Interstitial cystitis
Interstitial cystitis | |
---|---|
Other names | Bladder pain syndrome (BPS), overactive bladder, sexually transmitted infections, endometriosis, bladder cancer, prostatitis[1][6] |
Treatment | Lifestyle changes, medications, procedures[1] |
Medication | Ibuprofen, pentosan polysulfate, amitriptyline[1] |
Frequency | 0.5% of people[1][5] |
Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is
The cause of interstitial cystitis is unknown.
There is no cure for interstitial cystitis and management of this condition can be challenging.
In the United States and Europe, it is estimated that around 0.5% of people are affected.[1][5] Women are affected about five times as often as men.[1] Onset is typically in middle age.[1] The term "interstitial cystitis" first came into use in 1887.[7]
Signs and symptoms
The most common symptoms of IC/BPS are
In general, symptoms may include
During cystoscopy, 5–10% of people with IC are found to have Hunner's ulcers.[13] A person with IC may have discomfort only in the urethra, while another might struggle with pain in the entire pelvis. Interstitial cystitis symptoms usually fall into one of two patterns: significant suprapubic pain with little frequency or a lesser amount of suprapubic pain but with increased urinary frequency.[14]
Association with other conditions
Some people with IC/BPS have been diagnosed with other conditions such as
In addition, men with IC/PBS are frequently diagnosed as having
Causes
The cause of IC/BPS is not known.
Regardless of the origin, most people with IC/BPS struggle with a damaged
GP51 has been identified as a possible urinary biomarker for IC with significant variations in GP51 levels in those with IC when compared to individuals without interstitial cystitis.[27]
Numerous studies have noted the link between IC, anxiety, stress, hyper-responsiveness, and panic.[15] Another proposed mechanism for interstitial cystitis is the autoimmune mechanism.[28] Biopsies on the bladder walls of people with IC may contain mast cells. Mast cells, which contain histamine granules, respond to allergic stimuli. In this theory, Mast cells are activated in response to antigen detection in the bladder wall. The activation of mast cells triggers the release of histamine, amongst other inflammatory mediators.[29] Additionally, another proposed mechanism is increased activity of unspecified nerves in the bladder wall. An unknown toxin or stimuli may activate nerves within the bladder wall, causing the release of neuropeptides. These neuropeptides can induce a secondary cascade which stimulates pain in the bladder wall.[23]
Genes
Some genetic subtypes, in some people, have been linked to the disorder.
- An antiproliferative factor is secreted by the bladders of people with IC/BPS which inhibits bladder cell proliferation, thus possibly causing the missing bladder lining.[11][15]
- PAND, at gene map locus 13q22–q32, is associated with a constellation of disorders (a "pleiotropic syndrome") including IC/BPS and other bladder and kidney problems, thyroid diseases, serious headaches/migraines, panic disorder, and mitral valve prolapse.[15]
Diagnosis
A diagnosis of IC/BPS is one of exclusion, as well as a review of clinical symptoms.[8] The American Urological Association Guidelines recommend starting with a careful history of the person, physical examination and laboratory tests to assess and document symptoms of interstitial cytitis,[30] as well as other potential disorders.
The
For complicated cases, the use of hydrodistention with cystoscopy may be helpful. Researchers, however, determined that this visual examination of the bladder wall after stretching the bladder was not specific for IC/BPS[32] and that the test, itself, can contribute to the development of small glomerulations (petechial hemorrhages) often found in IC/BPS. Thus, a diagnosis of IC/BPS is one of exclusion, as well as a review of clinical symptoms.
