2. 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.”
(http://www.mayoclinic.com/images/image_popup/r7_interstitialcystitis.jp
g)
(Rovner & Kim)
3. Epidemiology
500,000 – 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 IC
Prevalence may be as high as 1 in 45 women
http://www.lasvegasurogynecology.com/PUF.pdf
Almost exclusively in women
40% report symptoms worsen pre-menstrually,
specifically around time of ovulation
(Marshall, 2003; Parsons et al., 2002)
4. 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)
5. 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)
6. Patient History
Questionnaires
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)
7. 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)
8. 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
(http://www.soothetube.com/tag/doctor/)
(Ching, 2013)
11. Clinical Guidelines
AUA 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)
12. Clinical Guidelines
1st line treatments: conservative
Patient education about IC and treatment options
Behavioral modifications (B)
Timed voiding
Controlled fluid intake
Stress reduction
Avoidance of triggers
Dietary 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)
14. Physical Therapy
FitzGerald et al., 2009;
FitzGerald et al., 2012
Weiss JM, 2001
Manual release of myofascial
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
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
15. Clinical Guidelines
2nd line treatments
Pharmacology for pain management
Amitriptyline (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 treatments
Dimethyl sulfoxide (B): anti-inflammatory, analgesic, and
muscle relaxant
Heparin (C): functions as GAG layer for bladder
Lidocaine (C): analgesic
(American Urological Association, 2011; The Japanese Urological Association, 2009)
16. 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
(http://www.umm.edu/graphics/images/en/1089.jpg)
(American Urological Association, 2011; The Japanese Urological Association, 2009)
17. 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 suprapubic placement
Internal placement of device
in vagina
(http://www.kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis_ez/images/nerve_
stimulation.jpg)
(American Urological Association, 2011; The Japanese Urological Association, 2009; Steinberg et al., 2007,
http://www.mayoclinic.com/health/interstitial-cystitis/DS00497 )
18. Clinical Guidelines
5th line treatments
Cyclosporine A (C)
Anti-inflammatory and immunosuppressive
More effective for patients with Hunner’s lesions
85% vs. 30% effective
Intradetrusor botox injection (C)
Risk of requiring intermittent catheterization after treatment
Up 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)
19. Clinical Guidelines
6th line treatment: surgery (C)
Cystoplasty
Part/all of bladder removed and replaced by section of bowel to
function as new bladder
Uncommon
Urinary diversion with/without cystectomy
Section 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)
21. Resources
Ching,
C.
Interstitial
Cystitis.
MDConsult.
2013.
Available
at:
http://www.mdconsult.com/das/pdxmd/body/4123693384/1445372623?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).
22. 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; 13:394401.
Rovner ES and Kim ED. Interstitial Cystitis. Medscape Reference: Drugs, Diseases
and
Procedures.
http://emedicine.medscape.com/article/2055505overview#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
23. 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 (antiinflammatory), 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)
Editor's Notes
LUT = ureters, bladder, urethra
There were NO level A recommendations
Research mixed: Weiss used Kegels in HEP, but Fitzgerald et al. explicitly avoided
