A to Z on IC Interstitial Cystitis Association August 23, 2009 1:00 PM ET Conquering IC.  Changing Lives . The goal of the...
Welcome <ul><li>This forum is hosted by the Interstitial Cystitis Association. </li></ul><ul><li>The ICA is dedicated to p...
Thanks <ul><li>Special thanks to the Centers for Disease Control and Prevention for the IC awareness activities. </li></ul...
Agenda Highlights <ul><ul><li>Overview of IC </li></ul></ul><ul><ul><ul><li>Dr. Jeffrey Proctor, Director of Interstitial ...
Jeffrey Proctor, MD <ul><li>Director of Interstitial Cystitis, Georgia Urology, PA  </li></ul><ul><ul><li>Received the Spr...
A to Z on IC TREATMENTS AND RESEARCH Jeffrey G. Proctor, M.D. Georgia Urology Cartersville, GA
EPIDEMIOLOGY <ul><li>Historically IC was thought to be rare </li></ul><ul><li>Strict NIDDK criteria do not include mild or...
SYMPTOMS <ul><li>Classic triad of symptoms: </li></ul><ul><ul><li>Urinary frequency </li></ul></ul><ul><ul><li>Urinary urg...
Symptoms <ul><li>Pelvic pain or pressure </li></ul><ul><li>Pain as bladder fills </li></ul><ul><li>Painful intercourse </l...
Symptoms   Mimicking Conditions <ul><li>Recurrent urinary tract infections </li></ul><ul><li>Endometriosis </li></ul><ul><...
Symptoms <ul><li>Symptoms may be episodic </li></ul><ul><li>If IC is left untreated, symptoms may progress </li></ul><ul><...
Symptoms   Patient Impact <ul><li>Emotional and physical stress </li></ul><ul><li>Pain </li></ul><ul><li>Sleep deprivation...
ASSOCIATED DISEASES <ul><li>Allergies </li></ul><ul><li>Irritable bowel syndrome </li></ul><ul><li>Fibromyalgia </li></ul>...
ETIOLOGY <ul><li>Likely multifactorial etiology </li></ul><ul><li>Bladder epithelial layer dysfunction </li></ul><ul><ul><...
Adapted with permission from Evans RJ.  Rev Urol . 2002;4(suppl 1):S16-S20. Proposed Pathogeneis A Continuous Cycle Bladde...
TREATMENT <ul><li>Pentosan polysulfate sodium (Elmiron) </li></ul><ul><li>Only FDA approved oral therapy for the relief of...
Treatment:  Elmiron <ul><li>In a prospectively designed retrospective analysis of 2499 IC patients on Elmiron </li></ul><u...
Treatment:  Elmiron <ul><li>Early use of Elmiron after IC Diagnosis (<6 months) had greater improvement in IC symptom reli...
Treatment:  Elmiron <ul><li>Prescribing information </li></ul><ul><ul><li>Clinical response to Elmiron may require 3 to 6 ...
Treatment:  Elmiron <ul><li>Adverse events tend to be mild and transient in a 8 year retrospective study, and occurred bet...
Treatment:  Patient Counseling <ul><li>Understand the IC disease process </li></ul><ul><li>Symptom relief may be gradual <...
Treatment:  Diet <ul><li>Avoid potassium and acids </li></ul><ul><li>Avoid alcohol, spicy foods, citrus fruits, bananas,ch...
Treatment:  Diet <ul><li>IC diet is very important when first diagnosed with IC, with flare of symptoms </li></ul><ul><li>...
Treatment : Diet <ul><li>When going out to eat </li></ul><ul><ul><li>Bottled water </li></ul></ul><ul><ul><li>Be selective...
Treatment : Bladder Instillations <ul><li>Dimethyl Sulfoxide (DMSO) </li></ul><ul><ul><li>FDA approved for symptomatic rel...
Treatment : Multimodality Therapy <ul><li>Amitriptyline HCL (Elavil)-tricyclic antidepressant </li></ul><ul><li>Used to mo...
Treatment:  Multimodality Therapy <ul><li>Hydroxyzine (Atarax)-antihistamine </li></ul><ul><li>Stabilizes mast cells and b...
<ul><li>Pregabalin (Lyrica) or gabapentin (Neurontin) </li></ul><ul><li>Used to modulate pain </li></ul><ul><li>FDA approv...
<ul><li>Anticholinergic medications </li></ul><ul><li>Used to treat urinary frequency and urgency, urge urinary incontinen...
Utilizing Multimodal Therapy in the Treatment of IC 1 Adapted with permission from Evans RJ.  Rev Urol . 2002;4(suppl 1):S...
<ul><li>Bladder training </li></ul><ul><li>Physical therapy </li></ul><ul><ul><li>Stretching and pelvic floor muscle relax...
<ul><li>Alpha receptor blockade therapy  tamsulosin (Flomax) </li></ul><ul><li>Relaxes alpha receptors in proximal urethra...
Treatment : Additional Treatments <ul><li>Muscle relaxants diazepam (Valium) </li></ul><ul><li>Can use lower doses daily, ...
Treatment : Analgesics <ul><li>Antidepressants </li></ul><ul><li>Anticonvulsants </li></ul><ul><li>NSAID’s </li></ul><ul><...
Treatment   Flare of IC Symptoms <ul><li>Periodic flare of symptoms </li></ul><ul><ul><li>Variation of IC symptoms </li></...
Treatment   Flare of IC Symptoms <ul><li>Go back to basics </li></ul><ul><li>Strict IC diet </li></ul><ul><li>Take all IC ...
Treatment   Persistent Symptoms <ul><li>Gynecologist </li></ul><ul><ul><li>Rule out endometriosis, or other gynecological ...
Treatment   Persistent Symptoms <ul><li>Hydrodistention under anesthesia </li></ul><ul><ul><li>Can cause an initial flare ...
Treatment   Persistent Symptoms <ul><li>Interstim neuromodulation </li></ul><ul><ul><li>“ Bladder pacemaker” </li></ul></u...
Treatment   Persistent Symptoms <ul><li>Uroplasty </li></ul><ul><li>Acupuncture </li></ul>
RESEARCH
Research   Intravesical Instillations <ul><li>Intravesical Alkalized Lidocaine (PSD597) Offers Immediate and Sustained Rel...
Research    Intravesical Instillations <ul><li>Daily instillation of PSD597 or placebo for 5 consecutive days </li></ul><u...
Research   Intravesical Instillations <ul><li>Day 22 63%, and day 29 56% had moderate or marked improvement of symptoms </...
Research URG101 Study <ul><li>URG101 is an investigational bladder instillation (Urigen Pharmceuticals) </li></ul><ul><li>...
Research URG101 Study: Results <ul><li>URG 101 significantly reduces PBS/IC symptoms after a single dose (interim analysis...
Research URG101 Study: Results <ul><li>Secondary endpoints: </li></ul><ul><li>50% pt’s had moderate or marked improvement ...
Research URG101 Study: Results <ul><li>This study suggests that after one instillation of URG101 there is clinical benefit...
Research URG101 Study: Results <ul><li>Unpublished clinical study by Dr’s J Teichman and B Welk demonstrated that administ...
Research Defective Tamm-Horsfall Protein in Patients With Interstitial Cystitis Cl Parsons, P Stein, P Zupkas, M Chenoweth...
Tamm-Horsfall Protein <ul><li>Most abundant protein in human urine. </li></ul><ul><li>30% sugar by weight due to presence ...
Tamm-Horsfall Protein <ul><li>The anionic THP neutralizes the cationic urinary toxic factors. </li></ul><ul><li>THP from c...
