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Valley OBGYN
Interstitial cystitis (IC), one of the chronic pelvic pain
disorders, is a condition resulting in recurring discomfort or pain in the
bladder and the surrounding pelvic region. The symptoms of IC vary from case
to case and even in the same individual. People may experience mild
discomfort, pressure, tenderness, or intense pain in the bladder and
surrounding pelvic area.
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Symptoms may include an urgent need to urinate (urgency), frequent
need to urinate (frequency), or a combination of these symptoms. Pain may
change in intensity as the bladder fills with urine or as it empties. Women's
symptoms often get worse during menstruation. In IC, the bladder wall may be
irritated and become scarred or stiff. Glomerulations (pinpoint bleeding caused
by recurrent irritation) may appear on the bladder wall. Some people with IC
find that their bladders cannot hold much urine, which increases the frequency
of urination. Frequency, however, is not always specifically related to bladder
size; many people with severe frequency have normal bladder capacity. People
with severe cases of IC may urinate as many as 60 times a day.
Also, people with IC often experience pain during sexual
intercourse. IC is far more common in women than in men. Of the more than
700,000 Americans estimated to have IC, 90 percent are women.
What Causes IC?
Some of the symptoms of IC resemble those of bacterial infection,
but medical tests reveal no organisms in the urine of patients with IC.
Furthermore, patients with IC do not respond to antibiotic therapy. Researchers
are working to understand the causes of IC and to find effective treatments.
One theory being studied is that IC is an autoimmune response
following a bladder infection. Another theory is that a bacterium may be
present in bladder cells but not detectable through routine urine tests. Some
scientists have suggested that certain substances in urine may be irritating to
people with IC, but no substance unique to people with IC has as yet been isolated.
Researchers are beginning to explore the possibility that heredity may play a
part in some forms of IC. In a few cases, IC has affected a mother and a
daughter or two sisters, but it does not commonly run in families. No gene has
yet been implicated as a cause.
Are There Different Types of IC?
Because IC varies so much in symptoms and severity, most
researchers believe that it is not one, but several, diseases. In the past,
cases were mainly categorized as ulcerative IC or nonulcerative IC, based on
whether ulcers had formed on the bladder wall. But many researchers and
clinicians have questioned the usefulness of this classification, since the
vast majority of cases do not involve ulcers, and their presence or absence
does not influence treatment options as much as other factors do.
Factors that influence treatment options include whether bladder
capacity under anesthesia is great or small, and whether mast cells are present
in the tissue of the bladder wall, which may be a sign of an allergic or autoimmune
reaction. In some cases, the success or failure of a treatment helps
characterize the type of IC. For example, some cases respond to changes in diet
while others do not.
How Is IC diagnosed?
Because symptoms are similar to those of other disorders of the
urinary system and because there is no definitive test to identify IC, doctors
must rule out other conditions before considering a diagnosis of IC. Among
these disorders are urinary tract or vaginal infections, bladder cancer,
bladder inflammation or infection caused by radiation to the pelvic area,
eosinophilic and tuberculous cystitis, kidney stones,endometriosis,
neurological disorders, sexually transmitted diseases, low-count bacteria in
the urine, and, in men, chronic bacterial and nonbacterial prostatitis.
The diagnosis of IC in the general population is based on presence
of urgency, frequency, or pelvic/bladder pain and cystoscopic evidence (under
anesthesia) of bladder wall inflammation, including Hunner's ulcers or
glomerulations (present in 90 percent of patients with IC).
Diagnostic tests that help identify other conditions include
urinalysis, urine culture, cystoscopy, biopsy of the bladder wall, distention
of the bladder under anesthesia, urine cytology, and, in men, laboratory
examination of prostate secretions.
Urinalysis and Urine Culture
These tests can detect and identify the most common organisms that
infect the urine and that may cause symptoms similar to IC. There are, however,
organisms such as Chlamydia that cannot be detected with these tests, so a
negative culture does not rule out all types of infection. A urine sample is
obtained either by catheterization or by the "clean catch" method.
