Interstitial Cystitis Causes, Types, Symptoms, Diagnosis, Treatment, Prevention

Interstitial Cystitis Causes, Types, Symptoms, Diagnosis, Treatment, Prevention


What Is Interstitial Cystitis?


Interstitial cystitis, 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 Interstitial cystitis 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. 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 Interstitial cystitis, 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 Interstitial cystitis 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 Interstitial cystitis may urinate as many as 60 times a day.

Also, people with Interstitial cystitis often experience pain during sexual intercourse. Interstitial cystitis is far more common in women than in men. Of the more than 700,000 Americans estimated to have Interstitial cystitis, 90 percent are women.

Read more: Intestinal Pseudo Obstruction Causes, Symptoms,Diagnosis, Treatment

What Causes Interstitial Cystitis?


Some of the symptoms of Interstitial cystitis resemble those of bacterial infection, but medical tests reveal no organisms in the urine of patients with Interstitial cystitis. Furthermore, patients with Interstitial cystitis do not respond to antibiotic therapy. Researchers are working to understand the causes of Interstitial cystitis and to find effective treatments.

One theory being studied is that Interstitial cystitis 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 Interstitial cystitis, but no substance unique to people with Interstitial cystitis has as yet been isolated. Researchers are beginning to explore the possibility that heredity may play a part in some forms of Interstitial cystitis. In a few cases, Interstitial cystitis 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 Interstitial Cystitis?


Because Interstitial cystitis 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 Interstitial cystitis or nonulcerative Interstitial cystitis, 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 Interstitial cystitis. For example, some cases respond to changes in diet while others do not. 

What are the signs and symptoms of interstitial cystitis?


The symptoms of PBS/IC vary greatly from one person to another but have some similarities to those of a urinary tract infection. They include

  • decreased bladder capacity;
  • an urgent need to urinate frequently day and night;
  • feelings of pressure, pain, and tenderness around the bladder, pelvis, and perineum (the area between the anus and vagina or anus and scrotum) which may increase as the bladder fills and decrease as it empties;
  • painful sexual intercourse (dyspareunia);
  • discomfort or pain in the penis and scrotum.
Most people suffering from PBS/IC have both urinary frequency/urgency and pelvic pain, although these symptoms may also occur singly or in any combination. In most women, symptoms usually worsen around the time of their periods. As with many other illnesses, stress also may intensify the symptoms, but it does not cause them. The symptoms usually have a slow onset, and urinary frequency is the most common early symptom. As PBS/IC progresses over a few years, cycles of pain (flares) and remissions occur. Pain may be mild or so severe as to be debilitating. Symptoms can vary from day to day.

How Is Interstitial Cystitis Diagnosed?


Because symptoms are similar to those of other disorders of the urinary system and because there is no definitive test to identify Interstitial cystitis, 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 Interstitial cystitis in the general population is based on

  • presence of urgency, frequency, or pelvic/bladder pain
  • cystoscopic evidence (under anesthesia) of bladder wall inflammation, including Hunner's ulcers or glomerulations (present in 90 percent of patients with Interstitial cystitis)
  • absence of other diseases that could cause the symptoms 
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 Interstitial cystitis. 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 Interstitial cystitis.

Culture of Prostate Secretions 


In men, the doctor might obtain prostatic fluid and examine it for signs of an infection, which can then be treated with antibiotics.

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 Interstitial cystitis, 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 Interstitial cystitis.

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 the Treatments for Interstitial Cystitis?


Scientists have not yet found a cure for Interstitial cystitis, 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 Interstitial cystitis 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 Interstitial cystitis, 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 Interstitial cystitis, 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 (Elmiron), the first oral drug developed for Interstitial cystitis, was approved by the FDA in 1996. In clinical trials, Elmiron 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 of Elmiron 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.

Elmiron's 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. Researchers have found no negative interactions between Elmiron and other medications.

Elmiron may affect liver function, which should therefore be monitored by the doctor.

Because Elmiron has not been tested in pregnant women, the manufacturer recommends that it not be used during pregnancy, except in the most severe cases.

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 Tylenol with codeine or longer acting narcotics may be necessary.

All drugs--even those sold over the counter--have side effects. Patients should always consult a doctor before using any drug for an extended time.

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 


There is no scientific evidence linking diet to Interstitial cystitis, but many doctors and patients find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation. Some patients also note that their symptoms worsen after eating or drinking products containing artificial sweeteners. Patients may try eliminating various products from their diet and reintroducing them one at a time to determine which, if any, affect symptoms. It is important, however, to maintain a varied, well-balanced 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 Interstitial cystitis 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--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.

To locate a surgeon experienced in performing specific procedures, check with your doctor.

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; Interstitial cystitis 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 Interstitial cystitis 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, involves permanent implantation of electrodes and a unit emitting continuous electrical pulses. Studies of this experimental procedure are now under way.

Are There Any Special Concerns?


Cancer


There is no evidence that Interstitial cystitis increases the risk of bladder cancer.

Pregnancy 


Researchers have little information on pregnancy and Interstitial cystitis but believe that the disorder does not affect fertility or the health of the fetus. Some women find that their Interstitial cystitis goes into remission during pregnancy, while others experience a worsening of their symptoms.

Coping 


The emotional support of family, friends, and other people with Interstitial cystitis is very important in helping patients cope. Studies have found that patients who learn about the disorder and become involved in their own care do better than patients who do not.

How to Prevent Interstitial Cystitis


There are no guidelines for preventing interstitial cystitis because the cause is unknown. However, recurrence or aggravation of interstitial cystitis could be reduced by avoiding the following foods or drinks:

  • Caffeine-containing beverages
  • High-acid citrus fruits
  • Spicy foods
  • Vinegar
  • Chocolate
  • Fermented foods
  • Alcohol