Tamm-Horsfall Protein <ul><li>Ability of THP to neutralize the toxic factor could be affected by: </li></ul><ul><ul><li>De...
Defective THP in Pts With IC <ul><li>Results </li></ul><ul><ul><li>The absolute amount of THP in urine was not significant...
Defective THP in Pts With IC <ul><li>Studied N-glycans released from the THP of 10 controls and 10 IC Pts. </li></ul><ul><...
Defective THP in Pts With IC Implications <ul><li>Propose a major function for THP as a protective urinary macromolecule t...
FIG. 2. Representative N-terminal residue results of MALDI-TOF MS analysis of intact glycosylation chains of THP from 10 c...
RESEARCH <ul><li>Interesting AUA abstracts from the AUA National Convention for the past 2 years </li></ul>
Research : Intravesical <ul><li>Comparison of Intravesical Botulinum Toxin A Injections Plus Hydrodistention and Hydrodist...
Research : Intravesical <ul><li>All pt’s remained on Elmiron and medications </li></ul><ul><li>Maximum bladder capacity in...
Research : Intravesical <ul><li>Intravesical injections of Botox followed by hydrodistention provided signifcantly better ...
Research : Intravesical <ul><li>Intra-Trigonal Injection of Botulinum Toxin A in Patients with PBS-Results at 9-Months Fol...
Research : Intravesical <ul><li>Symptom </li></ul><ul><li>Pain </li></ul><ul><li>Frequency </li></ul><ul><li>OLS Symptom s...
Research : Intravesical <ul><li>Intra-trigonal injection of 100 units of Botox in patients with refractory PBS is safe and...
Research : Food <ul><li>Differences in Food Sensitivities Between Female IC/PBS Patients and Chronic Prostatitis/CPPS Synd...
Research : Food <ul><li>Significant differences seen in food sensitivities  </li></ul><ul><ul><li>94.8% of female IC/PBS <...
Research : Food <ul><li>Foods that were the most bothersome were identical in both groups </li></ul><ul><ul><li>Coffee (mo...
Research : Epidemiology <ul><li>Prevalence of IC/PBS in the United States.  AH Berry et al.  Multiple sites. </li></ul><ul...
Research : Epidemiology <ul><li>High sensitivity definition of IC:  6.5% of US women have IC/PBS </li></ul><ul><ul><li>Dur...
Research : Epidemiology <ul><li>High specificity definition of IC:  2.6% of US women have IC/PBS </li></ul><ul><ul><li>Pas...
Research : Epidemiology <ul><li>Phenotypic Associations Between IC/PBS and Irritable Bowel Syndrome (IBS), Fibromyalgia (F...
Research : Epidemiology <ul><li>Associated condition </li></ul><ul><li>Irritable Bowel Syndrome </li></ul><ul><li>Fibromya...
Research : Sexual Function <ul><li>Female Sexual Function Improves in Treated IC Patients.  BK Welk and JM Teichman, Vanco...
<ul><li>Multiple domains of female sexual function improve as painful intercourse improves in treated IC/PBS pt’s </li></u...
<ul><li>50% had resolution of painful intercourse </li></ul><ul><ul><li>Pt’s with successful outcomes tend to have lower P...
Research : Oral Agents <ul><li>Urine Alkalinization Improves the Problems of Pain and Sleep in Patients With IC.  T Ueda e...
Research : Oral Agents <ul><li>Urine pH increased 5.8 to 6.2 </li></ul><ul><li>Frequency improved 14.5 to 13.5 </li></ul><...
Research : Complementary and Alternative Medicine <ul><li>The Effects of Chinese Herbal Medicine Containing Aconitine on t...
Research : Complementary and Alternative Medicine <ul><li>Both contain Aconitine, an alkaloid derivative that is a neuroto...
Research : Complementary and Alternative Medicine <ul><li>Success of Acupuncture in the Treatment of PBS/IC.  FA Reeves et...
Research : Complementary and Alternative Medicine <ul><li>Quality of life improved in 13/15 pt’s (86%) </li></ul><ul><ul><...
Research : Not Ready For Prime Time <ul><li>Pharmokinetics of Liposomes After Intravesical Administration. J Kaufman, Pitt...
Research : Not Ready For Prime Time <ul><li>Inhibition of Antiproliferative Factor (APF) Activity in Bladder Epithelial Ce...
Research : Not Ready For Prime Time <ul><li>Intravesically Applied Chondroitin Sulfate Restores Urothelial Barrier Functio...
Research : Other Studies <ul><li>The Relationship Among Symptoms, Sleep Disturbances and Quality of Life in Patients with ...
Research : Other Studies <ul><li>Assessment of Patient Outcomes Following Submucosal Injection of Triamcinolone for Treatm...
Research : Other Studies <ul><li>Extracorporeal Shock Wave Treatment (ESWT) for the Treatment of CPPS in Males:  A Randomi...
A to Z on IC SUMMARY <ul><li>Reviewed treatment options from  A mitriptyline to  Z yrtec </li></ul><ul><li>Pentosan polysu...
A to Z on IC Summary <ul><li>Special thanks to the NIH and ICA for their support </li></ul><ul><li>www.ichelp.org </li></ul>
Susan Bilheimer  <ul><li>Co-author of “Secret Suffering: How Women’s Sexual & Pelvic Pain Affects Their Relationships” </l...
Anna Kelly, MD <ul><li>Acupuncturist and Anesthesiology Consultant, Metro Anesthesia Services </li></ul><ul><ul><li>Presid...
Medical Acupuncture and Interstitial Cystitis <ul><li>Anna Kelly, MD </li></ul><ul><li>August 23, 2009 </li></ul>
Cartesian Model vs. Eastern Thought
Acupuncture <ul><li>The insertion of solid needles in various combinations and patterns for the purpose of promoting healt...
Definitions <ul><li>Qi </li></ul><ul><li>Yin & Yang </li></ul><ul><li>Organs </li></ul><ul><li>Meridians/Channels </li></ul>
Qi <ul><li>Energy </li></ul><ul><li>Impetus </li></ul><ul><li>Life force </li></ul><ul><li>Is present in all life </li></ul>
Yang and Yin <ul><li>Relative terms </li></ul><ul><li>Nothing is permanently or absolutely  </li></ul><ul><li>Yin or Yang ...
Yang and Yin Yang Light Male Outside Back Hot Hollow Heaven Yin Dark Female Inside Front Cold Solid Earth
Organs <ul><li>Yin </li></ul><ul><li>Kidney </li></ul><ul><li>Heart </li></ul><ul><li>Spleen  </li></ul><ul><li>Lung  </li...
Needle Stimulation <ul><li>Directed electron flow and transfer </li></ul><ul><li>Micro-battery/ Bimetallic Effect </li></u...
Directed Electron Flow
Meridian Pathway
Traditional Chinese Medicine (TCM) <ul><li>Acupuncture </li></ul><ul><li>Herbs </li></ul>
Traditional Chinese Medicine (TCM) <ul><li>Eight Principles </li></ul><ul><ul><li>Yin and Yang </li></ul></ul><ul><ul><li>...
Traditional Chinese Medicine (TCM) <ul><li>Patterns </li></ul><ul><ul><li>Damp </li></ul></ul><ul><ul><li>Dry </li></ul></ul>
IC from a Chinese Medicine Perspective <ul><li>Dampness </li></ul><ul><li>Heat </li></ul><ul><li>Excess </li></ul><ul><li>...
