Interstitial CystitisNora Brody, Will Huebner, Krysten Malcolm, Seema

Marshall, Anita Vadaken

What is IC?Clinical syndrome

AKA painful bladder syndrome

“Unpleasant sensation perceived to be related to the urinary bladder and associated with lower urinary tract

symptoms of 6+ weeks duration, in the

absence of infection or other identifiable

causes.”

(Rovner & Kim)(http://www.mayoclinic.com/images/image_popup/r7_interstitialcystitis.jpg)

Epidemiology500,000 – 1,000,000 cases estimated in U.S.

ICSI from 1990 to 2002: 1.2 to 450 per 100,000

Proposed pain and urgency/frequency symptom scale (PUF) has been used to identify patients with ICPrevalence may be as high as 1 in 45 womenhttp://www.lasvegasurogynecology.com/PUF.pdf

Almost exclusively in women40% report symptoms worsen pre-menstrually,

specifically around time of ovulation

(Marshall, 2003; Parsons et al., 2002)

Interstitial Cystitis Symptoms Index (ICSI)

During the past month: How often have you felt the strong need to urinate

with little or no warning?Have you had to urinate less than 2 hours after

you finished urinating? How often did you most typically get up at night to

urinate? Have you experienced pain or burning in your

bladder?

(Sirian et al., 2005)

Etiology Unknown, multifactorial

Deficiency in the glycosaminoglycan (GAG) layer Toxic substances

Autoimmune disorder

Infection History of UTIs

Toxic substance in urine

Neurogenic hypersensitivity or inflammation

Pelvic floor muscle dysfunction/dysfunctional voiding

(Nickel, 2000; Rovner & Kim) (http://jama.jamanetwork.com/data/journals/jama/23565/m_jpg120007fa.png)

Patient HistoryQuestionnaires

Risk factors: consumption of caffeinated and alcoholic drinks, anorectal disease, IBS

Associated conditions: depression, sexual dysfunction/abuse, emotional/physical abuse or neglect, constipation, chronic pain or inflammatory conditions

(Offiah et al., 2013; Quillin & Erickson, 2012)

Signs & Symptoms PAIN: suprapubic or pelvic Bladder pain that worsens

with bladder filling and is alleviated with voiding

Dysuria Urinary frequency &

urgency Nocturia: mild to severe (1

to >12 times per night) Spasm of the rectum and

levator ani muscles Anterior vaginal wall,

suprapubic region, and pelvic floor muscle tenderness on pelvic examination

Women Dyspareunia Female sexual dysfunction

Men Pain at the tip of the

penis, the groin, or the testes

Ejaculation often produces pain owing to severe spasm of the pelvic floor

Prostate, bladder, testes, and epididymis tenderness

(Ching, 2013)

Other Examination Techniques

Perform pelvic examination to help exclude gynecologic disease

Measure the patient's temperature Fever suggests infection

rather than IC

Examine the abdomen for masses, hernias, and other abnormalities suggesting alternate diagnoses

(Ching, 2013)

(http://www.soothetube.com/tag/doctor/)

Diagnosis

Cystoscopy Findings: glomerulations,

mucosal ulcers (Hunner’s lesions), petechial hemorrhage

Urodynamics Poorly compliant bladder

Urinary biomarkers Nitric oxide

Bladder biopsy Controversial

(Offiah et al., 2013; Quillin & Erickson, 2012)

(http://2.bp.blogspot.com/-cfuq6XwwRiE/ThRoNDIPU4I/AAAAAAAAAys/A2l6NTX6SEc/s1600/pathology.jpg)

Clinical Guidelines

(American Urological Association, 2011)

Clinical GuidelinesAUA created flowchart of suggested order of treatment

Progress 1st line through 6th line as needed

JUA created clinical practice guidelines Level A evidence: highly recommended Level B evidence: recommended Level C evidence: no clear recommendation possible Level D evidence not recommended

Conservative treatments first

Avoid surgery if possible Exception is fulguration of Hunner’s lesions, must be done first

