Index

Interstitial cystitis summary

Interstitial cystitis is a chronic inflammatory disease of the bladder that causes discomfort and/or pain in the bladder or pelvic area.¹.

Statistical data indicate that about 90% of affected patients are women after 40 years of age. However, due to the difficulty in diagnosing the disease, these data are not entirely accurate.

The cause of the disease is still unknown, however, some theories suggest that interstitial cystitis has an autoimmune, inflammatory, neurological or infectious origin.

Symptoms of the disease include pelvic pain and increased urgency and frequency of urination. The diagnosis can be made by cytoscopy and observing an extensive list of exclusion criteria for the disease, which can be confused with others (such as prostatitis and bacterial cystitis ).

Some diseases may be associated with interstitial cystitis, such as fibromyalgia and irritable bowel syndrome. Although the disease has no cure, treatment seeks to alleviate the patient’s symptoms. Some therapeutic measures include hydrodistention, use of analgesics, use of intravesical medication and surgery.

Some plants used as an adjuvant in therapy are lemon balm, zucchini and chamomile.

Certain foods such as fruits and acidic drinks, as well as alcoholic beverages, coffee and black tea can be avoided in order to improve the symptoms of interstitial cystitis.

Definition

Interstitial cystitis, or painful bladder syndrome, is a sterile inflammatory disease (not caused by microorganisms) characterized by pain in the bladder and urethra, increased urinary frequency and urgency, and nocturia (need to get up at night to urinate), which may, also, burning sensation occurs when urinating. Interstitial cystitis is an enigma for urology, as its causes remain unclear.

The disease can be classified into 2 types: the classic (or ulcerative) type, or the “early” (or non-ulcerative) type.

Epidemiology

Causes

The exact causes of interstitial cystitis are not known. However, there are theories about the etiology of the disease:

Inflammation
Although the causes of interstitial cystitis are unknown, one of the primary events is a change in urothelial permeability, with activation of mast cells and neurogenic inflammation. Histological examination reveals lesions such as mucosal ulcers, pancystitis and perineural inflammatory infiltrates. The presence of mast cells, with the release of histamine and, consequently, the appearance of pain, hyperemia and fibrosis, is clearly associated with the classic type, with its association with the non-ulcer type being less frequent.

Neurobiology
Another theory points out that there may be an alteration in the innervation of the bladder, with an increase in the sympathetic outflow. Studies indicate that there is a decrease in the S-100 protein and an increase in the activity of the enzyme tyrosine hydrolase in the bladder, which can increase the synthesis of catecholamines.

Neurogenic inflammation has also been identified as one of the causes of interstitial cystitis. In this case, mast cells release various vasoactive substances that cause inflammation. Once these mast cells are activated, inflammation can occur acutely or subacutely. The exact mechanism by which mast cells are led to release such substances is still unknown, however, studies indicate that there may be a hormonal cause influenced by estrogens.

Infection
Scholars point out that interstitial cystitis can be caused by a bacterium that is in small amounts. The presence of an infectious agent may not cause interstitial cystitis, however, it may trigger inflammatory and immune responses.

Glycosaminoglycan layer
Glycosaminoglycans are substances found in the cells of the bladder. There is a hypothesis that the defect would be in that layer of substances that increases the permeability of the mucosa with exposure of the lower layers to toxic elements in the urine.

Autoimmunity
Studies indicate that interstitial cystitis may be an autoimmune disease. In addition, patients usually have other associated autoimmune diseases, such as lupus erythematosus, scleroderma, fibromyalgia , and Sjögren’s syndrome . These patients could have antibodies against cells in the mucosa or muscle layer of the bladder. Although some immunological mechanisms have been identified in interstitial cystitis, there is still no definitive relationship between autoimmunity and the disease.

Other theories
There are several other theories for the causes of cystitis such as nitric oxide metabolism, psychosomatic disease, neuroimmunoendocrine disease, antiproliferative factors, among others.

Allergy is also associated with IC.

Groups of risk

Although there are not enough epidemiological data to classify risk groups for interstitial cystitis, studies indicate that 80-90% of cases of the disease are in women, aged over 40 years.