Literature Review <ul><li>Several studies published in peer-reviewed literature demonstrate that electroacupuncture is hel...
Current Active NIH Acupuncture Studies <ul><li>Acupuncture for the treatment of: migraines, dry-eye, polycystic ovarian sy...
Acupuncture and Electroacupuncture in the Treatment of Interstitial Cystitis
Individualized Treatment <ul><li>In our clinic, we don’t copy studies.  We treat individuals; the treatment may vary week ...
Chinese Herbs <ul><li>No over the counter (OTC) herbs </li></ul><ul><li>No self-prescribing </li></ul><ul><li>Herbs prescr...
Chinese Herbs <ul><li>Herb source known with product quality assurance measures in place </li></ul><ul><li>Herbs customize...
Herbs for Interstitial Cystitis <ul><li>Gentiana Drain Fire is a common herb recommended to IC patients.  It is composed o...
Frequency of Acupuncture Treatments <ul><li>Acute Onset </li></ul><ul><li>Fewer treatments </li></ul><ul><li>Treatments gr...
<ul><li>Zigong  -  Palace of the child CV 4  -  Infant’s Door </li></ul><ul><li>GV 4  -  Gate of Life SP 8  -  Earth Pivot...
Closing Remarks <ul><li>Thanks to all of you for joining us.  And a special thanks to the speakers and sponsors that made ...
Closing Remarks <ul><li>One final plug for the ICA:  Our work is made possible through the generous contributions of peopl...
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Ica patient forum in atlanta 2009

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The Interstitial Cystitis Association (ICA), a non-profit health association, hosted a Patient Forum in Atlanta on Sunday, August 23, 2009. This CDC-funded event offered healthcare providers, patients and caregivers a chance to meet with leaders in the field to learn more about interstitial cystitis - a severely painful and chronic bladder condition affecting an estimated 3 million women and 1 million men in the United States. Speakers included Dr. Jeffrey Proctor, Dr. Anna Kelly and Susan Bilheimer.

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Ica patient forum in atlanta 2009

  1. 1. A to Z on IC Interstitial Cystitis Association August 23, 2009 1:00 PM ET Conquering IC. Changing Lives . The goal of the forum is to offer patients an opportunity to learn more about IC treatments. The content presented reflects the opinions of individual speakers. 1
  2. 2. Welcome <ul><li>This forum is hosted by the Interstitial Cystitis Association. </li></ul><ul><li>The ICA is dedicated to providing advocacy, research funding, and education to ensure early diagnosis and optimal care with dignity for people affected by IC. </li></ul><ul><li>To learn more about current initiatives, talk with ICA Executive Director, Barbara Gordon </li></ul><ul><ul><li>Or, send an email to [email_address] . </li></ul></ul>2
  3. 3. Thanks <ul><li>Special thanks to the Centers for Disease Control and Prevention for the IC awareness activities. </li></ul><ul><li>Our gratitude to Drs. Proctor and Kelly, and Susan Bilheimer—for both their presentations and their daily work helping people with IC. </li></ul>4
  4. 4. Agenda Highlights <ul><ul><li>Overview of IC </li></ul></ul><ul><ul><ul><li>Dr. Jeffrey Proctor, Director of Interstitial Cystitis at Georgia Urology </li></ul></ul></ul><ul><ul><li>Discussion about IC and intimacy </li></ul></ul><ul><ul><li> Susan Bilheimer, author of Secret Suffering </li></ul></ul><ul><ul><li>Introduction to acupuncture, with demo Dr. Anna Kelly, Acupuncturist and Anesthesiologist </li></ul></ul>6
  5. 5. Jeffrey Proctor, MD <ul><li>Director of Interstitial Cystitis, Georgia Urology, PA </li></ul><ul><ul><li>Received the Sprague Carlton, M.D., award for proficiency in urology </li></ul></ul><ul><ul><li>Completed numerous publications in both urology and immunology and has led research studies exploring the safety and effectiveness of IC treatments </li></ul></ul>14
  6. 6. A to Z on IC TREATMENTS AND RESEARCH Jeffrey G. Proctor, M.D. Georgia Urology Cartersville, GA
  7. 7. EPIDEMIOLOGY <ul><li>Historically IC was thought to be rare </li></ul><ul><li>Strict NIDDK criteria do not include mild or atypical disease </li></ul><ul><li>US Prevalence range 33-24,000 per 100,000 </li></ul><ul><li>Some estimates suggest 12 to 16 million Americans have IC </li></ul><ul><li>More common in women </li></ul><ul><ul><li>Female to male ratio is 5:1 </li></ul></ul>
  8. 8. SYMPTOMS <ul><li>Classic triad of symptoms: </li></ul><ul><ul><li>Urinary frequency </li></ul></ul><ul><ul><li>Urinary urgency </li></ul></ul><ul><ul><li>Pelvic pain </li></ul></ul><ul><li>May not have all of the symptoms </li></ul><ul><li>If untreated, symptoms may progress </li></ul><ul><li>IC is often referred to as painful bladder syndrome (PBS) </li></ul>
  9. 9. Symptoms <ul><li>Pelvic pain or pressure </li></ul><ul><li>Pain as bladder fills </li></ul><ul><li>Painful intercourse </li></ul><ul><li>Flares after sex </li></ul><ul><li>Premenstrual flare </li></ul><ul><li>Flares during allergy season </li></ul>
  10. 10. Symptoms Mimicking Conditions <ul><li>Recurrent urinary tract infections </li></ul><ul><li>Endometriosis </li></ul><ul><li>Overactive bladder </li></ul><ul><li>Chronic pelvic pain </li></ul><ul><li>Vulvodynia </li></ul><ul><li>Chronic prostatitis </li></ul>
  11. 11. Symptoms <ul><li>Symptoms may be episodic </li></ul><ul><li>If IC is left untreated, symptoms may progress </li></ul><ul><li>Average 5 years before full symptoms </li></ul><ul><li>Many IC patients have symptoms for 4 to 7 years before being diagnosed </li></ul><ul><li>See 5 physicians before diagnosis </li></ul>
  12. 12. Symptoms Patient Impact <ul><li>Emotional and physical stress </li></ul><ul><li>Pain </li></ul><ul><li>Sleep deprivation </li></ul><ul><li>Avoidance of intercourse and/or intimacy </li></ul><ul><li>Travel restrictions </li></ul><ul><li>Occupational limitations </li></ul>
  13. 13. ASSOCIATED DISEASES <ul><li>Allergies </li></ul><ul><li>Irritable bowel syndrome </li></ul><ul><li>Fibromyalgia </li></ul><ul><li>Endometriosis </li></ul><ul><li>Chronic fatigue syndrome </li></ul><ul><li>Migraine headache (?) </li></ul><ul><li>Asthma </li></ul><ul><li>Skin sensitivity </li></ul>