Multiple simultaneous treatments often best Pain management should be priority

(American Urological Association, 2011; The Japanese Urological Association, 2009)

Clinical Guidelines1st line treatments: conservative

Patient education about IC and treatment optionsBehavioral modifications (B)

Timed voidingControlled fluid intakeStress reductionAvoidance of triggersDietary changes: avoid acidic foods, coffee, tea, soda,

spicy foods, artificial sweetener, and alcohol 4 C’s: carbonated, caffeine, citrus, high concentration of

vitamin C

(American Urological Association, 2011; The Japanese Urological Association, 2009; http://www.mayoclinic.com/health/interstitial-cystitis/DS00497)

Clinical Guidelines2nd line treatments

Physical Therapy (C)BiofeedbackSoft tissue mobilizationStretchingPelvic floor muscle training?

AUA says avoid JUA says nothing Research mixed

(American Urological Association, 2011; The Japanese Urological Association, 2009; Weiss, 2001)

Physical TherapyWeiss JM, 2001

Manual release of myofascial trigger points via internal palpation, compression, and lateral stretching

HEP: biofeedback, Kegel exercises, external pelvic muscle stretches and strengthening, and stress reduction

70% had moderate to marked improvement

FitzGerald et al., 2009; FitzGerald et al., 2012

Soft tissue mobilization of all trigger points found in pelvic floor, anteriorly from knees to costal cartilages, and posteriorly from T10 to popliteal crease

Manual stretching, scar mobilization, and myofascial release

Individualized HEP of stretching and exercises Explicitly told participants to

avoid Kegels until trigger points resolved

59% reported moderate or marked symptom improvement

Clinical Guidelines2nd line treatments

Pharmacology for pain managementAmitriptyline (B), Cimetidine (C), Hydroxyzine (C) :

inhibit histamine receptors to decrease pain signal transmission

Pentosan polysulfate (B): repairs damaged GAG layer of bladder mucosa Takes 3-6 months to see effects and only effective in

approximately 25% of patients

Intravesical treatmentsDimethyl sulfoxide (B): anti-inflammatory, analgesic,

and muscle relaxantHeparin (C): functions as GAG layer for bladderLidocaine (C): analgesic

(American Urological Association, 2011; The Japanese Urological Association, 2009)

Clinical Guidelines

3rd line treatment: cystoscopy with short duration, low pressure hydrodistension (B) Most common

treatment, 50% efficacy, effects last about 6 months

Inflate bladder with saline to 80cmH2O or 800-1000mL, maintain pressure for a few minutes then drain bladder

(American Urological Association, 2011; The Japanese Urological Association, 2009)

(http://www.umm.edu/graphics/images/en/1089.jpg)

Clinical Guidelines 4th line treatment:

neurostimulation (C) Bilateral S3 nerve stimulators

Significant decrease in frequency and nocturia

Significant improvement in Urinary Distress Inventory short form scores, showing patient satisfaction

Decrease in episodes of fecal incontinence

TENS for pain relief External low back or supra-

pubic placement Internal placement of

device in vagina

(American Urological Association, 2011; The Japanese Urological Association, 2009; Steinberg et al., 2007, http://www.mayoclinic.com/health/interstitial-cystitis/DS00497 )

(http://www.kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis_ez/images/nerve_stimulation.jpg)

Clinical Guidelines5th line treatments

Cyclosporine A (C)Anti-inflammatory and immunosuppressiveMore effective for patients with Hunner’s lesions

85% vs. 30% effective

Intradetrusor botox injection (C)Risk of requiring intermittent catheterization after

treatmentUp to 4 injections, separated by 6 months effective

for symptom and pain relief as well as increasing bladder capacity

Not as effective for patients with Hunner’s lesions

(American Urological Association, 2011; The Japanese Urological Association, 2009; Forrest et al., 2012; Kuo HC, 2013)

Clinical Guidelines6th line treatment: surgery (C)

CystoplastyPart/all of bladder removed and replaced by section of bowel

to function as new bladderUncommon

Urinary diversion with/without cystectomySection of bowel becomes conduit for ureters, stoma created

in abdomen, allows urine to drain continually into external collection bag

Section of bowel becomes conduit for ureters, drains into another section of bowel that has become internal pouch that must be emptied through intermittent self-catheterization

Rarely performed because many patients will still experience some symptoms, mainly pain, after surgery

(http://www.ichelp.org/page.aspx?pid=384 Revised June 03, 2011)

Questions?