For a clean catch, the patient washes the genital area before collecting urine
"midstream" in a sterile container. White and red blood cells and
bacteria in the urine may indicate an infection of the urinary tract, which can
be treated with an antibiotic. If urine is sterile for weeks or months while
symptoms persist, the doctor may consider a diagnosis of IC.
Cystoscopy Under Anesthesia with Bladder Distention
During cystoscopy, the doctor uses a cystoscope--an instrument
made of a hollow tube about the diameter of a drinking straw with several
lenses and a light--to see inside the bladder and urethra. The doctor will also
distend or stretch the bladder to its capacity by filling it with a liquid or
gas. Because bladder distention is painful in patients with IC, they must be
given some form of anesthesia for the procedure. These tests can detect bladder
wall inflammation; a thick, stiff bladder wall; and Hunner's ulcers.
Glomerulations are usually seen only after the bladder has been stretched to
capacity.
The doctor may also test the patient's maximum bladder
capacity--the maximum amount of liquid or gas the bladder can hold. This must
be done under anesthesia since the bladder capacity is limited by either pain
or a severe urge to urinate. A small bladder capacity under anesthesia helps
support the diagnosis of IC.
Biopsy
A biopsy is a tissue sample that is then examined under a
microscope. Samples of the bladder and urethra may be removed during a
cystoscopy and later examined with a microscope. A biopsy helps rule out
bladder cancer.
What Are theTreatments for IC?
Scientists have not yet found a cure for IC, nor can they predict
who will respond best to which treatment. Symptoms may disappear without explanation
or coincide with an event such as a change in diet or treatment. Even when
symptoms disappear, they may return after days, weeks, months, or years.
Scientists do not know why. Because the causes of IC are unknown, current
treatments are aimed at relieving symptoms. Most people are helped for variable
periods by one or a combination of treatments. As researchers learn more about
IC, the list of potential treatments will change, so patients should discuss
their options with a doctor.
Bladder Distention
Because many patients have noted an improvement in symptoms after
a bladder distention done to diagnose IC, the procedure is often thought of as
one of the first treatment attempts. Researchers are not sure why distention
helps, but some believe that it may increase capacity and interfere with pain
signals transmitted by nerves in the bladder. Symptoms may temporarily worsen
24 to 48 hours after distention, but should return to predistention levels or
improve after 2 to 4 weeks.
Bladder Instillation
During a bladder instillation, also called a bladder wash or bath,
the bladder is filled with a solution that is held for varying periods of time,
averaging 10 to 15 minutes, before being emptied. The only drug approved by the
U.S. Food and Drug Administration (FDA) for bladder instillation is Dimethyl
Sulfoxide (DMSO, RIMSO-50). DMSO treatment involves guiding a narrow tube
called a catheter up the urethra into the bladder. A measured amount of DMSO is
passed through the catheter into the bladder, where it is retained for about 15
minutes before being expelled. Treatments are given every week or two for 6 to
8 weeks and repeated as needed. Most people who respond to DMSO notice
improvement 3 or 4 weeks after the first 6- to 8-week cycle of treatments.
Highly motivated patients who are willing to catheterize themselves may, after
consultation with their doctor, be able to have DMSO treatments at home.
Self-administration is less expensive and more convenient than going to the
doctor's office.
Doctors think DMSO works in several ways. Because it passes into
the bladder wall, it may reach tissue more effectively to reduce inflammation
and block pain. It may also prevent muscle contractions that cause pain,
frequency, and urgency.
A bothersome but relatively insignificant side effect of DMSO
treatments is a garlic-like taste and odor on the breath and skin that may last
up to 72 hours after treatment. Long-term treatment has caused cataracts in
animal studies, but this side effect has not appeared in humans. Blood tests,
including a complete blood count and kidney and liver function tests, should be
done about every 6 months.
