INTERSTITIAL CYSTITIS TREATMENTdoctkhalil
Interstitial cystitis also referred to as BPS Bladder syndrome, which is basically characterized by a typical set of presenting complaints. interstitial cystitis symptoms include
Urinary urgency which is a strong feeling and sensation in the pubic / supra pubic, pelvic or urethral region to go to the washroom. It can range from mild irritation to a strong pressure sensation in the area described.
Urinary Frequency which is the need to go more than often to the washroom. Its also accompanied by a feeling of incomplete voiding where the patient perceives that complete voiding has not taken place and would want to return to washroom to empty the bladder again. This can also be accompanied by terminal dribbling.
The urgency and frequency are accompanied usually by nocturia which is also know nocturnal polyuria, which involves excessive urination or urination episodes during the night. During sleep, usually the urge to urinate should not wake you up for 6 to 8 hours at least provided you have a healthy bladder and urethral lining. However in patients with interstitial cystitis symptoms, they can be woken up with intense urge to urinate every 3 to 4 hours or even more frequently in very severe cases. Even if the sleep is uninterrupted , the body usually produces small amount of concentrated urine during sleep so upon waking up there should not be a very intense desire to urinate right away. In patients with interstitial cystitis symptoms, the first thought upon waking up is to relieve the bladder pressure built up as a result of not going to the washroom the whole night.
The bladder capacity in patients with interstitial cystitis symptoms is also markedly reduced with recurrent urination of small amount the neurological wiring also adjusts itself in a way that forces a bladder habit of going frequently with less volumes of urine. Normally, a healthy bladder can accommodate up to 400 ml of urine at low pressure. At such a capacity , the bladder in a majority of normal people can remain nice and relaxed without feeling the urge to go to washroom. However, if there is any abnormality in the epithelial lining, or an infection/ inflammation or an abnormal growth in the bladder then this capacity can be reduced markedly with the urge to go to washroom increasing accordingly at much lower volumes and much shorter durations.
I.C or interstitial cystitis can also present as pelvic pain and pressure with or without the urgency and frequency symptoms. The painful interstitial cystitis symptoms can be debilitating and chronic accompanied by flares which may respond poorly to most conventional therapies. The pelvic pain type is commonly associated with dyspareunia , decreased libido and subsequently development of various psychiatric issues including depression.
The condition as a whole is more common in women especially the pelvic pain subtype discussed above but its not restricted to females alone. Males can be affected as well.
Onset of interstitial cystitis symptoms
The onset of symptoms can vary according to the individual presentation. It can be acute onset or a gradual increase in symptoms. Many a times, patient can exactly recall a certain event in association with the onset of the symptoms. They usually correlate or link such an event with the onset. These may include a preceding urinary tract infection, catheterization, surgery, certain medications used prior to the onset of symptoms. As the etiology of the condition is not unanimously agreed upon , so the specific triggers for interstitial cystitis causation are not determined clearly , yet.
On and Off phenomenon and remissions
Many patients may have constant symptoms day in and day out. There may be degrees of improvement depending upon their subtype of I.C. However, some patients have intense flares with periods of increased pain, frequency and urgency interspersed with symptom free gaps in which there are very little or no symptoms. A significant population may even experience spontaneous remission with complete resolution of symptoms without any treatment. Pregnancy can cause the condition to be masked which is an immune compromised state so supporting the idea that the interstitial cystitis can be possibly linked to an autoimmune phenomenon and thus lending the question that whether steroids and other immune suppressant agents may have a role in its treatment or not as many other autoimmune conditions also tend to be resolved or reduce in severity in pregnancy.
INTERSTITIAL CYSTITIS DIAGNOSIS
I.C Diagnosis can be challenging. The history includes chronic and long standing symptoms related to nocturia, urinary frequency, urgency and pain (pelvic pain). These symptoms may last for years before a person may become aware or seek medical attention. There is no blood in urine (hematuria) nor is it usually associated with flank pain or burning urination. Your doctor may inquire about stress , anxiety and any medication that has been related with these symptoms. On physical examination, the abdomen, pelvis and the external genitalia including the urethral meatus are examined. A digital rectal exam to look for a possible growth or an enlarged prostate (in case of males w.r.t prostate) is also done.
