Painful bladder syndrome / interstitial cystitis
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS DEFINITION
Interstitial cystitis (in-tur-STISH-ul sis-TIE-tis) — also called painful bladder syndrome — is a chronic condition in which you experience bladder pressure, bladder pain and sometimes pelvic pain, ranging from mild discomfort to severe pain.
Your bladder is a hollow, muscular organ that stores urine. The bladder expands until it’s full and then signals your brain that it’s time to urinate, communicating through the pelvic nerves. This creates the urge to urinate for most people. With interstitial cystitis, these signals get mixed up — you feel the need to urinate more often and with smaller volumes of urine than most people.
Interstitial cystitis most often affects women and can have a long-lasting impact on quality of life. Although there’s no treatment that reliably eliminates interstitial cystitis, medications and other therapies may offer relief.
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS CAUSES
It’s not clear why it happens, but there are several ideas:
- A problem with bladder tissue lets things in your pee irritate your bladder.
- Inflammation causes your body to release chemicals that cause symptoms.
- Something in your urine damages your bladder.
- A nerve problem makes your bladder feel pain from things that usually don’t hurt.
- Your immune system attacks the bladder.
- Another condition that causes inflammation is also targeting the bladder.
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS PATHOPHYSIOLOGY
The pathophysiology of interstitial cystitis is poorly understood. Various etiologies have been proposed, including infectious, inflammatory, autoimmune, hypoxia-related, and neurologically related. However, none of these adequately explains the variable presentations, clinical course, or response to therapies. This may indicate that interstitial cystitis represents a number of as yet undefined, disparate pathologic conditions that, over time, ultimately present as the clinical syndrome of urinary frequency, urgency, and pelvic pain.
The transitional cell apical membrane of the bladder is coated with GAGs and proteoglycans. Disruption of this layer can lead to transmigration of urinary solutes across the mucosal surface, affecting nerves and muscles and potentially leading to pain. Thus, restoration of this layer remains a mainstay in treatment if IC/BPS.
Up-regulation of histaminergic and muscarinic neurotransmitter receptors has been shown to be present in patients with IC/BPS, which may contribute to the storate and inflammatory symptoms present. Additionally, up-regulation of neural afferent pathways has been shown in IC/BPS, as well as a central hyperresponsiveness in association with other conditions, including fibromyalgia, irritable bowel syndrome, and depression/anxiety disorders.
Clinically, interstitial cystitis is often divided into 2 distinct subgroups based on findings at cystoscopy and bladder overdistention. These categories are the ulcerative (ie, classic) and nonulcerative (ie, Messing-Stamey) types. Such differences may have important implications for diagnosis and therapy. Evidence showing progression of ulcerative to nonulcerative disease, or vice versa, is lacking. Clinical presentation is also variable, with nonulcerative patients presenting with a more diffuse pain syndrome and multiple systemic complaints. Ulcerative patients tend to have higher daytime and nighttime frequency and lower bladder capacity, indicating that it may be more of a condition of the bladder itself than the nonulcerative type.
As such, the ulcerative subtype responds better to bladder-targeted therapies, including cauterization and cystectomy. Cystectomy has also led to significant improvements in quality of life in ulcerative patients. In terms of fulguration, long-term outcomes have shown that patients with ulcerative disease can be significantly helped by this therapy if the ulcers involve less than 25% of the bladder. However, a significant subpopulation requires repeat treatment, and many progress to cystectomy.
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS SYMPTOMS
The signs and symptoms of interstitial cystitis vary from person to person. If you have interstitial cystitis, your symptoms may also vary over time, periodically flaring in response to common triggers, such as menstruation, sitting for a long time, stress, exercise and sexual activity.
Interstitial cystitis signs and symptoms include:
- Pain in your pelvis or between the vagina and anus in women or between the scrotum and anus in men (perineum).
- Chronic pelvic pain.
- A persistent, urgent need to urinate.
- Frequent urination, often of small amounts, throughout the day and night. People with severe interstitial cystitis may urinate as often as 60 times a day.
- Pain or discomfort while the bladder fills and relief after urinating.
- Pain during sexual intercourse.
The severity of symptoms caused by interstitial cystitis often varies, and some people may experience periods during which symptoms disappear.
Although signs and symptoms of interstitial cystitis may resemble those of a chronic urinary tract infection, urine cultures are usually free of bacteria. -However, symptoms may worsen if a person with interstitial cystitis gets a urinary tract infection.
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS DIAGNOSIS
There’s no test for interstitial cystitis. If you go to your doctor complaining about bladder pain along with frequency and the urgency to pee, the next step is to rule out what else it could be.
