Interstitial cystitis is a severe condition which affects the bladder causing high bladder pressure and painful bladder. The causative agent can sometimes spread to the pelvic causing pelvic pain. The pain ranges from a mild discomfort to severe. It is also known as painful bladder syndrome and affects women mostly with possibility of a long lasting impact on the quality of life.The bladder is a hollow, muscular organ purposely for the storage of urine. The bladder expands until it’s full. The brain is signaled by the nerves supplying the bladder to initiate the passage of urine, communicating through the pelvic nerves. This creates the urge to urinate for most people. However, with interstitial cystitis, these signals get mixed up. The urge to pass urine is there but the patient only passes very little amount of urine each time leading to inconvenience. Interstitial cystitis most often affects women and can have a long-lasting impact on quality of life. Although there’s no cure, medications and other therapies may offer relief.

Symptoms

Many factors affect individual perception of the signs and symptoms. If interstitial cystitis is present, the presentation of the symptoms may also vary over time, flaring periodically in response to common triggers such as menstruation, sitting for a long time, stress, exercise and sexual activity.However, the signs and symptoms of the disease may include:

• Pelvic pain or pain between the vagina and anus in women

• Pain 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 (up to 60 times a day)

• Pain or discomfort while the bladder fills and relief after urinating.

• Pain during sexual intercourse.

Severity of the symptoms may vary from person to person, and some people may experience symptom-free periods.Although signs and symptoms of interstitial cystitis may resemble those of a chronic urinary tract infection, there’s usually no infection. However, symptoms may worsen if a person with interstitial cystitis gets a urinary tract infection.

Causes

Many factors are believed to be responsible though the exact cause is unknown. For instance, people with interstitial cystitis may also have a defect in the protective lining (epithelium) of the bladder. A leak in the epithelium may allow toxic substances in urine to irritate your bladder wall.Though unproven, other contributing factors may include:

• an autoimmune reaction,

• heredity,

• infection or

• allergy.

Risk Factors

The following factors are associated with a higher risk of interstitial cystitis:

Sex: Women are diagnosed with interstitial cystitis more often than men. Inflammation of the prostate gland (prostatitis) is a condition that is particular to men and thus may mimic the symptoms of interstitial cystitis.

Age: Most people with interstitial cystitis are diagnosed during their 30s or older.Chronic pain disorder: Interstitial cystitis may be associated with other chronic pain disorder, such as irritable bowel syndrome or fibromyalgia.

Diagnosis 

Interstitial Cystitis may be diagnosed by:

Medical history and bladder diary: The doctor may ask the client to describe his/her symptoms and may ask she/he to keep a bladder diary, recording the volume of fluids taken and the volume of urine passed.

Pelvic examination: the organs within the pelvic girdle: external genitals, vagina and cervix, are examined for any inflammation or disease in order to rule out STIs.

Urinalysis and Culture and Sensitivity tests:  these tests help to analyse urine sample for possible signs of a urinary tract infection.

Cystoscopy: this procedure is carried out to visualize and probably detect any abnormality within the bladder which may be affecting the lining. A thin tube with a tiny camera called cytoscope may be inserted through the urethra, showing the lining of the bladder.  A solution may also be injected into the bladder to measure its capacity.  This procedure is known as hydrodistention,  and it is mostly done with an anesthetic medication to ensure patient’s comfort.

Biopsy: During cystoscopy under anesthesia, a sample of the bladder and urethral tissues may be taken for examination under a microscope. This is to check for bladder cancer and other rare causes of bladder pain.

Urine cytology:  Urine sample is collected and the cells are examined to help rule out cancer.

Potassium sensitivity test: in this case, two solutions: water and potassium chloride, are instilled into the bladder of the patient, one at a time and the patient is asked  to rate on a scale of 0 to 5 the pain and urgency felt after each solution is instilled. If any noticeable pain is felt more with the Potassium Chloride, then interstitial cystitis is diagnosed. People with normal bladders can’t tell the difference between the two solutions.

Treatment

There is no specific treatment to relieve the clinical manifestations as the body response varies. Thus a particular treatment for Mr A may not work for Mr B. Various treatments or combinations of treatments may be experimented with before finding the unique one that eliminates the patient’s signs and symptoms. Below are some treatment regimens that may relieve the patient’s presentations.