INTERSTITIAL CYSTITIS DIAGNOSIS:
Three basic and non invasive investigations are usually advised in the above scenario. A urinalysis, ultrasound of the abdomen plus pelvis and uroflowmetry test. The urine test is a simple investigation to rule out any infection, to look for possible hematuria or RBCs that may indicate a different diagnosis. The increased level of other products such as crystals, casts and protein or sugar may indicate an entirely different diagnosis or a comorbidity. The renal ultrasound can give a lot of information necessary to rule out many causes that may mimic similar symptomatology
The ultrasound is done to assess a number of things as part of the workup in Interstitial Cystitis Diagnosis . It is done to look for
- normal kidney morphology, size , architecture and adequacy of cortex
- Evidence of stones, strictures, tumors or other obstructive cause
- Hydronephrosis on either side
- Any evident urinary bladder lesion
- Estimated prostate size and weight that can be done easily via sonogram
- Liver, bile ducts, gall bladder, spleen and pancreas morphology
- common bile duct and portal vein caliber/diameter
- possible thrombosis in portal/hepatic veins
- possible para aortic lymph node enlargement
- significant Residual urine
- Any free fluid in peritoneal cavity
Urodynamic studies / uroflowmetry don’t have any diagnostic or pathognomonic findings related to interstitial cystitis diagnosis. However, they are done to look for the following parameters of the micturition process.
- Maximum and average urine flow
- Flow and voiding time
- Time taken to achieve and sustain maximum flow
- The total voided volume that also gives a good idea of the bladder volume/ capacity
The patient is instructed to drink 1 to 2 liters of fluid prior to the urodynamic study to be done on a full bladder. Some patients may not tolerate such high fluid intake and can opt to do it with lesser fluids. They are advised to undergo the study when they have a very strong urge to urinate. After the fluid intake, the ultrasound can be done on a full bladder followed immediately by the uroflowmetry.
Cystoscopy and Interstitial Cystitis Diagnosis
It is the most important tool in Interstitial Cystitis Diagnosis. This involves passing a cystoscope via the urethra into the bladder. It is both a diagnostic and therapeutic procedure. The camera at the tip is connected to a television screen / monitor to visualize the lining of the urethra and bladder. It can detect inflammatory changes, valve like folds, tumors, stones, abnormal growths including abnormal vessel structures that may indicate conditions such as interstitial cystitis. The rigid cystoscope can be utilized to remove and biopsy or destroy a suspected lesion/ stone. the flexible cystoscope is not very useful when it comes to the therapeutic procedures. It can be a useful tool for diagnostic purposes or follow up on progression. The rigid cystoscopy is always done under a general anesthetic. Fentanyl is usually the anesthesia of choice in such procedures of short duration. It usually takes 10 to 15 minutes to examine the urethra and bladder. If the cystoscopy is normal then the patient usually recovers within 40 minutes and can go home after an hour or two stay at the hospital in recovery room and adjacent facility. Usually , a biopsy of the bladder wall is taken and sent to the lab for microscopy, histopathology and if needed immunofluorescence studies. The biopsy is mainly done to rule out carcinoma in situ or malignant changes and other typical findings of cystitis. The biopsy also doesn’t show any typical findings of interstitial cystitis further elucidating that it is treated as a diagnosis of exclusion.
GABAPENTIN FOR INTERSTITIAL CYSTITIS
This article explores the possible option of gabapentin for interstitial cystitis treatment. Interstitial cystitis is a chronic condition characterized by bladder/ supra pubic / pubic and pelvic pain, pressure, urinary urgency, frequency and burning. Interstitial cystitis has been shown to involve sympathetic nervous system pathway pain, which is related to reflex sympathetic dystrophy (RSD) and is proposed to be one of the contributors of the overall pathophysiology.
Gabapentin is structurally similar to the neurotransmitter GABA (Gaba amino butyric acid). Its receptors and binding sites have been confirmed in the brain tissue at numerous areas. The exact mechanism of action leading to its analgesia and anticonvulsant action is not fully understood.
In Interstitial cystitis or Bladder pain syndrome there is thought to be inflammation of the nerves within the spinal cord as a result of chronic relaying of the signals. Gabapentin can be used to counter this proposed neurogenic inflammation and is especially used in patients with IC subset of pelvic pain predominantly.