In 2006, the ESSIC society proposed more rigorous and demanding diagnostic methods with specific classification criteria so that it cannot be confused with other, similar conditions. Specifically, they require that a person must have pain associated with the bladder, accompanied by one other urinary symptom. Thus, a person with just frequency or urgency would be excluded from a diagnosis. Secondly, they strongly encourage the exclusion of confusable diseases through an extensive and expensive series of tests including (A) a
They also propose a ranking system based upon the physical findings in the bladder.[11] People would receive a numeric and letter based score based upon the severity of their disease as found during the hydrodistention. A score of 1–3 would relate to the severity of the disease and a rating of A–C represents biopsy findings. Thus, a person with 1A would have very mild symptoms and disease while a person with 3C would have the worst possible symptoms. Widely recognized scoring systems such as the O'Leary Sant symptom and problem score have emerged to evaluate the severity of IC symptoms such as pain and urinary symptoms.[34]
Differential diagnosis
The symptoms of IC/BPS are often misdiagnosed as a
Treatment
In 2011, the American Urological Association released consensus-based guideline for the diagnosis and treatment of interstitial cystitis.[37]
They include treatments ranging from conservative to more invasive:
- First-line treatments – education, self care (diet modification), stress management
- Second-line treatments – physical therapy, oral medications (amitriptyline, cimetidine or hydroxyzine, pentosan polysulfate), bladder instillations (DMSO, heparin, or lidocaine)
- Third-line treatments – treatment of Hunner's lesions (laser, fulguration or triamcinoloneinjection), hydrodistention (low pressure, short duration)
- Fourth-line treatments – neuromodulation (sacral or pudendal nerve)
- Fifth-line treatments – cyclosporine A, botulinum toxin(BTX-A)
- Sixth-line treatments – surgical intervention (urinary diversion, augmentation, cystectomy)
The American Urological Association guidelines also listed several discontinued treatments, including long-term oral antibiotics, intravesical
Bladder distension
Bladder distension while under
Bladder instillations
Bladder instillation of medication is one of the main forms of treatment of interstitial cystitis, but evidence for its effectiveness is currently limited.[8] Advantages of this treatment approach include direct contact of the medication with the bladder and low systemic side effects due to poor absorption of the medication.[8] Single medications or a mixture of medications are commonly used in bladder instillation preparations. Dimethyl sulfoxide (DMSO) is the only approved bladder instillation for IC/BPS yet it is much less frequently used in urology clinics.[38]
A 50% solution of DMSO had the potential to create irreversible muscle contraction. However, a lesser solution of 25% was found to be reversible. Long-term use of DMSO is questionable, as its mechanism of action is not fully understood though DMSO is thought to inhibit mast cells and may have anti-inflammatory, muscle-relaxing, and analgesic effects.[8][11] Other agents used for bladder instillations to treat interstitial cystitis include: heparin, lidocaine, chondroitin sulfate, hyaluronic acid, pentosan polysulfate, oxybutynin, and botulinum toxin A. Preliminary evidence suggests these agents are efficacious in reducing symptoms of interstitial cystitis, but further study with larger, randomized, controlled clinical trials is needed.[8]
Diet
Diet modification is often recommended as a first-line method of self-treatment for interstitial cystitis, though rigorous controlled studies examining the impact diet has on interstitial cystitis signs and symptoms are currently lacking.
The mechanism by which dietary modification benefits people with IC is unclear. Integration of neural signals from pelvic organs may mediate the effects of diet on symptoms of IC.[43]
Medications
The antihistamine hydroxyzine failed to demonstrate superiority over placebo in treatment of people with IC in a randomized, controlled, clinical trial.[8]
Oral pentosan polysulfate is believed to repair the protective glycosaminoglycan coating of the bladder, but studies have encountered mixed results when attempting to determine if the effect is statistically significant compared to placebo.[8][45][25]
Pelvic floor treatments
Urologic pelvic pain syndromes, such as IC/BPS and CP/CPPS, are characterized by pelvic muscle tenderness, and symptoms may be reduced with pelvic myofascial physical therapy.[46]
This may leave the pelvic area in a sensitized condition, resulting in a loop of muscle tension and heightened neurological feedback (
Pelvic floor dysfunction is a fairly new area of specialty for physical therapists worldwide. The goal of therapy is to relax and lengthen the pelvic floor muscles, rather than to tighten and/or strengthen them as is the goal of therapy for people with urinary incontinence. Thus, traditional exercises such as Kegel exercises, which are used to strengthen pelvic muscles, can provoke pain and additional muscle tension. A specially trained physical therapist can provide direct, hands on evaluation of the muscles, both externally and internally.[48]
A therapeutic wand can also be used to perform pelvic floor muscle myofascial release to provide relief.[49]
Surgery
Surgery is rarely used for IC/BPS. Surgical intervention is very unpredictable, and is considered a treatment of last resort for severe refractory cases of interstitial cystitis.[38] Some people who opt for surgical intervention continue to experience pain after surgery. Typical surgical interventions for refractory cases of IC/BPS include: bladder augmentation, urinary diversion, transurethral fulguration and resection of ulcers, and bladder removal (cystectomy).[8][38]
Neuromodulation can be successful in treating IC/BPS symptoms, including pain.
