Table of Contents
Introduction to Interstitial Cystitis
Interstitial cystitis (IC) is a chronic condition characterized by a feeling of intense pain and pressure in the bladder. For this reason, it is also known as bladder pain syndrome (BPS). In addition to chronic pain, the patient usually suffers from other symptoms as well. These include lower urinary tract symptoms (urgency, frequency) lasting for 6 or more months without any gross pathology or known infection.
The severity and duration of symptoms usually vary in patients. In some, the condition may also be associated with other disorders such as fibromyalgia, irritable bowel syndrome (IBS), and other painful chronic conditions. 1 The diagnosis of interstitial cystitis is often challenging because of its variable symptomatic presentation. If left untreated, it may interfere with your daily activities, your relation with your family and surrounding people, and ultimately the overall quality of life.
Medically, the interstitium is a major tissue of any organ that provides support to it and a working environment to its functional cells. Cystitis means inflammation of the bladder. Inflammation is the body’s natural response to various pathogens and foreign agents, carried out by recruiting immune cells from the blood to the site of invasion. So, the term interstitial cystitis implies the inflammation of the interstitial tissue of the bladder. Because of a continuous stimulus impeding the bladder to perform its functions properly, the characteristic symptoms of interstitial cystitis appear.
Key Statistics Regarding IC
- Interstitial cystitis is a common condition with a male to the female preponderance of 1:5, which means women are five times more likely to suffer from it. 2
- According to another study, in a population of 100,000, the joint prevalence for both sexes is about 10.6 cases. 3
- The annual incidence of new cases in females is 1.2 per 100,000 women. 3
- The male population makes about one-tenth of all cases and the majority has a mild disease. 3
- Of all patients, only one-tenth report to have severe disease. The incidence has been rising for the past ten years. 3
Causes and Risk Factors
The exact cause of interstitial cystitis is not well understood. Several factors are implicated in its pathogenesis. 4,5
- The presence of any irritant in the urine may damage the inner lining of the bladder causing symptoms.
- A defective lining of the bladder allows the irritants in urine to easily enter it and initiate the inflammatory process.
- There is sometimes excessive activation of the immune cells such as mast cells. Mast cells release histamine – an important mediator in many inflammatory processes, thereby causing symptoms of interstitial cystitis. It also causes vasodilatation and direct bladder damage. 6
- There may be a problem with nerve signaling that carries pain sensation. It responds to non-painful stimuli such as filling of the bladder by giving a false impression to the higher pain signaling centers in the brain.
- Autoimmune conditions are those in which the body’s immune system reacts against its cells considering them foreign or pathogenic. Sometime the bladder may be a victim of autoimmunity, resulting in interstitial cystitis.
Certain risk factors increase the chance of having interstitial cystitis. These are:
- Family history of interstitial cystitis
- Urinary infection
Symptoms of Interstitial Cystitis
The symptoms of interstitial cystitis may be entirely different in two individuals. However, the chief complaint is intense pelvic pain 7, which is the same for all. There are certain characteristics of pain.
- The pain is either dull and diffuse or piercing in nature. You may feel like your bladder is burning. 5-10% of patients are usually diagnosed with bladder ulcers in interstitial cystitis.
- The pain reaches its peak when the bladder is full and some relief is there when the bladder empties after urination.
- The pain may radiate to the lower back and lower abdominal region.
- In women, it may also be felt in vulva, vagina, and the surrounding areas.
- In men, it may be felt in scrotum, testicles, penis, and surrounding areas.
- During sexual activity, there is pain. In men, orgasm may also cause pain.
Some other commonly reported symptoms are: 7
- Urgency – a sudden desire to void, that cannot wait
- Frequency – needing to urinate more often than usual
- Nocturia – having to frequently wake up at night to void
Currently, there are no specific tests to confirm the diagnosis of interstitial cystitis in particular. However, after taking a detailed history and doing relevant examination your doctor may order some tests to look for any functional or anatomical disturbances in the urinary tract. 5 These are:
- Urinalysis: This is a detailed analysis of urine carried out by looking at its physical appearance and biochemical composition.
- Urine culture: It is a technique in which bacteria obtained from the urine are grown in the laboratory by providing favorable conditions. Each favorable condition is called a medium, assigned to a particular type of bacteria. The medium in which growth occurs confirms the presence of a certain type of bacteria to which that medium corresponds to, ultimately confirming its presence in the sample.
- Postvoid residual volume: With the help of ultrasound, this test measures the amount of urine left behind in the bladder after voiding.
- Cystoscopy: In this test, the bladder is viewed from the inside to look for any gross pathology by inserting a thin tube that has a camera attached to its end. Your doctor may order this test if urinalysis shows the presence of blood in the urine. An Ambulatory Surgery Center can be more convenient for this procedure as it is a minor one, allowing the patient to return to daily activities shortly after.
- Biopsy: It is done to study the details of any tissue, under the microscope. In this test, a small piece of tissue is taken and then sent to a histopathologist to see what is happening at the cellular level.
- Bladder stretching: This test is carried out under anesthesia. The bladder is filled with a liquid or gas so that it is stretched out. It is usually done along with cystoscopy to visualize the changes that occur during stretching of the bladder.
- Urodynamics: It is a study of pressure changes in the bladder that occur during filling and voiding.
Interstitial cystitis may not be completely cured but remission occurs in a few weeks to months after the commencement of therapy. Usually, the symptomatic relief is of great value as it leads to an overall improvement in the quality of life, the patient gains confidence and can continue his daily activities without any stress.
