Article title: Interstitial Cystitis: NIDDK
Main condition: Interstitial Cystitis
Conditions: Interstitial Cystitis
In IC, the bladder wall may be irritated and become scarred or stiff. Glomerulations (pinpoint bleeding caused by recurrent irritation) may appear on the bladder wall. Some people with IC find that their bladders cannot hold much urine, which increases the frequency of urination. Frequency, however, is not always specifically related to bladder size; many people with severe frequency have normal bladder capacity. People with severe cases of IC may urinate as many as 60 times a day.
Also, people with IC often experience pain during sexual intercourse. IC is far more common in women than in men. Of the more than 700,000 Americans estimated to have IC, 90 percent are women.
One theory being studied is that IC is an autoimmune response following a bladder infection. Another theory is that a bacterium may be present in bladder cells but not detectable through routine urine tests. Some scientists have suggested that certain substances in urine may be irritating to people with IC, but no substance unique to people with IC has as yet been isolated. Researchers are beginning to explore the possibility that heredity may play a part in some forms of IC. In a few cases, IC has affected a mother and a daughter or two sisters, but it does not commonly run in families. No gene has yet been implicated as a cause.
Factors that influence treatment options include whether bladder capacity under anesthesia is great or small, and whether mast cells are present in the tissue of the bladder wall, which may be a sign of an allergic or autoimmune reaction. In some cases, the success or failure of a treatment helps characterize the type of IC. For example, some cases respond to changes in diet while others do not.
The diagnosis of IC in the general population is based on
| Pinpoint bleeding on the bladder wall. |
Urinalysis and Urine Culture
These tests can detect and
identify the most common organisms that infect the urine and that may
cause symptoms similar to IC. There are, however, organisms such as
Chlamydiathat cannot be detected with these tests, so a negative
culture does not rule out all types of infection. 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.
Culture of Prostate Secretions
In men, the doctor will
obtain prostatic fluid and examine it for signs of an infection, which can
then be treated with antibiotics.
Cystoscopy Under Anesthesia with Bladder Distention
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 will also distend
or stretch the bladder to its capacity by filling it with a liquid or gas.
Because bladder distention is painful in patients with IC, they must be
given either regional or general anesthesia before the doctor inserts the
cystoscope. These tests can detect bladder wall inflammation; a thick,
stiff bladder wall; and Hunner's ulcers. Glomerulations are usually seen
only after the bladder has been stretched to capacity.
The doctor may also test the patient's maximum bladder capacity--the amount of liquid or gas the bladder can hold under anesthesia. Without anesthesia, capacity is limited by either pain or a severe urge to urinate. Many people with IC have normal or large maximum bladder capacities under anesthesia. However, a small bladder capacity under anesthesia helps support the diagnosis of IC.
Biopsy
A biopsy is a tissue sample that is then examined
under a microscope. Samples of the bladder and urethra may be removed
during a cystoscopy and later examined with a microscope. A biopsy helps
confirm inflammation and rule out bladder cancer.
Because the causes of IC are unknown, treatments are aimed at relieving symptoms. Most people are helped for variable periods by one or a combination of treatments. As researchers learn more about IC, the list of potential treatments will change, so patients should discuss their options with a doctor.
Bladder Distention
Because many patients have noted an
improvement in symptoms after a bladder distention done to diagnose IC,
the procedure is often thought of as one of the first treatment attempts.
Researchers are not sure why distention helps, but some believe that it may increase capacity and interfere with pain signals transmitted by nerves in the bladder. Symptoms may temporarily worsen 24 to 48 hours after distention, but should return to predistention levels or improve after 2 to 4 weeks.
Bladder Instillation
During a bladder instillation, also
called a bladder wash or bath, the bladder is filled with a solution that
is held for varying periods of time, averaging 10 to 15 minutes, before
being emptied.
The only drug approved by the U.S. Food and Drug Administration (FDA) for bladder instillation is dimethyl sulfoxide (DMSO, RIMSO-50). DMSO treatment involves guiding a narrow tube called a catheter up the urethra into the bladder. A measured amount of DMSO is passed through the catheter into the bladder, where it is retained for about 15 minutes before being expelled. Treatments are given every week or two for 6 to 8 weeks and repeated as needed. Most people who respond to DMSO notice improvement 3 or 4 weeks after the first 6- to 8-week cycle of treatments. Highly motivated patients who are willing to catheterize themselves may, after consultation with their doctor, be able to have DMSO treatments at home. Self-administration is less expensive and more convenient than going to the doctor's office.
