Bladder Pain / Interstitial Cystitis

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What is Interstitial Cystitis?

Interstitial Cystitis (IC) is a condition with a group of symptoms that include bladder pain, frequency and urgency. This group of symptoms is called Painful Bladder syndrome (PBS). If the symptoms are associated with inflammatory changes inside the bladder, then it is called interstitial cystitis. It is often difficult to diagnose as the exact cause for this condition is still unknown.

Symptoms of Interstitial Cystitis/PBS
  • Urgency
  • Frequency of Urination-sometimes 60 times in a single day
  • Dysuria (burning and stinging during urination)
  • Bladder pain - may intensify when bladder is filling or emptying
  • Pelvic Pain
  • Blood in urine
  • Pain with intercourse.

They symptoms of Interstitial Cystitis vary from case to case or even in the same individual and can interfere with many aspects of daily life.

What causes Interstitial Cystitis?

It is currently unknown what the cause of IC is however there is research being done to find it. Some symptoms are similar to those of a bacterial infection however urine tests reveal no organisms in the urine. One of the theories suggests that there is damage to the lining of the bladder wall which exposes the damaged wall to acidic urine, causing urgency and frequency. The other theory is there is hypersensitivity of the nerves in the bladder.

Diagnosis

Since there is no definitive test to identify IC/PBS, other treatable conditions such as urinary tract infections or bladder cancer must be ruled out before considering a diagnosis of IC/PBS. In women, endometriosis is a common cause of pelvic pain. IC/PBS is not associated with any increased risk of developing cancer.

Diagnostic tests that help rule out other diseases include urinalysis, urine culture, and cystoscopy, biopsy of the bladder wall and urethra, and distension of the bladder under anaesthesia. A brief description of tests involved is below:

Urinalysis and Urine Culture

Examining urine with a microscope and culturing the urine can detect and identify the primary organisms that are known to infect the urinary tract and that may cause symptoms similar to IC/PBS. A urine sample is obtained either by catheterization or by the clean catch method. For a clean catch, the patient washes the genital area before collecting urine midstream in a sterile container. White and red blood cells and bacteria in the urine may indicate an infection of the urinary tract, which can be treated with an antibiotic. If urine is sterile for weeks or months while symptoms persist, the doctor may consider a diagnosis of IC/PBS.

Cystoscopy under Anaesthesia with Bladder Distension

The doctor may perform a cystoscopic examination in order to rule out bladder cancer. During cystoscopy, the doctor uses a cystoscope—an instrument made of a hollow tube about the diameter of a drinking straw with several lenses and a light—to see inside the bladder and urethra. The doctor might also distend or stretch the bladder to its capacity by filling it with water. This diagnostic procedure is done under anaesthesia.

Biopsy

A biopsy is a tissue sample that can be examined with a microscope. Tissue samples of the bladder and urethra may be removed during a cystoscopy. A biopsy may help to rule out bladder cancer.

Treatment

Treatment of IC/PBS is variable depending on the clinician’s experience and availability of the treatment as the exact cause of the condition is unknown. Some of the treatment modalities available are discussed below.

Aggravating conditions

Conditions like urinary tract infections, vaginal infections, inflammatory bowel disease, and endometriosis can aggravate the symptoms of interstitial cystitis. These patients may need multidisciplinary care under different specialists to manage these conditions.

Foods

Some foods and drinks might aggravate the IC symptoms. These should be cut down or used in moderation for improvement of symptoms. However, the validity of this is yet to be proven.

Behavioural modifications

This may be of some help to women who get the urge to void frequently. Timed voiding is one of the therapies used where you will be asked to void every 3 hours and avoid the urge. You may not be able to hold for 3 hours straightaway but you might have to delay for a few minutes initially and stretch it slowly. This technique does not need any special training and is inexpensive.

Medications

There are some medications available which may be of help to some women. The theory behind the medications is to repair the damage to the lining of the bladder. Some of these medications are taken orally, some need to be instilled into bladder and some need to be injected into the bladder wall. The doctor will decide medication that is appropriate after detailed consultations with you.

Pentosan Polysulfate sodium (Elmiron) – this medication is taken orally for 3 – 6 months. Some studies have shown a 50% improvement in symptoms in a small percentage of patients. Hair loss is a side effect and almost always involves scalp area.

Dimethyl sulfoxide – has been used in the past to treat interstitial cystitis. This medication has to be instilled into the bladder and patient is asked to hold for as long as possible. This can be done as a one off treatment or regular treatment for 2 weeks. Now-a-days, a combination of medications is used which include heparin, lidocaine and sodium bicarbonate. The symptoms might improve for a few days to few weeks.

Amitriptyline – this medication is taken orally and when used in low doses can help with reduction of pain perception. Fatigue is a common side effect. It is used in IC to reduce pain perception.

Gabapentin – this is an antiepileptic medication that helps to treat nerve related pain. It can be used in treating the pain experienced in IC

Intravesical steroid injection – This procedure is done under general anaesthesia and involves injecting a steroid (Triamcinolone) into the inflamed areas. It does provide short term relief for a few weeks and you may need more injections depending on your bladder condition. The treatment is relatively new and more studies are awaited.