of the pelvic exam, vaginally or rectally lithotomy position:Examination of the levator ani  muscles for function.


These function somatic syndromes are associated with depression and anxiety.

Non-bladder syndromes may precede or follow IC.

The presence of multiple non-bladder syndromes increases the risk of developing IC.

There is a suggestion of of a genetic predisposition to IC/bladder pain syndrome (BPS).

Treatment guidelines advocate is stepwise approach balancing benefits and adverse effects of therapies.

Antibiotics are not indicated without a documented infection.

 Stress management and behavioral modifications are first line treatments.

Avoidance of bladder irritants such as coffee/tea, acidic foods, carbonation, and alcohol are indicated.

Levels of hydration, bladder volume, and frequency of voids should be balanced.

 Pelvic floor physical therapy is recommended for women with myofascial abnormalities.

Oral agents including amitriptyline, cimetidine, hydroxyzine, and pentosan polysulfate may benefit a subset of patients.

Installations of lidocaine, heparin, and dimethyl sulfoxide can be beneficial.

Intrdetrusor botulinum injections may be beneficial for patients with factory symptoms. 

Major surgery with  ystectomy or diversion is rarely indicated.

Opioid management is discouraged.

Alkalinized lidocaine and heparin have been reported to provide relief from pain and urgency symptoms associated with Interstitial cystitis.

The heparin-lidocaine combination significantly reduced the % of bladder pain (38% versus 13%, and urgency (42% versus 8% p = 0.003) compared to lidocaine.

Heparin-lidocaine combination results in significantly better relief of interstitial cystitis symptoms compared to alkalinized lidocaine and the combination yields higher lidocaine absorption than USP lidocaine.
 

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