Doctors think DMSO works in several ways. Because it passes into the bladder wall, it may reach tissue more effectively to reduce inflammation and block pain. It may also prevent muscle contractions that cause pain, frequency, and urgency.
A bothersome but relatively insignificant side effect of DMSO treatments is a garlic-like taste and odor on the breath and skin that may last up to 72 hours after treatment. Long-term treatment has caused cataracts in animal studies, but this side effect has not appeared in humans. Blood tests, including a complete blood count and kidney and liver function tests, should be done about every 6 months.
A variety of other drugs, not yet approved by the FDA, have been used experimentally for bladder washes. In 1997, researchers from William Beaumont Hospital in Royal Oak, Michigan, reported promising results from a bladder wash containing bacillus Calmette-Guérin (BCG), a vaccine traditionally used to immunize against tuberculosis. This preparation is undergoing continuing clinical trials to determine how long the effect lasts in a larger sample of patients.
Oral Drugs
Pentosan polysulfate sodium (Elmiron), the first
oral drug developed for IC, was approved by the FDA in 1996. In clinical
trials, Elmiron improved symptoms in 38 percent of patients treated.
Doctors do not know exactly how it works, but one theory is that it may
repair defects that might have developed in the lining of the bladder.
The FDA-recommended dosage of Elmiron is 100 mg, three times a day. Patients may not feel relief from IC pain for the first 2 to 4 months. A decrease in urinary frequency may take up to 6 months. Patients are urged to continue with therapy for at least 6 months to give it an adequate chance to relieve symptoms.
Elmiron's side effects are limited primarily to minor gastrointestinal discomfort. A small minority of patients experienced some hair loss, but hair grew back when they stopped taking the drug. Researchers have found no negative interactions between Elmiron and other medications.
Elmiron may affect liver function, which should therefore be monitored by the doctor.
Because Elmiron has not been tested in pregnant women, the manufacturer recommends that it not be used during pregnancy, except in the most severe cases.
All drugs--even those sold over the counter--have side effects. Patients should always consult a doctor before using any drug for an extended time.
Other Oral Medications
Aspirin and ibuprofen are easy to
obtain and may be a first line of defense against mild discomfort. Doctors
may recommend other drugs to relieve pain.
Some patients have experienced improvement in their urinary symptoms by taking antidepressants or antihistamines. Antidepressants help reduce pain and may also help patients deal with the psychological stress that accompanies living with chronic pain. In patients with severe pain, narcotic analgesics such as Tylenol with codeine or longer acting narcotics may be necessary.
Transcutaneous Electrical Nerve Stimulation
With
transcutaneous electrical nerve stimulation (TENS), mild electric pulses
enter the body for minutes to hours two or more times a day either through
wires placed on the lower back or just above the pubic area, between the
navel and the pubic hair, or through special devices inserted into the
vagina in women or into the rectum in men. Although scientists do not know
exactly how TENS works, it has been suggested that the electric pulses may
increase blood flow to the bladder, strengthen pelvic muscles that help
control the bladder, or trigger the release of substances that block pain.
TENS is relatively inexpensive and allows the patient to take an active part in treatment. Within some guidelines, the patient decides when, how long, and at what intensity TENS will be used. It has been most helpful in relieving pain and decreasing frequency in patients with Hunner's ulcers. Smokers do not respond as well as nonsmokers. If TENS is going to help, improvement is usually apparent in 3 to 4 months.
Diet
There is no scientific evidence linking diet to IC, but
many doctors and patients find that alcohol, tomatoes, spices, chocolate,
caffeinated and citrus beverages, and high-acid foods may contribute to
bladder irritation and inflammation. Some patients also note that their
symptoms worsen after eating or drinking products containing artificial
sweeteners. Patients may try eliminating various products from their diet
and reintroducing them one at a time to determine which, if any, affect
symptoms. It is important, however, to maintain a varied, well-balanced
diet.
Smoking
Many patients feel that smoking makes their symptoms
worse. Because smoking is the major known cause of bladder cancer, one of
the best things smokers can do for their bladder is to quit.