Symptoms

Classic symptoms of interstitial cystitis include pelvic pain (greater than 6 months) accompanied by urinary symptoms such as increased frequency and urgency of urination and burning and discomfort when urinating.

In addition, a burning sensation and slow, small and incomplete elimination during urination are also symptoms of IC.

Diagnosis

There is still no standardization in the diagnosis of interstitial cystitis, therefore, different criteria are adopted to identify the disease. So far, there is no test or examination with a specific finding for the disease. The cytoscopy examination (observation of the bladder through a thin tube with a camera) is performed under anesthesia, however, the diagnosis is made by exclusion, with strict criteria. According to the National Institute of Health (NIH), the criteria required for the diagnosis of interstitial cystitis are:

One of two criteria must be present, visible in the bladder during endoscopic examination:

1) mucosal ″clusters″, or

2) classic Hunn’s ulcer (characteristic ulcer): This is a small ulceration of the bladder mucosa that usually appears during bladder distention in a small group of patients. Aggregates must be distributed at least 10 per quadrant.

One of the following two symptoms must be present:

1) cystalgia (bladder pain) or

2) urinary urgency

Criteria for eliminating the diagnosis of interstitial cystitis:

1) bladder capacity > 350 mL, in the absence of anesthesia, in cystometry;

2) unwillingness to urinate after filling the bladder with 150 mL of water in cystometry;

3) presence of involuntary bladder contractions during filling (at 30-100 mL/min);

4) symptoms for less than 9 months;

5) frequent absence of urination during the night;

6) symptoms relieved by antimicrobials, anticholinergics or antispasmodics;

7) daytime need to urinate (pollakiuria) <8 times throughout the day;

8) diagnosis of bacterial cystitis or prostatitis within three months;

9) presence of a stone in the bladder or lower urethra;

10) genital herpes in the activity phase;

11) uterine, cervical, vaginal or urethral cancer;

12) diverticulum in the urethra;

13) cystitis due to cyclophosphamide or any other chemical agent;

14) tuberculous cystitis;

15) cystitis after radiation;

16) benign or malignant tumor in the bladder;

17) vaginal infection;

18) patients under 18 years old

The potassium sensitivity test is positive in about 70 to 90% of patients with interstitial cystitis, but patients with chronic pelvic pain of gynecological origin also show hypersensitivity to instillation of potassium chloride in the bladder, showing that the test has little specificity. In this test, the doctor injects a potassium chloride solution into the patient’s bladder and the patient is asked about the pain and urinary urgency they feel when their bladder is full of the solution. The same test is done with water. If the patient experiences more pain and urinary urgency with the potassium solution, this may indicate interstitial cystitis. Patients with a normal bladder do not feel this difference.

Another test is the urine test, which aims to eliminate the possibility of a possible urinary infection. In addition, complete examinations of the pelvis (including examination of the external genitalia, cervix, etc.) aid in the diagnosis.

A biopsy is also used to remove tissue from the bladder to check for cell abnormalities or the presence of other diseases, such as cancer.

Complications

Interstitial cystitis can lead to thickening of the bladder walls, with consequent reduction in bladder capacity. In addition, due to the pain caused, the disease causes a reduction in the patient’s quality of life, in addition to other emotional and relationship problems, due to the constant need to urinate.

A study carried out in Canada in 2010 with patients with interstitial cystitis revealed that they have a higher prevalence of fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome. Other conditions associated with interstitial cystitis were pain, depression and sleep disturbances.

Treatments

Interstitial cystitis is an incurable but treatable disease. The therapeutic measures adopted are based on empiricism, since the causes of the disease are not known and are intended to alleviate the patient’s symptoms. It is important to emphasize that approximately 50% of patients present spontaneous remission with an average duration of 8 months.

Hydrodistention Hydrodistention
is also part of the diagnosis of the disease. It consists of filling the bladder with water until reaching a pressure of 80 cm of H2O. At this point, the bladder is emptied and refilled. Improvement lasts from 3 to 6 weeks, however, some patients may report worsening of symptoms after the anesthesia wears off. In this case, the patient must take medication orally.