  14. 14. ETIOLOGY <ul><li>Likely multifactorial etiology </li></ul><ul><li>Bladder epithelial layer dysfunction </li></ul><ul><ul><li>Solute (i.e. potassium) leak into interstitium </li></ul></ul><ul><li>Neural changes </li></ul><ul><li>Mast cell activation </li></ul><ul><ul><li>Histamine release </li></ul></ul>
  15. 15. Adapted with permission from Evans RJ. Rev Urol . 2002;4(suppl 1):S16-S20. Proposed Pathogeneis A Continuous Cycle Bladder Insult Origin of Bladder Insult (eg, Bacterial Cystitis, Childbirth, Pelvic Surgery, or Urologic Instrumentation) More Injury Mast Cell Activation and Histamine Release Activation of C-Fibers and Release of Substance P Solutes Leak Into Interstitium Bladder Urothelium Dysfunction
  16. 16. TREATMENT <ul><li>Pentosan polysulfate sodium (Elmiron) </li></ul><ul><li>Only FDA approved oral therapy for the relief of bladder pain or discomfort associated with IC </li></ul><ul><li>FDA dose is 100 mg three times a day on an empty stomach </li></ul><ul><li>Believed to act as a buffer for the bladder mucosal lining </li></ul>
  17. 17. Treatment: Elmiron <ul><li>In a prospectively designed retrospective analysis of 2499 IC patients on Elmiron </li></ul><ul><li>61 % of patients experienced symptom improvement at 3 months on therapy </li></ul><ul><li>At 6 months of treatment,13% had new relief of pain/discomfort </li></ul>
  18. 18. Treatment: Elmiron <ul><li>Early use of Elmiron after IC Diagnosis (<6 months) had greater improvement in IC symptom relief when compared to late use of Elmiron after IC diagnosis (>24 months) </li></ul><ul><li>HF Zhang et al 2006 </li></ul>
  19. 19. Treatment: Elmiron <ul><li>Prescribing information </li></ul><ul><ul><li>Clinical response to Elmiron may require 3 to 6 months of therapy </li></ul></ul><ul><ul><li>In patients whose pain has not improved after 6 months of therapy, the clinical benefits and risks of continued treatment are unknown </li></ul></ul><ul><li>Hanno showed Elmiron provided relief of IC symptoms for up to 3 years of continuous use </li></ul>
  20. 20. Treatment: Elmiron <ul><li>Adverse events tend to be mild and transient in a 8 year retrospective study, and occurred between 1% to 4% </li></ul><ul><ul><li>Diarrhea, nausea, alopecia (reversible), headache, rash, dyspepsia, abdominal pain, liver function abnormalities, and dizziness </li></ul></ul><ul><ul><li>I usually recommend to stop 7 days prior to major surgery </li></ul></ul>
  21. 21. Treatment: Patient Counseling <ul><li>Understand the IC disease process </li></ul><ul><li>Symptom relief may be gradual </li></ul><ul><li>Start with Elmiron </li></ul><ul><li>Role of diet modification </li></ul><ul><li>Role of multimodality therapy </li></ul><ul><li>Explain short term v long term goals </li></ul><ul><li>Flare of symptoms </li></ul>
  22. 22. Treatment: Diet <ul><li>Avoid potassium and acids </li></ul><ul><li>Avoid alcohol, spicy foods, citrus fruits, bananas,chocolate,tomatoes,sodas, coffee/tea (decaffeinated and acid free ok), tap water, certain bottled water (Dasani) </li></ul><ul><li>Strict diet for 1 week, then reintroduce 1 food at a time and wait for 48 hours </li></ul><ul><li>Food diary </li></ul><ul><li>Prelief before the offensive food is ingested </li></ul><ul><li>Baking soda in water after food is ingested </li></ul>
  23. 23. Treatment: Diet <ul><li>IC diet is very important when first diagnosed with IC, with flare of symptoms </li></ul><ul><li>Not just the type of food, but also the quantity of the offensive food </li></ul><ul><li>As bladder becomes “healed”, most IC patients are able to gradually reintroduce many foods back into their regular diet </li></ul>
  24. 24. Treatment : Diet <ul><li>When going out to eat </li></ul><ul><ul><li>Bottled water </li></ul></ul><ul><ul><li>Be selective (do not go overboard) </li></ul></ul><ul><ul><li>Explain to the waiter that you have an ”allergy” to certain spices/sauces </li></ul></ul><ul><ul><li>Prelief </li></ul></ul>
  25. 25. Treatment : Bladder Instillations <ul><li>Dimethyl Sulfoxide (DMSO) </li></ul><ul><ul><li>FDA approved for symptomatic relief or IC </li></ul></ul><ul><ul><li>Adverse events: pain, garlic odor to breath </li></ul></ul><ul><li>Anesthetic Instillations </li></ul><ul><ul><li>Not FDA approved, but use “off label” </li></ul></ul><ul><ul><li>Various “cocktails” </li></ul></ul><ul><ul><li>Use at initial diagnosis and with flares </li></ul></ul><ul><ul><li>Used to aid in acute pain relief </li></ul></ul>
  26. 26. Treatment : Multimodality Therapy <ul><li>Amitriptyline HCL (Elavil)-tricyclic antidepressant </li></ul><ul><li>Used to modulate chronic pain </li></ul><ul><li>Sedation-helps one to sleep through the night </li></ul><ul><li>Mild anticholinergic effect </li></ul><ul><li>Take 2 hours before bedtime </li></ul><ul><li>Start at a low dose and titrate up </li></ul>
  27. 27. Treatment: Multimodality Therapy <ul><li>Hydroxyzine (Atarax)-antihistamine </li></ul><ul><li>Stabilizes mast cells and blocks the action of histamine </li></ul><ul><li>Take 2 hours before bedtime </li></ul><ul><li>Start at a low dose and titrate up </li></ul><ul><li>If too sedating, can try cetirizine (Zyrtec) </li></ul>
  28. 28. <ul><li>Pregabalin (Lyrica) or gabapentin (Neurontin) </li></ul><ul><li>Used to modulate pain </li></ul><ul><li>FDA approved for anti-seizure, fibromyalgia </li></ul><ul><li>Take several hours before bedtime </li></ul><ul><li>Start at a low dose and titrate up to several times a day </li></ul>Treatment: Multimodality Therapy
  29. 29. <ul><li>Anticholinergic medications </li></ul><ul><li>Used to treat urinary frequency and urgency, urge urinary incontinence </li></ul><ul><li>Do not let the bladder get so full that it causes an increase in bladder pain </li></ul>Treatment: Multimodality Therapy
  30. 30. Utilizing Multimodal Therapy in the Treatment of IC 1 Adapted with permission from Evans RJ. Rev Urol . 2002;4(suppl 1):S16-S20. 1. Evans RJ. Rev Urol . 2002;4(suppl 1):S16-S20. 2. Chiang G et al. J Urol . 2000;164:2119-2125. 3. Chiang G et al. In: Bladder Disease, Part B: Research Concepts and Clinical Applications . Kluwer Academic/Plenum Publishers; 2003:713-729. Bladder Insult Origin of Bladder Insult (eg, Bacterial Cystitis, Childbirth, Pelvic Surgery, or Urologic Instrumentation) More Injury Mast Cell Activation and Histamine Release Activation of C-Fibers and Release of Substance P Solutes Leak Into Interstitium Bladder Urothelium Dysfunction Hydroxyzine, ELMIRON ®2,3 Amitriptyline ELMIRON ® (pentosan polysulfate sodium)