It is initiated at lower doses of 100 mg once at night but due to its safety and limited interactions with other medications, its slowly built up to a dose ranging from 300 mg to 3600 mg divided over 24 hours. The side effect of sedation, dizziness, decreased mental functioning, decreased or altered libido has to be kept in mind. Dose titration depends on these symptoms and can be adjusted accordingly. This is usually adjusted by the end of 4 weeks of therapy and can be continued thereafter at the same compatible dose. Adjustment with the side effects can take about 2 weeks at one dose. With incremental increase , this can take longer with gabapentin for interstitial cystitis treatment
OTHER TREATMENT OPTIONS FOR INTERSITITIAL CYSTITIS
Interstitial cystitis pathophysiology w.r.t pain and discomfort is associated with a paleospinothalamic and neospinothalamic mechanism. Paleospinothalamic portion of the pain is responsive to narcotic therapy while the Neospinothalamic pain is responsive to antiepileptic agents like gabapentin and Tricyclic antidepressants like amitryptiline or SSRIs like fluoxetine. This is yet another rationale for considering gabapentin as a treatment option for this condition.
One other approach with respect to gabapentin for interstitial cystitis treatment is to use it in combination with other treatment options for I.C rather than as monotherapy. For example with muscle relaxants and TCAs.
HYDROXYZINE FOR INTERSTITIAL CYSTITIS:
One of the suggested treatment options is hydroxyzine for interstitial cystitis. It is an H1-receptor blocker , meaning its basically an anti histamine. It doesn’t have significant antihistamine properties, though. It has both anti emetic and anticholinergic properties and thus has a wider use compared to other antihistamines. Hydroxyzine is one of the oldest antihistamines being a first generation drug in the line of antihistamines.
The main uses of hydroxyzine are
- Anxiety, psychoneurosis, insomnia
- Allergies, pruritus, acute or chronic urticarial rash, contact dermatitis
- Nausea and vomiting (antiemetic use is off label)
Rationale for use in interstitial cystitis
Rationale of hydroxyzine for interstitial cystitis is based on countering the histamine which is released by mast cell degranulation thought to be contributing to the overall inflammation in the bladder lining. Once the diagnosis is established , most urologists would start with mono therapy , that is , choosing to start with a single drug for 3 to 4 weeks to gauge the improvement in symptoms while the patient maintains the bladder diary with regards to frequency , painful episodes and flares. Hydroxyzine for interstitial cystitis is considered as the go to first-line drug in this regard. Its anxiolytic , anti-cholinergic properties and anti inflammatory mechanism with regards to inhibiting histamine makes it logical choice, too. The dose is started at a low 10 mg and built up to 75 mg per day based on tolerability and symptom relief.
The case against hydroxyzine for interstitial cystitis
However, on paper and based on pharmacological evidence , many drugs like hydroxyzine may sound promising but actual results when patients use it are somewhat different from the expectations. In many patients taking hydroxyzine for interstitial cystitis, there are reported side effects of increased urgency and frequency, insomnia, depression, dry mouth, burning urination. Yes, it can actually worsen the symptoms in many patients and result in a flare. For another set of patient , there may not be any significant improvement with respect to urgency , pain and frequency.
This does not mean that hydroxyzine is totally useless as for some patients with IC , hydroxyzine does provide some symptomatic relief. The sedation or anxiolytic part is different in different individuals. In some it may help with nocturia as patients with IC have difficulty in sleeping due to repeated urge for urination at night. The treatment duration should not exceed 4 weeks if there is no significant improvement in symptoms. Care should be taken while using any sensitive equipment. Activities such as driving or operating heavy machinery should be avoided and the tablet should preferably be initiated at a low dose at night.
Alternatives of Hydroxyzine in interstitial cystitis
If you are not able to tolerate hydroxyzine then you may ask your doctor for a different medication of the same pharmacological class. Other choices which are well tolerated do exist. The best alternative is cetirizine. Though loratidine, ebestine, fexofenadine and diphenhydramine are equally effective and can be used to see which one suits better and gives the maximum relief in symptoms. To truly gauge the symptomatic relief/ improvement, at least 3 weeks of treatment duration should be allowed before replacing or adding on medication. If the empiric treatment duration doesn’t lead to any significant improvement then , it should not be continued.
Caffeine and elimination diet in interstitial cystitis
This article explains caffeine and elimination diet in interstitial cystitis. Triggers involving food can vary greatly among Interstitial Cystitis patients. With the passage of time dealing with IC, patients tend to pinpoint certain routines, foods and actions related to flares and exacerbation of symptoms. However, for some that may not be as clear. There is no clear cut rule for diet changes. For some it may reduce or improve overall symptoms greatly. For others , it may not be as much of a factor.
