Interstitial Cystitis (IC)
See:
Interstitial Cystitis – Complementary and Alternative Medicine (CAM) Treatment
Toll-like – 4 Receptor Antagonists
See also:
Visceral Pain Syndromes – Overview
.
Interstitial Cystitis (IC)
See CAM Treatment of Interstitial Cystitis for dietary and nutritional approaches to IC.
Diagnosis
Interstitial cystitis (IC) is a condition associated with chronic pain or discomfort in the bladder and surrounding pelvic region. Symptoms typically includes:
▪ Urinary frequency and urgency (more than 8 voids per day).
▪ Nocturia (more than 2 voids during the night).
▪ Bladder and/or pelvic pain (> 75% of women with chronic pelvic pain also complain of irritation when voiding).
The clinical presentation of IC varies; 16% of women only have pain, 30% only have frequency, but most patients have both pain and frequency. The pain may be suprapubic, vaginal, urethral, perineal, groin, or lower back. While these symptoms are similar to urinary infections, IC occurs in the absence of infections with urinanalysis and urine cultures negative. Symptom flare-ups are common, and in women tend to occur around menstruation or sometimes after sexual intercourse. However, every woman experiences IC differently.
IC can have a significant impact on quality of life. Urinary frequency in patients with IC averages 16 times a day but may exceed 40-60 times per day. Depression is also common in patients with IC because work life, family life, and sexual enjoyment are often compromised.
For IC diagnosis, the time from the first doctor’s visit to a definitive diagnosis often takes a few years. The significant overlap between IC and other benign bladder dysfunction with similar urinary symptoms, including overactive bladder, creates challenges for IC diagnosis. A standard diagnostic test specific to IC has not yet been specifically defined so diagnosis is still dependent on subjective criteria. A better understanding of the causative mechanisms of IC and the identification of biomarkers to define and measure severity of IC are needed. Recent research has identified a biomarker found in a person’s stool that may help definitively identify someone with IC.
Until specific diagnostic tests are defined, IC is generally a diagnosis of exclusion, meaning other conditions must first be excludes (eg, bladder cancer, endometriosis, and infections). Less than 10% of patients with IC have the classical, or ulcerative, type, which is associated with large erythematous (red) patches, known as Hunner’s patches. These can be seen under cystoscopic exam and may present as ulcers or fissures. However, most women have the nonclassical, or nonulcerative, type, which is characterized by a lack of ulcerations on cystoscopy.
Recent Thinking About the Nature of Interstitial Cystitis
Historically, the bladder has been thought to be the origin of IC/BPS because symptoms are primarily related to the pain, pressure, or discomfort related to filling of the bladder. However, this concept is challenged by a lack of identifiable bladder pathology in many IC/PBS patients and the fact that patients without bladders can continue to report symptoms consistent with this syndrome.
In addition, numerous studies have shown that IC/BPS is associated with a higher prevalence of various conditions characterized by chronic pain, such as vulvodynia, endometriosis, fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome. These non-bladder syndromes are a strong risk factor for IC/PBS, suggesting that these patients may have a systemic syndrome. This also suggests that central sensitization mechanisms contribute to the manifestation of IC/PBS, at least in some patients. As a consequence, treatment directed at central sensitization should now be considered in appropriate patients with increased risk or findings of central sensitization – including both medication and behavioral management (see “central sensitization” below).
Functional abnormalities in the autonomic nervous system (ANS) have been proposed to contribute to IC/BPS symptoms. Investigators have also proposed that a correlation exists between increased sympathetic system (the “urgent response” branch of the ANS) outflow and dysregulation of the hypothalamic-pituitary- adrenal axis (e.g., lower circulating cortisol), and symptoms (e.g., pain and urgency) occurs in IC/BPS.
As a consequence of these insights into IC, a multi-disciplinary approach to the treatment of IC appears to offer significant potential benefit. Patients with IC are encouraged to explore mindful approaches to symptom management with the goal of reducing stress and gaining improved coping skills and cognitive techniques to reduce the impact of IC on quality of life. Meditation, yoga, tai chi, deep relaxation techniques, self-hypnosis and other skills are options available that are safe, effective and affordable.