  31. 31. <ul><li>Bladder training </li></ul><ul><li>Physical therapy </li></ul><ul><ul><li>Stretching and pelvic floor muscle relaxation exercises </li></ul></ul><ul><ul><li>Biofeedback for pelvic floor dysfunction </li></ul></ul><ul><li>Stress reduction </li></ul><ul><li>IC support groups </li></ul><ul><li>Trigger point release </li></ul><ul><ul><li>Manuel by physical therapist </li></ul></ul><ul><ul><li>Injection therapy </li></ul></ul>Treatment: Multimodality Therapy
  32. 32. <ul><li>Alpha receptor blockade therapy tamsulosin (Flomax) </li></ul><ul><li>Relaxes alpha receptors in proximal urethra </li></ul><ul><li>FDA approved for enlarged prostates </li></ul><ul><li>Used to improve bladder outlet obstruction symptoms </li></ul>Treatment: Multimodality Therapy
  33. 33. Treatment : Additional Treatments <ul><li>Muscle relaxants diazepam (Valium) </li></ul><ul><li>Can use lower doses daily, or on an as needed basis </li></ul>
  34. 34. Treatment : Analgesics <ul><li>Antidepressants </li></ul><ul><li>Anticonvulsants </li></ul><ul><li>NSAID’s </li></ul><ul><li>Antispasmotic’s </li></ul><ul><li>Tramadol (Ultram, Ultracet) </li></ul><ul><li>Opiod narcotics </li></ul><ul><ul><li>Not first line </li></ul></ul><ul><ul><li>Can lead to dependence </li></ul></ul><ul><ul><li>Chronic use best administered in a pain clinic setting </li></ul></ul>
  35. 35. Treatment Flare of IC Symptoms <ul><li>Periodic flare of symptoms </li></ul><ul><ul><li>Variation of IC symptoms </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Seasonal pollen </li></ul></ul><ul><ul><li>Off IC diet </li></ul></ul><ul><ul><li>Decreasing or stopping IC medications </li></ul></ul><ul><ul><li>During and/or after intercourse </li></ul></ul><ul><li>With IC treatment, flares often occur less frequently </li></ul>
  36. 36. Treatment Flare of IC Symptoms <ul><li>Go back to basics </li></ul><ul><li>Strict IC diet </li></ul><ul><li>Take all IC medications as prescribed </li></ul><ul><li>Intravesical instillations </li></ul><ul><li>Warm bath </li></ul><ul><li>Push oral fluids </li></ul><ul><li>Antispasmotics </li></ul><ul><li>Analgesics </li></ul>
  37. 37. Treatment Persistent Symptoms <ul><li>Gynecologist </li></ul><ul><ul><li>Rule out endometriosis, or other gynecological diseases if symptoms persist </li></ul></ul><ul><li>Pain Management Specialist </li></ul><ul><li>Physical Therapist </li></ul><ul><li>Gastroenterologist </li></ul><ul><ul><li>Evaluate for irritable bowel syndrome </li></ul></ul>
  38. 38. Treatment Persistent Symptoms <ul><li>Hydrodistention under anesthesia </li></ul><ul><ul><li>Can cause an initial flare of symptoms </li></ul></ul><ul><ul><li>Can get relief of symptoms lasting for weeks to months </li></ul></ul><ul><ul><li>Tachyphalaxis </li></ul></ul>
  39. 39. Treatment Persistent Symptoms <ul><li>Interstim neuromodulation </li></ul><ul><ul><li>“ Bladder pacemaker” </li></ul></ul><ul><ul><li>FDA approved to treat persistent urinary frequency, urgency, urge urinary incontinence </li></ul></ul>
  40. 40. Treatment Persistent Symptoms <ul><li>Uroplasty </li></ul><ul><li>Acupuncture </li></ul>
  41. 41. RESEARCH
  42. 42. Research Intravesical Instillations <ul><li>Intravesical Alkalized Lidocaine (PSD597) Offers Immediate and Sustained Relief From the Symptoms of IC/PBS; Results of a Phase II Multi-Center Placebo-Controlled Trial. JC Nickel, Kingston,ON, Canada. J Urol April 2008. </li></ul><ul><li>Evaluate intravesical alkalized lildocaine (PSD597) </li></ul><ul><li>102 Pt’s, 19 sites </li></ul>
  43. 43. Research Intravesical Instillations <ul><li>Daily instillation of PSD597 or placebo for 5 consecutive days </li></ul><ul><li>Day 15, all pt’s offered PSD597 instillation for 5 days </li></ul><ul><li>Day 8 30.0% who received PSD597 had moderately or markedly improved symptom scale vs. 9.6% of placebo </li></ul>
  44. 44. Research Intravesical Instillations <ul><li>Day 22 63%, and day 29 56% had moderate or marked improvement of symptoms </li></ul><ul><li>This study suggests clinical benefit can be increased with repeated doses of intravesical instillations </li></ul>
  45. 45. Research URG101 Study <ul><li>URG101 is an investigational bladder instillation (Urigen Pharmceuticals) </li></ul><ul><li>Proprietary treatment comprised of lidocaine and heparin </li></ul><ul><li>Phase II Multicenter, double-blind, placebo-controlled, crossover trial of URG101 in Pts with PBS/IC </li></ul><ul><li>I was the Principal Investigator for the study </li></ul><ul><li>21 patients at 6 sites </li></ul>
  46. 46. Research URG101 Study: Results <ul><li>URG 101 significantly reduces PBS/IC symptoms after a single dose (interim analysis, announced 3/12/08). </li></ul><ul><li>Primary endpoint: Improvement in average daytime pain </li></ul><ul><li>Urg101 41.9% vs placebo 20.7% (p=0.036) </li></ul>
  47. 47. Research URG101 Study: Results <ul><li>Secondary endpoints: </li></ul><ul><li>50% pt’s had moderate or marked improvement of symptoms vs 11% of placebo (p=0.013) </li></ul><ul><li>Daytime urgency improvement (p=0.033) </li></ul><ul><li>Total symptom score improvement (p=0.03) </li></ul><ul><li>PORIS symptom relief (p=0.01) </li></ul><ul><li>Early closure of URG101 study announced on 4/7/08 </li></ul>
  48. 48. Research URG101 Study: Results <ul><li>This study suggests that after one instillation of URG101 there is clinical benefit in IC pain, urgency, and IC symptoms </li></ul>
  49. 49. Research URG101 Study: Results <ul><li>Unpublished clinical study by Dr’s J Teichman and B Welk demonstrated that administration of URG101 relieves symptoms of painful intercourse in IC/PBS pt’s </li></ul><ul><ul><li>12 consecutive pt’s, URG101 3 times a week for 3 weeks </li></ul></ul><ul><ul><li>11/12 pt’s had >50% improvement </li></ul></ul><ul><ul><li>8 pt’s reported no painful intercourse after instillations </li></ul></ul><ul><ul><li>Note: No controls </li></ul></ul><ul><ul><li>Source: www.urigen.com </li></ul></ul>
  50. 50. Research Defective Tamm-Horsfall Protein in Patients With Interstitial Cystitis Cl Parsons, P Stein, P Zupkas, M Chenoweth, S Argade, JG Proctor, A Dutta and N Trotter. J. Urology 2007; 178: 2667.
