Interstitial Cystitis - by Karen Delhey
Cystitis is a very nonspecific term meaning inflammation of the bladder. Interstitial cystitis (IC) is a condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region. Symptoms vary, but most commonly include an urgent need to urinate (urgency), a frequent need to urinate (urgency), and/or pelvic pain usually worsened with bladder filling and lessened with bladder emptying. The symptoms may worsen with certain foods or stress. It occurs far more frequently in women than men and it is estimated that of the 1 million Americans with IC, up to 90% are women. Women’s symptoms often worsen during menses and many women experience pain with intercourse. In men, the pain may be at the tip of the penis, groin, or testicles.
Because symptoms are similar to those of other disorders of the urinary bladder and because there is no definitive test to identify IC, it is considered almost a diagnosis of exclusion. A doctor must rule out urinary tract infections and bladder cancer, and in men chronic prostatitis. An examination of urine will be done to look for red blood cells (possibly cancer or a stone) or an infection. A questionnaire may give a score which correlates with IC and fluids instilled into the bladder can either worsen the symptoms of patients with IC (potassium chloride sensitivity test) or lessen the symptoms (lidocaine, heparin, DMSO). A cystoscopy (looking into the bladder with a telescope) may be done under anesthesia and can rule out bladder cancer and may actually help with the symptoms afterwards. To date there is no one test that definitively diagnoses IC.
Stretching the bladder under anesthesia during cystoscopy can be both diagnostic and therapeutic. Symptoms may temporarily worsen for 1 to 2 days, but then will return to baseline or actually improve. It is felt that the stretching may interfere with pain signals transmitted by nerves in the bladder.
The only drug approved by the FDA for bladder instillation is dimethyl sulfoxide (DMSO, RIMSO-50). The drug is instilled into the bladder through a small tube (catheter) and is held in the bladder for 15 minutes before being expelled. Treatments are given every week for 6 to 8 weeks and then repeated as needed. Some patients learn how to do the catheterizations and instillations at home. It is felt that DMSO passes into the bladder and reduces inflammation, blocks pain and may prevent muscle contractions. The DMSO may be combined with other agents including heparin, kenalog (steroid),sodium bicarbonate (acid reducer), and lidocaine or marcaine (anesthetic), carrying these agents with it. One bothersome side effect of DMSO is a garlic-like taste and odor on the breath and skin that can last up to 3 days.
Lidocaine and marcaine are short and long acting anesthetics that can be instilled into the bladder for immediate relief and can last hours to several days, and can be done at home.
Pentosan polysulfate sodium (Elmiron)
This is the first oral drug approved by the FDA for IC in 1996. It is taken on an empty stomach three times a day, and can take up to 6 months to have a reduction in urinary frequency and IC pain.
It is felt that Elmiron may work by repairing defects in the bladder lining. Side effects include minor gastrointestinal discomfort and 4% risk of hair loss which is reversible when the drug is stopped.
This is a tricyclic antidepressant which can help with sleeping and is used at lower doses than that for treatment of depression. It can cause weight gain, constipation, and reduced libido.
Histamine Blockers (Atarax, Vistaril, Clarinex, Zyrtec)
These drugs prevent the release of histamine from mast cells in the bladder, which is felt to be one of the causes of IC. The newer agents are taken once daily and do not cause fatigue.
Gabapentin (Neurontin), Pregabalin (Lyrica)
These are antiseizure medications which have been used to treat chronic pain, and can have benefit in IC. They have variable dosing and their main side effects are dizziness and fatigue.
Anticholinergic Medications (Detrol LA, Ditropan XL, Enablex, Levbid, Oxybutynin, Oxytrol, Sanctura, Vesicare)
These medications are used to treat an “overactive bladder”, and may work by relaxing the bladder muscle causing less urgency and frequency, or by reducing the sensation of feeling the need to urinate. Their main side effects are dry mouth, blurred vision, and constipation.
This is an over the counter medication which is a tasteless additive
sprinkled on food to deacidify foods that would otherwise cause a flare.
This is an amino acid which is involved in the production of nitric oxide and is obtained from a health food store.
These can be used to effectively improve the patients mood, job status, and family life, but abuse can occur when the narcotics are used to escape from life’s problems, not just treat the pain. They come in long-acting and short-acting forms, and many times are best managed by a pain doctor. They also can cause side effects including constipation, sedation, confusion, respiratory depression and even death.
Tramadol (Ultram) is an atypical narcotic, and can help with mild and moderated pain with IC.
Urinary anesthetics (Pyridium, Urelle, Utira-C, Prosed DS, Pyridium Plus)
These agents turn the urine either orange or blue and may be combination drugs working as an anesthetic, antiseptic (kills bacteria), and anticholinergic.
Long-term Oral Antibiotics
There is some thought that IC may be caused by low levels of bacteria and antibiotic therapy for 6 months may be beneficial. Vaginitis may need to be treated.
There is no scientific evidence linking diet to IC, but many patients find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus drinks, and high-acid foods may contribute to bladder irritation and inflammation.
This includes electrical stimulation, biofeedback and bladder training to help with pain relief and frequency reduction. Many times it is covered by insurance.
(Botox) Intravesical Botox has been used with success to treat IC, and can help with both the pain and the frequency. It is an off label use of Botox, but occasionally insurance companies will pay for the procedure which can be done in the operating room under anesthesia, or in the office under local anesthesia. It lasts for 3 to 6 months before the symptoms return and it needs to be repeated.
Sacral Nerve Stimulation (InterStim)
Stimulation of the sacral nerves affects the muscles of the bladder and the pelvic floor and can aid with frequency, urgency, and sometimes even the pain. A test stimulation can be done in the office under local, but the permanent implant must be done in the operating room. It is approved by Medicare, and thus, many of the private carriers cover it. A thin wire is placed in the lower back and mild stimulation is delivered through an external device similar to a TENS unit, and if successful, the permanent device is placed in the operating room with the small stimulator placed under the skin in the lower back.
(Urological and Sexual Health Care Specialists)
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