Interstitial Cystitis
SUMMARY: Chronic bladder pain can be a debilitating condition that impacts the quality of life. The cause of chronic bladder pain is not well understood and a diagnosis of Interstitial Cystitis / Painful Bladder Syndrome is made when there is chronic bladder pain in the absence of other explainable causes.
Fact Sheet
Overview
Interstitial Cystitis (IC) is likely underdiagnosed.
The RICE study looked at 150,000 American women and found a rate between 2.7 to 6.5%
More common in women than men
Cause
Not well understood
Multiple factors are likely involved
Bladders have a protective glycosaminoglycan (GAG) layer that coats the inner lining (uroepithelium)
This GAG layer is altered in IC and no longer protects the bladder from irritating solutes in the urine
Underlying nerve and muscle tissue is activated leading to a cycle of tissue damage, pain and hypersensitivity
There is likely central sensitisation of pain signals and normal bladder filling now results in pain
Symptoms
Bladder symptoms are usually described as painful but can be pressure, discomfort or spasms
Symptoms vary from day to day and range in severity from mild to severe
Symptoms are felt suprapubic (lower abdomen over your bladder), urethral (wee tube) and sometimes in your back
There is usually gradual onset and worsening over months, although sometimes abrupt and severe
Triggers
Most patients cannot identify a triggering event, sometimes symptoms develop after
Urinary tract infections,
Surgical procedures
Trauma such as falling on your coccyx (tailbone)
Exacerbating Factors
Certain foods
Drinks such as alcohol
During stress
Certain activities (e.g. exercise, sex, prolonged sitting)
Luteal phase of the menstrual cycle (day 14 to 28)
Examination
There is often variable tenderness of the abdominal wall, hip girdle, pelvic floor, bladder base and urethra. This is likely due to sensitisation of the nerve fibres in the dermatomes associated with the bladder (thoracolumbar and sacral).
In men, scrotal pain and penile tenderness may be present
There may be allodynia (perception of non-harmful stimuli such as light touch to be felt as painful)
There may be tenderness or tightness of the pelvic floor muscles
Urine testing is typically normal
Associated Conditions
Other chronic pain syndromes may be present
Irritable bowel syndrome
Vulvodynia (pain or discomfort around the opening of the vagina)
Fibromyalgia
Sexual concerns and dysfunction are common in women which can be attributable to vulvodynia as well as the occurrence of bladder-specific symptoms during sex
Men with pelvic pain from the bladder (IC) often have concomitant sexual dysfunction
As with other chronic pain syndromes, psychosocial comorbidities are common
Evaluation
IC should be suspected in patients who have pain perceived to be related to the urinary bladder for several weeks.
There is usually no evidence of infectious causes or they have already been treated and symptoms persist
Frequent voiding to avoid discomfort should increase suspicion
Pelvic floor tenderness increases suspicion
Diagnostic Approach
In patients with at least 6 weeks of unexplained bladder symptoms
History to evaluate symptoms
Exam to rule out structural disease
Check urine for UTI or STI
If the above negative screen history and exam for red flags including
Prior pelvic radiation, surgery or trauma
Pelvic mass or organ prolapse
Neurological disorders affecting bladder function
If negative then screen for urological abnormality
Urinary incontinence
Elevated Post Void Residual
History of bladder cancer
Haematuria
If negative then diagnosis consistent with IC
Diagnosis
The diagnosis of IC/BPS is made in patients with an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.
Differential Diagnoses
Bladder or urethral cancer
Genital tract cancer (vagina, vulva, prostate)
Infection (atypical STI)
Benign pelvic abnormalities (leimyomas)
Intravesical pathologies (bladder stone)
Urethral diverticulum
Neurological conditions (bladder outlet obstruction)
Chronic pelvic pain syndrome
Management
Patient Education
Provide information about the diagnostic criteria, variability of symptoms and chronic nature of the condition.
Explain normal bladder function and encourage patients wto identify activities, foods, or behaviours that may exacerbate symptoms.
Evaluate for comorbidities
Look for concurrent disorders that can result in increased bladder sensitivity
Acute conditions
Exclude concurrent UTI or vulvovaginitis
Chronic conditions
Vulvodynia
Endometriosis
Chronic pelvic pain syndromes
Inflammatory bowel syndrome
Diverticulitis
Irritable bowel syndrome
Fibromyalgia
Evaluate psychosocial needs
An integral part of management
Patients may benefit with stress reduction and relaxation techniques
Anxiety and depression disorders are common in patients with chronic pain and may impede progress. Approaches such as Cognitive Behavioural Therapy (CBT) have been found to be helpful.
Self-care and lifestyle modification
These methods may be effective in some patients but most will need additional therapy.
Application of local heat or cold over the bladder or perineum.
Avoidance of activities or food or beverages that exacerbate symptoms (eg, caffeine, alcohol, artificial sweeteners, hot pepper, and vitamin C-containing foods)
Avoidance of exercises, recreational activities, sexual activities, or body positions that seem to worsen bladder symptoms. A symptom diary may be useful for some patients to self-identify such factors.
Fluid management – A fluid and voiding diary can be useful.
Patients who experience worsening of symptoms with concentrated urine may find increasing fluid intake helpful.
Others who experience pain with bladder filling may find that moderate fluid restriction provides some relief.
Bladder training with urge suppression.
Physical therapy
Many patients with IC have pelvic floor muscle tenderness. Pelvic floor physio in combination with other therapies is useful.
Medication
Although some patients have adequate symptom resolution with non-medication intervention, many will also require medication. Analgesia medication may be sufficient in patients with occasional symptom flares. However, for patients in whom flares are frequent or severe, oral medication is indicated.
Amitriptyline / Endep
Common first-line treatment however few comparative studies between different first medications
Choice of agent should depend on side effects and patient preference
Effective at high doses but can be limited by side effects
Typical dosing starts at 10mg at night
Increase at weekly intervals to 25mg, 50mg, 75mg
Side effects are dry mouth, urinary retention, constipation, weight gain, sedation
If effective, results can be observed within one month
Studies show a >30% decrease in symptoms in patients treated with 25 to 100mg daily
Pentosan polysulfate sodium
The proposed mechanism is reconstitution of the deficient protective GAG layer in the bladder
Treatment results in a 12% improvement
Dose is 100mg three times daily
May take 6 months to see improvement
Risk factor for macular degeneration and a detailed eye exam should happen prior to starting
Other side effects include nausea and diarrhoea
Antihistamines
For patients with IC and allergic disorders (allergic rhinitis, asthma), an antihistamine is a good first medication to trial
This is based on the hypothesis that hypersensitivity may be responsible for bladder symptoms due to increased mast cells in the bladder wall in IC
Analgesia
Non Steroidal Anti-inflammatory Drugs such as Ibuprofen
Paracetamol
Hipprex / Methenamine may be used short-term
Other options
Pregabalin or Gabapentin may be effective however there are no published studies for their use
Specialist referral
Referral to a Urologist if symptoms measures fail or if red flags for concerns about other conditions.
Intravesical therapies are an option
Bladder Hydrodistension
Patient Support Groups
References
Treatment of Interstitial cystitis / painful bladder syndrome - Up To Date
Clinical features of Interstitial Cystitis - Up To Date