Interstitial Cystitis (IC)

What is Interstitial Cystitis (IC)?
What causes IC?
What are the symptoms of IC?
What are some of the treatments available?

What is Interstitial Cystitis (IC)?
Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder that causes frequent, urgent, and painful urination and pelvic discomfort. The natural lining of the bladder (epithelium) is protected from toxins in the urine by a layer of protein called glycoaminoglycan (GAG). In IC this protective layer has broken down, allowing toxins to irritate the bladder wall. The bladder then becomes inflamed and tender and does not store urine well.

Unlike inflammation of the bladder caused by bacterial infection (cystitis), which is associated with urinary tract infections (UTI) and usually treated with antibiotics, no infectious agent has been found in IC. Though not curable, IC is treatable and most patients find some relief with treatment and lifestyle changes.

What causes IC?
IC is a poorly understood disease with unknown causes. Although no bacteria or viruses (pathogens) have been found in the urine of IC sufferers, an unidentified infectious agent may be the cause. Others believe that IC occurs with ischemia (tissue death) or a deficiency of GAG in the epithelium. It may be an autoimmune disease, in which the immune system attacks healthy cells, perhaps following a bladder infection. Spasms of the pelvic floor muscles may also contribute to the IC symptoms. It is likely that several factors cause the condition.

Other conditions associated with IC include the following:

• Asthma
• Endometriosis
• Food allergies
• Hay fever (pollen allergy)
• Incontinence
• Irritable bowel syndrome
• Lupus
• Migraine
• Rheumatoid arthritis
• Sinusitis

The connection between IC and these conditions is not understood.

IC may occur following gynecological surgery. Some evidence suggests an increased risk for IC in Jews; and studies of mothers, daughters, and twins who suffer from it suggest a hereditary risk factor.

What are the symptoms of IC?
Interstitial cystitis manifests differently in patients. For instance, some people experience chronic pelvic pain, while others do not. Symptoms may intensify as the bladder fills and diminish after urination. Classic symptoms include the following:

• Frequency — urination may exceed 60 times in a 24-hour period
• Pain — chronic pelvic, vulvar, urethral, or abdominal discomfort during urination and sex
• Urgency— sensation of having to urinate immediately, often accompanied by bladder pain, pressure, or spasm

Symptoms usually worsen within the first 5 years and then level off. Patients with IC typically experience periods of symptom flare, or intensification, followed by periods of remission, when symptoms abate.

For men, symptoms may include pain and inflammation of the prostate (prostatitis). Women may suffer increased vulvar pain. Both men and women may experience pain in the perineum (space between the vagina or scrotum and the anus) and painful or uncomfortable sex, including intercourse and touching. For some men, ejaculation may be painful.

What are some of the treatments available?
There is no cure for IC; the goal of treatment is to relieve symptoms. Often, treatment effectiveness wanes and a replacement must be found through trial and error. Most patients who suffer from IC find relief, usually with multiple, complementary treatments.

Types of treatment include the following:

• Biophysical techniques – behavioral changes, stress management, dietary changes
• Medications
• Surgery

Biophysical Techniques
Biophysical techniques used to control IC symptoms include bladder retraining, transcutaneous electrical nerve stimulation (TENS), stress reduction with biofeedback, diet modification, and exercise. Physical therapy for the pelvic floor muscles may help decrease pain and spasms. Bladder retraining is a self-help process in which patients learn to control their urge to urinate. The theory behind bladder retraining is that the bladder muscle actually weakens with frequent urination because it is not allowed to distend fully. Patients with IC experience the impulse to urinate frequently because they have pain or urgency as the bladder fills. Bladder retraining programs vary. Generally, the patient schedules times for urination (a voiding schedule) and uses a series of relaxation techniques and distractions to help keep the schedule. The interval is progressively lengthened, thus strengthening the bladder muscle. Bladder retraining may be complicated by severe pain.

Transcutaneous electrical nerve stimulation (TENS) TENS involves the application of mild electric pulses to the body for minutes or hours a day. It is believed that the electric pulses increase blood flow to the bladder, strengthen pelvic muscles that aid in control, and trigger the release of pain-blocking hormones. TENS therapy may help with IC pain, though it may take a couple of months before any benefit is realized. A TENS device is worn outside of the body, usually near the sacral nerve.

Sacral Nerve Stimulation
The InterStim® device, used traditionally to treat bladder-control problems, is being used experimentally in preclinical trials to evaluate its effects on IC. It is implanted under the skin of the lower back, near the sacral nerve, where it delivers electrical pulses to the nerves involved in bladder function. It may help control frequency and urgency associated with IC, although the Food and Drug Administration (FDA) has not approved it for IC therapy.