Prevalence
The exact prevalence of IC is unknown, but IC is likely underdiagnosed and may affect 3 to 8 million women in the United States. Although IC occurs in both men and women, 90% of IC patients are women, most often premenopausal white women. The median age is 42 to 46 years, but IC can occur at any age.
In people whose symptoms don’t strictly fit the diagnostic criteria for IC., the terms Bladder Pain Syndrome (BPS) or Painful Bladder Syndrome (PBS) are used frequently to describe the condition Many people with urinary pain that cannot be attributed to other causes, such as an infection or urinary stones, generally receives the diagnosis of IC/BPS or IC/PBS.
First-Line Treatments: Educational and Behavioral Therapies
Treatment for IC is multidimenstional, requiring approaches from different treatment modes spanning the range of behavioral techniques to reduce stress, dietary interventions, physical interventions that include exercise and massage as well as the use of nutritional supplements and medications and sometimes invasive procedures such as electrical nerve stimulators (neuromodulators) or surgery.
Bladder Training
In bladder training, the patient practices inhibiting the urge to urinate in order to extend the voiding interval between emptying the bladder. A decrease in frequency, nocturia, and urgency was seen in 15 (71%) of 21 IC/BPS patients in one study in which patients progressively increased voiding intervals of 15 to 30 minutes every 3 to 4 weeks.
Stress Management
Because stress is a major influence on the severity of symtoms of IC, first line treatmenst for IC is to focus on stress reduction through the incorporation of lifestyle changes, cognitive therapies such as Cognitive Behavior Therapy (CBT), meditation and mindful exercises. These strategies help reduce feelings of helplessness, increase perceived self-control, and decrease pain catastrophization (see: Using the Mind) as well as yoga and tai chi.
Central Sensitization
Interstitial Cystitis, as many other chronic pain conditions, is highly associated with the development of central sensitization in which changes in the nervous system over time result in the development of increased pain sensitivity as well other sensory sensitivities that intrude into quality of life. Efforts to minimize the development of central sensitivity and reduce the manifestations of central sensitivity are a cornerstone of effective, integrative management of IC.
Second-Line Treatments: Physical Therapy and Exercise and Medications
Physical Therapy and Exercise
A variety of manual physical therapies can be engaged to improve muscle pain in the pelvis, abdomen, lower back and hip areas. Different techniques including stretching exercises and deep tissue massage can be employed directed at resolving myofascial trigger points, lengthening muscle contractures, and releasing painful scars and other connective tissue restrictions. Because of the increased pelvic muscle tone associated with IC, pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided. Pelvic floor massage performed by an appropriately trained physical therapist is an especially technique for reducing pelvic pain and urinary frequency.
Medications
Urinary Alkalinization
Due to the sensitivity of the bladder in IC to acidic substances, urinary alkalinization with baking soda (a glass of water mixed with ½ tsp of baking soda [maximum 3 glasses/day]) or potassium citrate (Urocit-K®, twice a day) can be effective. Prelief, an OTC medication with calcium glycerophosphate, reduces acids in foods and has also been shown effective.
CystoProtek®
CystoProtek is a multi-agent dietary supplement formulated from glucosamine sulfate (120 mg), chondroitin sulfate (150 mg), hyaluronate sodium (10 mg), quercitin dehydrate (150 mg), rutin (20 mg), and olive kernel extract (45%). Isoflavinoids are present to decrease bladder inflammation and multiple mucopolysaccharides to replenish the bladder lining. CystoProtek contains multiple components similar to bladder surface glycosaminoglycans (GAGs) to help reduce bladder wall dysfunction and inflammation. It is thought that the mucopolysaccharide GAG bladder surface layer is composed primarily of chondroitin sulfate and sodium hyaluronate, with glucosamine sulfate serving as the synthetic building block. In one study, patients aged 18 to 69 years with IC who had failed other treatment options took two capsules of CystoProtek twice a day with food. In the 252 patients who participated in this study, about 50% had an overall positive response to CystoProtek.
