Interstitial cystitis
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Interstitial cystitis, also known as bladder pain syndrome (IC/BPS), is a condition that causes persistent pain, pressure, or discomfort in the bladder. The bladder pain may range from minor to severe. Interstitial cystitis leads to a persistent requirement for frequent urination (frequency) and abrupt, compelling urges to urinate (urgency) that last for a minimum of six weeks.
The urinary system of the body is made up of the bladder, kidneys, ureters, and urethra. Urine is stored in the bladder, which is a hollow, muscular structure. The bladder enlarges until it is full, at which point it sends a signal to the brain via the pelvic nerves that it is time to urinate.
In the case of interstitial cystitis, the signals become confused, resulting in a sensation of needing to urinate more frequently and with smaller amounts of urine. Unlike a healthy bladder, the walls of the bladder become irritated and inflamed.
Predominantly afflicting women, interstitial cystitis can exert a prolonged influence on one’s quality of life. While a definitive cure remains elusive, medications and alternative therapies might provide alleviation.
Symptoms
The symptoms of interstitial cystitis or bladder pain syndrome can vary significantly from person to person. Symptoms can range from mild to severe, exhibiting either a consistent presence or sporadic occurrence. These symptoms can also fluctuate over time, occasionally intensifying in response to typical triggers, such as menstruation, extended periods of sitting, stress, physical exertion, and sexual activity. It’s possible for some individuals to also experience symptom–free periods.
Although the signs and symptoms of interstitial cystitis may match those of a chronic urinary tract infection, an infection is rarely present. However, if a person with interstitial cystitis has a urinary tract infection, their symptoms may intensify.
The common signs and symptoms of interstitial cystitis include:
- Frequency of urination, typically in little amounts, up to 60 times per day
- Urgency of urination
- Discomfort or pain while the bladder fills, followed by relief after peeing
- Pelvic pain or pain between the vagina and anus in women
- Persistent bladder or pelvic pain
- Sexual discomfort
If any of the signs and symptoms persist, consult a healthcare provider for proper diagnosis and treatment. Tests may be necessary to rule out infections or other diseases that could be causing similar symptoms.
Causes
Interstitial cystitis has no known cause. Medical experts assume that it is related to certain medical disorders, such as autoimmune disease, allergies, mast cell abnormalities, unidentified infection, or genetics. Proteinuria, the presence of abnormal substances in the urine, such as regularly high protein levels can also be related to interstitial cystitis.
Some may have a defect in the bladder’s protective lining or epithelium. A breach in the epithelium could potentially enable harmful substances within urine to provoke irritation of the bladder wall.
Risk factors
Several risk factors may contribute to an increased risk of interstitial cystitis:
- Age: People at least 30 years old are more vulnerable to acquiring interstitial cystitis.
- Sex: Interstitial cystitis is more common among women than men. While men may experience symptoms resembling interstitial cystitis, these are often associated with prostatitis or inflammation of the prostate gland.
- Chronic pain disorder: One may be more vulnerable to acquiring IC/BPS if he or she has another chronic pain disorder, such as irritable bowel syndrome or fibromyalgia.
Diagnosis
Diagnosing interstitial cystitis typically does not rely on specific tests. Instead, it often entails gathering the patient’s medical history and symptom presentation, coupled with a pelvic examination. In some cases, individuals might need to keep a bladder diary, noting their fluid intake, urine output, and types of fluids consumed. This comprehensive approach aids in getting a diagnosis.
Additional tests may be ordered to rule out other infections and disorders, such as:
- Physical examination: During a pelvic exam, the healthcare provider assesses the external genitals, vagina, and cervix, and palpates the abdomen to evaluate the internal pelvic organs. Additionally, they may also conduct an examination of the anus and rectum.
- Urinalysis: A urine sample will be examined for blood, and evidence of illness, such as organisms, germs, pus, or white blood cells, which can be signs of a urinary tract infection.
- Cystoscopy: To rule out bladder cancer, this test may be performed. A cystoscope, a small, illuminated tube with an eyepiece on one end is used to check the inside of the bladder. Through the eyepiece, the urethra and bladder are examined. To determine the bladder’s capacity, a liquid may be injected into the bladder. This procedure known as hydrodistention.
Anesthesia is generally not administered during the procedure. Nevertheless, if a healthcare provider prescribes a bladder biopsy in conjunction with a cystoscopy, anesthesia might be necessary.
- Biopsy: A tissue sample from the bladder wall and urethra is extracted and examined to rule out other illnesses, such as bladder cancer and other uncommon causes of bladder pain.
- Urine cytology: To help rule out cancer, a urine sample is collected, and cells are analyzed.