Oral Drugs
Pentosan polysulfate sodium, the first oral drug developed for IC,
was approved by the FDA in 1996. In clinical trials. This drug improved
symptoms in 38 percent of patients treated. Doctors do not know exactly how it
works, but one theory is that it may repair defects that might have developed
in the lining of the bladder.
The FDA-recommended dosage is 100 mg, three times a day. Patients may
not feel relief from IC pain for the first 2 to 4 months. A decrease in urinary
frequency may take up to 6 months. Patients are urged to continue with therapy
for at least 6 months to give it an adequate chance to relieve symptoms.
Side effects are limited primarily to minor gastrointestinal
discomfort. A small minority of patients experienced some hair loss, but hair
grew back when they stopped taking the drug. This drug may affect liver
function, which should therefore be monitored by the doctor.
Other Oral Medications
Aspirin and ibuprofen are easy to obtain and may be a first line
of defense against mild discomfort. Doctors may recommend other drugs to
relieve pain.
Some patients have experienced improvement in their urinary
symptoms by taking antidepressants or antihistamines. Antidepressants help
reduce pain and may also help patients deal with the psychological stress that
accompanies living with chronic pain. In patients with severe pain, narcotic
analgesics such as acetaminophen with codeine or longer acting narcotics may be
necessary.
Transcutaneous Electrical Nerve Stimulation
With transcutaneous electrical nerve stimulation (TENS), mild
electric pulses enter the body for minutes to hours two or more times a day
either through wires placed on the lower back or just above the pubic area,
between the navel and the pubic hair, or through special devices inserted into
the vagina in women or into the rectum in men. Although scientists do not know
exactly how TENS works, it has been suggested that the electric pulses may
increase blood flow to the bladder, strengthen pelvic muscles that help control
the bladder, or trigger the release of substances that block pain.
TENS is relatively inexpensive and allows the patient to take an
active part in treatment. Within some guidelines, the patient decides when, how
long, and at what intensity TENS will be used. It has been most helpful in
relieving pain and decreasing frequency in patients with Hunner's ulcers.
Smokers do not respond as well as nonsmokers. If TENS is going to help,
improvement is usually apparent in 3 to 4 months.
Diet
Patients find that certain foods may contribute to bladder
irritation and inflammation. Refer to the list of dietary bladder irritants
below. Some patients note that their symptoms worsen after consuming these
products. Patients may try eliminating various products from their diet and
reintroducing them one at a time to determine which affect symptoms. It is
important, however, to maintain a varied, well-balanced diet. Click here to download IC Smart Diet.
Smoking:
Many patients feel that smoking makes their symptoms worse.
Because smoking is the major known cause of bladder cancer, one of the best
things smokers can do for their bladder is to quit.
Exercise
Many patients feel that gentle stretching exercises help relieve
IC symptoms.
Bladder Training
People who have found adequate relief from pain may be able to
reduce frequency by using bladder training techniques. Methods vary, but
basically patients decide to void (that is, empty their bladder) at designated
times and use relaxation techniques and distractions to keep to the schedule.
Gradually, patients try to lengthen the time between scheduled voids. A diary
that records voiding times is usually helpful in keeping track of progress.
Surgery
Many approaches and techniques are used, each of which has its own
advantages and complications that should be discussed with a surgeon. Surgery
should be considered only if all available treatments have failed and the pain
is disabling. Most doctors are reluctant to operate because the outcome is
unpredictable since some people still have symptoms after surgery.
Those considering surgery should discuss the potential risks and
benefits, side effects, and long- and short-term complications with a surgeon
and with their family, as well as with people who have already had the
procedure. Surgery requires anesthesia, hospitalization, and weeks or months of
recovery, and as the complexity of the procedure increases, so do the chances
for complications and failure.
Two procedures--fulguration and resection of ulcers--can be done
with instruments inserted through the urethra. Fulguration involves burning
Hunner's ulcers with electricity or a laser. When the area heals, the dead
tissue and the ulcer fall off, leaving new, healthy tissue behind. Resection
involves cutting around and removing the ulcers. Both treatments are done under
anesthesia and use special instruments inserted into the bladder through a
cystoscope. Laser surgery in the urinary tract should be reserved for patients
with Hunner's ulcers and should be done only by doctors who have had special
training and have the expertise needed to perform the procedure.