The Coffee Debate
Coffee is branded in most IC diets as the no 1 culprit. However, I have patients that do pretty well on coffee as compared to tea. I have had patients who substituted coffee for tea who reported a great improvement of symptoms with respect to frequency, urgency especially. Not so much with pain. As discussed earlier, diet is a highly individualized phenomenon as all of us have different bodies with unique systems that may not respond in a linear manner or consistently. Having said that this certainly does not mean that coffee isn’t a trigger or cause of flare in a huge subset of IC patients. It is one of the main triggers and foods to avoid with interstitial cystitis, if its one of the main factors in flaring up the IC symptoms. The same goes for tea w.r.t caffeine and elimination diet in interstitial cystitis.
Keeping a food diary and simultaneously keeping a record of the fluid balance chart is a good strategy for identifying the food triggers. These records can be correlated with the flares and days of the day where you feel the most pain or most frequency. Its a long term process and you need to be patient with it initially. Once you identify a good number of safe foods , say 15 then you can spread them around the week in a convenient manner and observe the symptoms again for a month. A general guide with respect to the second elimination may arise and you can follow that again and so on. The common triggers with most people such as carbonated drinks, citrus fruits, vinegar, alcohol , all spicy food, chocolates and OTC supplements can be eliminated initially to see for improvement. With time you may include one of these at a time and observe for flares. If no significant symptoms arises then you may include that again, carefully.
INTERSTITIAL CYSTITIS NATURAL TREATMENT
It include the treatment options which have been reported in individuals who did not respond or responded poorly to the conventional treatment options available.
Interstitial cystitis, also known as BPS or Bladder Pain Syndrome includes and is defined by its symptomatology of urinary frequency, urgency, and pelvic pain. Interstitial cystitis is a poorly understood condition with very few targeted therapies and hence a lot of confusion as to how it should be approached with respect to management.
INTERSTITIAL CYSTITIS NATURAL TREATMENT options include the following
Turmeric has a number of uses due to its anti-inflammatory and anti-oxidant properties. Its used in alone and as an ingredient / part of a number of indian medications. The two medically indicated uses for which proper dosing and recommendations exist are dyspepsia and colorectal cancer. Its also used for treating migraine headaches, amenorrhea, failure to gain weight or generalized weakness and anorexia. Its useful for external application in infected wounds and helps in quick resolution. Addition of regular turmeric daily half teaspoon with one glass of cold milk can result in overall improvement of symptoms in interstitial cystitis patients.
Ginger is a useful herb having been used n migraine headaches, nausea, morning sickness, osteoarthritis. Its also helpful in the period where the SSRI antidepressants are being discontinued / tapered. Its powdered form and extract both are used according to the ailment concerned. In interstitial cystitis, the ginger pieces can be soaked in boiling hot water for 10 minutes and consumed thereafter. Many patients report resolution of flares with ginger consumption in this way. Consistent use improves the overall functioning. Ginger is used as part of many detox agents and is claimed to have a healing effect on the bladder and urethral lining.
3. SODIUM BICARBONATE
Acidic food consumption will lead to a urine which has low ph which means a more acidic urine is produced. The acidic urine is theoretically irritant towards the already compromised and damaged / inflamed urothelial lining. Sodium bicarbonate is used as an anti flatulent agent and helps in dyspepsia and heart burn symptoms as well. It can help resolve an acute flare in symptoms of interstitial cystitis especially associated with an acidic urine.
4. POTASSIUM CITRATE
The rationale for use in interstitial cystitis is the same as that for sodium bicarbonate. It tends to bind to the calcium in the urine via its citrate component and also alkalinizes it. The burning sensation does improve in considerable patients with agents like sodium bicarbonate and potassium citrate. The urine alkalinizing effect with the help of OTC products like prelief or AZO can provide similar relief.
5. MARSHMALLOW ROOT
Marshmallow root has been used in Gastro intestinal and urinary tract disorders for centuries as part of traditional medicine. It protects and insulates the urothelial lining of the bladder and urethra membrane of bladder. The mucilage and tannin present in it as ingredients prevent inflammation. It is also proposed to have detoxifying and antioxidant properties. It is available in the form of tea and capsules, both and can be used as per convenience. The tea form works best for IC.
A type of flavonoid antioxidant, quercetine has been studied and proven to provide considerable relief in a large subset of IC patients. It is usually combined with bromelain added. Though some prefer to use it without the bromelain. Many IC patients report marked improvement in bladder pain, urgency and frequency as well as enhanced food tolerance after starting quercertin.