Exercise
Many patients feel that gentle stretching exercises
help relieve IC symptoms.
Bladder Training
People who have found adequate relief from
pain may be able to reduce frequency by using bladder training techniques.
Methods vary, but basically patients decide to void (that is, empty their
bladder) at designated times and use relaxation techniques and
distractions to keep to the schedule. Gradually, patients try to lengthen
the time between scheduled voids. A diary that records voiding times is
usually helpful in keeping track of progress.
Surgery
Many approaches and techniques are used, each of
which has its own advantages and complications that should be discussed
with a surgeon. Surgery should be considered only if all available
treatments have failed and the pain is disabling. Most doctors are
reluctant to operate because the outcome is unpredictable--some people
still have symptoms after surgery.
Those considering surgery should discuss the potential risks and benefits, side effects, and long- and short-term complications with a surgeon and with their family, as well as with people who have already had the procedure. Surgery requires anesthesia, hospitalization, and weeks or months of recovery, and as the complexity of the procedure increases, so do the chances for complications and failure.
To locate a surgeon experienced in performing specific procedures, check with your doctor.
Two procedures--fulgurationand resectionof ulcers--can be done with instruments inserted through the urethra. Fulguration involves burning Hunner's ulcers with electricity or a laser. When the area heals, the dead tissue and the ulcer fall off, leaving new, healthy tissue behind. Resection involves cutting around and removing the ulcers. Both treatments are done under anesthesia and use special instruments inserted into the bladder through a cystoscope. Laser surgery in the urinary tract should be reserved for patients with Hunner's ulcers and should be done only by doctors who have had special training and have the expertise needed to perform the procedure.
Another surgical treatment is augmentation, which makes the bladder larger. In most procedures, scarred, ulcerated, and inflamed sections of the patient's bladder are removed, leaving only the base of the bladder and healthy tissue. A piece of the patient's bowel (large intestine) is then removed, reshaped, and attached to what remains of the bladder. After the incisions heal, the patient may void less frequently. The effect on pain varies greatly; IC can sometimes recur on the segment of bowel used to enlarge the bladder.
Even in carefully selected patients--those with small, contracted bladders--pain, frequency, and urgency may remain or return after surgery, and the patient may have additional problems with infections in the new bladder and difficulty absorbing nutrients from the shortened intestine. Some patients are incontinent, while others cannot void at all and must insert a catheter into the urethra to empty the bladder.
Bladder removal, called a cystectomy,is another surgical option. Once the bladder has been removed, different methods can be used to reroute urine. In most cases, ureters are attached to a piece of bowel that opens onto the skin of the abdomen; this procedure is called a urostomy, and the opening is called a stoma. Urine empties through the stoma into a bag outside the body. Some urologists are using a second technique that also requires a stoma but allows urine to be stored in a pouch inside the abdomen. At intervals throughout the day, the patient puts a catheter into the stoma and empties the pouch. Patients with either type of urostomy must be very careful to keep the area in and around the stoma clean to prevent infection. Serious potential complications may include kidney infection and small bowel obstruction.
A third method to reroute urine involves making a new bladder from a piece of the patient's bowel and attaching it to the urethra. After healing, the patient may be able to empty the newly formed bladder by voiding at scheduled times or by inserting a catheter into the urethra. Few surgeons have the special training and expertise needed to perform this procedure.
Even after total bladder removal, some patients still experience variable IC symptoms in the form of phantom pain. Therefore, the decision to undergo a cystectomy should be undertaken only after testing all alternative methods and after seriously considering the potential outcome.
A surgical variation of TENS, called saccral nerve root stimulation,involves permanent implantation of electrodes and a unit emitting continuous electrical pulses. Studies of this experimental procedure are now under way.
Pregnancy
Researchers have little information on pregnancy
and IC but believe that the disorder does not affect fertility or the
health of the fetus. Some women find that their IC goes into remission
during pregnancy, while others experience a worsening of their symptoms.
Coping
The emotional support of family, friends, and other
people with IC is very important in helping patients cope. Studies have
found that patients who learn about the disorder and become involved in
their own care do better than patients who do not. See "IC
Patient Support" for an association that can refer you to the nearest
support group.
Although answers may seem slow in coming, researchers are working hard to solve the painful riddle of IC. Some scientists receive funds from the Federal Government to help support their research, while others receive support from their employing institution, drug companies, or patient support associations.