Because of significant variation in the presentation of interstitial cystitis, the treatment options are usually entirely different for any two patients. Your doctor may keep on prescribing you different options until the one that works for you is found, considered as the “best treatment for your symptoms”. Your doctor will discuss with you all aspects of it in detail. The treatment is generally more focused towards pain management and relief from the symptoms. It is given in a step ladder fashion starting from simple lifestyle modification advice to complex surgical procedures for a refractory disease not responding to any other treatment option. 8 The stage at which symptomatic control is achieved is the best treatment for a specific individual. Following are the treatment options in a stage-wise manner:
Lifestyle changes are an integral part of the management of functional disorders. The important aspects of lifestyle modification include dietary changes, stress management, and physical exercises.
Several foods are known to increase the bladder irritation causing the symptoms of interstitial cystitis. This list is long but not all of them can act as an irritant for an individual. Also, it is not possible to avoid them all. A simple and effective method to find out which one is causing symptoms is to eliminate all of them for 1-2 weeks. Then, try them all one by one and wait 24 hours before the consumption of the next, to check for symptoms. In this way, the causative food item can be singled out and eliminated from the diet. Citrus fruits, tomatoes, chocolates, spicy food, alcohol, and coffee, when limited, provide relief to the majority of patients.
Stress is another important culprit in the complex pathogenesis of interstitial cystitis. Therefore, stress management with meditation, psychotherapy, and other techniques plays a crucial role in the alleviation of symptoms. Physical exercise is also shown to be effective.
If you do not get any benefit from lifestyle changes, your doctor may advise you to start certain medications. The following drugs are usually prescribed for interstitial cystitis:
- Pentosan: The mechanism of action of this drug is not well understood. It possibly works by restoring the epithelium lining the bladder. You may experience gastric issues such as nausea and diarrhea after starting this drug but these are generally no major side effects. The symptoms resolve in a few months for most patients.
- Amitryptiline: This drug reduces bladder spasm and is very effective in pain management. It belongs to the class of tricyclic antidepressants, which are prescribed for depression. It is also used for other chronic painful conditions like cancer and nerve damage. The possible side effects that you might notice are drowsiness, constipation, and increased appetite.
- Hydroxyzine: It is an antihistamine. Histamine is an important molecule in the pain initiation process. It is also used to treat nocturia (frequent need to void during the night). You may experience excessive drowsiness after starting this medicine.
- Dimethyl sulfoxide: If the patient is not getting benefit from oral drugs, the doctor may advise switching to intravesical medications. These drugs are put in a bag that is placed inside the organ for a few weeks. Dimethyl sulfoxide is placed into the bladder via catheter where it works by reducing the swelling, pain, and free radicals that cause extensive damage. This is not often a drug of choice because of its propensity to exacerbate the symptoms.
- Neuromodulation therapy: It comprises of special techniques that work by altering the interaction of nerves carrying pain signals to the brain. It is prescribed when second-line therapy also fails. It includes:
- Neurostimulation: In this, small harmless electrical impulses are delivered that modify the nerve functioning and reduce the sensation of pain.
- Botox injection: It paralyzes the bladder muscles for a certain period, reducing the symptoms of pain.
- Immunosuppressants: Immunosuppressants are drugs that dampen the activity of the immune system. Cyclosporine is commonly used from this class for the treatment of interstitial cystitis. However, your doctor uses it cautiously as it may increase the risk of infections and cause some other complications too in previously ill patients.
- Surgery: This is the last-line treatment option and is reserved for those having a refractory disease. When the patient doesn’t respond to all the treatment options, surgery becomes inevitable.
- Nickel, J. C., Tripp, D. A., Pontari, M., Moldwin, R., Mayer, R., Carr, L. K., Doggweiler, R., Yang, C. C., Mishra, N., & Nordling, J. (2010). Interstitial cystitis/painful bladder syndrome and associated medical conditions with an emphasis on irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome. The Journal of urology, 184(4), 1358–1363.
- Propert, K. J., Schaeffer, A. J., Brensinger, C. M., Kusek, J. W., Nyberg, L. M., & Landis, J. R. (2000). A prospective study of interstitial cystitis: results of longitudinal followup of the interstitial cystitis data base cohort. The Interstitial Cystitis Data Base Study Group. The Journal of urology, 163(5), 1434–1439.
- Oravisto K. J. (1975). Epidemiology of interstitial cystitis. Annales chirurgiae et gynaecologiae Fenniae, 64(2), 75–77.
- Grover, S., Srivastava, A., Lee, R., Tewari, A. K., & Te, A. E. (2011). Role of inflammation in bladder function and interstitial cystitis. Therapeutic advances in urology, 3(1), 19–33.
- Sant G. R. (2002). Etiology, pathogenesis, and diagnosis of interstitial cystitis. Reviews in urology, 4 Suppl 1(Suppl 1), S9–S15.
- Sant, G. R., & Theoharides, T. C. (1994). The role of the mast cell in interstitial cystitis. The Urologic clinics of North America, 21(1), 41–53.
- Cho Y. S. (2016). Interstitial Cystitis/Bladder Pain Syndrome: A Urologic Mystery. International neurourology journal, 20(1), 3–4.
- Han, E., Nguyen, L., Sirls, L., & Peters, K. (2018). Current best practice management of interstitial cystitis/bladder pain syndrome. Therapeutic advances in urology, 10(7), 197–211.