Interstitial cystitis

Background

• Also known as bladder pain syndrome
• Diagnosis that applies to patients with chronic bladder pain in the absence of other explanatory etiologies
• Frequently occurs in patients with other chronic pain syndromes such as fibromyalgia or irritable bowel syndrome

Epidemiology

• More common in women than in men
• Most often diagnosed in 4th decade or later
• Prevalence depends on study, ranging from:
  • 197 per 100,000 women and 41 per 100,000 men
  • Between 2.7 and 6.5% of women

Clinical Features

• Persistent unpleasant sensations attributable to the bladder, can include pressure, spasms, or discomfort
• Most frequent symptom is increased discomfort with bladder filling and relief with voiding
• Symptoms usually constant but can vary from day to day and range from mild to severe
• Location is usually suprapubic or urethral, but may also be unilateral lower abdominal pain or low back pain
• Typically gradual onset over months
• Most patients cannot identify a triggering event, but some patients note onset after a UTI, surgical procedure, or trauma
• Exacerbation of symptoms can occur in the setting of stress, following intake of certain food or drinks, or after certain activities (e.g. sexual intercourse, exercise, sitting for a prolonged period), or during luteal phase of menstrual cycle

Differential Diagnosis

• Bladder, urethral, or genital tract cancer
• Urinary Tract Infection (UTI)
• STI
• Benign pelvic mass
• Bladder stone
• Foreign body
• Urethral diverticulum
• Bladder outlet obstruction
• Neurological dysfunction
• Chronic pelvic pain syndrome

Evaluation

• Detailed physical exam to evaluate for alternative diagnoses
• Urinalysis and urine culture (typically patients will have a normal UA and sterile urine culture)
• Sexually transmitted infection testing may be considered if patient is at risk for these
• Postvoid residual
• Cystoscopy may be considered
• Diagnosis is made if the patient meets has “an unpleasant sensation (pain, pressure, discomfort) perceieved to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes”

Management

• There is no curative treatment, the goal is symptom relief
• Evaluate for comorbities, psychosocial needs
• Lifestyle modification (trigger avoidance)
• Bladder training
• Application of heat or cold over the bladder or perineum
• Consider pelvic floor muscle physical therapy
• Pharmacologic options
  • Amitriptyline generally first line
  • Alternatives include pentosane polysulfate sodium, antihistamines, cimetidine, sildenafil, adjuvant analgesia (acetaminophen, NSAIDs)
• For refractory symptoms, options include
  • Bladder hydrodistension
  • Intravesical therapies (such as local anesthestics)
  • Intradestrusor botulinum toxin
  • Sacral neuromodulation
  • Cyclosporine A
  • Treatment of last resort is urinary diversion

Disposition

• Discharge with possible referral to urology or urogyn