- Potassium sensitivity test: During the procedure, two solutions are injected, one at a time, into the bladder: water and potassium chloride. The patient is asked to rate the level of pain and urgency experienced on a scale of 0 to 5 after each instillation. Normally, individuals with normal bladders are unable to distinguish between the two solutions. If the patient perceives significantly more pain or urgency with the potassium solution compared to water, it could indicate a potential diagnosis of interstitial cystitis.
Treatment
There is no one specific treatment for interstitial cystitis. Treatment usually aims to alleviate the signs and symptoms. Even if the symptoms go away, they may recur later.
Since there is no way of knowing how the body will react to each treatment, one will have to go through a trial–and–error procedure with several treatments to observe how the body responds. In some cases, several treatments may be combined.
- Physical therapy: The pelvic muscles help control pee by holding the bladder in place. Exercising, stretching, and particularly relaxing the pelvic muscles may help alleviate symptoms. It may help getting rid of pelvic discomfort caused by muscle tenderness, tight connective tissue, or muscle abnormalities in the pelvic floor.
- Oral medications: These may help treat IC/BPS symptoms:
- Nonsteroidal anti–inflammatory drugs: Naproxen sodium and ibuprofen may be prescribed to alleviate pain.
- Tricyclic antidepressants: A low dose of tricyclic antidepressants such as amitriptyline or imipramine may help reduce pain and urinary frequency.
- Antihistamines: These medications can potentially reduce urinary urgency and frequency and alleviate other associated symptoms.
- Pentosan polysulfate sodium: With this treatment, it could take two to four months to feel pain alleviation and up to six months to see a decrease in urine frequency. It rebuilds the bladder’s inner surface, which shields the bladder wall from toxins in urine that could irritate it. This is an FDA–approved treatment for interstitial cystitis.
A full eye check may be required before beginning this treatment. As the treatment progresses, one may require additional eye exams to monitor for eye problems due to the medication’s linkage to macular eye disease.
- Nerve stimulation: Nerve stimulation techniques include:
- Transcutaneous electrical nerve stimulation (TENS): During the procedure, electrodes positioned either on the lower back or just above the pubic area administer electrical pulses. The duration and frequency of this therapy are adjusted based on what yields the most effective results. Mild electrical pulses used in TENS ease pelvic pain and, in some situations, reduce urine frequency.
TENS has been shown to enhance blood flow to the bladder. This may strengthen the muscles that help control the bladder or cause the release of pain–blocking chemicals.
- Sacral nerve stimulation: Throughout the procedure, a thin wire positioned close to the sacral nerves emits electrical impulses directed towards your bladder.
The sacral nerves are the connector between the spinal cord and bladder nerves. Stimulating these nerves may help relieve urinary urgency caused by interstitial cystitis.
If the procedure relieves the symptoms, a permanent device may be surgically implanted. This treatment does not relieve pain caused by interstitial cystitis. However, it may assist in alleviating some symptoms such as urine frequency and urgency.
- Bladder distention: This treatment involves stretching the bladder with water. During bladder distention, botulinum toxin A (Botox) may be injected into the bladder wall. Some people find temporary alleviation in their symptoms. If long–term improvement is achieved, the procedure can be repeated if necessary.
However, this treatment approach may result in incomplete bladder emptying during urination. Consequently, one might require self–catheterization, which involves the ability to insert a tube into your bladder to facilitate urine drainage following this treatment.
- Bladder instillation: During the procedure, a catheter will be inserted into the urethra and extended to the bladder. A medication mixture that may contain dimethyl sulfoxide (DMSO) and a numbing agent is filled in the bladder. DMSO is a steroid that helps relieve symptoms. This is often given weekly for six to eight weeks, then maintenance treatments as needed.
The solution may be combined with other medications, including a local anesthetic, and is left in the bladder for approximately 15 minutes. Afterward, one expels the solution by urinating.
An alternative method of bladder instillation involves using a solution containing medications such as lidocaine, sodium bicarbonate, and either pentosan or heparin.
- Surgery: People with severe symptoms and do not respond to treatment may be recommended a more invasive surgical option. In such cases, they may consider performing a cystectomy, which involves the removal of part or all the bladders. However, this is rarely suggested because removing the bladder does not reduce discomfort and can lead to other issues.
Surgical options include:
- Fulguration: Ulcers that could be present due to interstitial cystitis can be cauterized. This less invasive procedure entails inserting instruments through the urethra to perform the procedure.
- Resection: A minimally invasive procedure that involves inserting devices into the urethra to cut around any sores.
- Bladder augmentation: This is only done in extremely particular and uncommon cases. The treatment does not relieve pain, and some patients must empty their bladders with a catheter several times per day. Bladder augmentation involves placing a patch of intestine on the bladder to expand the capacity of the bladder.