Another surgical treatment is augmentation, which makes the
bladder larger. In most procedures, scarred, ulcerated, and inflamed sections
of the patient's bladder are removed, leaving only the base of the bladder and
healthy tissue. A piece of the patient's bowel (large intestine) is then
removed, reshaped, and attached to what remains of the bladder. After the
incisions heal, the patient may void less frequently. The effect on pain varies
greatly; IC can sometimes recur on the segment of bowel used to enlarge the
bladder.
Even in carefully selected patients--those with small, contracted
bladders--pain, frequency, and urgency may remain or return after surgery, and
the patient may have additional problems with infections in the new bladder and
difficulty absorbing nutrients from the shortened intestine. Some patients are
incontinent, while others cannot void at all and must insert a catheter into
the urethra to empty the bladder.
Bladder removal, called a cystectomy, is another surgical option.
Once the bladder has been removed, different methods can be used to reroute
urine. In most cases, ureters are attached to a piece of bowel that opens onto
the skin of the abdomen;this procedure is called a urostomy, and the opening is
called a stoma. Urine empties through the stoma into a bag outside the body.
Some urologists are using a second technique that also requires a stoma but allows
urine to be stored in a pouch inside the abdomen. At intervals throughout the
day, the patient puts a catheter into the stoma and empties the pouch. Patients
with either type of urostomy must be very careful to keep the area in and
around the stoma clean to prevent infection. Serious potential complications
may include kidney infection and small bowel obstruction.
A third method to reroute urine involves making a new bladder from
a piece of the patient's bowel and attaching it to the urethra. After healing,
the patient may be able to empty the newly formed bladder by voiding at
scheduled times or by inserting a catheter into the urethra. Few surgeons have
the special training and expertise needed to perform this procedure.
Even after total bladder removal, some patients still experience
variable IC symptoms in the form of phantom pain. Therefore, the decision to
undergo a cystectomy should be undertaken only after testing all alternative
methods and after seriously considering the potential outcome.
A surgical variation of TENS, called saccral nerve root
stimulation, involvespermanent implantation of electrodes and a unit emitting
continuous electrical pulses.
DIETARY IRRITANTS TO THE URINARY TRACT
These may aggravate Bladder Control Problems
All alcoholic beverages
Apples, apple juice
Apricots
Avocados
BBQ Sauce
Bananas
Beer
Beets
Cabbage
Caffeine
Cantaloupes
Carbonated drinks
Cheese (except American, cottage, ricotta, cream)
Chicken livers
Chilies/spicy foods
Chocolate
Citrus fruits
Coffee (except no-acid type)
Cocktail Sauce
Cola
Corned beef
Cranberries
Cranberry juice and sauce
Grapefruit, grapefruit juice
Grapes, grape juice
Green Pepper
Guava
Honey
Hot Sauce
Jalapeno
Ketchup
Lemons, lemon juice
Lentils
Lima beans
Limes, lime juice
Mustard
Mayonnaise
Artificial sweetners
Nuts (almonds, peanuts and pine nuts are tolerable)
Onions
Oranges, orange juice
Peaches
Pickles (vinegar)
Pickled herring
Pineapple and pineapple juice
Pizza with tomato sauce
Plums
Prunes
Raisins
Red pepper
Relish
Rhubarb
Rye bread
Salad dressing
Salsa
Saccharine
Sauerkraut
Soda pop
Sour cream
Soy sauce
Spaghetti sauce
Steak Sauce
Strawberries
Sweet/Sour sauce
Tea
Tobacco
Tomatoes (except low-acid types)
Tomato juice, sauce and soup
Vinegar
Vitamins buffered with aspartate
Vitamin C and B complex
Watermelon
Yogurt