  51. 51. Tamm-Horsfall Protein <ul><li>Most abundant protein in human urine. </li></ul><ul><li>30% sugar by weight due to presence of 8 potential N-glycosylation sites. </li></ul><ul><li>THP shows a urothelial cytoprotective effect against potentially toxic compounds. </li></ul>
  52. 52. Tamm-Horsfall Protein <ul><li>The anionic THP neutralizes the cationic urinary toxic factors. </li></ul><ul><li>THP from controls is more protective than from IC Pts against protamine (earlier study) </li></ul>
  53. 53. Tamm-Horsfall Protein <ul><li>Ability of THP to neutralize the toxic factor could be affected by: </li></ul><ul><ul><li>Decreased THP concentration in urine, or </li></ul></ul><ul><ul><li>Qualitative deficiency in the molecule. </li></ul></ul>
  54. 54. Defective THP in Pts With IC <ul><li>Results </li></ul><ul><ul><li>The absolute amount of THP in urine was not significantly different in IC pts vs. healthy controls (28.8 vs. 28.2 mg/l urine). </li></ul></ul><ul><ul><li>Total sialic acid was almost 2-fold lower in 22 IC pts than in 20 controls (46.3 vs. 75.3) p<0.0001. </li></ul></ul>
  55. 55. Defective THP in Pts With IC <ul><li>Studied N-glycans released from the THP of 10 controls and 10 IC Pts. </li></ul><ul><li>Pattern on N-glycosylation was qualitatively different in all controls vs. all IC Pts. </li></ul><ul><li>Controls had heavy chains that end with 3 or 4 sialic acid residues. </li></ul><ul><li>IC Pts had lighter chains that end in 0 to 2 sialic acid residues. </li></ul><ul><li>Expect sialic acid content in C THP:IC THP be 2:1, which is what the data showed. </li></ul>
  56. 56. Defective THP in Pts With IC Implications <ul><li>Propose a major function for THP as a protective urinary macromolecule that functions by biologically inactivating cations that could injure the mucus. </li></ul><ul><li>Defective THP could be the primary factor in the cause of IC. </li></ul><ul><li>THP could be a diagnostic marker of IC. </li></ul><ul><li>If a defective THP initiates IC, genetics are implicated in IC. </li></ul>
  57. 57. FIG. 2. Representative N-terminal residue results of MALDI-TOF MS analysis of intact glycosylation chains of THP from 10 controls ( A ) and 10 patients with IC/painful bladder syndrome ( B ). All 10 patients and all 10 controls showed same basic patterns. Patients had preponderance of lower molecular weight chains and little of heavier chains containing tri-antennary and tetra-antennary terminal sialic acid residues, whereas controls had preponderance of heavy chains, representing primarily tri-antennary and tetra-antennary terminal sialic acid residues
  58. 58. RESEARCH <ul><li>Interesting AUA abstracts from the AUA National Convention for the past 2 years </li></ul>
  59. 59. Research : Intravesical <ul><li>Comparison of Intravesical Botulinum Toxin A Injections Plus Hydrodistention and Hydrodistention Alone For Treatment of Refractory IC. HC Kuo Taiwan, MB Chancellor, Royal Oak, MI </li></ul><ul><li>67 IC pt’s failed conventional therapy </li></ul><ul><li>44 pt’s Botox injection (200 units in 15, 100 units in 29) followed by hydrodistention 2 weeks later </li></ul><ul><li>23 pt’s (controls) hydrodistention only </li></ul>
  60. 60. Research : Intravesical <ul><li>All pt’s remained on Elmiron and medications </li></ul><ul><li>Maximum bladder capacity increased </li></ul><ul><li>3 months Botox had successful results (VAS, FBC, cystometric bladder capacity) and decreased IC symptom score </li></ul><ul><li>6 months 70% Botox successful IC symptom score improvement </li></ul><ul><li>12 month 54% Botox vs 26% control </li></ul><ul><li>24 month 26% Botox vs 17% control </li></ul>
  61. 61. Research : Intravesical <ul><li>Intravesical injections of Botox followed by hydrodistention provided signifcantly better clinical results compared to hydrodistention alone </li></ul>
  62. 62. Research : Intravesical <ul><li>Intra-Trigonal Injection of Botulinum Toxin A in Patients with PBS-Results at 9-Months Follow-up. RA Pinto, Porto, Portugal. </li></ul><ul><li>Botox can prevent neurotransmitter release in sensory nerve fibers </li></ul><ul><li>17 pt’s with refractory PBS given 100 units of Botox </li></ul><ul><li>Results evaluated at 1 and 3 months </li></ul>
  63. 63. Research : Intravesical <ul><li>Symptom </li></ul><ul><li>Pain </li></ul><ul><li>Frequency </li></ul><ul><li>OLS Symptom score </li></ul><ul><li>Quality of life </li></ul><ul><li>Bladder volume at first episode of pain </li></ul><ul><li>Baseline, 1 and 3 m </li></ul><ul><li>5.7 to 2.2 and 1.9 </li></ul><ul><li>17 to 8.9 and 10 </li></ul><ul><li>15.3 to 9 and 6.2 </li></ul><ul><li>5.1 to 1.8 and 0.9 </li></ul><ul><li>38 to 109 and 110 </li></ul>
  64. 64. Research : Intravesical <ul><li>Intra-trigonal injection of 100 units of Botox in patients with refractory PBS is safe and might be an effective alternative treatment </li></ul>
  65. 65. Research : Food <ul><li>Differences in Food Sensitivities Between Female IC/PBS Patients and Chronic Prostatitis/CPPS Syndrome Patients. AS Herati et al, New Hyde Park, NY. </li></ul><ul><li>325 female IC pt’s, 268 male CP/CPPS pt’s were surveyed (32% and 34% responded) </li></ul>
  66. 66. Research : Food <ul><li>Significant differences seen in food sensitivities </li></ul><ul><ul><li>94.8% of female IC/PBS </li></ul></ul><ul><ul><li>77.1% of male CP/CPPS </li></ul></ul><ul><li>Correlation between pt’s being the most sensitive and those with the highest PUF and CP/CPPS scores </li></ul><ul><li>No correlation with Hunner Ulcer’s </li></ul>
  67. 67. Research : Food <ul><li>Foods that were the most bothersome were identical in both groups </li></ul><ul><ul><li>Coffee (most aggravating), tea, alcohol, citrus fruits, spicy foods, tomato products </li></ul></ul><ul><li>Supplements that help relieve symptoms </li></ul><ul><ul><li>Prelief, Colace, Metaucil </li></ul></ul><ul><ul><li>Popcorn </li></ul></ul>
  68. 68. Research : Epidemiology <ul><li>Prevalence of IC/PBS in the United States. AH Berry et al. Multiple sites. </li></ul><ul><li>Rand IC Epidemiology (RICE) Study </li></ul><ul><li>599 IC/PBS pt’s and/or OAB endometriosis pt’s used to develop an epidemiology definition of IC/PBS </li></ul><ul><li>National telephone survey 100,000 homes over 1 year </li></ul>
  69. 69. Research : Epidemiology <ul><li>High sensitivity definition of IC: 6.5% of US women have IC/PBS </li></ul><ul><ul><li>During the past 3 months had pain, and frequency (>10) or 2 urgency questions </li></ul></ul>
  70. 70. Research : Epidemiology <ul><li>High specificity definition of IC: 2.6% of US women have IC/PBS </li></ul><ul><ul><li>Past 3 months pain or pain with bladder filling plus frequency, or 2 urgency questions and negative response to both UTI symptoms disappear after antibiotics and did you ever have hormone injections to treat endometriosis </li></ul></ul>
