Accurate Education – Interstitial Cystitis

Interstitial Cystitis (IC)

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:

 

Urgent PC:

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:

  1. Interstitial Cystitis Association

References:

Interstitial Cystitis – Overviews

  1. Diagnosis and treatment of interstitial cystitis NGC Guidelines 2014
  2. Treatment Approaches for Interstitial Cystitis- Multimodality Therapy
  3.  Complementary and Alternative Therapies as Treatment Approaches for Interstitial Cystitis
  4. novel-research-approaches-for-interstitial-cystitisbladder-pain-syndrome-thinking-beyond-the-bladder-2015

 

Interstitial Cystitis – Central Sensitization

  1. segmental-hyperalgesia-to-mechanical-stimulus-in-interstitial-cystitisbladder-pain-syndrome-evidence-of-central-sensitization-2014
  2. Inflammation and central pain sensitization in Interstitial Cystitis:Bladder Pain Syndrome – 2015

 

Interstitial Cystitis – Diagnosis

  1. stool-based-biomarkers-of-interstitial-cystitisbladder-pain-syndrome-2016
  2. metabolomics-insights-into-pathophysiological-mechanisms-of-interstitial-cystitis-2014

 

Interstitial Cystitis – Dysautonomia

  1. Sympathetic Nervous System Dysfunction in Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, and Interstitial Cystitis

 

Interstitial Cystitis – Genetics

See also:  Stress, the stress response system, and fibromyalgia

Interstitial Cystitis – Systemic Inflammation

  1. Inflammation and Inflammatory Control in Interstitial Cystitis: Bladder Pain Syndrome – Associations with Painful Symptoms – 2014
  2. Inflammation and Symptom Change in Interstitial Cystitis: Bladder Pain Syndrome – A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study – 2016
  3. 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
  4. Inflammation and central pain sensitization in Interstitial Cystitis:Bladder Pain Syndrome – 2015

 

Interstitial Cystitis – Treatment
  

Interstitial Cystitis Tx – Overviews

  1. Interstitial Cystitis:Painful Bladder Syndrome
  2. diagnosis-and-treatment-of-interstitial-cystitis-ngc-guidelines-2014

 

Interstitial Cystitis Tx – Complementary & Alternative Medicine (CAM)

See:  Accurate Education, CAM – Interstitial Cystitis

  1. Complementary-and-alternative-medical-therapies-for-interstitial-cystitis-an-update-from-the-united-states-2015
  2. complementary-and-alternative-therapies-as-treatment-approaches-for-interstitial-cystitis
  3. 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

  1. interstitial-cystitis-and-dietary-impact-2014
  2. diet-and-its-role-in-interstitial-cystitisbladder-pain-syndrome-icbps-and-comorbid-conditions-pubmed-2014-ncbi
  3. nutritional-considerations-for-patients-with-interstitial-cystitisbladder-pain-syndrome-2015

 

 

Interstitial Cystitis Tx – Medications

Interstitial Cystitis Tx, Medications – Pentosan Polysulfate

  1. The Role of Pentosan Polysulfate in Treatment Approaches for Interstitial Cystitis

Interstitial Cystitis Tx, Medications – Urinary Antispasmodics

  1. urinary_antispasmodics_2013

 

Interstitial Cystitis Tx – Laser

  1. elimination-of-hunners-ulcers-by-fulguration-in-patients-with-interstitial-cystitis-is-it-effective-and-long-lasting-2013

 

Interstitial Cystitis Tx – Neurostimulators:

  1.  Neuromodulation for the Treatment of Refractory Interstitial Cystitis

 

Interstitial Cystitis Tx – Pelvic Floor Therapy

  1. Pelvic floor myofascial trigger points: manual therapy for intersti… – PubMed – NCBI

Interstitial Cystitis Tx – Timed voiding

  1. Interstitial cystitis – successful management by increasing urinary … – PubMed – NCBI

Emphasis on Education

 

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