Oral medication
Some medications are indicated to improve the symptoms of interstitial cystitis, such as:

– tricyclic antidepressants: indicated for their analgesic properties;

– antihistamines: used in patients with concomitant allergy. It has the ability to reduce the action of mast cells;

– Sodium pentosan polysulfate (Elmiron®, 100 mg capsules) is a drug authorized in the United States by the FDA since 1996 for the treatment of interstitial cystitis. Since 2017, this medicine has also been authorized in the European Union (EU), through a marketing authorization from the European Medicines Agency (EMA). This medication works by promoting repair of the affected layer of the bladder, as seen in Causes above, a possible source of IC is damage to the protective mucus layer that lines the inside of the bladder. This results in decreased pain, urinary urgency, and urinary frequency.

– cystistat: is another medication launched in 2006 specifically for interstitial cystitis. The drug is composed of a fraction of the active substance of hyaluronic acid with a high degree of purity, produced by biotechnology, which temporarily restores the protective layer of deficient glycoaminoglycan, alleviating the symptoms.

– analgesics: for mild or moderate interstitial cystitis, antidepressants, anticonvulsants (such as gapapentin, clonazepam) and muscle relaxants are used. In intermittent cases, opioids such as hydrocodone associated with paracetamol and oxycodone with paracetamol can be used. In severe cases, transdermal fentanyl may also be used.

– other drugs that may be used include antispasmodics, anticholinergics, ranitidine, cimetidine, α-blockers and urine alkalizing agents.

Terapia intravesical

Dimethyl sulfoxide (DMSO) can be instilled directly into the bladder. It is thought to act as an anti-inflammatory agent in interstitial cystitis.

Lidocaine can also be applied directly to the bladder and relieve pain due to its anesthetic properties.

Nerve Stimulation:

Nerve stimulation is a treatment that helps to regulate the bladder. These treatments are most helpful for reducing urinary urgency and frequency, but can sometimes help relieve bladder/supra pubic pain.

Surgery can remove parts of the bladder or even the entire bladder. If a person has tried all other treatment options and the pain is unbearable, surgery may be considered.

Surgical treatment

Surgical treatment is considered the last alternative and must always be performed with great caution, since serious complications can result from this technique, including absence of improvement in symptoms.

Some conservative surgical modalities include laser elimination of ulcers. Transurethral resection removes nerve endings affected by the inflammatory process as well as a decrease in inflammatory mediators responsible for irritative symptoms.

However, some patients with interstitial cystitis do not respond to these measures. In this case, surgical techniques such as cystectomy (removal of part of the bladder) and urinary diversion (surgery to divert the normal flow of urine) may be applied.

Lifestyle:

Diet and physical activity are effective ways to treat IC (read more below in Tips).

Herbal medicine

Some literature data suggest some plants as an adjuvant treatment in interstitial cystitis.

Among them: chamomile , zucchini, peppermint, lemon balm and acacia.

It is important that the doctor is aware of and indicates the best treatment for the patient.

Tips

The mechanisms of interstitial cystitis are still not entirely known, however, some factors may alleviate or worsen the patient’s symptoms .

Some of the aggravating factors are:

– Alcoholic beverage

– Café

– Black tea

– Spicy foods

– carbonated drinks

– sexual relations

– stress

Factors that help improve symptoms:

– Urinating several times

– Analgesics

– Anti-inflammatories

In addition, some foods seem to make the symptoms felt worse. Although there is no well-defined correlation between the pain of interstitial cystitis and the patient’s diet, some individuals report worsening of symptoms when they ingest acidic foods or drinks.

– Exercise and physical activity can help relieve symptoms of IC. Exercises can include walking, cycling, or gentle stretching.

Jeanne Kenney

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I’m a stylist trainer, a content creator, and an entrepreneur passion. Virgo sign and Pisces ascendant, I move easily between my dreams, the crazy world I want, and my feet on the ground to carry out my projects.