Alternative medicine
There is little evidence looking at the effects of alternative medicine though their use is common.[53] There is tentative evidence that acupuncture may help pain associated with IC/BPS as part of other treatments.[54] Despite a scarcity of controlled studies on alternative medicine and IC/BPS, "rather good results have been obtained" when acupuncture is combined with other treatments.[55]
Biofeedback, a relaxation technique aimed at helping people control functions of the autonomic nervous system, has shown some benefit in controlling pain associated with IC/BPS as part of a multimodal approach that may also include medication or hydrodistention of the bladder.[56][57]
Prognosis
IC/BPS has a profound impact on quality of life.
International recognition of interstitial cystitis has grown and international urology conferences to address the heterogeneity in diagnostic criteria have recently been held.[61] IC/PBS is now recognized with an official disability code in the United States of America.[62]
Epidemiology
IC/BPS affects men and women of all cultures, socioeconomic backgrounds, and ages. Although the disease was previously believed to be a condition of menopausal women, growing numbers of men and women are being diagnosed in their twenties and younger. IC/BPS is not a rare condition.[63] Early research suggested that the number of IC/BPS cases ranged from 1 in 100,000 to 5.1 in 1,000 of the general population. In recent years, the scientific community has achieved a much deeper understanding of the epidemiology of interstitial cystitis. Recent studies[62][64] have revealed that between 2.7 and 6.53 million women in the USA have symptoms of IC and up to 12% of women may have early symptoms of IC/BPS. Further study has estimated that the condition is far more prevalent in men than previously thought ranging from 1.8 to 4.2 million men having symptoms of interstitial cystitis.[citation needed]
The condition is officially recognized as a disability in the United States.[65][66]
History
Philadelphia surgeon Joseph Parrish published the earliest record of interstitial cystitis in 1836 describing three cases of severe lower urinary tract symptoms without the presence of a
Names
Originally called interstitial cystitis, this disorder was renamed to interstitial cystitis/bladder pain syndrome (IC/BPS) in the 2002–2010 timeframe. In 2007, the
In 2008, terms currently in use in addition to IC/BPS include painful bladder syndrome, bladder pain syndrome and hypersensitive bladder syndrome, alone and in a variety of combinations. These different terms are being used in different parts of the world. The term "interstitial cystitis" is the primary term used in ICD-10 and MeSH. Grover et al.[70] said, "The International Continence Society named the disease interstitial cystitis/painful bladder syndrome (IC/PBS) in 2002 [Abrams et al. 2002], while the Multinational Interstitial Cystitis Association have labeled it as painful bladder syndrome/interstitial cystitis (PBS/IC) [Hanno et al. 2005]. Recently, the European Society for the study of Interstitial Cystitis (ESSIC) proposed the moniker, 'bladder pain syndrome' (BPS) [van de Merwe et al. 2008]."
See also
- Chronic prostatitis/chronic pelvic pain syndrome—women have vestigial prostate glands that may cause IC/BPS-like symptoms. Men with IC/BPS may have prostatitis, and vice versa.
- Overactive bladder
- Trigger point—a key to myofascial pain syndrome.
References
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External links
- Interstitial cystitis at Curlie
- Parsons JK, Parsons CL (2004). "The Historical Origins of Interstitial Cystitis". The Journal of Urology. 171 (1): 20–2. PMID 14665834.
- The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) Archived 24 May 2011 at the Wayback Machine
- Homma Y, Ueda T, Tomoe H, Lin AT, Kuo HC, Lee MH, Lee JG, Kim DY, Lee KS (2009). "Clinical guidelines for interstitial cystitis and hypersensitive bladder syndrome". International Journal of Urology. 16 (7): 597–615. S2CID 20796904.
- European Urology Archived 24 May 2011 at the Wayback Machine