  71. 71. Research : Epidemiology <ul><li>Phenotypic Associations Between IC/PBS and Irritable Bowel Syndrome (IBS), Fibromyalgia (FM), Chronic Fatigue Syndrome (CFS): A Case Control Study. JC Nickel et al, various sites. </li></ul><ul><li>Questionnaires completed by 208 IC/PBS pt’s and 180 controls </li></ul><ul><li>Prevalence of self-reported associated condition diagnosis in IC/PBS vs controls </li></ul>
  72. 72. Research : Epidemiology <ul><li>Associated condition </li></ul><ul><li>Irritable Bowel Syndrome </li></ul><ul><li>Fibromyalgia </li></ul><ul><li>Chronic Fatigue Syndrome </li></ul><ul><li>IC/PBS pt vs control </li></ul><ul><li>38.7% vs 5.6% </li></ul><ul><li>17.6% vs 1.7% </li></ul><ul><li>9.4% vs 1.1% </li></ul>
  73. 73. Research : Sexual Function <ul><li>Female Sexual Function Improves in Treated IC Patients. BK Welk and JM Teichman, Vancouver, BC, Canada. </li></ul><ul><li>32 IC/PBS pt’s with painful intercourse were treated with intravesical lidocaine, heparin, and bicarbonate </li></ul><ul><li>Symptom scores were obtained before, and 4 weeks after instillation therapy </li></ul>
  74. 74. <ul><li>Multiple domains of female sexual function improve as painful intercourse improves in treated IC/PBS pt’s </li></ul><ul><ul><li>Improvement seen in desire, arousal, lubrication, orgasm, satisfaction, and pain </li></ul></ul>Research : Sexual Function
  75. 75. <ul><li>50% had resolution of painful intercourse </li></ul><ul><ul><li>Pt’s with successful outcomes tend to have lower PUF scores and bladder neck tenderness alone on exam </li></ul></ul>Research : Sexual Function
  76. 76. Research : Oral Agents <ul><li>Urine Alkalinization Improves the Problems of Pain and Sleep in Patients With IC. T Ueda et al, Japan and Pittsburgh, PA. </li></ul><ul><li>Acidic urine (low pH) plays a role in urinary frequency and pain in IC pt’s </li></ul><ul><li>50 IC pt’s treated with oral citrate for 2 to 4 weeks </li></ul>
  77. 77. Research : Oral Agents <ul><li>Urine pH increased 5.8 to 6.2 </li></ul><ul><li>Frequency improved 14.5 to 13.5 </li></ul><ul><li>Number of pain episodes at voiding per day 7.8 to 6.1 </li></ul><ul><li>If urine pH >6.2 tended to have better improvement in frequency, pain, and sleep disturbance </li></ul><ul><li>Note: most intravesical instillations use bicarbonate to increase the pH </li></ul>
  78. 78. Research : Complementary and Alternative Medicine <ul><li>The Effects of Chinese Herbal Medicine Containing Aconitine on the Pain Relief in IC Patients- A Preliminary Study. T Tsuchida et al, Chuo, Japan. </li></ul><ul><li>Two Chinese herbs containing Acotine, Keisika-jutsu-buto, and Mao-bushi-saisinto were used to manufacture’s guidelines in 10 IC pt’s (resistant to usual med’s) for a mean of 5.7 months </li></ul>
  79. 79. Research : Complementary and Alternative Medicine <ul><li>Both contain Aconitine, an alkaloid derivative that is a neurotoxin </li></ul><ul><li>IC problem score 17.8 to 8.8 </li></ul><ul><li>Bladder capacity 51.1 to 117.8 ml </li></ul><ul><li>Pain VAS 88.0 to 13.2 </li></ul><ul><li>Note: not a controlled study </li></ul><ul><li>These 2 Chinese herbal medicine may be effective in relieving some IC symptoms </li></ul>
  80. 80. Research : Complementary and Alternative Medicine <ul><li>Success of Acupuncture in the Treatment of PBS/IC. FA Reeves et al, Sheffield, UK. </li></ul><ul><li>Retrospective case review on 15 IC/PBS pt’s who failed to respond to therapy </li></ul><ul><ul><li>Failed therapy: 80% hydrodistention, 73% intravesical sodium hyaluronate, gabapentin (4 pt’s). Note: No Elmiron in this UK study. </li></ul></ul><ul><li>Note: No controls or sham </li></ul>
  81. 81. Research : Complementary and Alternative Medicine <ul><li>Quality of life improved in 13/15 pt’s (86%) </li></ul><ul><ul><li>Pretreatment leisure 67% </li></ul></ul><ul><ul><li>Work 20% </li></ul></ul><ul><ul><li>Intercourse 13% </li></ul></ul><ul><ul><li>Average number of sessions for subjective improvement of symptoms was 3 </li></ul></ul>
  82. 82. Research : Not Ready For Prime Time <ul><li>Pharmokinetics of Liposomes After Intravesical Administration. J Kaufman, Pittsburgh, PA. </li></ul><ul><li>Use intravesical empty liposomes as a coating therapy in rats </li></ul><ul><li>Plasma half life of radiolabel was 7 hr, the bladder resident time of liposomes was 24 hours </li></ul><ul><li>Supports use of empty liposomes as a local therapy for IC/PBS pt’s </li></ul>
  83. 83. Research : Not Ready For Prime Time <ul><li>Inhibition of Antiproliferative Factor (APF) Activity in Bladder Epithelial Cells by Two Synthetic APF Derivatives. S Keay et al, Frederick, MD. </li></ul><ul><li>Bladder epithelial cells from IC/PBS pt’s make APF that inhibits cell growth, increase paracellular permeability </li></ul><ul><li>Screened inactive synthetic APF derivatives and found 2/30 in cell culture that blocked APF activity in IC and/or normal bladder cells </li></ul>
  84. 84. Research : Not Ready For Prime Time <ul><li>Intravesically Applied Chondroitin Sulfate Restores Urothelial Barrier Function in Acid-Damaged Bladder. TM Sofinowski et al, Oklahoma City, OK. </li></ul><ul><li>Intravesical GAG replenishment therapy has been proposed to restore bladder function (used chondroitin sulfate) </li></ul><ul><li>Intravesical chondroitin sulfate binds to rodent bladders and restores urothelial impermeability to levels similar to controls </li></ul>
  85. 85. Research : Other Studies <ul><li>The Relationship Among Symptoms, Sleep Disturbances and Quality of Life in Patients with IC. JC Nickel et al, multiple sites. J Urol. June 2009 </li></ul><ul><li>Multidose trial of pentosan polysulfate (Elmiron), 32 week trial </li></ul><ul><li>Sleep dysfunction is common symptom of IC, and can have a negative impact during daytime functioning </li></ul><ul><li>At 32 weeks, IC symptom scores improved as well as sleep scores and QOL improvement </li></ul>
  86. 86. Research : Other Studies <ul><li>Assessment of Patient Outcomes Following Submucosal Injection of Triamcinolone for Treatment of Hunner’s Ulcer Subtype IC. Cox et al, Can J Urol, April 2009. </li></ul><ul><li>Hunner’s ulcers treated with fulguration </li></ul><ul><li>30 pt’s, cystoscopy under anesthesia with injection of 10 ml triamcinolone (40 mg/ml), 0.5 ml at a time into submucosal space </li></ul><ul><li>Postop 70% had very much improvement </li></ul><ul><li>4 weeks, avg IPSS 21 to11, PUF 20 to 11 </li></ul>
  87. 87. Research : Other Studies <ul><li>Extracorporeal Shock Wave Treatment (ESWT) for the Treatment of CPPS in Males: A Randomized, Double-Blind, Placebo-Controlled Study. Zimmermann et al, Eur Urol March 2009. </li></ul><ul><li>60 men with CP/CPPS for > 3 months </li></ul><ul><li>ESWT, low sound waves to the perineum without anesthesia, or sham treatment, once a week for 4 weeks </li></ul><ul><li>Effects on pain, QOL, and voiding were highly significant for ESWT compared to sham </li></ul><ul><li>As CP/CPPS is similar to IC, may see this tried in IC pt’s in the future </li></ul>