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), a part of the National Institutes of Health (NIH), leads the Federal Government's research efforts on IC. Most studies funded by NIDDK result from unsolicited grant applications sent to NIH by scientists at universities and medical centers throughout the United States. Other NIDDK-funded studies result from solicitations issued to encourage increased research on a particular topic.
By law, all applications sent to NIH are first reviewed by non-Government experts in the field of the proposed research for scientific merit and feasibility before being reviewed by NIDDK's National Advisory Council. This council is made up of non-Government scientists, health professionals, and people who represent voluntary groups interested in the Institute's research. Approved applications are eligible for funding based on a rating of scientific merit, or priority score, assigned by the initial reviewers. Applications are usually funded in order of priority score; the best applications are funded first.
Largely because of special solicitations, NIDDK's investment in scientifically meritorious IC research across the country has grown considerably since 1987. The Institute now supports research that is looking at various aspects of IC, such as how the components of urine may injure the bladder and what possible role organisms identified by nonstandard methods may have in causing IC. In addition to funding research, NIDDK sponsors scientific workshops where investigators share the results of their studies and discuss future areas for investigation.
Database
An important part of NIDDK's IC research program
has been the National IC Database Study, the first systematic, long-term
look at a large number of people with IC. Data from this study are now
being analyzed.
Clinical Treatment Group
In 1998, NIDDK initiated the IC
Clinical Treatment Group, a project designed to develop and test new
treatment strategies for patients with IC.
Articles and Book Chapters
Brody, J. (1995, January 25).
Interstitial cystitis: Help for a puzzling illness. New York
Times,p. B7.
Hanno, P. (1998). Interstitial cystitis and related diseases. In P. C. Walsh, A. B. Retik, E. D. Vaughan, & A. J. Wein (Eds.), Campbell's urology (7th ed., pp. 631-662). Philadelphia, PA: W. B. Saunders Company.
Wein, A., & Hanno, P. (Eds.). (1997). Interstitial cystitis: An update of the current information. Urology,49 (5A, Suppl.).
Books and Booklets
Chalker, R., & Whitmore, K. E.
(1990). Overcoming bladder disorders: Medical and self-help advice on
incontinence, cystitis, interstitial cystitis, prostate problems, and
bladder cancer. New York: Harper & Row. (Available by calling
1-800-242-7737.)
Sant, G. (Ed.). (1997). Interstitial cystitis. Philadelphia, PA: Lippincott-Raven.
American Pain Society
5700 Old Orchard Road
Skokie, IL
60077
(708) 966-5595
American Uro-Gynecologic Society
401 North Michigan Avenue
Chicago, IL 60611-4267
(312) 644-6610
IC Patient Support
Interstitial Cystitis
Association of America, Inc.
51 Monroe Street, Suite 1402
Rockville, MD 20850
(301) 610-5300
(800) HELP-ICA
http://www.ichelp.org/
International Pain Foundation
909 Northeast 43rd Street,
Suite 306
Seattle, WA 98105-6020
(206) 547-2157
National Chronic Pain Outreach Association
7979 Old
Georgetown Road, Suite 100
Bethesda, MD 20814
(301) 652-4948
National Kidney Foundation
30 East 33rd Street
New York,
NY 10016
(212) 889-2210 or 1-800-622-9010
National Organization of Social Security Claimants'
Representatives
6 Prospect Street
Midland Park, NJ 07432
(201) 444-1415 or 1-800-431-2804
Social Security Administration
(Write or call your local
office:
look in the telephone book under U.S. Government,
Department of Health and Human Services; or call 1-800-234-5772.)
United Ostomy Association
36 Executive Park, Suite 120
Irvine, CA 92714
(714) 660-8624
3 Information WayThe National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1987, the clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. NKUDIC answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and Government agencies to coordinate resources about kidney and urologic diseases.
Bethesda, MD 20892-3580
E-mail: National Kidney and Urologic Diseases Information Clearinghouse
Publications produced by the clearinghouse are carefully reviewed for scientific accuracy, content, and readability.
This e-text is not copyrighted. The clearinghouse encourages users of this e-pub to duplicate and distribute as many copies as desired.
NIH Publication No. 99-3220
August 1999
e-text last updated: February 2000
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