Both men and women would first need to rule out urinary tract infections, bladder cancer, sexually transmitted diseases, and kidney stones.
In women, endometriosis is another possibility. For men, IC can be mistaken for an inflamed prostate or chronic pelvic pain syndrome.
These tests can rule out other conditions:
- Urinalysis and urine culture. You’ll be asked to pee in a cup. It’ll be sent to a lab to check for infection.
- Postvoid residual urine volume. Using an ultrasound, this test measures the amount of pee that remains in your bladder after you go to the bathroom.
- Cystoscopy. A thin tube with a camera is used to see the inside of the bladder and urethra. This is usually done only if there is blood in your pee or if treatment doesn’t help.
- Bladder and urethra biopsy. A small piece of tissue is taken and tested. This is usually done during cystoscopy.
- Bladder stretching. Your bladder is filled with liquid or gas to stretch it out. You’ll be asleep under anesthesia. Sometimes this is also used as a treatment. This is done with a cystoscopy.
- Prostate fluid culture (in men). Your doctor will need to press on your prostate and milk a sample to test. This is not commonly done.
PAINFUL BLADDER SYNDROME / INTERSTITIAL CYSTITIS TREATMENT
No simple treatment exists to eliminate the signs and symptoms of interstitial cystitis, and no one treatment works for everyone. You may need to try various treatments or combinations of treatments before you find an approach that relieves your symptoms.
Working with a physical therapist may relieve pelvic pain associated with muscle tenderness, restrictive connective tissue or muscle abnormalities in your pelvic floor.
Oral medications that may improve the signs and symptoms of interstitial cystitis include:
- Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), to relieve pain.
- Tricyclic antidepressants, such as amitriptyline or imipramine (Tofranil), to help relax your bladder and block pain.
- Antihistamines, such as loratadine (Claritin, others), which may reduce urinary urgency and frequency and relieve other symptoms.
- Pentosan (Elmiron), which is approved by the Food and Drug Administration specifically for treating interstitial cystitis. How it works is unknown, but it may restore the inner surface of the bladder, which protects the bladder wall from substances in urine that could irritate it. It may take two to four months before you begin to feel pain relief and up to six months to experience a decrease in urinary frequency.
Nerve stimulation techniques include:
- Transcutaneous electrical nerve stimulation (TENS). With TENS, mild electrical pulses relieve pelvic pain and, in some cases, reduce urinary frequency. TENS may work by increasing blood flow to the bladder, strengthening the muscles that help control the bladder or triggering the release of substances that block pain. Electrical wires placed on your lower back or just above your pubic area deliver electrical pulses — the length of time and frequency of therapy depends on what works best for you.
- Sacral nerve stimulation. Your sacral nerves are a primary link between the spinal cord and nerves in your bladder. Stimulating these nerves may reduce urinary urgency associated with interstitial cystitis. With sacral nerve stimulation, a thin wire placed near the sacral nerves delivers electrical impulses to your bladder, similar to what a pacemaker does for your heart. If the procedure decreases your symptoms, you may have a permanent device surgically implanted.
Some people notice a temporary improvement in symptoms after undergoing cystoscopy with bladder distention. Bladder distention is the stretching of the bladder with water or gas. The procedure may be repeated as a treatment if the response is long lasting.
MEDICATIONS INSTILLED INTO THE BLADDER
In bladder instillation, your doctor places the prescription medication dimethyl sulfoxide (Rimso-50) into your bladder through a thin, flexible tube (catheter) inserted through the urethra. The solution sometimes is mixed with other medications, such as a local anesthetic, and remains in your bladder for 15 minutes. You urinate to expel the solution.
You might receive dimethyl sulfoxide — also called DMSO — treatment weekly for six to eight weeks, and then have maintenance treatments as needed — such as every couple of weeks, for up to one year.
A newer approach to bladder instillation uses a solution containing the medications lidocaine, sodium bicarbonate, and either pentosan or heparin.
Doctors rarely use surgery to treat interstitial cystitis because removing part or all of the bladder doesn’t relieve pain and can lead to other complications. People with severe pain or those whose bladders can hold only very small volumes of urine are possible candidates for surgery, but usually only after other treatments have failed. Surgical options include:
- Fulguration. This minimally invasive method involves insertion of instruments through the urethra to burn off ulcers that may be present with interstitial cystitis.
- Resection. This is another minimally invasive method that involves insertion of instruments through the urethra to cut around any ulcers.
- Bladder augmentation. In this procedure, surgeons remove the damaged portion of the bladder and replace it with a piece of the colon, but the pain still remains and some people need to empty their bladders with a catheter many times a day.