  88. 88. A to Z on IC SUMMARY <ul><li>Reviewed treatment options from A mitriptyline to Z yrtec </li></ul><ul><li>Pentosan polysulfate (Elmiron) as the foundation of treatment for most pt’s </li></ul><ul><li>Multimodality therapy </li></ul><ul><li>Intravesical instillations for initial treatment and for flares </li></ul><ul><li>Reviewed some of the current research </li></ul>
  89. 89. A to Z on IC Summary <ul><li>Special thanks to the NIH and ICA for their support </li></ul><ul><li>www.ichelp.org </li></ul>
  90. 90. Susan Bilheimer <ul><li>Co-author of “Secret Suffering: How Women’s Sexual & Pelvic Pain Affects Their Relationships” </li></ul><ul><ul><li>Award-winning freelance writer and author with expertise in midlife issues, meditation, self-publishing, and technical writing </li></ul></ul><ul><ul><li>Currently developing “The Midlife Woman” radio show </li></ul></ul>100
  91. 91. Anna Kelly, MD <ul><li>Acupuncturist and Anesthesiology Consultant, Metro Anesthesia Services </li></ul><ul><ul><li>President of the Georgia Association of Medical Acupuncturists </li></ul></ul><ul><ul><li>Board-certified by the American Board of Anesthesiology and American Board of Medical Acupuncture </li></ul></ul>102
  92. 92. Medical Acupuncture and Interstitial Cystitis <ul><li>Anna Kelly, MD </li></ul><ul><li>August 23, 2009 </li></ul>
  93. 93. Cartesian Model vs. Eastern Thought
  94. 94. Acupuncture <ul><li>The insertion of solid needles in various combinations and patterns for the purpose of promoting health, decreasing pain and improving function. </li></ul>
  95. 95. Definitions <ul><li>Qi </li></ul><ul><li>Yin & Yang </li></ul><ul><li>Organs </li></ul><ul><li>Meridians/Channels </li></ul>
  96. 96. Qi <ul><li>Energy </li></ul><ul><li>Impetus </li></ul><ul><li>Life force </li></ul><ul><li>Is present in all life </li></ul>
  97. 97. Yang and Yin <ul><li>Relative terms </li></ul><ul><li>Nothing is permanently or absolutely </li></ul><ul><li>Yin or Yang </li></ul><ul><li>Opposite but complementary </li></ul><ul><li>Interdependent and Intertransforming </li></ul>
  98. 98. Yang and Yin Yang Light Male Outside Back Hot Hollow Heaven Yin Dark Female Inside Front Cold Solid Earth
  99. 99. Organs <ul><li>Yin </li></ul><ul><li>Kidney </li></ul><ul><li>Heart </li></ul><ul><li>Spleen </li></ul><ul><li>Lung </li></ul><ul><li>Liver </li></ul><ul><li>Master of Heart </li></ul><ul><li>Yang </li></ul><ul><ul><li>Bladder </li></ul></ul><ul><ul><li>Small Intestine </li></ul></ul><ul><ul><li>Stomach </li></ul></ul><ul><ul><li>Large Intestine </li></ul></ul><ul><ul><li>Gall Bladder </li></ul></ul><ul><ul><li>Triple Heater </li></ul></ul>
  100. 100. Needle Stimulation <ul><li>Directed electron flow and transfer </li></ul><ul><li>Micro-battery/ Bimetallic Effect </li></ul><ul><li>Thermoelectrical gradient phenomenon </li></ul>
  101. 101. Directed Electron Flow
  102. 102. Meridian Pathway
  103. 103. Traditional Chinese Medicine (TCM) <ul><li>Acupuncture </li></ul><ul><li>Herbs </li></ul>
  104. 104. Traditional Chinese Medicine (TCM) <ul><li>Eight Principles </li></ul><ul><ul><li>Yin and Yang </li></ul></ul><ul><ul><li>Hot and Cold </li></ul></ul><ul><ul><li>Interior and Exterior </li></ul></ul><ul><ul><li>Deficient and Excess </li></ul></ul>
  105. 105. Traditional Chinese Medicine (TCM) <ul><li>Patterns </li></ul><ul><ul><li>Damp </li></ul></ul><ul><ul><li>Dry </li></ul></ul>
  106. 106. IC from a Chinese Medicine Perspective <ul><li>Dampness </li></ul><ul><li>Heat </li></ul><ul><li>Excess </li></ul><ul><li>Internal phenomenon </li></ul><ul><li>Emotional and dietary factors are important to consider </li></ul>
  107. 107. Literature Review <ul><li>Several studies published in peer-reviewed literature demonstrate that electroacupuncture is helpful for intractable interstitial cystitis </li></ul><ul><li>Several studies published in the Journal of Chinese Medicine demonstrate that acupuncture, moxibustion, and chinese herbs are helpful for IC </li></ul><ul><li>Current NIH study is underway to evaluate the efficacy of acupuncture in IC patients </li></ul>
  108. 108. Current Active NIH Acupuncture Studies <ul><li>Acupuncture for the treatment of: migraines, dry-eye, polycystic ovarian syndrome, insomnia, hypertension, breech presentation, Bell’s Palsy, dyspepsia, irritable bowel syndrome, and 100 others! </li></ul>
  109. 109. Acupuncture and Electroacupuncture in the Treatment of Interstitial Cystitis
  110. 110. Individualized Treatment <ul><li>In our clinic, we don’t copy studies. We treat individuals; the treatment may vary week to week depending on presenting symptoms. </li></ul><ul><li>Individualized treatments are not likely to be shown in any study to be effective, as they do not fit the model of the randomized trial. </li></ul>
  111. 111. Chinese Herbs <ul><li>No over the counter (OTC) herbs </li></ul><ul><li>No self-prescribing </li></ul><ul><li>Herbs prescribed by trained practitioner </li></ul>
  112. 112. Chinese Herbs <ul><li>Herb source known with product quality assurance measures in place </li></ul><ul><li>Herbs customized for each patient </li></ul><ul><li>Herbs usually taken twice a day </li></ul>
  113. 113. Herbs for Interstitial Cystitis <ul><li>Gentiana Drain Fire is a common herb recommended to IC patients. It is composed of 12 separate herbs. </li></ul><ul><li>It drains fire from the liver and gall bladder, clears and drains damp-heat from the lower burner. </li></ul><ul><li>Golden Flower Herbs is the best source. </li></ul>
  114. 114. Frequency of Acupuncture Treatments <ul><li>Acute Onset </li></ul><ul><li>Fewer treatments </li></ul><ul><li>Treatments grouped close together </li></ul><ul><li>Chronic Condition </li></ul><ul><li>Weekly treatments </li></ul><ul><li>Herbs required </li></ul><ul><li>Maintenance </li></ul><ul><li>Seasonal treatments </li></ul>
  115. 115. <ul><li>Zigong - Palace of the child CV 4 - Infant’s Door </li></ul><ul><li>GV 4 - Gate of Life SP 8 - Earth Pivot </li></ul><ul><li>KD 1 - Gushing Spring GV 20 - Hundred Meetings </li></ul><ul><li>ST 36 - Walk 3 Miles CV 7 - Yin Intersection </li></ul><ul><li>CV 9 - Water Divide KI 5 - Water Spring </li></ul>The Poetry of Acupuncture
  116. 116. Closing Remarks <ul><li>Thanks to all of you for joining us. And a special thanks to the speakers and sponsors that made this event possible. </li></ul>128
  117. 117. Closing Remarks <ul><li>One final plug for the ICA: Our work is made possible through the generous contributions of people like you. </li></ul><ul><ul><li>If you are not a member, please consider joining. Membership cards are included in the registration packet. </li></ul></ul><ul><ul><li>If you are a member, please consider making a special donation. </li></ul></ul>130

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