Pentosan polysulfate sodium (Elmiron)
Pentosan polysulfate sodium (Elmiron) is the only oral medicine that is FDA approved for treating the pain and discomfort of interstitial cystitis (IC). In clinical trials, 38-61 percent of patients treated with Elmiron for three months reported improvement of their IC symptoms. Elmiron is thought to work by restoring a damaged, thin, or “leaky” bladder surface. This surface (glycosaminoglycans, or GAG layer) is composed of a coating of mucus, which protects the bladder wall from bacteria and irritating substances in urine. It is believed that Elmiron functions as a synthetic GAG layer, but the drug’s mechanical action in IC is unknown.
While some patients report symptom improvement in 3-4 weeks, others may take up to six months to see improvement. Patients are encouraged to continue Elmiron for at least six months before discontinuing treatment. Pain subsides first, but a decrease in urinary frequency may take six to nine months.
The side effects of Elmiron include minor gastrointestinal disturbances. Some patients have also experienced hair loss that is reversible upon discontinuing the drug. Elmiron has few if any negative interactions with any other medicines and is usually well tolerated.
The usual dosage for IC patients is 100 mg. of Elmiron three times a day, for a total of 300 mg/day.
Antidepressants
Antidepressants such as Elavil (amitryptiline) and Savella (milnacaprin) can be effective for the pain associated with IC. As noted elsewhere in the management of neuropathic pain, the analgesic benefit of the antidepressants is not related to the presence of depression as they are effective regardless of the presence or absence of depression.
Gabapentinoids (Gabapentin [Neurontin] and Pregabalin [Lyrica])
Neuromodulating medications such as gabapentin (Neurontin) and pregablin (Lyrica) can also be effective for the pain associated with IC, as well as contributing to the reduction of central sensitization.
Urinary Antispasmodics
Mirabegron (Myrbetriq®) and trospium (Sanctura) relaxe the detrusor smooth muscle around the bladder during the storage phase of the urinary bladder fill-void cycle, thereby increasing bladder capacity and reducung voiding frequency, urge urinary incontinence, urgency and frequency.
Mirabegron was evaluated in three 12-week, studies of patients with overactive bladder and symptoms of urge urinary incontinence, urgency and urinary frequency. Results from all three studies demonstrated statistically significant improvements in incontinence episodes and micturitions/24 hours across all doses of mirabegron (25, 50 and 100 mg) compared to placebo.
Medications Instilled into the Bladder
A few medications have been shown to be effective when instilled directly into the bladder, including dimethyl sulfoxide (DMSO, lidocaine, heparine and botulinum toxin A (Botox). One potential complication of the use of Botox, however, is that it can sometimes reduce bladder muscle activity so effectively that a reduced ability to void occurs, requiring the patient self-catheterize themselves until the effects of the Botox wear down or off, possibly requiring 3 months or more.
Third-Line Treatments: Bladder Distentions
Cystoscopy under anesthesia with short-duration, low-pressure hydrodistension may be undertaken if first- and second-line treatments have not provided acceptable symptom control and quality of life or if the patient’s presenting symptoms suggest a more-invasive approach is appropriate.
If Hunner’s lesions are present, then treatment with laser or electrocautery and/or injection of triamcinolone should be performed.
The quality of evidence for the basis of these third-line treatment recommendations for bladder distention treatments are primarily based on observations studies and are considered Grade C:
“Observational studies are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data. Because treatment data for conditions that are difficult to interpret in the absence of a placebo control, bodies of evidence comprised entirely of studies that lacked placebo control groups (i.e., observational studies) are assigned a strength rating of Grade C.”
Fourth Line Treatments: Neuromodulation
Electrical nerve stimulators (neuromodulators), are electronic devices that send mild electrical pulses to nerves in the lower back to help manage urinary function and relieve pain. These nerves, called sacral nerves, influence the bladder and surrounding muscles that manage urinary function. Neuromodulators can be worn externally or surgically implanted. Before surgically placing under the skin, typically in the lower back, a test stimulation procedure is performed with an external device. Only patients who respond positively to the test stimulator are considered for the permanent, surgical implants.
Neuromodulators can be helpful for some IC patients, but should be limited to those who fail to respond to other therapies. Based on the U.S. government’s National Guideline Clearinghouse published in 2014,, neurostimulators for IC are Fourth Line treatments, to be considered only if first, second and third line treatments are unsuccessful, including behavioral treatments, stress management, physical therapy including pelvic floor exercises and massage, medication management including oral medications as well as medications instilled into the bladder and bladder distention treatments.