(http://i.qkme.me/35n0m0.jpg)

Resources Ching, C. Interstitial Cystitis. MDConsult. 2013. Available at:

http://www.mdconsult.com/das/pdxmd/body/412369338-4/1445372623?type=med&eid=9-u1.0-_1_mt_1010371#1144427. Accessed May 29, 2013.

Hanno PM, Burks DA, Clemens JQ, et al. AUA guidelines for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170.

Homma Y, Ueda T, Tomoe H, et al. Clinical guidelines for interstitial cystitis and hypersensitive bladder syndrome. Int J Urol. 2009;16:597-615.

FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2009;182:580-580.

FitzGerald MP, Payne CK, Lukacz ES, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2012;187:2113-2118.

Forrest JB, Payne CK, Erickson DR. Cyclosporine A for refractory interstitial cystitis/bladder pain syndrome: experience of 3 tertiary centers. J Urol. 2012;188(4):1186-1191.

Hanley RS, Stoffel JT, Zagha RM, Mourtzinos A, Bresette JF. Multimodal therapy for painful bladder syndrome/interstitial cystitis: pilot study combining behavioral, pharmacologic, and endoscopic therapies. Int Braz J Urol. 2009;35:467-474.

Kuo HC. Repeated intravesical onabotulinumtoxinA injections are effective in treatment of refractory interstitial cystitis/bladder pain syndrome. Int J Clin Pract. 2013:67(5):427-434.

Marshall, K. Interstitial Cystitis: understanding the syndrome. 2003. Alternative Medicine Review, 8 (4).

Resources Nickel JC. Interstitial cystitis. Canadian Family Physician. 2000;46:2530-2440. Offiah I, McMahon SB and O’Reilly BA.  Interstitial cystitis/bladder pain syndrome:

diagnosis and management.  Int Urogynecol J.  2013 Feb 22.  Epub ahead of print. Parsons C, Dell J, Stanford E et al. Increased prevalence of interstitial cystitis:

previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. 2002. Adult Urology, 4295(02).

Quillin, Renee B and Erickson, Deborah R.  Practical use of the new American Urological Association Interstitial Cystitis guidelines.  Curr Urol Rep.  2012; 13:394-401.

Rovner ES and Kim ED. Interstitial Cystitis. Medscape Reference: Drugs, Diseases and Procedures. http://emedicine.medscape.com/article/2055505-overview#aw2aab6b2b3. Accessed May 27, 2013.

Sirinian E, Azevedo K, Payne CK. Correlation between 2 interstitial cystitis symptom instruments. J Urol. 2005;173:835-840.

Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3 stimulator in patients with interstitial cystitis. Urology. 2007;69(3):441-443.

Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166:2226-2231.

http://www.mayoclinic.com/health/interstitial-cystitis/DS00497 http://www.ichelp.org/page.aspx?pid=384 http://www.lasvegasurogynecology.com/PUF.pdf

Example of Treatment Protocol Dietary restrictions Fluid restriction to 64 oz per day, 16 oz per meal and 8 oz

between each meal Timed voiding every 2-3 hours Kegels: 15 contractions 2x per day Pharmacology: macrodantin (anti-inflammatory),

hydroxyzine (anti-inflammatory), Urised (anti-spasmodic) Continued pentosan polysulfate if patient had been on it at

least 6 months prior Hydrodistension

3x in one session, 2 weeks after treatment initiated All participants did not have Hunner’s lesions Saw statistically signficant improvement in quality of life

measured on O’Leary-Sant IC Symptom Index

(Hanley et al., 2009)