Stress reduction techniques, biofeedback, and exercise may reduce the occurrence of flares by strengthening the muscles of the pelvic floor. For some, exercise exacerbates symptoms by irritating an already tender bladder or sore abdomen.

Diet:  Many people find that eliminating acidic, spicy, and sugary foods, as well as dairy products from their diet helps to control symptoms. The Interstitial Cystitis Association (ICA) provides a list of foods that may be problematic:

• Beverages — hard liquor, beer, wine, carbonated drinks, coffee, tea, cranberry juice
• Carbohydrates and grains — rye and sourdough bread
• Condiments — seasonings, mayonnaise, miso, soy sauce, salad dressings, vinegar
• Dairy products — aged cheese, sour cream, yogurt, chocolate, milk
• Fruits — apples, apricots, avocados, bananas, cantaloupes, citrus fruits, cranberries, grapes, nectarines, peaches, pineapples, plums, pomegranates, rhubarb, strawberries, fruit juices
• Meats and fish — aged, canned, cured, processed, or smoked meats and fish, anchovies, caviar, chicken liver, corned beef, meats containing nitrates or nitrites (e.g., ham, bacon)
• Nuts
• Others substances — tobacco, caffeine, diet pills, junk food, cold and allergy medication containing ephedrine or pseudoephedrine, vitamins that contain fillers (especially aspartate), tofu
• Preservatives and additives — benzol alcohol, citric acid, monosodium glutamate, aspartame (Nutrasweet®), saccharine, artificial ingredients and colors
• Vegetables — favabeans, lima beans, onions, tomatoes

Most IC patients have the least amount of trouble with rice, potatoes, pasta, vegetables, and chicken. Foods from the above groups that may be tolerable include the following:

• Beverages — decaffeinated and acid-free coffee and tea, certain herbal teas
• Carbohydrates and grains — breads other than rye and sourdough, rice
• Condiments — garlic
• Dairy products — cottage cheese, white chocolate
• Fruits — melon other than cantaloupe, pears
• Nuts — almonds, cashews, pine nuts
• Vegetables — fresh, homegrown potatoes and tomatoes

Some find that over-the-counter dietary aids such as Prelief®, which helps to make food less acidic, allow them to eat many foods that would otherwise be intolerable.

Smoking worsens symptoms for some people; symptoms improve for many after quitting.

Surgery
Surgery is typically performed only when other treatments fail to provide relief. It may be ineffective and may worsen IC symptoms.

Laser burning (fulguration) and surgical removal (resection) are two methods used to remove Hunner’s ulcers from the bladder in ulcerative IC. They are performed with a cystoscope inserted through the urethra under general anesthesia.

Urostomy involves creating a tube in the abdomen from intestinal tissue, rerouting the tubes that carry urine from the kidneys (ureters) to the tube, and connecting it to an opening (stoma) in the abdomen. Urine then drains continuously into a collection bag that can be emptied as necessary. Alternatively, an internal pouch, known as a Koch, Florida, or Indiana pouch, may be constructed from intestinal tissue to hold urine from the ureters. The patient periodically drains the pouch through the stoma with a self-administered catheter.

Bladder removal (cystectomy) may be performed with urostomy and internal pouch procedures.

Augmentation cytoplasty is performed rarely in cases where heavily scarred portions of the bladder need to be removed, though it is not considered a standard treatment. A section of intestinal tissue may be cut and shaped to replace the damaged portion of the bladder. It is attached to the remainder of the natural bladder so that urine can be stored and expelled through the urethra.

A relatively new procedure known as orthotopic diversion involves the removal of the entire bladder and the creation of a new one from intestinal tissue. The new bladder is connected to the urethra and works like a natural bladder. This allows people to urinate through the urethra without the use of catheters or collection devices.

Urgency, frequency, and phantom pelvic pain may remain following surgery, even if the bladder is removed. Possible risk factors and side effects, combined with the irreversible nature of these procedures make many surgeons reluctant to perform them and many patients wary of their effects. There is a risk for IC to develop in transplanted intestinal tissue, including that used to create an internal pouch. Normal urination may be impossible or difficult and self-catheterization may be necessary. Also, there is a risk for urinary incontinence (involuntary urination), especially with orthotopic diversion.

Some research suggests that putting urine in contact with intestinal tissue is risky. Infections, disturbances in metabolism, and problems with the mucosal lining of the bowel tissue may occur. Long-term kidney damage is also associated with these procedures.