The quality of evidence for the basis of these recommendations for neuromodulators is primarily based on observations studies and are considered Grade C:
“Observational studies are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data. Because treatment data for conditions that are difficult to interpret in the absence of a placebo control, bodies of evidence comprised entirely of studies that lacked placebo control groups (i.e., observational studies) are assigned a strength rating of Grade C.”
FDA Approved Neuromodulators for Urinary Symptoms and Pain
There are a variety of electrical nerve stimulators approved by the FDA for IC. Consult with a urologist for futher information. The following descriptions are taken from Interstitial Cystitis Association:
The Urgent PC Neuromodulation System, also called percutaneous tibial nerve neuromodulation (PTNS), is a combination of a stimulator and a lead set. This system is designed to treat urinary urgency, urinary frequency and urge incontinence. The stimulator generates a specific kind of electrical impulse that is delivered to the patient through the lead set. Using a needle electrode placed near the ankle as an entry point, the stimulator’s impulses travel along the tibial nerve to the nerves in the spine that control pelvic floor function. The needle electrode is connected to a battery-powered stimulator. After turning on the stimulator, your physician will observe your body’s response to determine the ideal strength of the impulses.
Each of your treatments will last approximately 30 minutes. You will receive an initial series of 12 treatments, typically scheduled a week apart. After the initial 12 treatments, your physician will discuss your response to the treatments and determine how often you will need future treatments to maintain your results. For most patients it takes at least 6 treatments to see changes in symptoms. However, continue receiving treatments for the recommended 12 treatments before you and your physician evaluate whether this therapy is an appropriate treatment for your symptoms.
The most common side-effects include transient mild pain or skin inflammation at or near the stimulation site. Urgent PC is not recommended for patients with pacemakers or implantable defibrillators, patients prone to excessive bleeding, patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function, or patients who are pregnant or planning to become pregnant during the duration of the treatment.
InterStim Therapy for Urinary Control: This device is FDA approved for urinary urge incontinence, nonobstructive urinary retention, and significant symptoms of urgency-frequency in patients who have failed to respond to, or could not tolerate, more conservative treatments. Some IC patients report that InterStim also helps to relieve their pain, as well as symptoms of urinary frequency and urgency. However, the FDA has not approved it for pain management.
Patients interested in the implant surgery are initially evaluated with a complete history, physical examination, voiding diaries, and a bladder function study. If they qualify, they undergo test stimulation, conducted by a urologist or urogynecologist, which typically takes less than one hour, and is considered a “same day” procedure. The test stimulation involves the placement of a needle into the lower back in a location where nerves travel to the bladder. Typically, a local anesthetic is used during the test stimulation. A small wire (lead) is left in place and transmits electrical impulses to these nerves. The patient returns home with the test stimulator in place for 3 to 7 days, and keeps a voiding diary. The wire is then removed by the surgeon. Some patients report the test stimulation to be painful, while others do not. If you are concerned about this, please discuss pain management options with your physician.
If the test stimulation is successful, and improvement is noted within five to seven days, then the permanent system can be surgically implanted under general anesthesia. This generally requires an overnight stay in the hospital. The patient is given a small device that can be used to turn on/off and modulate the level of stimulation to nerves. InterStim can only be implanted by a urologist or urogynecologist who has been specifically trained to perform the procedure. Read answers to FAQs about InterStim.
Eon Mini Rechargeable IPG System: Advanced Neuromodulation Systems (ANS), a division of St. Jude Medical, Inc., makes the Eon Mini, the world’s smallest, longest-lasting rechargeable neurostimulator to treat chronic pain of the trunk or limbs and pain from failed back surgery. The Eon Mini has the longest-lasting battery life of any rechargeable spinal cord stimulation (SCS) device in its class. It is the only small rechargeable neurostimulator to receive a 10-year battery longevity approval by the FDA. While not approved specifically for interstitial cystitis, neuromodulation devices such as this have been tried and tested in people with IC with varying degrees of success. The Eon Mini blocks pain signals from traveling up the spinal cord to the brain.
