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Interstitial Cystitis
Nora 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 urina...
Epidemiology
 500,000 – 1,000,000 cases estimated in U.S.
 ICSI from 1990 to 2002: 1.2 to 450 per 100,000
 Proposed pai...
Interstitial Cystitis Symptoms
Index (ICSI)
 During the past month:
 How often have you felt the strong need to urinate ...
Etiology
 Unknown, multifactorial
 Deficiency in the
glycosaminoglycan (GAG)
layer
 Toxic substances

 Autoimmune diso...
Patient History
 Questionnaires

 Risk factors: consumption of caffeinated and alcoholic
drinks, anorectal disease, IBS
...
Signs & Symptoms
 PAIN: suprapubic or pelvic
 Bladder pain that worsens with






bladder filling and is alleviate...
Other Examination
Techniques
 Perform pelvic examination
to help exclude gynecologic
disease

 Measure the patient's
tem...
Diagnosis
 Cystoscopy
 Findings: glomerulations,
mucosal ulcers (Hunner’s
lesions), petechial hemorrhage

 Urodynamics
...
Clinical Guidelines

(American Urological Association, 2011)
Clinical Guidelines
 AUA created flowchart of suggested order of treatment
 Progress 1st line through 6th line as needed...
Clinical Guidelines
 1st line treatments: conservative
 Patient education about IC and treatment options
 Behavioral mo...
Clinical Guidelines
 2nd line treatments
 Physical Therapy (C)





Biofeedback
Soft tissue mobilization
Stretching
...
Physical Therapy
FitzGerald et al., 2009;
FitzGerald et al., 2012

Weiss JM, 2001
 Manual release of myofascial



Soft ...
Clinical Guidelines
 2nd line treatments
 Pharmacology for pain management
 Amitriptyline (B), Cimetidine (C), Hydroxyz...
Clinical Guidelines
 3rd line treatment:
cystoscopy with short
duration, low pressure
hydrodistension (B)
 Most common
t...
Clinical Guidelines
 4th line treatment:
neurostimulation (C)
 Bilateral S3 nerve stimulators
 Significant decrease in
...
Clinical Guidelines
 5th line treatments
 Cyclosporine A (C)
 Anti-inflammatory and immunosuppressive
 More effective ...
Clinical Guidelines
 6th line treatment: surgery (C)
 Cystoplasty
 Part/all of bladder removed and replaced by section ...
Questions?

(http://i.qkme.me/35n0m0.j
pg)
Resources












Ching,
C.
Interstitial
Cystitis.
MDConsult.
2013.
Available
at:
http://www.mdconsult.com/da...
Resources













Nickel JC. Interstitial cystitis. Canadian Family Physician. 2000;46:2530-2440.
Offiah I...
Example of Treatment Protocol
 Dietary restrictions
 Fluid restriction to 64 oz per day, 16 oz per meal and 8 oz between...
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Interstitial Cystitis

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Interstitial Cystitis

  1. 1. Interstitial Cystitis Nora Brody, Will Huebner, Krysten Malcolm, Seema Marshall, Anita Vadaken
  2. 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. 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. 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. 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. 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. 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. 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)
  9. 9. Diagnosis  Cystoscopy  Findings: glomerulations, mucosal ulcers (Hunner’s lesions), petechial hemorrhage  Urodynamics  Poorly compliant bladder  Urinary biomarkers  Nitric oxide  Bladder biopsy  Controversial (http://2.bp.blogspot.com/cfuq6XwwRiE/ThRoNDIPU4I/AAAAAAAAAys/A2l6 NTX6SEc/s1600/pathology.jpg) (Offiah et al., 2013; Quillin & Erickson, 2012)
  10. 10. Clinical Guidelines (American Urological Association, 2011)
  11. 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. 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)
  13. 13. Clinical Guidelines  2nd line treatments  Physical Therapy (C)     Biofeedback Soft tissue mobilization Stretching Pelvic floor muscle training?  AUA says avoid  JUA says nothing  Research mixed (American Urological Association, 2011; The Japanese Urological Association, 2009; Weiss, 2001)
  14. 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. 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. 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. 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. 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. 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)
  20. 20. Questions? (http://i.qkme.me/35n0m0.j pg)
  21. 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. 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. 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)

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