Physical therapy

Doing some pelvic floor muscle exercise may help to relieve the pain associated with muscle tenderness, restrictive connective tissue or muscle abnormalities in the pelvic floor.

Oral medications

Oral medications that may improve the signs and symptoms of interstitial cystitis include:

• Nonsteroidal anti-inflammatory drugs, (NSAIDs) such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (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 polysulfate sodium (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 the patient begins to feel pain relief and up to six months to experience a decrease in urinary frequency.Nerve stimulationNerve stimulation may help relieve the painful symptoms felt in the pelvis. 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 increase blood flow to the bladder. This may strengthen the muscles that help control the bladder or trigger the release of substances that block pain. Electrical wires placed on the lower back or just above pubic area of the patient’s pelvic region deliver electrical pulses.

• Sacral nerve stimulation: The sacral nerves are a primary link between the spinal cord and nerves in the bladder. Stimulating these nerves may reduce urinary urgency associated with interstitial cystitis. With sacral nerve stimulation, a thin wire placed near the sacral nerves sends electrical impulses to the bladder. If the procedure decreases the symptoms, a permanent device may be surgically implanted. This procedure doesn’t manage pain from interstitial cystitis, but may help to relieve some symptoms of urinary frequency and urgency.

Bladder distention

Some people notice a temporary improvement in symptoms after cystoscopy with bladder distention. Bladder distention is the stretching of the bladder with water. Long-term improvement may necessitate the repetition of the procedure.

Instillation of Medications into the bladder

In bladder instillation, doctor may place the prescribed medication dimethyl sulfoxide (Rimso-50) into the patient’s 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 bladder for about 15 minutes. The patient is then asked afterwards to urinate to expel the solution.The patient may also receive dimethyl sulfoxide (also called DMSO) treatment weekly for six to eight weeks, and then have maintenance treatments as needed. A newer approach to bladder instillation uses a solution containing the medications lidocaine, sodium bicarbonate, and either pentosan or heparin.

Surgery; Surgical procedure is rarely used to treat interstitial cystitis because removing 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 fail and symptoms affect quality of life. 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, a surgeon increases the capacity of the patient’s bladder by putting a patch of intestine on the bladder. However, this is performed only in very specific and rare instances. The procedure doesn’t eliminate pain and some people need to empty their bladders with a catheter many times a day.

Complications

Interstitial cystitis may be mistaken for Urinary Tract Infection (UTI) and thus not managed properly. When this occurs, complication is possibly imminent and may include:Reduced bladder capacity: Interstitial cystitis can cause stiffening of the bladder wall, which allows your bladder to hold less urine.Lower quality of life: Frequent urination and pain may interfere with social activities, work and other activities of daily life.Sexual intimacy problems: Frequent urination and pain may strain your personal relationships, and sexual intimacy may suffer.Emotional troubles: The chronic pain and interrupted sleep associated with interstitial cystitis may cause emotional stress and can lead to depression.

Sources

Interstitial cystitis/painful bladder syndrome. National Institute of Diabetes and Digestive and Kidney Diseases. http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/. Accessed July 1, 2016.

Clemens JQ. Pathogenesis, clinical features, and diagnosis of interstitial cystitis/bladder pain syndrome. http://www.uptodate.com/home. Accessed July 1, 2016.

Interstitial cystitis. Merck Manual Professional Version. http://www.merckmanuals.com/professional/genitourinary_disorders/voiding_disorders/interstitial_cystitis.html. Accessed July 1, 2016.

Wein AJ, et al., eds. Bladder pain syndrome (interstitial cystitis) and related isorders. In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. http://www.clinicalkey.com. Accessed July 1, 2016.

Clemens JQ. Management of interstitial cystitis/bladder pain syndrome. http://www.uptodate.com/home. Accessed July 1, 2016.

Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Linthicum, Md.: American Urological Association. http://www.auanet.org/education/guidelines/ic-bladder-pain-syndrome.cfm. Accessed July 1, 2016.

Longo DL, et al., eds. Dysuria, bladder pain, and the interstitial cystitis/bladder pain syndrome. In: Harrison’s Principles of Internal Medicine. 19th ed. New York, N.Y.: McGraw-Hill Education; 2015. http://www.accessmedicine.com. Accessed July 1, 2016.

The urinary tract and how it works. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-topics/Anatomy/urinary-tract-how-it-works/Pages/anatomy.aspx. Accessed July 1, 2016.