IF 3WAVE: The IF3WAVE from Empi may be used to treat pain associated with IC, in conjunction with other forms of therapy. This device is used to treat deep pain by delivering nearly 50 times the power of a TENS unit. It delivers two different types of current – neuromuscular electrical stimulation (NMES) and pulse direct current (PDC) – and a combination of both of these currents. The IF 3WAVE features a digital, LCD user interface screen and easy to use push buttons as well as a compliance monitor for tracking usage of the device. The IF 3WAVE requires a prescription from your physician or physical therapist.
Resources:
References:
Interstitial Cystitis – Overviews
- Diagnosis and treatment of interstitial cystitis NGC Guidelines 2014
- Treatment Approaches for Interstitial Cystitis- Multimodality Therapy
- Complementary and Alternative Therapies as Treatment Approaches for Interstitial Cystitis
- novel-research-approaches-for-interstitial-cystitisbladder-pain-syndrome-thinking-beyond-the-bladder-2015
Interstitial Cystitis – Central Sensitization
- segmental-hyperalgesia-to-mechanical-stimulus-in-interstitial-cystitisbladder-pain-syndrome-evidence-of-central-sensitization-2014
- Inflammation and central pain sensitization in Interstitial Cystitis:Bladder Pain Syndrome – 2015
Interstitial Cystitis – Diagnosis
- stool-based-biomarkers-of-interstitial-cystitisbladder-pain-syndrome-2016
- metabolomics-insights-into-pathophysiological-mechanisms-of-interstitial-cystitis-2014
Interstitial Cystitis – Dysautonomia
Interstitial Cystitis – Genetics
See also: Stress, the stress response system, and fibromyalgia
Interstitial Cystitis – Systemic Inflammation
- Inflammation and Inflammatory Control in Interstitial Cystitis: Bladder Pain Syndrome – Associations with Painful Symptoms – 2014
- Inflammation and Symptom Change in Interstitial Cystitis: Bladder Pain Syndrome – A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study – 2016
- Toll-like Receptor 4 and Comorbid Pain in Interstitial Cystitis: Bladder Pain Syndrome – A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study – 2015
- Inflammation and central pain sensitization in Interstitial Cystitis:Bladder Pain Syndrome – 2015
Interstitial Cystitis – Treatment
Interstitial Cystitis Tx – Overviews
- Interstitial Cystitis:Painful Bladder Syndrome
- diagnosis-and-treatment-of-interstitial-cystitis-ngc-guidelines-2014
Interstitial Cystitis Tx – Complementary & Alternative Medicine (CAM)
See: Accurate Education, CAM – Interstitial Cystitis
- Complementary-and-alternative-medical-therapies-for-interstitial-cystitis-an-update-from-the-united-states-2015
- complementary-and-alternative-therapies-as-treatment-approaches-for-interstitial-cystitis
- interstitial-cystitis-patients-use-and-rating-of-complementary-and-alternative-medicine-therapies-2009
Interstitial Cystitis Tx – Cognitive Behavior Therapy (CBT)
See: CBT
Interstitial Cystitis Tx – Diet
- interstitial-cystitis-and-dietary-impact-2014
- diet-and-its-role-in-interstitial-cystitisbladder-pain-syndrome-icbps-and-comorbid-conditions-pubmed-2014-ncbi
- nutritional-considerations-for-patients-with-interstitial-cystitisbladder-pain-syndrome-2015
Interstitial Cystitis Tx – Medications
Interstitial Cystitis Tx, Medications – Pentosan Polysulfate
Interstitial Cystitis Tx, Medications – Urinary Antispasmodics
Interstitial Cystitis Tx – Laser
Interstitial Cystitis Tx – Neurostimulators:
Interstitial Cystitis Tx – Pelvic Floor Therapy
Interstitial Cystitis Tx – Timed voiding
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
For more information, please contact Accurate Clinic.
Supplements recommended by Dr. Ehlenberger may be purchased commercially online or at Accurate Clinic.
Please read about our statement regarding the sale of products recommended by Dr. Ehlenberger.
Accurate Supplement Prices
.