Malady Wise

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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

Fact Sheet